Dr. Jonathan Weinkle talks with rheumatologist Dr. Brittany Panico about whole person care, believing patients’ narratives even when objective data doesn’t match, learning from tough feedback, decoding the language of pain and flares, bridging diagnostic gaps, the value of osteopathic training, and practical ways specialists and primary care clinicians can collaborate for people who fall between the criteria.
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In this episode of Healing People, Not Patients, Dr. Jonathan Weinkle interviews board-certified rheumatologist Dr. Brittany Panico about shifting from “survival mode” and checklist-driven care to a more patient-centered approach. Brittany shares how listening deeply, observing body language, and building relationships transformed her practice.
They discuss rheumatology’s diagnostic challenges, including patients who don’t fit formal criteria, gout with normal uric acid, the value of serial labs, and collaboration across specialties. Brittany also explains how osteopathic training and systems thinking shaped her approach to medicine and leadership.
Top 3 Takeaways
About the Show
Healing People, Not Patients explores ways to enhance medical practice by infusing it with compassion, humanity, and a deeper sense of purpose, aiming to help healthcare professionals rediscover the "soul" of their work. Framed around the four questions of the Passover Seder, it probes how to transform medicine for the better, promoting an empathetic and supportive approach that empowers patients to create meaningful, sober lives, while drawing on Jewish teachings about community and friendship.
"Our theme song, 'Room for the Soul,' is available on Bandcamp at https://jonathanweinkle.bandcamp.com/track/room-for-the-soul."
About the Guest
Dr. Brittany Panico is a board-certified rheumatologist. She completed residency and fellowship in Chicago and has practiced academic and private-practice rheumatology in Phoenix, caring for the full spectrum of inpatient and outpatient autoimmune and musculoskeletal disease. She is a DO whose training emphasized problem based learning, osteopathic manipulative medicine, and systems thinking. She is active on social media advocating for whole-person, narrative-centered care.
Connect with the Guest
About the Host
Dr. Jonathan Weinkle is an internist and pediatrician who practices primary care at a community health center in Pittsburgh. He strives to be a "nice Jewish doctor" focused on patient-centered healthcare, emphasizing effective communication and holistic well-being.
He teaches the courses, “Death and the Healthcare Professions” and “Healing and Humanity” at the University of Pittsburgh, authored the books Healing People, Not Patients and Illness to Exodus, and runs ‘Healers Who Listen’, where he blogs on healing and Jewish tradition. Once an aspiring rabbi, he now integrates faith and medicine to support other physicians and his own patients.
🌐 Website: healerswholisten.com
🔗 LinkedIn: linkedin.com/in/jonathan-weinkle-3440032a
📸 Instagram: @HealersWhoListen
📘 Facebook: @JonathanWeinkle
[00:00:00] If you're in the hospital or going for a checkup, I'm guessing you want your doctor to wash their hands both before and after they touch you. But what if that doctor is washing their hands of you? That's a kind of handwashing we could all do without. The phrase "to wash your hands of," fill in the blank, is often traced to the Christian Bible, the story of Pontius Pilate, but there's probably an even earlier source.
It's Deuteronomy 21, and a strange law from this past weekend's Torah reading . The law concerns what to do if a person is found murdered in an open field. It's between two or more towns, but doesn't belong to any one of those towns. The elders and judges of the time would measure the distance to each of the towns from the spot of the murder.
The town nearest the spot would have to take a calf that had never pulled a plow, slaughter it in a ravine, and then the elders of that town would wash their hands over the calf and say, "Our hands have not shed this blood, nor have our eyes seen it." It's a [00:01:00] messy ritual. I think they'd have been better off taking a page from Bart Simpson and just saying, "I didn't do it."
Unfortunately, for a lot of people in our fractured, subspecialized health system, it can feel like you are that person struck down in a field. No one wants to claim responsibility for you, especially if your symptoms are vague or you're too complex or you visit the wrong specialist for your condition.
You go to a cardiologist instead of a pulmonologist, or a gastroenterologist instead of a urologist. Often it can seem like the various tests and procedures that they do are just an elaborate way of discharging their obligation to you, especially when the test results are normal, but the person doesn't feel normal .
My guest on this episode is Dr. Brittany Panico, a rheumatologist and writer who's also spent a lot of time thinking about how we can help the people whose illnesses occupy the gray areas of medicine, the open fields. Through our conversation, I'm hoping we can better understand how to care for the people we meet, even when they don't, quote, [00:02:00] "meet the criteria for whatever disease we think they have or fit neatly into one of the preordained boxes that we've created for our specialties."
Stay tuned
[00:00:00] All right. Welcome back, everyone. I am joined by somebody that I'm just meeting for the first time today, but who I found through the wonderful world of LinkedIn. Dr. Brittany Panico is a rheumatologist, and turns out that we kind of operate in the same headspace when we're talking about whole person care and really listening to our patients' stories and understanding what they're going through.
since we've just met, Brittany, I don't know if you'd mind introducing yourself a little bit for the audience and telling us what you do and how you got into this space. Absolutely. Thank you for having me. So I am Brittany Panico. I'm a board-certified rheumatologist. I've practiced in Chicago.
