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Podcast, Provider Interviews

Understanding Rheumatoid Arthritis: Diagnosis, Medications, and Hope from Dr. Julius Birnbaum

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Summary:

If you’re newly diagnosed with rheumatoid arthritis (RA), this episode offers clarity, reassurance, and perspective from Dr. Julius Birnbaum, a physician uniquely trained in both rheumatology and neurology. He explains how RA is diagnosed through patterns rather than a single test, as doctors listen closely to symptoms, examine joints, and use labs to support the bigger picture, including your lived experience.

Dr. Birnbaum also addresses common early fears, including confusion about autoimmune disease and anxiety around immunosuppressive medications, reframing treatment as dialing down an overactive immune response rather than taking away your immune system. 

Throughout the episode, he encourages self-advocacy, realistic hope, and partnership with your care team, and shares insights from his book“Living well with autoimmune diseases”  A Rheumatologist’s Guide to Taking Charge of Your Health. The takeaway is empowering and hopeful: we’re living in a “golden era” of RA care, with more effective treatments and real reason to believe a full, meaningful life is possible alongside this diagnosis.

Episode at a glance:

  • 00:20 Dr. Burnbaum’s Background and Passion for Arthritis & Neurology
  • 05:19 The Diagnostic Process in Rheumatology
  • 08:59 Understanding Inflammatory Arthritis
  • 15:22 Explaining Autoimmune Diseases and Inflammation
  • 23:11 The Role of Immunosuppressive Therapies
  • 28:16 Personalized Treatment Plans in Rheumatology
  • 30:50 Understanding Diagnostic Criteria and Nuances
  • 31:31 Dealing with Diagnostic Ambiguity
  • 32:57 Empowerment Through Patient-Doctor Partnership
  • 38:10 Practical Tips for Patient Empowerment
  • 46:03 Realistic Hope and Coping Strategies
  • 56:34 Concluding Thoughts and Resources

Medical disclaimer: 

All content found onArthritis 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! 

Speaker Bios:

Dr Julius Birnbaum bio

Julius Birnbaum, MD, MHS, is a rheumatologist with 20 years of clinical experience. He is the only physician in the United States trained in internal medicine, neurology, and rheumatology, giving him a rare and valuable perspective on treating patients with autoimmune diseases. Dr. Birnbaum is dedicated to developing personalized treatment plans tailored to each patient’s unique needs.

He completed his neurology residency at Mount Sinai Hospital, internal medicine residency at Jacobi Medical Center, and rheumatology fellowship at Johns Hopkins University School of Medicine. Currently, he serves as an Associate Professor in the Division of Rheumatology and as Division Chief of Rheumatology at University of Pittsburgh Medical Center Mercy Hospital.

Over the past two decades, Dr. Birnbaum has cared for thousands of patients with autoimmune diseases. He is a passionate advocate, fiercely committed to improving the lives of those he treats.

Cheryl Crow

Cheryl is an occupational therapist who has lived with rheumatoid arthritis for over twenty 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:

[00:00:05] Cheryl Crow: All right. I’m so excited today to have Dr. Julius Burnbaum with me. Welcome.

[00:00:14] Dr Julius Birnbaum: Oh, thank you for having me.

[00:00:16] Cheryl Crow: It’s so great to have you. And I I just thought it’d be good to give a quick introduction. Where do you live and what is your relationship to inflammatory arthritis?

[00:00:26] Dr Julius Birnbaum: Well, I live right now in Wexford, Pennsylvania.

I grew up in New York City. I’ve lived in virtually every borough there and I’m still a diehard Yankees fan, which doesn’t sit too well here. And where I, my experience with arthritis is I just keep learning from my patients and every year I think I evolve and find another area Interesting. So I’m just very passionate about very broad areas of arthritis.

[00:00:57] Cheryl Crow: That’s wonderful. We need all the help we can get. I think I speak for a lot of the patients and I think I’m always really fascinated what makes people choose, of all the different medical fields, what makes, a medical student or doctor choose to be, to specialize in your case, not only rheumatology, but also neurology.

Can you tell us a little bit about that process? What drew you to those fields?

[00:01:22] Dr Julius Birnbaum: Oh, sure. So I’m a neurologist as well as a rheumatologist, and I think what often is not known is that when you’re a medical student, you do rotations and you’re asked to make career decisions after rotating five weeks on a certain rotation.

And so it could be difficult. So I loved neurology. What I liked about neurology is you can take equipment that’s been around really since the early 1900s, You can localize is a certain injury, is it in the brain, the spinal cord? It’s very powerful. And this was all done before the years of MRI machines.

I loved internal medicine as well. I’ve loved how, whether you’re an internist, you could try and take care of patients with heart disease and lung disease. And it’s that ubiquitous nature of internal medicine that I also found really enthralling. So, for someone who has difficulty making decisions in general in life that was something that was challenging for me.

So I started neurology and what I found was that I love doing the neurological examination, but loving to do the examination for what purposes and what diseases. And what I found was that as I got later in my neurology residency, I found that I found it fascinating to take care of patients with autoimmune diseases, and I started seeing patients with neurological complications of rheumatoid arthritis, how rheumatoid arthritis can affect the cervical spine.

So there was this interface between neurology and rheumatology that I really was excited about, and I really felt that rheumatology was an area that I could grow, learn about autoimmune diseases, and use my training in neurology to also particularly help patients with neurological complications of inflammatory arthritis.

[00:03:30] Cheryl Crow: That’s really wonderful. I mean, I think it’s such a diamond in the rough situation. I think a lot of patients they wish they could have doctors that specialized in multiple things to see, like I know when I was pregnant, I’ll just say I wished like somebody was a specialist in both OB GYN and rheumatology.

’cause sometimes when you have multiple things going on, you feel like they’re giving you opposite. Yeah. Sometimes. And that makes sense. I mean, OB GYN is a unique case, right? Because like, or the, there was the pediatric side of like keeping the baby safe. There was a rheumatology side keeping me safe and, everyone had different opinions.

But anyway, that’s my story. But back to your story, I think I think that’s really wonderful. And the cervical spine, for those listening, just in case I always try to define terms that’s like your neck essentially. So it’s, I it’s less common in with people diagnosed in the last 20 years to have severe complications that affect their cervical spine, I’ve heard.

Is that right?

[00:04:25] Dr Julius Birnbaum: It is. And that’s because within the past 20 years arthritis is treated so much more effectively. So if you go back 20, 30 years ago, I actually have, my father was a physician, so I have his Bates textbook of physical diagnosis and what rheumatoid arthritis looked like in the 1970s.

