Rheumatologist Dr. Munoz – A 360-Degree Approach To Healing
We discuss in this podcast:
- The importance of being a healer and speaking to the heart of people
- Integrating holistic/natural approaches with a conventional setting
- A life-changing event and a path of self-discovery
- Drug reps and their relationships with doctors
- How the perception of biologic drugs has evolved
- The influence insurance companies can have on disease treatments
- The AARA (American Arthritis and Rheumatology Associates)
- Letting go of heaviness as a practitioner
Clint – Thanks for joining me, you’re going to love today’s episode. Our guest for today is rheumatologist, Dr. George Muñoz. He was one of the three rheumatology panel guests that we had on a live webinar a few months ago. And one of my clients from the rheumatoid support watched it. And then, she went to Dr. Munoz and she became his patient. So she went and saw him for a consultation over Zoom after she saw Dr. Munoz on that COVID panel. Well, she came back to me and said, he was fantastic and she kept telling me about how wonderful it was to do that conversation with him over Skype. So I reached out to Dr. Munoz and said, hey, we heard such wonderful things about your work, and also some of the things that you said in the COVID panel really caught my attention and I’d love to have you on the show.
Clint – So he agreed and today he pulls back the curtain on what it’s like to be a rheumatologist and it’s a fascinating discussion. Dr Munoz is one the most interesting, most well-spoken, most intelligent, and yet one the most humble people that I’ve met in a very long time. I really, really like this man. Now he goes into detail and dispels some myths. He answers questions about whether or not everyone with autoimmune arthritis must be on medication. He talks about drug reps, and is it true they come to the office and try and push their products and influence the treatment of patients? He talks about biologic drugs and how the evolution of the perception of those who changed tracks over the years. He also talks about insurance companies and the way in which they can also potentially influence the potential treatment regime for a patient. And I ask him some personal questions, too, and we get quite personal. He talks about a real-life death experience which is fascinating, and he goes into detail about how that helped him to evolve as a human being and as a physician and to influence the way in which he created his clinic. And now he has an integrated clinic where he has a 360-degree approach to help people heal. And he is not just offering medicines or the conventional Western approach, that rheumatology tends to embrace. So I think you’re going to love this episode. And if you’re a member of the rheumatoid support or the rheumatoid solutions, you know that we do live monthly Q&A with special health experts. Well, the July guest this year is going to be Dr. Munos. He’s going to be available and answer questions on the fly on our July webinar. So if you’re a member of the rheumatoid support or the rheumatoid solutions, make sure you check the webinar schedule and attend that webinar. You’ll see why, because you’re going to love hearing from him today. And he also does Skype consultations as well. At the moment he’s taking Skype calls consultations from everyone in the world. So don’t miss this opportunity and the details of how to contact Dr. Munos are on the show notes of this episode over at Rheumatoid Solutions.com. So let’s get into it.
Clint – Well, we have a very special guest today and he’s going to be joining us today. It is his first time on the Rheumatoid Solutions podcast. If you’ve been watching some of the information being shared over the past few months particularly around COVID-19, you would have seen him as part of the special rheumatology panel that we had dealing with all of the intricacies of covered and having an autoimmune disease. His name is Dr. George Munoz and he’s joining me. He’s also from Florida and he has two areas of expertise, rheumatology and integrative medicine. And his clinic, integrative medicine portion of the clinic’s known as the Oasis Institute. Dr. Munoz is a world class scholar trained arthritis specialist, an internist, a medical anthropologist, an integrative medicine specialist, a national lecturer, an author, and a martial artist who blends his training experiences and acquired knowledge into cutting edge wellness, age management and disease prevention techniques. His clients include elite professional athletes, celebrities, professionals, corporations, in addition to any individual seeking alternative and futuristic approaches to age management at the physical and or energetic level, as well as his highly esteemed rheumatology profession. So thank you, Dr. George Muniz, for joining me today.
Dr. Munoz – Thank you so much for having me Clint, it’s always a pleasure and I’m honored to be working with you, speaking with you, and sharing knowledge with all the audience.
Clint – Thank you, that means a lot to me coming from you. The first moment that you blew my socks off was during our rheumatology panel discussion, and why? We feel that a question from the live chat about glutathione and of the three guests, you jumped on it quickly and you gave a thorough answer about glutathione. And this caught my attention so much because there are so many rheumatologists that may not have been able to provide the level of depth to an answer about glutathione, and you did. And that made me look into you a little further and do some more research. And after that, I really wanted to reach out to you, not just for this one episode, but we’ve got a few scheduled because I really want to tap into your vast knowledge.
