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Creating a Better Future for Autoimmune Care 

1 month ago
50 min read
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Summary:

In this episode, Cheryl sits down with rheumatologist Micah Yu and passionate patient advocate Dr. Bonnie Feldman to discuss creative ways to improve healthcare for people living with rheumatic disease.  They start by sharing their patient experiences and exploring problems with current healthcare systems. They then share how these problems led them to form creative patient programs and services. Cheryl shares the origin story for her Rheum to THRIVE program, and Dr. Yu and Dr. Feldman share how they created Rheumission,  a virtual first integrative Rheumatology and Lifestyle clinic for people living with autoimmune disease. 

Overall, our passion for reimagining autoimmune care shines through as we highlight gaps in current treatment paradigms, and outline visions for a more inclusive, holistic and effective healthcare model that is proactive versus reactive. 

The discussion concludes with an exploration of cutting-edge advancements in telemedicine and personalized medicine, and all speakers share their best advice for newly diagnosed patients. 

Medical disclaimer: 

All content found on Arthritis Life public channels was created for generalized informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

Episode Sponsors

Rheum to THRIVE, an online course and support program Cheryl created to help people with rheumatic disease go from overwhelmed, confused and alone to confident, supported and connected. See all the details and join the program or waitlist now! 

Main themes of the episode:

  • Importance of personalized care: we discuss the importance of personalized treatment plans tailored to individual needs, rather than one size fits all solutions.
  • Revolutionizing autoimmune care: we explore the potential positive impact of integrating biotech, digital health, and virtual-first approaches to enhance research, diagnostics, and treatment, with Rheumission as an example.
  • Multidisciplinary approach: we highlight the importance of team-based care in rheumatology and autoimmune care, where you can see not only a rheumatologist and rheumatology nurse but also get care from a multidisciplinary team (including registered dietitians, mental health therapists, physical and occupational therapists, etc) 
  • Taking a holistic approach:  we explore the interconnectedness of physical and mental health, addressing lifestyle factors, stress management, and environmental influences.
  • Exploring Mental Health: The conversation highlights the well-documented correlation between autoimmune diseases and mental health issues like anxiety and depression.
  • Why is accessibility important: we discuss the problem of long waiting times for rheumatology appointments and possible solutions.  
  • Advocacy for patient involvement: Dr. Bonnie emphasizes the importance of empowering patients to take charge of their health and actively participate in decision-making processes.

Speaker Bios:

Dr Bonnie Feldman, DDS (dentistry)

After a decade of being a patient advocate, Dr. Feldman co-founded Rheumission, a virtual first integrative Rheumatology and Lifestyle clinic for people living with autoimmune disease.  As the Chief Patient Officer, Dr. Feldman believes strongly in bringing the patient’s voice to the creation of the program. With her “Patient First Strategy”, there is ongoing patient research, a patient feedback program, and a first of its kind, patient advisory council. Join us in reshaping autoimmune care at Rheumission—where patients are heard, cared for, and empowered in their health journey.

Dr Micah Yu, MD 

Dr. Yu is an integrative rheumatologist who incorporates complementary medicine with traditional rheumatology. He is quadruple board-certified in Rheumatology, Internal Medicine, Integrative Medicine and Lifestyle Medicine. He obtained his MD from Chicago Medical School and holds a Masters in Healthcare Administration and Biomedical sciences. He completed his internal medicine residency and rheumatology fellowship at Loma Linda University in Southern California. He is a graduate of the Andrew Weil Integrative Medicine Fellowship at the University of Arizona. In addition, he is certified in functional medicine through the Institute of Functional Medicine.  

Dr. Yu is the founding integrative rheumatology director at Rheumission, a virtual integrative rheumatology practice.  He is also the integrative rheumatologist and co founder of Dr. Lifestyle, a integrative and functional medicine clinic located in Newport Beach, California where he serves patients in over 15 states in the USA. 

He is also the integrative expert panel member for the Arthritis Foundation, a council member of the True Health Initiative, and the summary advisory committee member for the Spondylitis Association of America.  He has spoken for multiple organizations including the Arthritis Foundation, LearnSkin, Lupus Foundation of America, Lupus LA, and Spondylitis Association of America.  He has also published several papers including “Lifestyle Medicine as Treatment for Autoimmune Disease” which was featured in The Journal of Family Practice.

He has a very unique perspective on autoimmune disease and arthritis as he is both a patient with arthritis and physician. Dr. Yu was diagnosed with gout at the age of 17 and later diagnosed with spondyloarthritis as well. He is able to understand his patient’s medical problems from a patient perspective. The foundation of his practice is to combine integrative medicine and rheumatology. 

Dr. Yu is on social media under @MYAutoimmuneMD on Youtube, Instagram, Tiktok and Facebook educating his audience on autoimmune diseases and integrative medicine.

Cheryl Crow

Cheryl is an occupational therapist who has lived with rheumatoid arthritis for nineteen years. Her life passion is helping others with rheumatoid arthritis figure out how to live a full life despite arthritis, by developing tools to navigate physical, emotional and social challenges. She formed the educational company Arthritis Life in 2019 after seeing a huge need for more engaging, accessible, and (dare I say) FUN patient education and self-management resources.

Episode links:

Full Episode Transcript

Cheryl:  00:06

I’m so excited today to have two guests from an amazing innovative new practice called Rheumission. We love our plays on words. We have Dr. Micah and Dr. Bonnie. So, how about I’ll go first with Dr. Bonnie. Where do you live, and what is your relationship to inflammatory arthritis?

Dr. Bonnie:  00:24

I live in Los Angeles and myself and my family have multiple autoimmune diseases. Some of them could be called inflammatory arthritis and some of them could be classified as some of the other 100 types of autoimmune disease.

Cheryl:  00:41

Awesome. I mean, awesome that you —not awesome that you have that and your family has that but awesome that you have, you’re going to share with us how you’ve used that patient experience to make some really innovative solutions for other autoimmune inflammatory arthritis patients. So, I’m excited. Okay, what about Dr. Micah? 

Dr. Yu:  01:01

Yeah, so I am a rheumatologist. I live in Southern California also, not too close to Bonnie, but maybe an hour away. And my relationship with arthritis is that I have gout and spondyloarthritis for over a decade now.