And then you saw a lot more spinal cord disease just because that occurs when there’s a lot of inflammation that goes undertreated. So we’re seeing that less often today than we used to.

[00:04:59] Cheryl Crow: Yeah. And that I always try to sprinkle in that historical perspective because I think I, I get why patients are scared to start medications or treatments, but I think understanding how transformative they’ve been and how dangerous the disease is, if left uncontrolled is it helps me feel more confident personally in taking my medications.

But back to this combination of kind of having the neurology perspective and the rheumatology perspective. One of the things that, before we started the episode, we talked about what are you most passionate about and what are some things that you love discussing? I think the diagnostic process is such a fascinating one in rheumatology.

I would love to hear more from you about, what are the steps you go through when someone comes into your clinic and they, you suspect they might have some form of inflammation, inflammatory arthritis. What’s that process like from your end?

[00:05:53] Dr Julius Birnbaum: Sure. So I think it could seem a little bit naturally like intimidating at first because we don’t have any tools like a blood pressure cuff that’s gonna tell you within 30 seconds, whether you have high blood pressure, you’re not gonna have, a throat swab to tell you within 15 seconds that you have a strep throat.

But there are certain patterns that we follow, for example, when we think about whether someone has rheumatoid arthritis. So I’m gonna be carefully listening to your symptoms and I want to find out is the pain called inflammatory joint pain. So inflammatory joint pain tends to be the pain, which is worse at rest, get better as patients move around.

Non autoimmune or mechanical pain gets worse with activity. So I wanna see in the get-go is this possibly symptoms of an inflammatory arthritis. So we move from symptoms, then we use physical examination techniques. So I’m gonna press over joints and try to figure out are the joints tender? Are they swollen, are they slightly red?

And these are diagnostic tools on the examination that goes along with symptoms. And then the last part of it is I’m trying to understand whether there’s inflammation, whether there’s blood markers of inflammation that are high, whether there are other markers of an autoimmune disease in the blood. So I think it’s pattern recognition and how these are assimilated.

It’s based on your symptoms, based on your physical examination findings and based on blood work. Again, this is very powerful because it offers a way to render a diagnosis, but in a very patterned way that’s organized and efficient.

[00:07:42] Cheryl Crow: That’s really helpful. And I think what, for any patients listening sometimes, I have people listening who they suspect they might have some sort of inflammatory arthritis, like rheumatoid arthritis, but they’re not sure yet.

I always, little tip I always say is, really start paying attention to those patterns of the pain. When is it, like you said, when is it worse? Is it worse at rest or is it worse when you move around? Is it worse in the morning or worse at night? Those little, those things that seem maybe small to you are really helpful to the rheumatologist.

Is that right?

[00:08:14] Dr Julius Birnbaum: It is, and it’s really incredible to think about how your bedrock of symptoms are always gonna remain the thing that drives a diagnosis. So. We can have blood work now in 30, or actually in, maybe in the next 10 years, we’ll have gene chips, which will tell us more quickly, like what treatments might be more efficient for you.

But what’s never going to go away in rheumatoid arthritis is a physician carefully listening to your symptoms. So it’s such a powerful thing to remember that the way you articulate your symptoms is really gonna still be the centerpiece of the diagnosis.

[00:08:57] Cheryl Crow: Yeah, that’s really powerful. And one of the other things that I remember my rheumatologist, I mean, this was over 20 years ago in my case when I got diagnosed, but it was, is it happening on both sides of your body?

I know like that’s what you’re doing when you’re doing the physical exam, but that’s a big differentiator between maybe an injury causing, just one joint being swollen on one side of the body versus both sides. Is that correct in your experience?

[00:09:24] Dr Julius Birnbaum: Yeah, so exactly. Rheumatoid arthritis is definitely more likely to be symmetric, affecting the left and right side of the body. And, but that’s what I mean. It’s, that’s what makes rheumatology so interesting is that, and I find it really fascinating that we’re going to go into new ways of helping you care for your disease. But again, the thing that’s not gonna go changing now is how it presents how you describe your symptoms.

What your examination will feel like. I mean, boils back to the point that we need to listen to you as patients and that’s not gonna be supplanted anytime soon.

[00:10:03] Cheryl Crow: Yeah. I love that. And how, maybe I’m curious how you do what, I guess they call it the differential diagnosis, like between maybe you suspect there’s some sort of inflammatory arthritis.

How do you differentiate between whether it might be rheumatoid arthritis versus psoriatic arthritis versus ankylosing spondylitis or something else?

[00:10:24] Dr Julius Birnbaum: Sure. So again it’s recognition about patterns. So like you were mentioning, rheumatoid arthritis, it tends to more often than not affect both sides of the body.

It can affect one side of the body sometimes, but what we described as symmetric, right, left side being equal is more common In a disease such as psoriatic arthritis, there are different patterns. Most of them will be different. So there can be just a few joints that are affected, maybe three or four or less.

When rheumatoid arthritis tends to affect board joints, for example, in psoriatic arthritis, you also have inflammation of tendons and ligaments that insert on muscles, and that’s given a term, it’s called an enthesitis, and that’s not really seen in rheumatoid arthritis. One of the things, and that’s

[00:11:16] Cheryl Crow: that sausage finger, it kind of is that the result of that?

[00:11:19] Dr Julius Birnbaum: So Right. And then the next thing you could develop is

[00:11:22] Cheryl Crow: oh, sorry, I didn’t mean to jump.

[00:11:22] Dr Julius Birnbaum: Yeah. No, but like, no, so this is a thing like you first show it to medical students and this kind of like wets, their architect appetite is the sausage finger. So this is not just one joint swelling up, it’s the entire finger or toe that’s swelling up and that’s like called a sausage isge or the or the dactylitis, psoriatic arthritis, you’re have a higher likelihood not only to develop psoriasis, but certain inflammation in the gut diseases and eye diseases. So I think that arthritis has a lot more pieces to it compared to rheumatoid arthritis, but it’s really the presence of asymmetry. It’s obviously the presence of the rash and other findings as noted above.

Ankylosing spondylitis is just as painful. Initially starts as back pain and again, it’s what we’ve been talking about. The back pain that we see not due to autoimmune components get worse as you bend over as you use it. And then the ankylosing spondylitis, it’s worse with inactivity. Worse in the morning, gets better as the day goes on.