Dr. Munoz – Well, I really appreciate the opportunity. For me, it’s humbling to be able to share what others have been able to share with me. And I hope that by mutually discussing these topics, these experiences, it’s going to help someone.
Clint – Yes and hopefully, we will help a lot of people. I think a lot of people are going to be really interested in this topic today and hearing what you have to say. You see, you’re on the other side of the desk from a lot of my audience. And when we go to see a rheumatologist, particularly for the very first time, it can be a very daunting experience. I underestimated my condition when I first went to the rheumatologist. I was told that it was very serious and I need to be expedited to see my rheumatologist. I had seropositive with multiple joints affected and it’s really severe early-onset. And the whole experience can be challenging and overwhelming. And so today you and I had a discussion and I come up with the idea and you said, that’ll be okay. We’re going to pull back the curtain behind rheumatology and you’re going to share with us what it’s like being a rheumatologist and the experience you’ve had in this profession. And just give us that insight from the other side of the desk and I think it’s going to be fascinating. So why don’t we kick it off with, what got you into this, why rheumatology, was it something you always wanted to do?
Dr. Munoz – So, no, it wasn’t something, you know, I always wanted to do. I was one of these med students that was interested in a lot of things but, had no clue really as to what I would get into. I would say that there were a few reasons I got into rheumatology and they had to do with two things. One was phenomenal mentors, that really jazzed me about how to think about rheumatology issues. And I admired them for their humanistic qualities and how they interact with patients. And that blew my mind because I thought it looked different and felt different. And that was something I aspired to, and I didn’t understand it like that in the beginning. It was just a strong affiliation and this happened a couple of times. And then the autoimmune conditions themselves, the immunology was very, very interesting. But I also have a passion for in my quest to help someone. The analysis of looking at what they’re experiencing, what they’re feeling, how it’s affecting them from different aspects, then narrowing it down and then putting it in language verbally, emotionally, written, auditory,or whatever the person needs. Because we all learn differently and hear differently to be able to communicate a few things. First of all hope, which I’ve learned from my mentors. Then number two is utilizing skill sets, that I’ve been able to hone over the past 35 years in practice outside of medicine, and that’s the short version.
Clint – I’ve got a prepared set of questions here for you, but I’m want to just jump off those questions very quickly. And before I get onto my next prepared question, one comes to mind that I know when we hear the word hope, I know that everyone may not experience a shiver through the body and get goosebumps. It’s a different feeling, it’s a feeling in the heart or the chest and I’ve described hope when I’ve given public talks about this or all or keynote presentations about my journey. Hope is the path that you can now see between point A to point B. And then the lack of hope is having no apparent way to get from point A to point B. And also, hope can be returned to the human very quickly, just like love. If you haven’t had love in a long time or felt loved, that someone can sometimes look at you in the eye in a certain way or might be a pet, even if it’s just one spirit to another. You can feel the love and in the same way, hope can come back quickly. Now I’m putting you on the spot here but, sometimes clients will say that they’ve felt they lost their hope after seeing their rheumatologist. Because it can feel like, a lifetime of drugs and all these problems. But, you know, are there any ways that you’ve found that can instill the hope in someone? And do you think it is giving them a path forward that seems appropriate and acceptable?
Dr. Munoz – So the answer is yes, and that’s the language of a healer vs. being someone who’s not in touch, in sensing fear in a human being, not having the sensitivity that this can feel frightening, and remembering that someone just hearing the diagnosis goes to a part in their emotions that isn’t always logical. Where they begin to lose hope because of things they’ve heard. Perhaps things they’ve seen or experienced. And don’t come in logically and say, well, that’s not going to be me because I’m in front of this highly trained individual who’s going to give me answers and a path forward, that’s not how human emotions work. And learning to be a clinician, a healer, and not a physician or a person who’s trying to help people putting themselves way up here and the person receiving the healing or the advice or the patient or the client, whichever way you want to put it, is way down here. No, I’ve shown the sea before it’s got to be together and it’s got to sink in and that’s a process. And basically, it takes by allowing myself to become vulnerable, to allow my human side to be seen, and to meet the person and their fear at a place that they feel comfortable. And then basically, metaphorically, I walk with them and if I sense or hear that they have fear, loss of hope is usually right there. If they have experienced bad outcomes previously or loss of hope maybe where they’re at. So my job is to not create fictional hope but, really to help build a solid foundation of a plan. Which they can feel that the person feeling is realistic. And that itself is a part of the whole process, as well as me verbalizing things like, I don’t explain who we are, but I say things like we are not going to allow you to become crippled, and that’s not going to happen. And sometimes I just take the worst-case scenario to say this is not going to happen. Now, can I 100 percent guarantee that? No, because anything can happen but, I do believe with my experience what the repertoire of treatments, both holistic and conventional, that we have available. And what I’ve seen over and over again is the experience that I relay as work can give somebody hope, and those outcomes overall are vastly more positive than negative. And this is the framework of the language that I use as well.