Cheryl:  01:19

Yeah, and I would love to know a little bit more about both of your backgrounds and, you know, professionally. And then, into how did you get led to integrative rheumatology? What does that mean to you? How about Bonnie, Dr. Bonnie, you go first. 

Dr. Bonnie:  01:40

Sure. I actually started as a practicing clinical dentist, but as fate would have it, much as I loved treating patients, I broke my right wrist which turned out to be a permanent injury and the, oh, very sad and unexpected ending of my first career. At that time, I had four kids and I had to sort of get my act together. 

I went to a career counselor; all you career changers. They told me I was good at numbers and people, which was hardly profound. But I took the opportunity to go to business school. I have an MBA in finance, and I subsequently worked all over Wall Street, which is a really tough job. I was a sell-side equity research analyst, buy-side long-short hedge fund analyst. I did investor relations and communications. And all of this with limited use of my right hand and arm. In business school, I was actually technically a disabled student where I learned voice technology. 

So, I, for all you listeners out there who can’t hold things and have trouble with their hands, this is an ex-dentist who has somewhat recovered, but not totally in terms of my arm, my hand, and my neck. That’s outside of my autoimmune diseases. And then, I became a de-facto autoimmune patient advocate for myself, my family, my son-in-laws, and my 10 grandchildren. And I was first a consultant. And then, I was looking for a company that would serve my needs and the needs of my family. And I waited and I waited, and I put together my own teams until finally I said, “There’s no one that’s going to do this, but me.” And I gathered my resources at the age of 68-years-old, with 10 grandchildren and I went out to form this company. 

And I, the first thing I wanted to find was a rheumatologist who shared my belief in complete patient care, who shared my philosophies about putting together a care team. And I interviewed a lot of them and they didn’t even come close until I met Dr. Yu. And literally, I thought it was a sign from up above that this company was meant to be. Not only was he trained in conventional rheumatology, but he is trained in integrative lifestyle functional medicine. He has the largest toolkit of any rheumatologist I have ever met. And over the last year-and-a-half where we’ve worked together very, very closely, he is what I call a Chinese mensch.

Cheryl:  04:29

[Laughs] I was like, oh, is that a, is that a Chinese —? Oh, okay, I get it. I love it. I love it. I mean, first of all, though, Dr. Bonnie, I’ll just say, I already knew Dr. Yu. And so, I’m like, yes, of course, this unicorn — because he also has the patient experience. 

But also, I’ve never met anyone with your mix of experience as well, you know, Dr. Bonnie, because most people who want, like – I’ll say myself, I had a similar thing, the origin story for forming Arthritis Life and forming my Rheum to THRIVE support groups. Like, “someone needs to do this, someone needs to do this.” And then, like, the pandemic hit, and I was like, I need a project. Let me do this. Like, I guess that’s me. 

But, you know, I don’t have any financial background. And that’s been really hard. Anyway, that’s my story, figuring, for me, out how to make create a sustainable solution to the kind of complex problems that are in our healthcare system, and that a lot of autoimmune patients face. So, I’m fascinated by how you kind of put together all of your patient and professional experiences. And I always do think of as an occupational therapist, dentist, I always say, one of the hardest jobs to do, if you have something like rheumatoid arthritis, is like a massage therapist, dentist, surgeon, like —

Dr. Bonnie:  05:47

I loved being a dentist. And in fact, right now with Rheumission, I talk to every single one of our incoming patients. And believe it or not, one of the many reasons I enjoy that is, first of all, it’s a dream come true. But second of all, it reminds me of my dental practice. Yeah.

Cheryl:  06:06

Well, and I actually even have someone who refers to themselves as an integrative dentist, which I know it’s not, like, there’s not like a board certification for, you know, dentists, as far as I’m aware. But I had Dr. Victoria Sampson on to talk about, like, the oral microbiome. And so, anyway, sorry, I’m already derailing.

Dr. Bonnie:  06:23

It’s okay. 

Cheryl:  06:24

Episode 127. I’m still having, I have a hard time sticking to my schedule. But how about Dr. Micah? You know, you’ve already shared a little bit of your experience, but what does integrative rheumatology mean to you? And how did you get into it?

Dr. Yu:  06:43

Yeah. Yeah. Before we dive into that, I want to talk about how Bonnie actually found me because it was a very, very — it was by luck, I think. Because she messaged me on LinkedIn. And usually, I get a lot of spam on LinkedIn. My profile wasn’t even updated at the time, I didn’t really use it. And so, I saw a message. And I thought it was spam, so I’ll just ignore her message on LinkedIn. But luckily, I responded, and it was a real person. And then, we got talking. And that’s how we started working together. So, very grateful for that LinkedIn message. I’m very grateful for working with Dr. Bonnie here, who has been very, very compassionate and such a great mentor in this space as well. 

And so, let’s talk about my story here, how I got involved with rheumatology and integrated rheumatology to begin with. Well, as you know, I’m a patient got diagnosed very, very early on with gout at the age of 17 based off a high protein diet at that time, the Atkins diet, and then over time, my diagnosis did shift. And I got pain in many different joints. And I got diagnosed with spondyloarthritis after seeing like three or four rheumatologists with no diagnosis for many years, and I got diagnosed during residency. And I was offered medications. Potentially, I was flaring about at least once a month. I was very stubborn. Doctors are the worst patients. We don’t want to do anything. 

Yeah, I would live to work. I would sit on a stool on my ICU rotations because I couldn’t walk. So, it was a very challenging time. And luckily, I did find lifestyle medicine. And I tried, I heard that diets could potentially work. I was very skeptical at the time, because we get no training on nutrition at all during our residency or medical school. So, I tried going on a plant-based diet. I think within two months, three months, my pain just went away. I thought that was very unusual. I was like, a month goes by, no pain. I would flare every month, sometimes every couple of weeks. Two months go by, nothing. 

And then, I’m going to get my labs. My labs, inflammatory labs actually went negative as well. So, I was very, very shocked, but also very relieved at the same time. So, that’s when I got on this path of how does food affect our body and inflammation? What’s the science behind this? How come I’m not being taught about this? 