I started my medical journey in Chicago with residency and fellowship, and then have moved my way over to Phoenix, where I've done academic medicine, private practice and really taking care of the whole gamut of the patient experience, from inpatient medicine to outpatient rheumatology, where I'm working now.
So happy to be here and happy to see where this conversation goes. [00:01:00] Wonderful. So we've already used the word a few times, whole person care, which is where I'm focused, but I also realize I have this very heavy bias towards primary care kind of living in that bubble, especially working as I do in a community health center.
So I often don't have the opportunity to refer out, and I assume that every encounter is happening in my own office. But you caught my attention last fall because you posted something on LinkedIn where I saw a specialist making the same points that I make, and that made me really happy. You know, you talked about believing the patient's narrative even when the, quote, "objective evidence" didn't fit what you were hearing- Exactly
and understanding their lived experience. So tell me how you got into that mindset and how you make it happen in your practice. I think it's just been the whole journey of doctoring. For me, early in my career as a young attending, I was really in survival mode. It was about me. I was trying to learn the language.
I was trying to keep the patients [00:02:00] happy and, you know, hopefully get results at the same time. But I was really learning the definition of what rheumatology was in that- Mm-hmm ... timeframe. And it was right around the same time that online reviews were becoming a thing that we were being graded on, essentially.
So my clinical supervisor sat me down and was like, "We need to talk about your reviews." And I'm like, what does this mean, my reviews?" And it took a couple patients really giving rather harsh feedback that I wasn't paying attention, that they came- Hmm ... to the visit, they took a day off work, they, came looking for answers, and didn't feel like I was giving them the time or the ears that they needed to solve their issue.
Because as a specialist, our fallback is, "Well, you don't have anything that fits into my specialty. Let's have you go back to your primary care doctor." That's not the best way to make friends in medicine is to just- Mm-hmm ... keep pushing patients back where they came from. So I had to really, [00:03:00] like, come to terms with the fact that It's not about me.
It's not about what I want for the patient. It's about what the patient's trying to say to me when they're in the office and what- ... they're trying to get across that they've had difficulty communicating or struggling to get someone else to notice. And really developing that language or watching their body language of what is it that's happening that they're either ashamed to say or can't express in words, or hiding physical pain behind clothes or behind something to diminish the experience because they're used to not being believed, right?
And so it really took me just slowing down and just saying, "I'm okay if I don't get my notes done in the moment. I'm okay if I have to take extra work home." I would like sit and ruminate and like watch, and it really was like asking those in-depth questions like, "Tell me more. Tell me what you mean by [00:04:00] pain.
Is it pain or is it stiffness? Are you struggling to move your body or are you struggling to coordinate your body with your brain?" Mm-hmm. So it was like teasing out the language, and that took time. That's not doable in 5 or 10 or 15 minutes, and so I was chronically running late, but I was getting better results because I was- Mm-hmm
taking more time and actually connecting with the person. So that's really where my journey started, and now I really think, especially in rheumatology, because we're dealing with so many organs, we're one of the specialties that really has to know the brain, the gut, the joints, the heart, like every single organ system- Mm-hmm
is involved in our care and potentially a side effect of our drugs and our treatment. And so you almost are forced to develop this sort of sense of when something isn't... doesn't seem right, but that the patient isn't quite telling you. And then also just allowing them to come [00:05:00] in. If people call and send me a message on the portal, they're complaining of something- I say, "Come in. I can't really deal with this over a portal message. I can't communicate this through my medical assistant over the phone." And it helps having those repetitive visits where you see somebody over and over, and you get to figure out when something is off for patients- Yeah
in that way. I remember hearing some of my attendings... So I trained right around the turn of the century, of the 21st century, not the 20th century. It feels like it was the 20th century sometimes. But I remember my attendings at that point who were a quarter of a century earlier training in the era prior to managed care, right?
So they had been in the era where you would routinely check into the hospital to get worked up for something and stay a week or two, and they would see an illness unfold in front of them. Yeah. Right. And now people were checking in to get stabilized and immediately being sent home in 36 hours, and [00:06:00] so you didn't see the illness develop.
Mm-hmm. And what I hear you creating is that ability to watch something unfold on a slower timescale of, you know, over weeks to months- instead of hours to days, but seeing the illness develop and the story tell itself by frequent contact, which, you know, I have to say, you talked about the tendency for specialists, and I'm glad you said it and not me, 'cause it sounds like you owning up to something instead of me accusing you of something.
But turfing people back to the PCP, which we'll get to in a minute. But quite the opposite. You're actually, y- when you do see someone regularly in a specialty, it's often maybe quarterly, maybe twice a year, maybe once a year. You know, I have people routinely come back from their cardiologist.