Clint – Yeah, I love it and that’s great. And thanks for sharing your unique approach to that. And I think that’s what does separate you from a lot of physicians. Because it does sound very different to the way that many meetings with rheumatologists are reported, because some people have experiences that are far less empathetic, far less compassionate, far less based on experience and tricks in the bag as what you have. So, thank you for sharing that. Now, a much simpler question, the path through university and the education path, just really quickly, I mean, is it there like a handful of years as a medical student and then on to specialist training? Is that the basic path?
Dr. Munoz – Yeah. So pretty much here in the States, college, and then in the medical school four years. At which time when you graduate, you know nothing. And you are severely frightened when you are let out to be in your apprenticeship of how to interact with other humans in the yard of healing. And you’re trusted in doing things as an intern and being primarily responsible for patients who are very sick. But you have always somebody who’s backing you up, overseeing you and supervising you. And you go through a ritual of over three years of internal medicine, where you become more proficient in the general field of internal medicine through all the specialties. At the end of those three years, if you decide to specialize, you can do what’s called the fellowship. And it’ll be either two or three years in a subspecialty of internal medicine, of which rheumatology is one of them. But cardiology, gastroenterology, pulmonary diseases, psychiatry, and etc. are all other subspecialties and then during that time, you’re concentrated and focus on learning those conditions and treating those patients. Now I’m at a higher level. And you’re learning also to be a consultant to other doctors. You’re learning not only the specialty the , but you’re learning how to be a doctor who helps other physicians, you’re learning to be a primary specialist for the patients and you’re learning how to give advice in both the hospital and in the clinic. And also, you’re learning that, for lack of a better word, the tricks of the trade in conventional training. Now, after you finish that and after you take the test for board certification in internal medicine and your specialty, then supposedly you’re set to go. But I would say that my experience was that over the next one to five years was a rapid ascent of learning things that, I never learned in my training that was very basic in terms of practicality and day to day operations. I knew a lot about complex diseases but, I didn’t know a lot about how to operate the nuts and bolts. For example, running my own practice and how to take care of people who didn’t have esoteric diseases. And it came down to these things that we talked about, speaking to people on a heart level, understanding where they are, not dictating to them, not talking at them, but talking or communicating with them, listening more and stopping to interrupt.
Clint – Yeah. Wow. So there’s so much into it, isn’t it? I mean, you’ve just described almost a minimum of around 10 years before you can actually start a clinic.
Dr. Munoz – Well, I started it technically in my sixth year. And what I’m saying is, that it took me another two to five years to really get comfortable in the day to day. I could handle complex cases but, that’s not what we’re talking about. We’re talking about how to do the day to day, how to do the human to human, how to work with others, play well with others, learn how to meet my patient, and how not to try to impose past thoughts that were picked up during medical education about the role of a physician. When it comes to the therapeutic relationship, I personally there was always respect for the patient. But how can you have heartfelt respect? If you’re always dictating down at someone. So I was never a big proponent of that, I was more into creating a working relationship with a partnership, where there was communication back and forth and we could discuss issues of concern, issues of contention and issues where they could become stumbling points in someone who is accepting treatment to create success for the best outcome or best journey for them. Now, that took me a long time because I had to work on myself for the next ten to fifteen years. And, I’m not saying I’ve arrived and I’m perfect, I’m not saying that. But I have learned a lot and I’m wiser than I was. And, if I had to do it all over again, I wouldn’t change how it happened, because it all happened for a reason. But I would understand that even I have been in the best institutions, top tier institutions. It doesn’t guarantee that I’m going to be a good healer. I have paperwork and I also have all these things. But the work of being a good healer is learning the art of healing in medicine, it’s not black and white. There’s lots of grey, there are new ones and I’m a student of learning that.
Clint – And even the word healer doesn’t tend to come up in many other discussions with rheumatologists. And so this leads me to my next question, which is regarding your particular clinic. You’ve got an integrated clinic here and you use integrative medicine. And you’ve also been doing this for so long that your integrated clinic would have been called it was called an integrated clinic, for it became popular to have inverted commerce, an integrated clinic. You’ve been doing it for a long time. I want to know how that came about. And I think that this might lead us into some of your personal journeys and so on. So can you take us through, how this developed?