So, I started reading books; I started looking at scientific articles. And I realized that I can’t work anywhere else. Like, I have to open my own practice. There’s ‘s no one that can do this. Just like Dr. Bonnie, there was no one that can form her other company. She has multiple things that she’s done in the past. I had to do things with my own way as well. 

So, I opened my own practice where I did integrative rheumatology, and I still do, but then we, with Dr. Bonnie, have combined together to try and find ways to bring this out to the public in the insurance model so that patients can get access to this with a whole person care team. Because I’m trying to do this on my own private practice, but in Rheumission, we have so many different clinicians that can help with their own specialties. We have me as a rheumatologist, we have lifestyle medicine, and we have digestive and mental health as well. So, it’s something that is very, very special. 

And the public, I feel like they’re demanding the whole person care team where we can talk about diet, we can talk about medications, we can talk about supplements as well. And how do we use this to help patients with their priorities, their culture, their beliefs, and not force things down patients, and not telling them that, “Your food is the only way to fix this. Medications are evil.” That’s not true at all. As a rheumatologist, I use medications, I balance it out with diet with some patients. They do really well, that’s great. Some patients, they need it, then we’ll still use it. So, it’s a fine line, that it’s an art between the teamwork between the clinician and the patient as well. So, that’s my story on arthritis. It’s been a very long one, many decades.

Cheryl:  11:04

No, it’s beautiful. And it’s — what’s really, to me, as an occupational therapist living with rheumatoid arthritis, it’s really congruent with my understanding as an occupational therapist, which is we are trained in all the lifestyle that’s non-pharmaceutical. We’re saying, okay, what’s under your control in your daily habits, routines, activities, whether that’s exercise, stress management – we’re a little bit that jack of all trades, master of none, to some degree. 

But, you know, when I first started looking into lifestyle, I was like, wow, why is there no guidance for patients on this? You know, and when I was diagnosed in 2003, there was this idea that there isn’t any good evidence for lifestyle. But now, you know, flash forward, the American College of Rheumatology in 2022 even put out their first ever integrative guideline for rheumatoid arthritis with a supplemental, you know, 500-page PDF of all these different evidence-based, you know, guidelines, the strongest one being exercise followed by like Mediterranean diet. 

So, anyway, sorry, I’m going on a tangent, but it’s been, for me, just in my 20-year patient journey, amazing to see. I’m halfway — I’m 42 and I got diagnosed 21 years ago, at age 21. So, I’m in this, like, perfect midpoint of my life living with this. But also, like, it’s really, really exciting to see that more, the general population and doctors are more receptive to a combination. 

So, integrative care is not alternative care, doesn’t mean that you’re not ever doing medications, right? Integrative means that you’re integrating both of these potentially. Or potentially, if it’s important to the patient, some patients will say, right, like, “It’s a meaningful goal to me to try to reduce my medication. Can I up my lifestyle factors and variables?” Do you ever hear, have that be like a goal with your patients, so that they can titrate down? Yeah.

Dr. Yu:  12:54

Yeah. Yeah, we have patients who come in and say, “My goal is to get off medication, I don’t want to be on my medications.” Oh, well, it was let’s slow down here. Let’s take it one thing at a time. Let’s use all the lifestyle factors, integrative factors, therapeutics that we can use that’s evidence-based to help you. And at the same time, let’s take it step-by-step. Maybe you are, your biologics are every two weeks, maybe you go every three weeks. Let’s see how you do. Well, let’s see if you flare and if you do, then we’re not ready for that yet. So, our goal is to keep them in remission and tapering off medications. That can be challenging, but it has been done before. 

Dr. Bonnie:  13:29

Yeah. So, one of the things, one of my touch points — actually two of them that we’re combining at Rheumission is chronic pain and movement therapy. So, I’ve been in a fibromyalgia patient for over three decades. And one of my frustrations was I had to be the CEO of my own health and put together a program of what I call movement therapy. No one helped me. The physical therapists, ome of them were helpful, some of them weren’t. But it has things like gyrotonic, and Feldenkrais, and Tai Chi, and Qi Gong, and meditation. 

And so, at Rheumission, we’re trying to incorporate the things I’ve learned and other people have learned and the things Dr. Yu and Mondala support in our exercise program for our patients who think who don’t necessarily always think that — what do they call it? Lotion is motion; motion is lotion. And it’s hard when you’re depressed and/or obese and your body hurts to understand that exercise may be one of your best things to do for yourself.

Cheryl:  14:40

Yeah, and it’s really the devils in the details, right? Like, I have a lot of patients who are hesitant about movement strategies or exercise. You know, I try to break it down. Well, there’s kind of these three to four pillars, right. You have strengthening, strength training. You have cardiovascular exercise. You have stretching, and then like balance kind of goes in there, which is more important as you age, balance is much more important. So, I should really just say four of them all the time.

 But, you know, I found the biggest bang for my buck on my fatigue and brain fog has been strength training, which really surprised me because I was doing strength training, hoping that it would help with, you know, just overall feelings of robustness and supporting, obviously, the joints and the muscles. But I always assumed that the brain fog and fatigue benefits were from cardio because, like, getting the blood pumping to the brain. I was literally imagining that. But I was doing cardio consistently and not doing strength training until September of 2023. And then, I started strength training, and it was really noticeable. I was like, whoa, I’m thinking more clearly. 

And so, and that’s not to say that everyone should do what I did. It’s that when you experiment with your own body, you kind of learn like, okay, someone else might have the opposite. They might say, “Wow, the strength training didn’t really do anything for my fatigue and brain fog, but the cardio did,” you know, so having some guidance with that I’m at the point where I’m obviously like an occupational therapist, and a patient educator. And even so, I was gonna say, I know how to do it on my own. But actually, I also did go to a personal trainer, because I’m like, I know that I know what to do. But I’m not going to do it unless I put, you know, some investment into it. And I have this thing on my schedule. And I know that April is going to be waiting for me on Thursday, so I gotta go see her, you know. 

And so, I love, one thing I love about Rheumission, which by the way, when we say Rheumission, this is the name of their clinic. It’s R-H-E-U-M-I-S-S-I-O-N-, so ‘Rheum’ like rheumatic disease, ‘mission’. I love it. And Rheumission, we want to get into remission, R-E-M-I-S-S-I-O-N, for our diseases. But that’s one of the most important things that stood out for me when I first learned about your programs is that it’s a team, you’re not just on your own.