So different diagnoses. But I find that when you can talk about patterns of these diseases and it’s something that the patient has a better handle on to understand windows into their own disease.

[00:12:46] Cheryl Crow: Yeah, a hundred percent. And I had an experience recently that I wanted to share really quickly that relates to all this.

’cause you can also have, if you have one established form of inflammatory arthritis, like I have rheumatoid, you can also have joint pain in a different non-traditional area, but that’s not from that disease, from a either an injury or an overuse in overuse kind of inflammation tendonitis type thing.

So I started running this year again, which I hadn’t run in a long time. I used to be a soccer player and a runner, and then I started having hip pain and I was doing my own little differential diagnosis in my head and I was like, this is definitely not rheumatoid arthritis. First of all, it’s on, or it is my assessment, it was only on one side.

It didn’t feel like it was in the ball and socket joint. It was like more kind of wrapping around from my hip bone to like my glute and and it wasn’t noticeably worse in the morning. It was worse with activity and worse with even. And it was like, came on extremely fast. Like, went from, just a little bit of like this muscles, something’s kind of tight there to being like, I can’t even roll over in bed comfortably.

So I went to a physical therapist and she did a great assessment and realized that yeah, I have some SI joint, sacroiliac inflammation most likely from just really not great posture. Like I have a little bit of a pelvic asymmetry, some muscle imbalances around it. Anyway, point being, this is not related to my RA that we can tell right now.

And it responded really well to the physical therapy exercises. And when I shared about this in my Instagram story, someone said, well, wait, I thought if you had hip pain or axial pain, then you know, spine pain, then that means you must have AS, or you must have spondyloarthritis, but not all back pain or spine or hip pain is from AS, does that make sense?

Sorry, long story. Sorry.

[00:14:44] Dr Julius Birnbaum: No, it does make sense. And so, the, so the book I’ve written in it’s called Living Well With Autoimmune Diseases, A Rheumatologist Guide to Taking Charge of Your Health. I think that’s the first goal, because like you’re saying, joint pain can be due to a variety of causes.

So that’s the very, very first step. You’re saying, am I having joint pain due to an autoimmune disease due to inflammation and like you’re describing, or am I having joint pain due to another cause? And that’s the very, very first step that physicians think about right off the bat, inflammation or not inflammation.

Yeah.

[00:15:22] Cheryl Crow: Well, that you perfectly led to my next question and which is, you asked me before we started recording, you said, oh, you probably define this all the time. Like, what is an autoimmune disease and what is inflammation? And I actually had to look at my records and realize we haven’t actually defined on this podcast in a while.

What inflammation, actually, what is an autoimmune disease? What is inflammation mean? Partly I feel like they ought to read your book, but also maybe what in your words how do you explain that?

[00:15:53] Dr Julius Birnbaum: No, that that’s a great question. When we talk about inflammation there’s inflammation that’s helpful.

So, we get a cut, and then the inflammation that happens afterwards where the cut turns red or warm that’s inflammation, that’s protective. Inflammation that’s excessive and is not damned down a little bit. When it goes to a ride, that’s what we call harmful inflammation. Now, when we talk about autoimmune diseases, what I often like to tell my patients is that we normally have an immune system that helps us.

It normally fights off infections, it could fight off cancers, but in autoimmune diseases, the immune system can become confused. Instead of being helpful in this way, it could target different parts of our body. So for example, in rheumatoid psoriatic arthritis, ankylosing spondylitis, those are cases, and with the immune system, in addition to fighting off infections and cancers, it starts affecting different parts of our joints.

[00:16:59] Cheryl Crow: Yeah. And just to put the immune system in the context of inflammation, when you were saying that like when we get a cut, it turns red and warm and that’s like a protective response, that is our immune system driving that response. Is that right?

[00:17:14] Dr Julius Birnbaum: Yes, it is. So that’s the very, very first part of the the immune system.

It’s it’s called the beginning stages is the innate immune system. It’s what we share with single cells of bacteria that very tive. You get into a a cut and it’s called almost like a flight or fight response. And it’s it is helped me, help me alarm and there’s that first stage. So yeah, that, that type of inflammation is at the beginning of the cause of different types of arthritis.

[00:17:44] Cheryl Crow: Yeah, I think that’s just, it’s really helpful to kind of get clear on, on these definitions and understand that it’s almost, I try to imagine, my, the disease process, having my body in a bit of a self-compassionate way. ’cause I know a lot of people feel like I’m, oh, my body’s attacking myself. Like, my body’s broken.

It’s doing this terrible thing, which it’s a, whatever works for you. For me, I think of it as, it’s kind of like a toddler that’s trying to help you in the kitchen. When you have a toddler that’s like, I’m gonna help you bake that, and they’re like, spilling the flour and like, right breaking the eggs.

I try to think of it in that compassionate way. Like it’s trying its best. It just accidentally decided that the synovial lining of my joints is a virus. And it’s like, we’re gonna get rid of that. We’re helping you. And it’s, that’s for me that is, maybe it’s just my personality, but that helps me feel less like, oh, right, I’m the, basically like, this horrible thing is happening in my body.

Obviously I don’t like it. I would like it to be gone, but I’m like, oh, okay. It’s trying its best. It just made a mistake.

[00:18:49] Dr Julius Birnbaum: Yeah. No, it’s interesting you say that because, I purposely, when people ask what an autoimmune disease is? I always say an autoimmune disease affects different joints.

I don’t say it targets different types of joints. I don’t say it injures joints because then you have this image of a military battle being four and won. And, are you being like, victimized by this and I kind of wanna paint it that there’s an autoimmune process that’s going on, it’s affecting joints, but it’s not because you’re weak or you didn’t do anything wrong.

It’s not being attacked. It’s affecting. And I think if you start, like, I think it sounds like you’re doing the same thing, viewing it in a more compassionate way, then that helps you get to a blame yourself less. And don’t worry about like what you’ve done, that you’re culpable and having this disease.

[00:19:40] Cheryl Crow: And that, yeah, you again read my mind. My next, question was gonna be that a lot of people, and again, maybe I joke that I’m like a product of the 1980s parenting style that was self-esteem movement. Like, tell your kid they’re special nine times a day and they think they’re special. So I didn’t like a lot of Mr. Rogers neighborhood, like, I love you. So I internalized that. So I didn’t blame myself when I got diagnosed. It also for me seemed absurd to blame myself because I was at the peak of health. I was a captain of my college soccer team, now division three, but still, it was very healthy, very athletic, nothing, no ACEs in my childhood, no, no rhyme or reason as to why this happened.