Dr. Munoz – Sure, so I’m going to share a little something that you don’t know about this path. Because as I reflect, even on how you are asking me to walk through this development. The very first memories of natural approaches and natural healing remedies were from my mother and my grandmother. So I grew up with that in my brain and seeing it and I never really question that. I just assumed that for them, it was true there was something to it. But I never heard about it in medical school. I never saw it or heard it again until I started to go after that knowledge base. As a direct result of patients asking me information about natural products, supplements, and approaches in my complete ineptitude in the topic, I decided that it was a part of my duty to learn about what they’re asking me. So, I started to self educate myself but, I didn’t have a great format and I didn’t know how to do that. I just started reading and trying to learn what I thought the topics were that I was being asked about and they are about supplements. They are questions like, can they be taken with their medications, their disease-modifying drugs, etc?
Dr. Munoz – And then after a life-changing event, which is what I shared with you, which I’ll get into now. It was a major life and death event where I had a significant automobile accident and I rolled my vehicle multiple times on a deserted highway coming across Florida. It’s called the Alligator Alley from the west coast to the east coast of Florida. And the reason was I needed to have my attention struck by the universe. But the concrete reason of what caused the accident, there was an animal crossing the road right in front of me and it was a Florida Jagwar. We lacked eyes and I just made an instant decision that I was not going to kill the animal, so I veered. Now at that point, it was a fraction of a second, but it seemed like a long time and then I lost control of the vehicle gradually. And as I started to swerve my car, it was just going too fast. And I was in a safe vehicle and I started to roll now and flip over multiple times. At that time or at that point, time changed and this is the first time in my life that I experienced, a time warp. The normal frame of time was no longer there and I went into super slow-mo. It was just like when they replay sports events, super slow and super slowed. For example, a player steps his foot on the line and it was like that. And I felt like I was in a dream state, but I would bet it was real. And I also had a fantasy, thinking if I put my arm over my head to protect my head and neck, that when I rolled the next time, I would not break my neck. Because I was afraid to be paralyzed at night in a deserted road in the everglades. So I did that and I put my arm over and we rolled at least two more times, keep notice that I keep on saying we. And all of the glass blew out of the car and the entire roof caved inside the vehicle. Because it was a big and heavy vehicle. So I landed in the everglades, and luckily I was not hurt. The seatbelt strapped me in and all of the glass was shattered, the engine was smoking, and I was in the Everglades and I had flown over a canal, that’s how fast we were going. And I’d gone through a fence. And when I stepped out of the vehicle, I immediately sank into the Everglades and that was like a dream state. And when I stepped back out, I had leeches on me and I had to find my cell phone to make a call. I had to call the person that I had just met on that side of Florida. And they called for help and I was found fairly quickly. So once I stepped out, time changed again. At first, it was super slow-mo and then it accelerated. And now, it was a normal time and I was scared. Because I was no longer in that dream state. And I was like, holy moly and then the adrenalin came in.
Dr. Munoz – So it took me about a year and a half, to really have the courage and the willingness to find out what that all meant. Why did I survive that? Why it didn’t hurt? What was the message there? And when I was ready to ask the question, when the student is ready, the teacher will appear and that’s what happened. A friend of mine said, Hey, George aren’t you curious as to why you survived that thing? I have a shaman that’s gonna be here the day after tomorrow and I think you should meet her. And I said, what is that shaman? And I was rather arrogant about it. Nonetheless, I did meet with her and I didn’t know what was going to happen. I didn’t know what a shaman was and what occurred then was another life-changing experience by my interaction with this very spiritual, talented, and brilliant psychic who was (Inaudible). And what happened with her was that I had my second time warp experience in the three hours that I spent with her, it just felt like an hour. And what she did was an analysis of the event that I just outlined to you. She sounded like a dream state, but it was live. And she also conducted her energetic and shamanic testing, just like as a rheumatologist, I would conduct my testing, my imaging, my x rays, my database, and my laboratory. Well, she did her own set of testing. For example, numerology, and it included writing to read the right side of my brain. It was for me to write this story using my non-dominant hand to activate my non-dominant hemisphere, which speaks in images and not in blocking words of logic. She checked my energetic fields and she also did a hypnosis session, because she’s a trained hypnotist. And she took that amount of time and I was able to, at the end of the session, understand that there was something that was out of my usual training, that had more to do with spirituality, the universe, and messaging that I needed to become aware of it and I had a choice I could remain dull to the event or pretend it never happened. And then pretend that this session with the shaman where again, time warp change than other things occurred, that I could not explain by conventional science. And if I wanted to gain more knowledge about this and a deeper understanding of myself, what makes me tick? What’s my purpose here? I decided to go ahead and do work with her, and I did that for the next couple of years. And I spent weeks with her at a time over the next couple of years. And then she led me towards the end. She said, we’ve done all we can do and I think you need to go to your homeland and work with shamans from there. So that led to synchronicities and meeting future mentors like Dr. Alberto Villoldo and Dr. Andrew Weil, who I did the integrative medicine training with. And this is basically was an entry point to the next decade of self-discovery of energetic healing and training of doing the work, that’s what led to all of that.