Dr. Bonnie:  17:04

Right, and we do have an exercise program. Our first partnership is with Andrea Strong of Andrea Wool of Autoimmune Strong, and —

Cheryl:  17:12

Oh, yeah, I follow her. Yeah. 

Dr. Bonnie:  17:14

Yes, she is very experienced with autoimmune patients. And so, we’re very proud to have this personalized approach for the chronic pain that is associated with many of our patients.

Cheryl:  17:29

Yeah, did you want to say something else, Dr. Yu? Or you are you just not —

Dr. Yu:  17:32

Yeah, I would say exercise is often overlooked, and it’s so important, anti-inflammatory. And our program, you know, we want patients, if they can’t run, then they can walk. If they can’t walk, then stretch. There’s a little bit for everyone. Some patients can’t get out of bed, but we our goal is to just get them to stand up. So, that, in a sense, is so important. 

And Rheumission, we are focused on different factors here, there’s different pillars we’re focused on. So, exercise is one of them. Nutrition is another one, stress management, mind-body medicine is so important, as you know, as an occupation. And also, avoiding risky substances, smoking, alcohol, drinking, yeah, can sometimes cause more inflammation. As you know, just smoking has been strongly associated with rheumatoid arthritis. Well, we know that literature. So, there’s multiple factors here to get patients better. 

And what’s special about Rheumission is that this is the first time that lifestyle medicine and rheumatology are working hand-in-hand under one umbrella, one clinic. So, generally when you go see rheumatologist, they’ll say, “Okay, go find your own dietician,” or, “Go see a dietician,” there’s someone else. Or even if they’re in the same university, sometimes it’s so hard to navigate a big system and people get lost.

Cheryl:  18:54

Yeah, they, it’s a rude awakening. Like that’s, I mean, it’s very, almost like parallel evolution a little bit to how I developed my Rheum to THRIVE program because it’s like, I was so, you know, I saw patients have to cobble together their own care teams, and it’s very stressful, and it requires a lot of medical literacy, a lot of executive function, you know?  And in the time and money, like, most people don’t have that, right?

Dr. Bonnie:  19:23

Well, if you have chronic pain and you’re fatigued and depressed, there’s no — it’s going to be extraordinarily difficult to be this assertive, aggressive CEO of your own health, which is what I had to become before we founded Rheumission. 

Cheryl:  19:40

Yeah. Yeah. And you mentioned some pillars that you address at Rheumission. Stress, nutrition, exercise, and then overall kind of healthy habits like smoking cessation. So, what about sleep? This is what I always called the underrated lifestyle factor.

Dr. Yu:  20:00

Yeah, and you’re not missing one. I was like, I counted, I was counting them. 

Cheryl:  20:02

Oh, no, I wasn’t trying to be like, what about sleep? No, I meant like, I wanted to give you a chance to talk about sleep.

Dr. Yu:  20:08

Yeah. So, our lifestyle medicine team does focus on the sleep. And sleep is, you know, as you know, when you don’t get much sleep as an autoimmune patient, you feel worse in the morning, you might flare up, more stiff. So, sleep is a very important part of our program as well. So, our lifestyle medicine team focuses on that and we do have habits that we can help patients sleep better. If that doesn’t work, then maybe our psych department can help with that or supplements can potentially help with that. Also, we don’t want to jump to medications right away. Of course, they want to emphasize other lifestyle, your sleeping habits to help with this.

Cheryl:  20:48

Yeah, I always say that, like, you know, the space — and not I always say, sorry, I’m gonna give credit. Dr. Afton Hassett introduced me to the to the acronym SPACE symptoms. Like, sleep, pain, affect, you know, emotions, cognition, and energy, fatigue, and I kind of put exertion in there too, like exercise, they can kind of, they all interrelate to each other, right. That’s the great news. The great news is like turning the dial up on one can improve all of them. The down, the bad news is that when one of them is bad, it also affects the others, right? And would you agree, yeah.

Dr. Bonnie:  21:25

Especially in rheumatoid arthritis, let’s not forget the oral microbiome. So, let’s add in that you need to have a healthy mouth and, you know, regular checkups with your dentist. And there are oral microbiome tests to see the types and quality of saliva because the studies show that it a dysbiotic oral microbiome can be a predictor to rheumatoid arthritis, as well as heart disease, and other things.

Cheryl:  21:54

We should really call this SPACE symptom ‘SPACE-and’, put an ‘and’ at the end. Like, nutrition, put microbiome, that’s such a good point. Yeah, how, you know, I don’t know how much the average dentist knows about the oral microbiome in relation to autoimmune disease. How do you recommend patients who are interested in like learning more about this? Do you recommend they ask their dentist or is there like a good website people can learn more about this?

Dr. Bonnie:  22:24

They can ask their dentist or there happens to be a few companies that do oral microbiome testing. One of them is called Bristle, like the brush. 


Cheryl:  22:34

Haha, nice. 

Dr. Bonnie:  22:35

And they have some good educational material.

Dr. Yu:  22:40

Right. And that’s an emerging space right now is the oral microbiome and rheumatoid arthritis and all these oral microbiome companies. I mean, rheumatoid arthritis, we’ve known for many years that the P.gingivalis bacteria has been associated with rheumatoid arthritis. So, how do we help with that? I mean, going to the dentist, clean that out, making sure you floss, all those things are very important. But how do probiotics, how does that affect that? We don’t know much about that at this time. So, those are things that we’re working on Rheumission, we’re always looking at the most cutting edge evidence-based medicine to get ahead and help patients in many different aspects.

Cheryl:  23:19

Yeah, it is really exciting to think like, there are, you know, additional things, like, under our — again, to me, it’s all about what can I control in my daily life, that small changes, you know, you want to be the most efficient you can if you live with fatigue, so you’re like, “Wow, if I just increase my oral hygiene,” and if that has, if it moves the needle.

Dr. Bonnie:  23:40

Well, it can’t hurt. Let’s put it that way. 