It just, as far as we know, it was, genetic susceptibility, met some sort of environmental trigger. Just I got a little, I got a virus. Some virus and probably then that may, who knows? It’s just random for me that I didn’t blame myself. But a lot of people do end up blaming themselves.

When you have those conversations with your patients, like how do you help them think through that, I guess? Or do you have time to in your appointments?

[00:20:48] Dr Julius Birnbaum: Well, I, so yeah. I mean, basically what you’ve just suggested is the way I try to explain it to my patients when they’re asking like, what causes autoimmune diseases?

And, the answer to that is gonna win a Nobel prize is, but that doesn’t prevent someone from understanding that if you wanna think about autoimmune diseases in ways that are simplistic but are actually very powerfully from a scientific way, it’s basically, a genetic predisposition.

It might be an infection it might be some environmental influence. It’s pretty much what you’re saying. It just brings hope. The point that when you have inflammatory arthritis, it’s not a single thing that’s the cause. It’s what we call multifactorial a lot of different elements that contribute to it.

So that’s why a lot of times I get the questions like, is it a genetic disease? And it’s not a genetic disease in the sense that your son or daughter is going to develop it. It’s just that there are genetic predispositions, but lots of other things go into whether you develop an inflammatory arthritis.

[00:21:59] Cheryl Crow: Yeah. Yeah. I think that’s a really, that’s really helpful to remember. And I think another area of confusion is just because certain lifestyle choices you make might, let’s say you choose to adopt an anti-inflammatory diet or eating pattern, or, you choose to exercise and that’s kind of helps tamper down that inflammation.

That doesn’t mean that, that your failure to do those things before your diagnosis caused it either. Do you know what I’m saying? Like, it’s kind of a confusing thing for people sometimes.

[00:22:31] Dr Julius Birnbaum: Yeah. And, but it’s a natural, it’s a natural thing. ’cause I think when you go back and, if you have high blood pressure and let’s say you had a high salt diet, then there’s a direct link. But yeah. Autoimmune diseases are complicated enough without trying to like search and claw your way for your own history saying, aha, that’s the moment. Or this is the incident? It’s just if we knew directly how to cause it, then we’d be able to cure.

And I, but I, but we can still use therapies could be enormously powerful and immeasurably help your quality of life.

[00:23:10] Cheryl Crow: Yeah. Yeah. And I wanted to just go into your book a little more before we’re gonna, we’re gonna talk about advocacy, self-advocacy and that’s such a you have a great set of, perspectives on that from both sides, provider side and your family story.

But I wanna make sure to mention that your book covers, it’s about living well with autoimmune diseases. So it’s not just rheumatoid arthritis, which is obviously my specialty and my personal interest selfishly, but also vasculitis, lupus, sjogren’s, fibromyalgia psoriatic arthritis, myositis, scleroderma, which I do have a blood relative that just got diagnosed with scleroderma.

I have one blood relative, great aunt that had juvenile idiopathic arthritis, and then I, so those are the only two of all my extended family. Lots of cousins, lots of aunts, uncles, it just, it’s interesting how there’s only a couple. But anyway, but you’re back to your book, you walk people through the, not only like what is inflammation like we just talked about a little bit, but also, how do these treatment options work and how do you decide in, as the provider, like when to introduce like immunosuppressive therapies and why they’re necessary?

Oh yeah, that’s another question. Or thing that I think something that I, again, tell me if the way I’m visualizing this is correct. I obviously don’t like being the concept of being immunosuppressed, but one of the things that makes me feel more comfortable with it is that my immune system was already doing too much of something.

So it’s not like you’re taking a normal amount and suppressing it. You’re taking too much and reducing it. Is that correct on, I’m honestly asking that is, yeah. Is that helpful or is, am I oversimplifying it maybe or

[00:24:49] Dr Julius Birnbaum: No

I think it’s, I think it’s perfect.

[00:24:51] Cheryl Crow: Oh, okay. Well, gimme a gold star.

Yay.

[00:24:55] Dr Julius Birnbaum: Yeah, because, but because your point in it I think it’s really important because a lot of times when it’s the vocabulary, so if you hear like immune suppressing immunosuppressive medications, people or patients naturally get scared. And what I tell patients is like what you’re saying, we’re targeting excessive inflammation. But you still have an immune system. Now you’re more prone to develop infection. Yes. But your immune system is still pretty good. Yeah. At being able to care for itself. So we’re not taking away, your immune system. We’re just taking the edge off the harmful part of the immune system that’s contributing to your disease, but you still have an immune system that functions.

[00:25:41] Cheryl Crow: Yeah. I think that was really helpful for me getting through COVID the COVID initial time without, my anxiety going too far ahead of me because I had so many experiences already. By the time COVID started, I had my rheumatoid arthritis for 17 years. And so I had, and I had a baby and I had gone through postpartum flare up.

But point being, I know I had gotten the flu here or there, and I noticed, yeah, I take a little longer potentially than someone like my husband. A lot of us are married to people who, at least I noticed in my support groups married to people with unusually robust immune systems. It’s like, come on, gimme some of yours.

But it takes me a little longer. Things linger, like sinus infections and stuff. But it’s not like I was walking around feeling like I can’t ever, I was swing dancing, touching a lot of people, breathing on a lot of people, and, not getting deathly ill on the amount of immunosuppression with, methotrexate plus a biologic.

So, but I know with people diagnosed during the COVID times, I think it was a little bit more scary for them just because you’re like, you haven’t experienced surviving your first infection on your medication yet, right? Yeah. So, yeah, like I kinda had, it’s like that thing, like I’ve survived a hundred percent of my worst days, like I’ve survived all this stuff, but yeah.

Okay. I’m glad that my immunosuppression metaphor makes sense to you as well. And I had these two researchers from Benaroya Research Institute here in Seattle on the podcast Dr. Dve and, Dr. Campbell and they had a they went into some great explanations on, this one of them’s a PhD in immunology researcher, and the other one is a rheumatologist who also does research.

And they all linked to that episode here. But it, they talked about how, it, there’s still something unknown about why you might have, a hundred patients on the same medication regimen for the same diagnosis. One of them is a kindergarten teacher and never gets sick.

Someone else works from home and they keep getting sick. Like they don’t really understand sometimes why the same amount of immunosuppression doesn’t like on paper results in different amounts of functional illness. Does that make sense?

[00:27:47] Dr Julius Birnbaum: Yes. Yes.