Clint – Yeah. Wow, you certainly haven’t had the typical backstory for your average rheumatologist. And I think that it just adds so much more depth and it provides you with an ability to treat a patient in more of a 360-degree manner, as opposed to just the one-dimensional approach of Western medicine. In which, it can work so often but it may be limited from some perspectives. So I’m curious but, I’m sorry you go ahead.
Dr. Munoz – No, no, you go ahead, I’m just shaking my head. Because that is what happens and it’s like I can’t stop it sometimes.
Clint – Yeah. So give us maybe an example or just in general terms, if you’re seeing somebody and they have classic symptoms of rheumatoid arthritis. And they’ve got elevated CRP and their finger joints hurt or whatnot, how might you draw upon your different skill set to approach that person’s best path forward?
Dr. Munoz – So, I use my classic training and even without wanting to or with consciously knowing I’m doing it to my patients. For example, hearing, listening, seeing the person in front of me, sensing their energy, their emotions, hearing their voice, and their intonation. I see the entry point on why they came to see me. So that means, what are the complaints they actually have physically, that they think is the real reason they’re there to see me. I look at those reasons, but I also look at those symptoms or complaints as an entry point as to what’s happening in their life. And I’m looking at them, you call it 360 but, I call it three dimensional. We’re seeing the same thing and I don’t look at it as just complaints of the joint. I look at it and I’m evaluating on how it’s affecting them emotionally. I’m evaluating how much pain they are and that’s pretty standard. I’m gauging their frustration and fear and that’s not standard. And I’m sensing from them or from their family, what’s the story behind the story? And I’m also looking to see what’s the family history. And are there energetic ties that are affecting this patient from their ancestry? And that’s not just called family history that’s called, family ties or cords. We don’t use those terms in standard medicine, but we use them in shamanic healing. So I’m listening, hearing, sensing, seeing, and I’m moving back and forth from conventional paradigms to unconventional paradigms and I do it fairly seamlessly. I’m not even thinking about it and that’s just what I do now. In the beginning, I had to say, ok, now I’m going to check this person’s energetic field and I’m doing that from the second I see them. And I’m trying to sense what’s the dominant emotion that they’re emitting and usually, that emotion is out of balance. So I try to give them something on the emotional side, in addition to the conventional approaches and even the lifestyle, nutrition, and diet supplements. And we also talk about medications or start medication but, I don’t always start medications right off the bat. And I gauge, what does the person want? Some people say I don’t want meds right now, so I respect that. But I also tell them where they are at. And try to be a mirror for them, not tell them what to do, but be a mirror. And show them this is where you are and if you don’t take medicines for a long time, this is what can happen. I try to be honest and say, hey, you have some time, it’s not super urgent and we can go this way or why don’t we do both natural and medicine? And I try to meet them at a place that they’re comfortable with because, if they’re uncomfortable, they’re not going to do it. And if they’re not going to do it and they’re not going to have any benefit. So I don’t worry about being sued for not giving them all drugs because I don’t have that relationship with them. As long as I’m truthful with what they need, I’m good with the paradigm.
Clint – Okay, it’s beautiful. Can you give us a couple of recommendations, not to necessarily one patient in particular, but some recommendations that you feel are probably quite unique to you as a physician and as a healer? Recommendations that few other rheumatologists may have recommended in the past.
Dr. Munoz – So I think now, it’s becoming more and more common and I’m less unique in that way, thank goodness. But I think for a long time I did use to, even before I did the Fellowship in Integrative Medicine, which was another two-year fellowship at the University of Arizona Centre for Integrative Medicine with Dr. Andrew Weil. Even prior to that, understanding what someone’s nutrition and diet look like. It was very important in understanding that high sugar, high fructose corn syrup, and high sugar, in general, are pro-inflammatory. And red meat, omega 6’s, and trans fats are also pro-inflammatory. So I’m going to say that was really out there and it was rather unique, but it isn’t. And I’m glad it’s not so unique now. But what unique is the consistency of checking all the disciplines that are part of integrative medicine and making them a part and parcel of the total person approach. An approach in which medication is just one sector and this includes their emotions, exercise, sleep, nutrition, and supplements. I love the area of supplements because I’ve studied it, I’m fascinated by it and I’ve taken it. I also had the opportunity to become the chief formulator for my rheumatology group for our supplement line, of which though the flagship inflammation product is unique. Because it has three methods of treating inflammation naturally. So I would say that’s unique and I borrowed that piece from conventional medicine. I have learned in conventional medicine, when we have demarches biologic specifically, for example, if a TANF fails, why would we keep giving them TANF’s over and over again? Maybe we need to change the mechanism of action and give them something else. And the way the system is set up it’s called, step edits. For many times it has required us to use the same agents over and over again. Even though it doesn’t make logical sense. So when I’m using nutraceuticals, I like using different mechanisms of action simultaneously, less of it to reduce even side effects of nutraceuticals. But working on inflammation at different points in the inflammatory cascade. So I like that and I think that’s unique. And that’s an awesome application of conventional medicine to integrative approaches, as opposed to just using one type of supplement line. Once say just don’t make it through but combining them with botanicals that work differently.