Cheryl:  23:44

Yeah. Even if it’s not like massively influencing your disease and inflammation, it’s at least, you know, you’re more likely, especially for me, I’ve been on methotrexate plus biologics are 20 years and, you know, there’s the immunosuppression that you do experience with that. So, you know, if you have good oral hygiene, you can at least be less likely to develop like gum disease and some of those — so I’m very, very consistent, like, I am actually militant about my dental care. 

Dr. Yu:  24:13

It’s very white!


Cheryl:  23:14

Yeah, yeah. I was gonna say, back to, you know, you’re saying why, why is this team-based approach not done as commonly the only place I’ve ever seen it done consistently is pediatrics. It seems like with pediatrics, they’ve kind of figured it out — and in pediatric rheumatology, most people don’t know, is like a completely — Dr. Yu you know what I’m talking about — that it’s a different specialty. Like, adult rheumatologist can’t just decide to see kids and vice versa. Like, pediatric rheumatology, you’re a pediatrician that then specializes in rheumatology; whereas adult rheumatologist, it’s internal medicine first, right, and then you do the fellowship and rheumatology. 

So, these are different professionals to different diseases even though they both have rheumatologist in the name. But in pediatric rheumatology, I have seen, at least as an occupational therapist, I know there’s OT’s that I’ve met through the Association of Rheumatology Professionals that they’re like, “Oh, yeah, I work in this multidisciplinary clinic and like the patients get diagnosed, and then they see the PT, the OT, they see a dietitian,” but I’ve never seen that done in, you know, in adult rheumatology, like in a very systematic way, especially addressing the mental health and the stress management along with it, because you know, who wouldn’t be stressed? 

Like, literally, I’ve told my, you know, I told my — sorry, this is maybe a little side note — I told my own psychiatrists and psychologists, I’m like, okay, so if anxiety is like, a too big reaction to a fear that’s out of proportion to the threat, like, tell me if my body is attacking myself, and I have a progressive autoimmune disease, like, in your opinion, what’s the appropriate amount of stress I should have? Because it’s not zero. Like, it’s not adaptive for human beings to have zero stress about their body being, like, their health. Like, I don’t want to be the person, the human that, like, died, because they were like, “There’s a fire coming. Oh, well, no stress,” you know?

Dr. Bonnie:  26:08

Well said, Cheryl. And in doing research, before I founded Rheumission, I was a digital health consultant for many of these companies. The anxiety and depression piece is well documented in the academic literature as accompanying autoimmune diseases, whether it’s a chicken or the egg, whether it’s the inflammation or not, whether it’s just the shock of getting this long-term diagnosis that you’re describing in very good detail. I would say, most patients who have an autoimmune disease have some level of anxiety and depression. And when I talk to our incoming new patients, and I say that I can honestly say all of them say, “Yeah, that’s me.” And me, and you, and probably almost everybody else. Yeah.

Cheryl:  26:58

Yeah. And learning about that, it helps normalize it, and it helps them see like, you know, it’s not your own moral failing that you’re stressed, you know? Saying: okay, yeah, we all experience (it), if you’re having chronic health issues, especially pain, it’s normal to be stressed. And it doesn’t mean that your stressed caused your condition, it just, you know, but we can still do things to improve our quality of life. 

So, I also wanted to ask Dr. Bonnie, you know, I read your LinkedIn profile. We’re all hanging out on LinkedIn. No, I don’t actually spend time there. But you said — I thought this was interesting wording, and I just, I want to give you a chance to share more about this. You said, “The biotech and digital revolutions offer new tools that can speed research, create new diagnostics and treatments, and support patient-centered virtual-first care (V1C) delivery.” That’s just, I’m literally just wanting to learn more. Like, what do you think is — what are some of these new revolutions? And why is virtual-first care important in your mind?

Dr. Bonnie:  28:03

Well, the first is telemedicine was normalized during COVID. And Dr. Yu himself has been doing telemedicine longer than that. And in his practice, without even talking about new tools and technology, he’s found remarkable results on getting patients to remission. And at our Rheumission, we are now looking at new tools, and what would those tools look like? 

One could be an oral microbiome test. Or maybe we’re going to look at gut microbiome, we don’t know. One is screening blood tests, but I’m going to let Dr. Yu tell us about the other new technologies that we’re kind of thinking about. They’re at the intersection of AI, digital health, virtual-first. Biotech has a few, there’s drugs in the pipeline, for sure. And hmm, I’m not sure what’s going to happen in our biotech world to be exact. Dr. Yu, can you add some?

Dr. Yu:  29:07

Yeah. So, I mean, I’m all about tests, Bonnie mentioned already gut microbiome test. How valid is it, there’s so many companies that do this. And also, there’s emerging devices in the literature that can help with autoimmune diseases. Also, we, what else is there? So, we talked about the oral microbiome, the gut microbiome, devices, and also — I’m trying to think here, I think those are the main things. Oh, also, there is a test for rheumatoid arthritis that can tell whether a patient is resistant to a certain biologic as well, Prism RA. So, there are some cutting edge tests out there.

Cheryl:  29:46

And —

Dr. Bonnie:  29:47

What we — 

Cheryl:  29:48

Oh, I’m sorry.

Dr. Bonnie:  29:48

What we’re looking for is new tests that will help predict flares, to be exact. 

Cheryl:  29:54

Yes. Yeah. And I think what I was thinking about that you might have been, like, referring to as maybe like precision medicine as well, like giving the right treatment to the right patient at the right time, which, historically, it’s been a little bit of like throwing darts at a dartboard, like a slightly informed version. You have like an area of the dartboard that you kind of target a quadrant, but you want to make it really specific, right?

Dr. Yu:  30:21

Yeah. So, there’s, there’s so many things out there. And also, looking at their environment. How do the pollution, smoking, toxins, BPA, VOCs, all these. There’s more and more evidence in the literature how does that affect the body. So, those are all things that we can look forward to in the future that we can possibly use to the advantage of rheumatology. And we don’t forget genomic testing and genetic testing as well. That’s up and coming, emerging.

Cheryl:  30:49

Yeah, I was talking to Benaroya Research Institute researchers. And that’s just in my backyard here in Seattle, I’ve donated my own blood to their biorepository for testing. I keep meaning to get my siblings and my parents too as well, because they’re looking into that family hereditary, you know, pattern and trying to figure out, you know, why did the RA precision, why did it turn on in me and not my siblings, you know.