[00:27:47] Cheryl Crow: Kind of why I say I’m like power to anyone out there who became a rheumatologist.

I feel like that would be the hard, I think that’s the hardest field of all medicine. I’m going on the record. No one asked me. I’m like, why would you ch, I mean, I’m so glad you did, but when I ask rheumatologists, why’d you choose it? They usually say something similar to what you said that you, it’s so interesting, like it’s not black and white.

Is that kind of what drew you to it?

[00:28:16] Dr Julius Birnbaum: It is because there’s a lot of nuances to the disease because if you’re curious, you get to understand and explore what autoimmune means, autoimmunity means, and that’s fascinating. You learn to take care of patients with a lot of diseases that you might not encounter that much during your training, and that’s interesting.

But then the last piece of it is you get to absorb all of this scientific knowledge and the way you apply it to help individual patients. That’s just fascinating because seeing how the disease plays out in different patients that’s something that’s important because that enables you to help them and empower patients to develop a personalized treatment plan.

So it’s the, yeah. Fascination with the disease and the ability to then take your understanding and how you can help patients.

[00:29:13] Cheryl Crow: Yeah, I think that’s beautiful. And I know you talk about that in the book too, about the importance of really developing a personalized treatment plan, because you’ve probably heard this already if you’re listening to this podcast, there’s no one size fits all right in anything, but especially rheumatology, it feels like.

How do you as a physician cope with the uncertainty, the uncertainties are all the gray areas, like that thin knowledge of, okay, I’m giving it my best at some because you don’t have that, blood pressure cuff or that like, I don’t know, A1C where you’re like, it’s diabetes or it is not diabetes.

Like you don’t have that silver bullet. How do you cope with all those ambiguities, out of curiosity?

[00:29:54] Dr Julius Birnbaum: Well, it’s a good question. ’cause I think from a research standpoint, there’s a term used, it’s called classification criteria. And these are criteria that’s used to help researchers during the conduct of clinical studies.

But then there’s the other aspect of it, which is called diagnostic criteria. And those are criteria that you use to diagnose rheumatic different types of autoimmune diseases like inflammatory arthritis. So you have to develop your own sense of understanding and appreciate nuance because you could take some of the criteria that’s used for research purposes.

But then the way you deal with that in diagnosis is having a one-to-one discussion with the patients. And I always tell my patients if they come in, they’re like, well, I meet five outta seven criteria, but the criteria say I actually have to admit six out of eight criteria. And I, I just tell patients is, to a certain extent these criteria are oversimplifications and in real life, not everyone gets put in a certain diagnostic box.

So there has to be a lot of a latitude in how these diseases are diagnosed. So I think that then, but again, that little bit of nuance makes it a very fascinating disease and also helps the patient understand that they have ownership of their disease and they have a real autoimmune diseases, even if, it doesn’t meet all the criteria.

[00:31:28] Cheryl Crow: Yeah. Yeah, I think that’s really helpful. I think what I would struggle with is like this is again, maybe me having an anxiety disorder, but I would feel like I would be haunted by this idea that what if I got it wrong? Like what, and I know you’ve obviously accrued many years of experience at this point, so maybe you have more, just built more confidence.

But I feel maybe a new, like do you find with the fellows and like your newer rheumatologists that do they, or maybe they just self-selected into here ’cause they have good ambiguity, tolerance themselves, but I feel like it would be just be hard to feel like, oh, like what if it’s something else? Like what if it’s lupus?

Right.

[00:32:03] Dr Julius Birnbaum: Well, it’s, it is I think it’s interesting because I think the fellows at the beginning of the year, they wanna get everything right, so they kind of come at diseases like there’s or recipe, for example. And I think you need that in the beginning, but once you become more experienced, you understand like where the gray areas are and you know what are, what, where is the uncertainty?

And not to penalize the patients because they don’t fit all of their criteria. There is a certain amount of certainty. So you wanna know the traditional recipes, but then over time you wanna also get a sense of how to validate the patient is having a disease. Even if older parts of the recipe don’t go checked off.

It’s a very much human humane as opposed to just a scientific field of medicine.

[00:32:56] Cheryl Crow: Yeah. Well, that leads perfectly to the next topic I wanna talk about, which is, something you’ve spoken a lot you’ve volunteered your time many times speaking, with like the Autoimmune Association, and you have a great video, i’m gonna link in the in the show notes, about partnering with your doctor. And I would love to hear more about your perspective about how patients can advocate for themselves within that patient provider, relationship and explore some of the themes like you mentioned before we start talking the themes of disempowerment and what, how do we navigate all of that and are we your own personal story, however makes sense to you.

I’m sorry, that was like a nine part question.

[00:33:37] Dr Julius Birnbaum: No, it’s all right. No, it’s interesting because like. I’ve heard this before. I obviously I haven’t known this before as an author, but how someone could write a book and have a message, which seems so obvious to readers, but was not obvious to me in writing this book.

So I wanted to inform, I wanted to help patients. I wanted to come across as a someone of empathy. But what really I think has resonated is patients, they tell me that this is a book about empowerment. And I was like, really? ’cause I didn’t sit there consciously saying, I want to empower, I want to help.

And they’re like no. This is a book about, and they term, someone’s told me autoimmune empowerment. And when you hear these themes, and I was thinking about it, it was like, well, whoa, what’s been at the back of my mind growing up? And I realized that there’s times that I felt disempowered in my own life and I felt pretty like angry about it. So I have an oldest son who has autism and I remember he’s 17 now and he’s driving, doing great in high school, but when he was in first and in second grade, and there were some behavioral difficulties, I remember that he just the school system basically wanted him put into classes where he would be basically confined from a behavioral perspective, but no one would be challenging him academically. And it could be pretty contentious, like where they wanted to silo him. And I know where my new, where my son’s gifts lay, and I just wanted that to be uncovered. And when you go into the school board meetings sometimes they could be really contentious.

And that was certainly hurtful and disempowering for me as a parent. I saw it in my father who was world renowned as a, he was a physician and a lawyer who worked for mentally ill patients and who are involuntary committed to hospitals. But when you look at his life, he grew up basically on the equivalent of a chicken farm in Brooklyn in the 1920s, as his parents were illiterate. I remember he told me a story about how he read a lot and he wanted to go to a high school, and then there was a guidance counselor who looked at him. And my dad never had a lot to eat, and he was gaunt, he was constantly having episodes of conjunctivitis.