Clint – Yeah, fantastic and fascinating. I know that you have a lot to offer us and our audience on that topic. And we’ll have to cover that information now another time. Because I want to still learn more behind the curtain stuff here. But we will definitely be going to address all that at a different time. I know that we could do a whole episode on supplements and their impact on inflammation and what can work for folks. Let me just move forward with some common, commonly held myths or perhaps their truth here. You’ve addressed medications so I’ll skip my question about, must everyone be on medication? Because I think you’ve said, well, that’s conditional if patient or person to person. And people can contact you and discuss their situation with you, you can gauge the feedback from you and work with you on that. Let’s talk about this next question I have here, is it true that drug representatives that come to your office and they want to push a certain type of drug? My next-door neighbor is a drug rep, a pharmaceutical rep and I think you she works with cardiovascular patients and all cardiovascular medical products. So, I mean, is it true that someone that you are influenced externally for certain medical suggestions to patients?
Dr. Munoz – So it’s true that medical representatives or drug reps, visit the physician office or physicians that are peddling their wares. They are in sales and this is what they do. And that’s what the drug, the pharmaceutical company pays them to do and it is to boost sales. I mean, they don’t make qualms about it, but through the education of the physician and the patient with proper indications. Then, yes, they’re there to influence your prescriptive patterns. I mean, it’s true and I don’t think there’s anything wrong with it as long as a physician or practitioner uses their best judgment in picking the right patients, who have the right diagnosis, who may benefit from that therapy, and not exclude other treatments that could be as good or safe for the patient, and that works. So, there’s a lot of room right now in rheumatology and there are a lot of medicines. When I started in rheumatology, we only had like three things. I mean, we had steroids, which is a nightmare for a patient to be on too long and too much. We had Plaquenil hydroxychloroquine, which we’ve had for 37 years and it’s tested. By the way, it’s not dangerous in how we prescribe it as rheumatologists, but we typically don’t prescribe it with antibiotics like AZT typically. And we’re usually using standard lower doses and we measure the level in the blood now to help reduce the toxicity. We’ve also had Methotrexate for a long time and other a few other disease-modifying drugs, which we’ve had for a long time as well. But we had no biologics, zero biologics for my first ten years in medicine. And we had chemotherapy Cytoxan, which was a bit frightening to use, for example, in rheumatoid arthritis. Did I lose you?
Clint – No, I’m still here.
Dr. Munoz – There you are, I lost my video. And so when the biologics started in the mid-90s, they opened up a new era in medicine. And now we have so many drugs both biologic and small molecule that it’s hard to keep track of it. You stay abreast of it but, we have many pharmaceutical options. But we also have more whole person integrative capability now than we used to. And I think the best is yet to come as we put all of this together.
Clint – Just sticking on the biologics for a second. It’s when I was first diagnosed like 14 years ago, it certainly wasn’t something that was in any of the early discussions with my rheumatologist over the first few years. And I think that’s because my personal attitude was very drug adverse. And I don’t think he wanted to talk about treatments that were over and above the ones that I was already reluctant to take, which was the Methotrexate, for example. But just observing anecdotally, people’s stories over the years since I’ve communicated with just so many people with RA. Is it true that the biologic approach, being on a biologic drug in today’s day and age is not considered as a last resort as what it used to be, and instead, it’s quite often simply considered the appropriate choice for some patients?