Dr. Bonnie:  31:15

Exactly. And the bigger picture, in my view of why I founded Rheumission, as we were talking about, Cheryl, is for my 10 grandchildren, some of whom have a double dose of these genes. And the fundamental question, as their grandmother is, what are the lifestyle modifications for children that we might be able to prevent that switch from turning on? So, yes, I teach my grandchildren to meditate. I’ve introduced them to yoga. I try to talk about living in the moment and being happy to children. But we need, we need more than that. 

And at Rheumission, we’re going to stay cutting edge with new novel things that we’re looking at in order to at least begin to answer my fundamental questions of how to leave a legacy for the next generation that isn’t better than our current tools.

Cheryl:  32:12

That’s absolutely beautiful. I mean, and I couldn’t really agree more. I mean, I only have one child. But I do think about, you know, him having — he has a 1% chance, or 2% chance of developing RA, from what I understand. It’s like 1%, typically, and then since he has a parent with RA, it’s twice as likely, which only brings it up to 2%. But still, you know, knowing that there, you know, there’s so many things that I, you know, I want him to be set up for success, mental health wise, like you mentioned, with meditation, you know, mindfulness practices. It’s kind of a win-win, right, even if you don’t have an autoimmune condition, but it’s even more important when you do. 

So, I think that’s, yeah, that’s really truly amazed. Are you from New York originally? I’m sorry, I can’t stop myself from asking that. Are you from the East Coast? 


Dr. Bonnie:  33:03

Yes. 

Cheryl:  33:04

Okay. That’s what I thought. I went to school at Vassar, in upstate New York, you know, but I was like, I detected like the New York.

Dr. Bonnie:  33:12

I’m from Hartford, Connecticut.

Cheryl:  33:14

Oh, from Connecticut. Okay. Okay. Yeah, I love it. I love it. That’s just, that’s just me. Word vomiting. But back to the, you know, yeah, the formation of Rheumission. Is there anything else you to wanted to share about, you know, the process? Maybe how I do — I think people listening are probably like, oh, how do I sign up? It is only in California currently, right? Even if you’re telemedicine, you have to be a resident in California. Is that right?

Dr. Yu:  33:46

Correct. We’re currently we’re only in the state of California, we’re expanding potentially to Pennsylvania very, very soon. So, maybe by the time this podcast gets released, we’ll be in Pennsylvania. So, to get the most up-to-date information on what states we’re likely to see patients in, just go to the website. And our goal is to be a national provider. So, our goal is to be in all 50 states. 

Cheryl:  34:09

Nice. It makes sense to start in one, you know, start it, get the proof of concept. I’m not giving you advice. Dr. Bonnie, you’ve done a lot more actual business than I have. But I just think it makes sense. I mean, the whole country is huge, so.

Dr. Yu:  34:25

Yeah. And signing up to be a patient is very simple. Just go on the website. There is a ‘Book now’. And it will take you through a form where you answer some questions and then you can make it a visit with me pretty fast. We’re available within a week.

Cheryl:  34:41

And then, you have kind of, you end up getting like a personalized plan. And you have various, depending on your needs, different professionals that you check in with, right, whether it’s —

Dr. Yu:  34:50

Right. 

Cheryl:  34:50

Yeah.

Dr. Yu:  34:51

Right. So, they will see me or another, someone else from a rheumatology team and then they’re gonna see the lifestyle medicine team, and go through the whole person care process.

Cheryl:  35:02

I love it. I love it. Is there anything you would add, Dr. Bonnie? 

Dr. Bonnie:  35:06

Yes, it’s very personalized, customized, tailored. It’s all the things I wish I had been able to find.

Cheryl:  35:15

Yeah, yeah, I mean, I don’t even want — I was going to ask like, you know, what were some of the, I mean, we could spend a whole episode talking probably about like the horror stories, you know, the gaps in your own care that led you, or your family’s care that led you to, but what do you think are some of the biggest things missing in the current standard of care? 

The kind of I say, you know, one 20-minute appointment with a rheumatologist is not sufficient, no matter how amazing that rheumatologist is. Actually, people are like, “20 minutes? I only get 10 minutes every three months.” I’m like, whoa, I thought 20 minutes, once every three months, was egregiously small.

Dr. Bonnie:  35:58

It’s more systemic than that. The current treatment for autoimmune disease is divided by body parts. So, and if you have an undiagnosed one that doesn’t fit into a conventional medicine bucket, you know, that it’s chronic pain, maybe it’s mixed connective tissue, maybe it’s lupus, maybe it’s RA, maybe it’s Ehlers Danlos, maybe it’s fibromyalgia. The current system will send you from specialist to specialist, you know, you’ll see a dermatologist and endocrinologist, a rheumatologist, a GI doc, etc, etc. Heavens help you if you end up in the anesthesia chronic pain category, don’t get me started on that one. 

But the system needs to realize that the head is connected to the body and that we are one connected system, we should not be you have to see specialist by body parts. And the literature is now only beginning to understand that inflammation is a spectrum. They’re, you know, they’re linking all sorts of other diseases that may be part of this inflammatory spectrum. I’ll let Dr. Yu give his expertise on that. 

So, I’d say two things. Don’t treat us by body part, don’t send us to a million specialists. And if we’re undiagnosed, it’s not in our head. It’s merely in parts of our body you don’t understand yet, because of this inflammatory spectrum that is being redefined. Your turn. 

Cheryl:  37:20

Wow. No, that was beautiful.

Dr. Yu:  37:24

I agree with Dr. Bonnie on all points here. A 20-minute, 10-minute visit isn’t enough. At Rheumission, you actually get one hour, in the initial visit. And half an hour on follow ups. And if you need more, we can also offer more as well. 

And currently, the gaps in rheumatology, number one, is it’s not enough time for visits; number two, is the time to see a rheumatologist is sometimes six months, one year. I’ve heard one year from some patients. Up in Canada, I’ve heard two years from a patient as well who crossed the border just to see a doctor, a rheumatologist. So, in Rheumission, we can see you within three days, one week at the latest. So, very quickly. And other gaps here are the rheumatologist, like Dr. Bonnie said. In rheumatology, traditionally, we see symptoms by specialist. In Rheumission, we try to gather all together, oh, you have a GI issue? Is that causing inflammation that’s making your flares worse? How can we address that? What, you have anxiety, depression? Yeah, let’s talk about that. Let’s bring it all under one clinic. 