I imagine he looked at this scrawny red-eyed kid in front of him, and he said to him, son if I were you, I would just focus on getting a vocation. I don’t see any good for you to go to a high school. So I’ve heard about these things of disempowerment and how it fuels people. So I, it was something that was definitely percolating below my experience when I wrote it, I think it’s helped me become a more empathic physician. But it was something that surprised me. I mean, I’m glad that patients are finding this book to be empowering as well as like learning about medical details.

[00:36:44] Cheryl Crow: Yeah. Yeah. I think it, I mean, I think it first of all, helps humanize you to know that, I think sometimes as a patient, we can feel like our doctors are just like, they exist.

It’s like, kids think of their teachers as like, only existing at school. You think of your doctors like only existing at the doctor’s office, and that you’re a real human being, having your own challenges and ups and downs, just like us, as patients. It’s not like an us versus them.

But but yeah, I think it is being, I would speak for myself in the, it feels at times disempowering. Navigating the healthcare system can feel intrinsically disempowering at times when there are, you find out that, okay, my doctor wants me to take this medication, but now there’s gonna be all these insurance barriers, sorry, trigger warning to everyone who’s experienced this and that, maybe you then you find out there’s all these things outside of your control maybe that are gonna affect your access to care.

But that said, there’s always gonna be like, when I’m overwhelmed, I always think to myself, okay, what’s, I start like literally making a chart in my head. Like, what can I control? What’s in my zone of control? What’s in my zone of influence? Maybe not full control, but I can influence it, and then what’s in my out of my control?

And that helps kind of ground me. And then okay, there’s always something in my control. And I think that’s empowering as a control freak.

[00:38:09] Dr Julius Birnbaum: Yeah. And I always think, when you go see a new physician, it could seem overwhelming. One of the things that I tell patients is actually they, it sounds a little bit weird, but they should rehearse their visit.

It does. There’s a,

[00:38:26] Cheryl Crow: great.

[00:38:26] Dr Julius Birnbaum: Yeah. Yeah. Well, there’s too that, I mean, when you rehearse your visit, the chronology actually goes easier and the visit is more efficient. But what happens is, like when you rehearse your visit, you wanna practice like who you are and you know what you want after the medications and it helps the, so I’ve had the two points I gave, there was one patient of mine who is a fly fisherman and he loved going in streams and, fishing and the rheumatoid arthritis was affecting his fingers and he couldn’t put the bait on the hook, so that told me like, we would wanna be more targeted and aggressive to knock out any degree of joint pain. And then there was a a woman who came in, diagnosed a little bit later on in her seventies, and she didn’t necessarily want disease perfectly controlled. She would be happy, what we call low disease activity.

If there was certain inflammation, maybe if someone one or two joints But as long as she could hold up her grandson without a, fear that they were gonna drop her. So again, when you create these narratives for yourself and unveil and up, open up yourself who you are to your physician it’s a very compelling narrative.

And I think that it helps you build a empathic bond with your physician.

[00:39:50] Cheryl Crow: I love that. ’cause it’s like a two for one deal because you’re talking about, you’re informing as a patient. I’m informing my provider as to the functional impact of my condition, right? I can’t do my required tasks of putting the bait on the thing or holding my grandson, but you’re also then implicitly communicating to your provider, your humanity, and that you’re not just a series of tissues you’re a human being.

And that makes I’m, it just forges a connection. Yeah I want, I had a patient on recently on the podcast who said, I just love the way she said it. She said, I plan for my doctors’ appointments like I plan for a business meeting. Think of what you wanna say, get your bullet points out.

What are some other practical tips or just general tips for patients to become more empowered? I mean, we have rehears visits. We have, I think of the foundational one that’s covered in your book is like learn or in, in my, I have my own like self-paced course, which is like a video book where it’s like Rheum to thrive, which is like learning about your condition, learning about the tools to manage it, learning basic self-management.

That would be another one. What are some others?

[00:41:00] Dr Julius Birnbaum: Yeah, so I think, actually making yourself vulnerable in the sense of really showing in an intimate way. I had a patient and he was this big strapping guy and he was six five and he would always show up to his visit. And he would always say he was fine.

And and one time his wife came to the visit and he is, how are you doing? And I said, I’m fine. And she looks at him and was like, what are you talking about? You’re crying like every morning before you wake up. And I think that, and then I saw him differently. But yeah I think that making yourself vulnerable, if possible, as much as you feel comfortable, that also really helps physicians into, your life.

I think that’s important. I think it is important empowerment is through learning about the disease, and there’s so many different opportunities. There’s disease foundations, there’s there’s support groups, there’s websites. So I think empowering yourself from that standpoint. So, I think that rehearsing your disease, showing what you still want out of life making yourself comfortable so you can really have a heart to heart with your physician that’s emotional resiliency. And then when you combine that with learning about your disease in different venues, you’re going away to making yourself as a compelling patient.

[00:42:29] Cheryl Crow: I love that. I have a related question.

Sometimes so I teach people about the topic of symptom tracking, how that can be a helpful tool. Sometimes it can be a harmful tool if we become obsessive about our tracking and kind of track without thinking about what’s the point of it, and get Right. But I’ve had patients tell me, well, I’m worried that if I bring my symptom tracking journal to my doctor, they’re gonna be like, I don’t even have time to look at this or like that.

They’re, they have anxiety about sharing their tracking with their physician. What do you say? Do you find it helpful when your patients come to you with their trackers?

[00:43:12] Dr Julius Birnbaum: It is very helpful. So, I have some friends who are and this is not to say that patients with inflammatory arthritis it’s in their head.

But I know that patients who see provides for depression. There’s like a depression chapter. Like my mood was a zero out of 10 that day. And that night before I got like four or five hours of sleep and did I feel too high, too low. So I think it’s, it is helpful, you.

I don’t wanna be overly detailed ’cause that’s gonna detract from the visit. But if you have like a journal on a day-to-day, like today, overall I fell from a zero outta 10. And today is how much pain I was in a zero outta 10. And today how many joints were hurting me? A zero outta 10. So, even it sounds like that’s just on the surface and you want that just to provide a covering.

’cause at the end of the day, you want your physician to listen more to you and focus on your symptoms. But I do find that from the day to day changes that you experience, that bringing such a, a tracker to your physicians can help.

[00:44:20] Cheryl Crow: Yeah. That’s good to hear. And yeah I don’t know how many other people are like me, but I do tend, what I noticed, and my doctor had to call me out on this gently was that I think there’s some people that underreport or some people that over report their pain potentially.