Dr. Munoz – I would say that that’s true and I would say that the speciality has matured that our experience over time has led us to understand more about all autoimmune conditions better than we did, specifically rheumatoid arthritis. We understand what some of the knowledge gaps are better now than we did before. We understand the relationship of the microbiome in the gut to chronic inflammation. We understand the role that stress, anxiety, and depression plays on a person’s response, pain, sleep, and their ability to stay on a regimen. And we understand that for some individuals, getting them under rapid control faster is the way to go. Now, that doesn’t mean though, that if those people are typically going to be in high disease activity. And we have different ways of measuring that now. We can do it by the old tried and true physical exam and metrics, what we call patient-reported outcomes and measurements such as the Clinical Disease Activity Index CDI or the Rapid 3 or the D disease activity score for the number of joints involved. And you get numbers and scores that tells you if the person is in low, medium, or high disease activity. And that is not the ultimate guide to what one should do. But it is a significant factor in evaluating how much inflammatory burden does this person in front of me have. And by inference, what is their risk for structural damage over the next three to five years? As well as internal Oregon involvement and then we have imaging like MRI or diagnostic ultrasound that shows us changes that maybe an X-ray doesn’t show anything. And then we have what’s called biomarkers, blood tests, complex biomarker tests that have been validated that help us understand if somebody is, again, in low, medium,or high disease activity. So that we can gauge, hey, does this person need to be in a biologic sooner rather than later? Yes or no based on those things and the discussion with my patient. So the short answer is yes, some people have a quicker course on biologics than others. And the concept is there’s a time clock ticking as to how quickly we can get someone into remission. And getting them into remission sooner, early on in the disease is very, very important. Because in rheumatoid, for example, the longer the inflammation is, the disease starts to become different, more difficult, and in a different characteristics than early on in the first year specifically. So all these factors influence, the desire to hold or give biologics early or to wait in an individual.
Clint – Okay. Yeah. Thank you for that comprehensive answer. One more, true or false question for you before I can ask you a personal question and we wrap this up. The true or false question is here in the US, we’ve been shell shocked by the cost of health insurance. My family and I pay an incredible amount of money given that we’re self-employed for our monthly health insurance. And I’m just wondering, how much do insurance companies or is this a fact of fallacy that insurance companies may actually influence the course of treatment for an individual by making it more difficult to get onto a certain prescription or otherwise?
Dr. Munoz – It’s a fact and things like that leads to a denial of a treatment that a physician or practitioner needs, for example, changing the category of the biologic. And also, the need to start somebody through too many disease-modifying drugs, where it’s obvious that they’re going to need a biologic sooner. Because they’ve already had the condition a long time, they’ve got a lot of inflammation. They already have damage and those people needs to be on the biologic way sooner, along with the whole person approach. Now, I’m not going to say that every insurance company is trying to prevent that, but I am saying that it is built into the system in general, step edits is one of these barriers. Number two, having to have requirements for two or three demarches. For an extended period of time, that seems to be a bit onerous and then having to prove that the person needs a particular treatment when it’s clear that it’s FDA approved and it’s not an experiment. Why would it not be approved? And so on and so forth. So we ran into those things and those things are true, in terms of delay. As well as delaying diagnostic testing that are needed, such as an MRI and having to do physical therapy for one to three months. I could see a month of delay but, more than that seems unreasonable. And failing multiple oral analgesics or anti-inflammatory when it’s clear that that’s not going to help and this is a delay tactic.
Clint – And I know that you’re part of a group and you’re actually one of the board members. And I think you started the foundational sort of aspect of this, is it pronounced as AARA? Would you like to talk a little bit about that? And how you and a group of professionals have tried to make the system a little bit more workable for both physician and patient?
Dr. Munoz – And so you hit the nail on the head as to why we formed it here in South Florida. We formed it five years ago, a group of 12 of us formed FARA, Florida Arthritis, and Rheumatology Associates, with the concept of protecting our specialty, our patients and being able to practice rheumatology in a way that, we felt the necessary best care for our patients. So after about a year, it was clear that this was needed and extremely well received by our colleagues. And we expanded out of the state of Florida and became AARA, American Arthritis, and Rheumatology Associates, in the last five years. We’ve gone from those 12 original rheumatologists to over 250 to date, in 25 states where the largest rheumatology super group in the United States, we are one group. We are operating under one Medicare number and one tax I.D. number. The data that we have from our electronic medical record, it is one platform that has over one million patients in it. And it is able to answer, what are the best future treatments for rheumatoid arthritis, lupus, etc… How do the drugs look in terms of effectiveness or side effects? And moving towards being able to answer questions that are coming up in the next 12 to 24 months about what’s called value-based reimbursement? Because reimbursements are going to be changing by the payers and value has to be demonstrated by all, which isn’t simply lowering costs. But how do you improve care? How does the patient or patient population improve with best practices? And being able to prove that and show that is what we’re able to do through our Columbus registry and database.
Clint – Would you vouch for or feel that it’s a good recommendation for a patient, who may be wanting to see someone locally to contact a rheumatologist through your group as opposed to any other random rheumatologist?