As a rheumatologist, in my training, I never talked about their mental health. I just approached the disease, gave a medication, and that’s it. Now we’re gonna revolutionize this and say, ask them what — anxiety, depression — and what other symptoms do you have? We have a team dedicated to this that will talk to the rheumatologist and we will, we actually have meetings in the clinical team to bring up patients and how to fix and get them better by a multidisciplinary approach. Because how could you see a psychologist, psychiatrist, talk to your rheumatologist? You never see that even in a university system where they have all these specialties.

Cheryl:  39:22

Yeah, no, it really is only on the doctors own time and time, really. And I think it really struck me when I was pregnant in 2013 to 2014, and I was like, hi, guys. I’m one body but I have another, I have another, I have like a baby in me, but I — the gynecol, like the OBGYN recommendations for medications were opposite of the American College of Rheumatology recommendations which were opposite somehow of the pediatric. 

And I was like, y’all need to — someone needs — I’m not a doctor, so somebody help me look through this and be like, okay, is like —? They’ll say, “You should take this medicine,” I was on Remicade and Imuran and they’re like, “You should, you shouldn’t, you should, you shouldn’t.” Everyone was telling me different – and I’m like, one thing. What do I do? You know, so that was just such a distinct example. Because, you know, literally the stakes are so high when you’re pregnant. 

So, I knew that there are, by the way, updated guidelines from the American College of Rheumatology for medications during pregnancy, and reproductive health during family planning for both female and male people. So, how it affects sperms and how different medications affect everything. So, that that came out in 2020. So, people should know there’s a lot better guidance now. Back then, though, only 10 years ago, was quite stressful to try to figure it out. 

Dr. Yu:  40:46

Right. 

Cheryl:  40:47

Yeah, yeah. 

Dr. Yu:  40:49

Yeah, and talking about guidelines. You mentioned earlier, the rheumatology integrative medicine guidelines. Well, I must say that not all rheumatologist know those guidelines. Some don’t even know that even was even released. So, at Rheumission, what’s beautiful about our clinic and our full person care team is that we understand integrative medicine in and out. We understand how you supplement, when you go to a rheumatologist, you ask them about all these herbs and supplements, they don’t know what that is. 

So, at Rheumission we’re able to say, “Okay, this is what you’re taking already, when you’re coming in. This is evidence behind that. This is how it can potentially affect your condition or affect your other medications or other supplements.” We now have a board-certified integrative medicine doctor, Melissa, Dr. Melissa Mondala, the lifestyle medicine doctor, she is in her fellowship for integrative medicine. So, we know how to use those supplements in and out, and not only just for the autoimmune disease, but also for diabetes, high blood pressure; we integrate the whole system together. That’s what makes it beautiful.

Cheryl:  41:51

No, I love it. And yeah, in my — I have been facilitating, I call them educational support groups, like the Rheum to THRIVE support groups, we spend part of the time giving evidence-based tips and guidelines for the various lifestyle factors, and then the rest of the time facilitating a support group. 

But I can’t tell you how often the people in the group say like, it’s like, who is going to look at my whole body, my whole body, my whole not just my body, but the context of my life? Like Bonnie was saying, Dr. Bonnie, you know, your heads control your body and your body and head exists in a context, right? And yeah, I mean, it’s huge.

 You know, people often will say, look, like, oh, well, how, you know, you, you did so well when you were, when I was first diagnosed, I was on — you know, or there’s been periods of my life where I’ve done really well on the medication treatments, and I’ll be able to do stuff. And I say, look, if I wasn’t married to my husband, who works for a rich tech company, I didn’t have access to his medications through his insanely good insurance, like, my whole life would be so different. 

Like, before I was married, I had, I worked 20-hours a week and a government job and then 24-hours a week at a nonprofit just so I could get health benefits, health insurance, because the nonprofit didn’t give health, you know, that’s like, and I also had socioeconomic privilege just coming into my diagnosis. My parents hired a designer, or they called it a designer doctor, but then now it’s called the concierge doctor, because I kept being told, “She’s not sick. She’s just anxious. She’s just type A, she’s, it’s all in her head, go to psychiatry.”

 You know, obviously, I’m still salty about that 21 years later, because that was that was by far the worst day in my life. People are always like, “Oh, was the worst day of your life you got diagnosed?” No, that was like one of the best days of my life because finally someone believed me. Like, being medically gaslit was just — and I’m sorry to anyone who’s also been medically gaslit, it’s a horrible experience. 

And so, anyway, long story short, the context, social and economic, how much social and family support you have affects your function. As occupational therapists, we take that into account in our first evaluation. Sorry, not to like go on a thing about like how great occupational therapy is, but that’s part of our job, is knowing what is your daily life like, how much support do you have. Like, such simple questions but often aren’t asked, you know, just, “Oh, watch your blood work.” Okay, well, that tells you like one tiny sliver of what’s important, you know?

Dr. Bonnie:  44:20

That’s why we’re eager and anxious to have more patients demonstrate outcomes, bring this to as many people as possible. 

Cheryl:  44:32

Well, hopefully the podcast will help. We have a good little listener, healthy listener base. I know we only have about nine minutes left. Is there anything else you wanted to share with the audience before I go to the, quote unquote, ‘rapid fire questions’, which we could, I might edit these down a little bit. But yeah. 

Dr. Yu:  44:49

Yeah, I do want to add one thing. Typically, when you see a rheumatologist you go on a biologic, potentially, but then that doesn’t work. They just cycle through all the different biologics without anything else? At Rheumission, we can potentially cycle through biologics, but we take a step back, and we see what else is driving your inflammation. Why are you still resisting these medications to potentially, you know, instead of cycling through 10 biologics, maybe they can stop at biologic number three, and then work on everything else, and then get their whole other chronic inflammation down beyond just a biologic. 

So, it does take a village; it takes a team to create this. It’s a lot of work. We’ve been working on this for many months. We’re so happy that it’s finally, we’re finally seeing patients now. And every single patient we’ve seen so far has been so appreciative, this is what I’ve been looking for. I’m like, yeah, great. Can you spread the news to other patients, because patients — we are new, it takes a while for patients to find you. So, we’re very thankful for this podcast, that you’re reaching this population to help us get this message out. 