And some people like me underreport our pain. So I want so badly for everything to be okay that I’ll be like, oh, it was fine. It was fine. And then she has to be like, was it really, and so I, and it’s not that I’m like literally like incapable of lying. Like I’m just like the most like straightforward, like, honest person ever.

But it’s more like my lying to myself. Like, I’m like, oh, it’s okay. Like after, anyway, my postpartum flareup, if I could do something differently, I would’ve been more attentive to the fact that my I was kind of disassociating from my body. ’cause I kept this wanting it to get better.

So I kind of wasn’t paying attention to it. And the inflammation and the pain, the swelling, I was like, it’s fine. It’s about to get better. It’s about to get better. And then we had to have this like, come to Jesus moment where she’s is if it was gonna get better, it would’ve gotten better.

Like, and so we had to switch medications at that point. But anyway, so knowing that if I wish I had, I mean, at that point I was so overwhelmed and, with taking care of a baby and taking care of myself. But if I had like some sort of app now there’s all sorts of apps.

This was like over 10 years ago. There weren’t symptom tracking apps that I knew of at the time. But that could have like, pinged me a couple times a day and made me, force me to say, what is your joint pain or swelling or tenderness at this moment? It would’ve forced me to actually realize that it’s there and that I would’ve communicated that to her versus being like, it’s, that’s phobia one.

I don’t know.

[00:45:56] Dr Julius Birnbaum: But it’s natural because I think there’s a tension between wanting to be like optimistic. Yes. But then there’s a tension of also realizing that there are parts of you that are hurting and suffering and sos a real tension in how you can honestly describe your symptoms to your physician without being so deflated that your sense of hope is gone.

So I think that’s a natural like tension. Yeah.

[00:46:26] Cheryl Crow: We, I there’s a concept that ,Lauren, who she is a, like, she’s a virtual assistant for me in my business, and she also is a, she’s about to graduate with her occupational therapy degree. She also has lived experience with arthritis, and we’ve all, we kind of have this concept overall with all of my content as being realistic, yet hopeful or finding like a sense of realistic hope.

Like not just, I think a lot of people who are on social media in particular are kind of defining the only hope, as hope that you’re gonna heal or cure your condition or get it completely perfectly controlled, which sometimes that is realistic, right? Especially in the early days, more mild disease. But other times it’s like more helpful to say, okay, like I, my realistic hope comes from the sense that I will be able to cope with and thrive despite whatever is going on in my life, whatever challenge it is, if it’s arthritis or anxiety or dealing with other things outta my control. So if that’s help, I don’t know where I came up with that.

[00:47:25] Dr Julius Birnbaum: No, I think that’s great.

No, it’s great because I think that if, there, there can be like focus on the granular level is looking at scale. Like, is my disease active? Is a, is it a little bit active?

Am I in remission? And but that has to be juxta for as well. What can you do and how do you feel and are you feeling better or worse and not getting caught up and something. So I think the physicians we could go and say this is remission, load admission, low disease activity.

But I think that goes back to what the patients tell us. Like, this is what I hope for. You told me this is what your goal was, let’s say two, three months ago. Are you there? And again, always bring it back to the patients. And that’s what makes it interesting. ’cause every patient will just find success in many different ways.

And that’s the fun of caring about patients, because it’s not formulaic. You really have to listen to patients as individuals, and it’s really important.

[00:48:26] Cheryl Crow: Yeah. I do think that’s that is one of the things that in occupational therapy, it’s very similar. It’s really customized to the patient in their specific life context.

So, oh my gosh, I can’t believe we have to actually already get to the rapid fire questions. All right. Yeah. Well, I wanna first say, is there any hot topics or are there any hot topics in the field of rheumatology that are exciting to you at the moment?

[00:48:53] Dr Julius Birnbaum: Yeah, well, what’s really exciting to me is that we’re basically entering the era of precision medicine.

And what that means from a very broad way is that when you come even during your initial visit, the physicians will be able to tailor care towards you as an individual. We don’t know a hundred percent of the time which medications are gonna work in the beginning, and we might have to try a second one when in precision medicine, the hope is that we’ll be able to look at the products of your genes and be able to customize a medicine for you very early in the treatment process.

[00:49:32] Cheryl Crow: That’s gonna be a huge I’m really excited for that. And what are, I mean, everything you’ve said so far has is helpful to somebody newly diagnosed. What in, if you just had to give one message to somebody who’s newly diagnosed, what would you say? With rheumatoid arthritis, let’s say,

[00:49:50] Dr Julius Birnbaum: I would say, think of this, that we are in a golden era of inflammatory arthritis and we’re really entering a cusp where there’s so many different medications where precision medicine, like I just talked about, is there. So I think there’s a lot of reasons to be hopeful right now.

[00:50:09] Cheryl Crow: Yeah. I love that. I’m very, I feel very lucky to be diagnosed in 2003.

I got in just under the wire to get on enil and methotrexate right away. Do you have a favorite, like mantra or inspirational saying that just gets you through tough days?

[00:50:27] Dr Julius Birnbaum: I do. It’s from the Office. It’s from Andy Bernard. It’s actually right here. I was gonna, so I wish there was a good, I wish there was a way to know you’re in the good old days before you’ve actually left them.

Yes. Just appreciate the the present moment and not just be nostalgic for things that have passed.

[00:50:46] Cheryl Crow: Wow, that’s, I need to, yes, I needed to hear that today. I am sure other people listening. Now this is kind of the a hundred thousand dollars question here, maybe with inflation million dollar question, but what does someone living a good life and thriving with rheumatic disease mean to you as a provider?

[00:51:06] Dr Julius Birnbaum: Well, it means knowing from a realistic perspective that you do have an a rheumatic disease, but also knowing in the same breath that you’re someone with a disease that have lives that of your own, that can be helped by rheumatic diseases. It’s the disease in general, but it’s against you as a, as an individual patient, just you’re a patient and you’re not just a nameless person with a disease.

I think that’s helpful.

[00:51:35] Cheryl Crow: Yeah. Really recognizing your humanity. And it doesn’t, I think, sorry, I’m gonna expand on this, but that one of the things I didn’t expect when I started running support groups for people with rheumatoid arthritis in 2020 was that this concept of ableism would come up a lot and or the, whether or not it’s named as ableism and internalized ableism.