Dr. Munoz – So I humbly say yes, for a number of reasons. Number one, we have embedded within our group the concept of whole-person care approach, that 360 in addition to highly trained and qualified conventional rheumatologists. We are looking to become, if not already are, the preferred destination for rheumatology in the United States. As far as outpatient clinical medicine goes, due to the resources that are directed at improving the patient’s journey. And also by, answering this kind of questions that go towards improving and answering, what it does value look like in rheumatology care? Our business partners, Ben Care, which handles the business aspects of medicine. Because us, the physicians or the doctors, we are doctors and we are not businessmen. Their guidance, their metrics, their informatics, they’re scaling in being able to help us to have best practices nationally in our offices. So that our patients are the ones who are experiencing optimal care and that’s the winning formula right now, especially in the environment that we’re living in.
Clint – Okay. Wonderful, and then a personal question before we wrap. I do know that there’s a belief that psychologists find it difficult sometimes to let go of their work when they get home. Because they’ve dealt with emotional issues all day and it can affect them personally. And there can be a high depression rate and worse for psychologists in rheumatology, where we touched upon earlier about how patients can feel lack of hope, concerned, and worried, they’ve got a very serious condition. And whilst, you have the skill set to be able to appropriately treat them. Do you often find that you take home a little bit of that heaviness? And do you have a way of combating that?
Dr. Munoz – So the answer is no, I don’t take home the heaviness very often. At this point in my evolution, there was a point when I did in learning self-care as a physician, which is not taught in medical school. For example, self-care, exercising regularly, understanding that the same things I suggest to my patients, and how to eat. And that doesn’t mean that we don’t cheat or we don’t have favorite things, it doesn’t mean that. It also means that I need to sleep decently and enough. And that I also need to take my vitamins and that I also need to get checked by the doctor just to make sure everything’s ok. And then not delay if you’re worried men in particular from societal reasons. In general, having a mindset of delaying self-care, whether it’s attitudes towards medical care physicians, or whether it’s machismo, or whether it’s I can do it alone. Whatever the attitude is, it’s important for men, in particular, to take the opposite approach and basically surrender to the concept that we need the same self-care as anyone else. And the worst physician is to try to be oneself one’s own doctor. Because I heard that only a fool would do that. So I ascribe to all those things and it’s easy to self-treat. I personally don’t do it, I have a doctor. And it’s important for both the physical, the mental and spiritual aspects of self-care. As a result, I don’t burn out. So the prevention of burnout is a part of what I heard you asking, because if I wasn’t doing these things, then it starts to slowly decay into that pattern. And that’s something that I don’t have at this point. I really enjoy what I do and I don’t bring it home. And that doesn’t mean that at times I’m not concerned about something or there’s perhaps some business aspect. But again, I have learned not to be a workaholic. I learned to shut it off and I’ve learned about energetic protection from my shamanic colleagues, including the clothing colors we wear. And actually doing a particular mental energetic exercise if we have a particularly difficult situation or patient who’s draining. We want to not get negatively influenced or drawn down by that, so I don’t buy into that.
Clint – Yes, absolutely. I can relate to the men wanting to self-heal or self-work without any assistance. You know, that certainly was something that I adhered to very, very much early in my diagnosis. Well, thanks so much for all the time that you’ve shared with us in this episode. It’s been very, very insightful. You’ve really, really given us some great personal insights with your story with the Jaguar, which was very interesting and we talked about some of these true or false scenarios. And that was very surprising, actually, some of the answers to that, so thank you for that.
Clint – And I know that you are practicing in South Florida, but you do Zoom consultations. Because someone who saw you on the rheumatology panel, that we were part of then, contacted you. And then she became part of my support group and she shared how impressed she was with the consultation that she did with you. How thorough you were, how reassured she was, and how pleased she was with the suggestions that you made for her and her path forward. So given that you offered that service to someone else. Are you open to offering that service to people from all over the world?
Dr. Munoz – I am and I’m happy to help anyone that needs help, that is willing to contact us. In that regard, we do it primarily through the Oasis Institute website as the main contact and the OasisInstitute.com in Miami. And we’re able to go ahead and set up a consultation for someone who would like to do that.
Clint – Fantastic. Well, I’m sure a lot of people will want to do that after listening to you. You have the attributes that are quite different from at least the stereotypical traditional rheumatologist and I think that’s very refreshing. And you’re going to get quite a lot of interest to people that are wanting to talk with you about their circumstances. So thanks again for coming to this episode, it’s been a real pleasure and it was very interesting. And I look forward to having you back again real soon.
Dr. Munoz – Thank you. Clint, always a pleasure and a privilege. Thank you for having me.