Dr. Bonnie:  45:56

Yes, and let me add, my official title at remission is co-founder and chief patient officer. And as the chief patient officer, not only do I love to talk to the patients, because it reminds me of my dental practice, but we are creating a new novel program from a business perspective. It’s called the ‘patient first strategy’, and it has a foundation in patient research. I’ve done over 500 patient interviews to really understand what patients want and need. And we continue to do more interviews. 

The second is we have a patient feedback program, where we are asking patients how to iterate our product and how to improve it for other autoimmune patients coming after them. And the third, that’s considered a first of its kind new and novel idea is called a ‘patient advisory council’ where we are having strategic advisors who have these diseases give us strategic input into our business decisions. 

Cheryl:  46:50

I love that. And I’ve only ever seen that done in nonprofits that maybe have advisory councils on certain things. But to put that into that concept into a, like, nonprofits aren’t in charge of, you know, the actual care. They’re in charge of, you know, advocacy, and education to some degree.

So, anyway, I think that’s brilliant. You’re very, like, I just want to talk to you for like, 10 more hours, but I, oh, I try to get myself to not talk too much during these but I’m still working on it. Progress, not perfection. Well, yeah, you just have a very, like, big picture in mind, which is just, I think, really, it’s inspirational to me. So, the rapid-fire questions. The first one is, what is your best words of wisdom for someone newly diagnosed with inflammatory arthritis?

Dr. Yu:  47:40

Bonnie, do you want to go first?

Dr. Bonnie:  47:41

No, you go first.

Dr. Yu:  47:43

Okay. I would say if you’re not happy with the first opinion, always get a second opinion. All rheumatologists work a little bit differently. They have different training backgrounds. Some process might not fit with you, even though they’re the smartest doctor, doesn’t mean that that’s the best doctor for you because the person just doesn’t fit. So, find someone that will listen to you and will take everything into consideration and also be open minded about your care. 

Cheryl:  48:11

Love it. I don’t even know second opinions were possible. I’m such a little rule follower. I’m like, this is your rheumatologist. Okay, you know? So, yeah, you have to tell people that Yeah. What about you, Dr. Bonnie? 

Dr. Bonnie:  48:23

Ah, be the CEO of your own health. Take charge and find your team that gives you what you need when you need it.

Cheryl:  48:33

Love it, love it. And what’s something that’s bringing each of you joy right now? Could be related to Rheumission, could be in regular life.

Dr. Bonnie:  48:41

Oh, my 10 grandchildren bring me joy. And every morning I wake up and look at their pictures, imagine the legacy I’m going to leave to them when we are reimagining autoimmune care for them. 

Cheryl:  48:57

That’s beautiful. What about you?

Dr. Yu:  49:00

Yeah, I’m right now it gives me joy, every day waking up, being able to be pain free after suffering for so many years, of being able to spread this message to the world and have my passion be my job and not feel like work is work. So, eager to everyday read articles, scientific articles, be on social media, see patients, living my best life, and be able to spend that with my family. Because 20 years ago, I thought I would be in my 30s, crippled in a wheelchair and a cane. But here I am. I’m able to do a lot of intense exercises and work and not be in a cane just yet. I’m very grateful.

Cheryl:  49:46

Yeah, yeah. Well, I always say this is possible partly with one of my internships was in spinal cord rehab. You know, I definitely, I know what you mean, if you can, most people’s meaningful goal would be to avoid, you know, having to use a wheelchair or cane for mobility. But many people do live beautiful, wonderful lives, very active lives in — so, that’s my little sorry, that’s my little soapbox on that. 

Dr. Yu:  50:12

Yeah, and that’s totally okay. And, but I’m just happy to be living my best life right now, be able to do my job.

Cheryl:  50:20

Yeah, certainly like the future that you envision for yourself. Like, the best-case scenario is what you’re able to live, which is totally beautiful. Well, thank you. Thank you both seriously so much. I’m going to put — y’all have a lot of links for social media. So, I’m putting them in the show notes. Just for anyone listening, I always have a full episode page on arthritis.theenthusiasticlife.com. That’s my full website, or you can get to it just at myarthritislife.net. There’s an episode page for each episode that has like full links to all of the things we discussed, the different guidelines, links to Rheumission. But if you want to, what’s one social media handle you’d like people to follow you on? Tik Tok or Instagram?

Dr. Yu:  51:06

Yeah, well can start with Rheumission. Rheumission does have their social media handle. I think it’s Rheumission — I have to look it up.

Cheryl:  51:15

H-L-T-H. Yeah.

Dr. Yu:  51:16

Yeah. @Rheumissionhlth. Yeah, @Rheumissionhlth. It’s a little bit different on each handle, on social media, but it’s on Instagram, it’s @Rheumissionhlth. And we have, we’re on Tik Tok. We’re on YouTube. We’re on Instagram, Facebook as well, and also LinkedIn. So, we’re on five channels. And on the website as well. Yeah, don’t have them all spelled out at this time.

Cheryl:  51:40

That’s okay. It just, I always imagined someone having their phone out like while they’re listening like, oh, I want to follow them before I forget. That’s like kind of how I —

Dr. Bonnie:  51:48

Definitely follow us. We want to reimagine autoimmune care for every single patient.

Cheryl:  51:53

Yeah, it’s really, yeah. And it’s, I should clarify that, it’s not just rheumatoid arthritis. And sometimes when people see the ‘Rheum’, or you know, Rheumission, they think it’s just about — for even me, Rheum to THRIVE, they think it’s only for rheumatoid arthritis, but Rheumission is really about autoimmune care, overall. So, yeah, I think that’s beautiful. Well, thank you both so much. I know you’re extremely busy reimagining health care for everyone.

Dr. Bonnie:  52:17

Thank you.

Dr. Yu:  52:18

Thank you so much. 

Cheryl: 52:20

I hope that everyone goes to your website and learns more. And thank you for spending time with me today. We’ll talk to you later. Bye-bye.

Dr. Yu:  52:55

Thank you, Cheryl.

Cheryl:  52:56

Bye!

[Ending music]

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