So just like racism is like discrimination against people and specific race racial groups. Ableism is discrimination against people with disabilities or health conditions. And I think there’s a lot of people that automatically believe that they are, somehow their personhood is threatened when you have a diagnosis that you are less than, and that therefore the only way to become whole again is to heal or cure your condition. And the only way to live a good life is to be a hundred percent healthy and able bodied, which is really a limited perspective, given that the, there’s actually disability is the only minority category that anyone can enter at any time, right?

It’s, there’s, just healthy lifestyle can move the needle, but there are no, no guarantees, as we all know, right? There’s babies that die of lung cancer, they’ve never smoked or done anything, it just happens. Like, so I think for me confronting my own internalized ableism and realizing that, yeah, I’m not gonna, I refuse to think of myself as less than because I have this diagnosis that has been, eh, empowering, there’s that word empowering again.

So, so for what that’s worth, if that’s helpful. And I know we’ve again mentioned, I wanna mention again the name of your book, the Living Well With Autoimmune Disease, a Rheumatologist Guides Taking Charge of Your Health. Very helpful for all autoimmune conditions or autoimmune? I mean, I think fibromyalgia is included in there.

I think there’s like a debate sometimes is, I think it’s not really known if fibro is autoimmune or is it known now?

[00:53:23] Dr Julius Birnbaum: I don’t think it’s known. I chose that because I think patients with rheumatoid arthritis, like in the beginning, especially 40% in their first year have fibromyalgia.

So it’s it could be associated depression and fatigue and brain fog. So that’s why I brought it into and I also talk about diet. I talk about depression. I talk about a primary autoimmune diseases. So there’s different things that kind of, alternative treatment type things that work its way into the book as well.

Yeah,

[00:53:52] Cheryl Crow: That’s huge. And that’s a big if we talk about that sphere of control versus sphere of influence. A lot of the lifestyle stuff, not all of it can be under your control, but it is empowering to think, okay, like, can I maximize my sleep today? Can I choose to put my phone outside of my room?

Yes. So I don’t look at my phone before I go to bed.

[00:54:10] Dr Julius Birnbaum: It’s all of the things that I tell my 10 and 12 year olds with variant successes to get the phone. Yeah.

[00:54:16] Cheryl Crow: Oh, you know what we’re doing. And it’s not, it’s for the 44-year-old me and my 11 year-old is we’re buying a phone jail. We’re buying a phone jail.

And he doesn’t have a phone. He has a watch, but and he knows it’s supposed to be on the charger at night, but sometimes there’s a little pitter-patter of little feet that have gone over to, or get the watch out to text the friends that we realized recently. So we’re like, you know what? And I’m gonna practice what I preach.

I’m putting my phone in phone jail every night. So I dunno if you’ve seen these, they’re literal, like containers that you physically

[00:54:43] Dr Julius Birnbaum: I have not, but I will look.

[00:54:46] Cheryl Crow: Okay. We gotta talk off line about that because that’s, yeah. And I did have replacement behavior, so my whole life, one of the only things that has, one of the only habits that I’ve been consistent about, or just something that’s been with me since I was a young child, is I love to read before going to bed every, and I’ve talked people at this point will have listened to, if they listened to the episode with Carrie Bradshaw Marathon Runner, the first person ever to finish a marathon with double hip replacements from congenital hip dysplasia.

Anyway, she’s a really cool person. I mentioned that in her episode two. But anyway now, so ever since I was little, I would always read before going to bed, my I joke, my husband has a picture of me with my Kindle on our honeymoon in Fiji. Like, I’m always doing this. I have it. Okay. But during the pandemic.

I didn’t even consciously realize this, but I started scrolling my phone. Oops. I raised my hand. I scroll my phone instead of reading books, and I started scrolling for a couple years. I just I would be like, oh, I’m just gonna scroll a little bit and then I’ll read, but then I’d be too tired to read ’cause I’d be scrolling.

So I, I was like, oh my gosh, I’ve broken this like, beautiful tradition that I’ve had since I was little of reading before bed. So then I started I put my phone outside of the bedroom and so I started again maybe two years ago reading again. Anyway, so that’s then helpful for me ’cause I still, it’s something I can do kinda laying down that’s relaxing, but I’m not being, just getting into it.

The whole thing about scrolling is that like there’s all these algorithms that have figured out how to get you to keep scrolling and not stop. Whereas a book is a one cohesive story that you’re, reading. So, and anyway, so, if anyone else is struggling with that, get a phone slash device jail for, and you can set it for I, I don’t know.

Have to I’ll send you the link to the one I’m looking at. I haven’t gotten it yet. And anyway, so yeah. Okay. Back to the other thing. So, yeah, is there anything else you wanted to share before we wrap it up? It’s okay if there’s nothing else.

[00:56:40] Dr Julius Birnbaum: No, I mean, that’s it. I just I love care for patients and I hope that comes across in the book and I think it’ll help, I think it’ll help patients so.

[00:56:49] Cheryl Crow: A hundred percent. I wanna do a giveaway too. So I’m, I’ve with, I have purchased a couple copies of it, and I’m gonna have, when this episode comes out, I’ll do a little giveaway of one of them because I do believe in the message so much. And thank you so much for taking the time to share it here.

Your passion definitely comes through like,

[00:57:10] Dr Julius Birnbaum: oh, thank you.

[00:57:10] Cheryl Crow: Yeah. And your website where people can find you, you’re not really a social media guy, right.

[00:57:16] Dr Julius Birnbaum: Yeah, it was just my website.

[00:57:17] Cheryl Crow: Or just julius burnbaum.com.

[00:57:20] Dr Julius Birnbaum: Yep. Designed by my son. Of course.

[00:57:22] Cheryl Crow: Oh, fun. The 17-year-old. Yeah.

[00:57:24] Dr Julius Birnbaum: Yeah. So that’s, that was a 15-year-old? Yes, he did.

[00:57:27] Cheryl Crow: Oh, the 15-year-old. Okay. Oh, awesome. Okay.

[00:57:30] Dr Julius Birnbaum: Yeah.

[00:57:30] Cheryl Crow: Yeah, no that’s, they did a great job and really you have a very busy schedule. You’re high in demand. You’re the only person who is a rheumatologist and a neurologist.

So I appreciate you taking the time today to share your wisdom with our audience. And again, I’ll put all links, everything we talked about in the show notes, which you can find on my website, the Arthritis Life website, which is my arthritis life.net. So thank you so much, and we’ll talk to you later.

[00:57:57] Dr Julius Birnbaum: Thank you.

[00:57:57] Cheryl Crow: Thanks. Bye.

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