They say, "So when are you seeing Dr. So-and-so again?" It's like, "Oh, in June of 2027." It's like, "It's August of '26." Yeah. Yeah. "I guess I'm managing this on my own until then." Yeah. that's a [00:07:00] really wonderful strategy. You said a couple other things, though, one of which I really wanna focus on, which is your journey started with you doing something very unusual, which was hearing negative feedback and acting on it in a way that was corrective rather than defensive which I think is unusual.
I don't know, I don't know if your supervisor found that to be unusual or if you found that to be unusual in your career, but it certainly seems me, that we tend to, put up our defenses and say, "Well, that, you know, that patient was demanding," But rather saying, "What can I do to get better?"
Well, and I, I did do that. I did that with my peers, right? My other mentors and my, my peers in clinic, we would, gripe about, "I can't believe somebody wrote this on the internet." But then as, as I sat in that, it was like, but I have to live with this every day. I have to live with the fact that's public.
So either I have to do something about that [00:08:00] and change the image that I'm portraying to the world- Mm-hmm ... or I have to sit with the fact that people don't think I'm helpful. And so it, when you're at a stage where you're building your career, you have the chance, and really this could be a mid-career change.
It could be, you know, if you're redefining yourself later, deciding on a niche, right? you have to be able to internalize, why am I doing this? Yes, a paycheck. Everyone needs to support their family and participate in the economy, but there's other ways that people make money. It's not about that, right?
Are we in this to help people improve their health? Are we in this for our communities so that our communities have better economies and grow? Right. And the people that we support, if we're taking care of the principal at our kids' school, that's important, right? Because they- Yeah.
That's gonna- ... supervise our children. For sure. So there's, there's all these downstream trickle effects- [00:09:00] Mm-hmm ... that when you're opening your door in and out every 10 minutes, you're not really understanding the reality of how that patient, that person impacts y- your global environment. And I think I had to really come to terms with that because I was living in the community I was practicing in.
And so if somebody found me at the grocery store and was like, "Oh, well, that's the lady that turned me away- Mm-hmm ... and didn't take care of me," and then, you know- years later or months later or whatever is telling her friends that and her community, you know, "Don't bother going to that office because they don't listen to you."
That's not how we grow as clinicians. That's not how we grow as humans, as people. That's not how we understand that we can change. And I-- you brought up a good point about our attendings and how we were trained. I was trained in the, you have 10 minutes to figure this out and 15 minutes to wrap it all up. [00:10:00] Mm-hmm. And now we're coming back, decades later saying that is the downfall of medicine. The, the... That is what has created poor outcomes, is that we aren't treating the things that are unfolding. We're just trying to put a Band-Aid on it, stop the leak in the moment, right?
Here's your prescription, rather than understanding- Right ... how that developed and the trickle effect. And 15 minutes isn't necessarily a bad thing if you're seeing some- Like as, as you described, if you're saying, "Come back in and I'll see you for 10 or 15 minutes to get a quick update, and I'll see you again in a month."
Right? Like, so that we're, using those as check-ins rather than trying to process the whole thing. So if I'm doing- The lunch and you're out ... half an hour or even 45 minutes for a good comprehensive visit with somebody a couple of times a year, and then in between I see them five or six more times, that 15 minutes is fine 'cause I can- Right
check their blood pressure or inject their shoulder or look at a rash or even, you know- Help them process a, a really [00:11:00] traumatic interaction with somebody in their family ... as if that's the only thing I'm doing, then I can do that in a short period of time because we're developing a relationship.
It's like you run into your friend in the street and you spend 10 minutes chatting with them, that perpetuates your friendship, but that's not the only contact you have with them. So I wanna circle back also, you talked about language. And obviously I deal with language a lot. We t- we're talking in the pre-interview about my work with immigrants and refugees, and anybody who's listened to the podcast knows that I, come back to that well often.
But you're not talking necessarily about people with whom you don't share a common spoken language or a common culture, but you still have to learn their language. So tell me a little bit about that. Yeah. So this actually did-- I think I realized it when I was, when I did have a language barrier- Mm
because that first time that a patient says, "Well, I ran out of medication," and you, and you're like, "Well, I gave you refills. What do you mean you ran out of it? Did you go pick it back up?" "Well, I didn't know I was supposed to do that." So [00:12:00] just because you give somebody a medication with three refills to get them to their next visit doesn't mean they understand that that's the behavior you're asking them- Mm-hmm
to accomplish. Plus, they might not necessarily have transportation to go get their pills on time, or this was even in the middle of COVID when pharmacies didn't have meds, right? They were- ... not appropriately stocked. Well, sure. So a lot of it is understanding or communicating What barriers are, keeping the patient from doing the things you're asking them to do or, having a conversation about.
But then also it's the language they're saying. So in my world, people come to me for pain, joint pain. But I'm not a pain specialist, I'm an autoimmune specialist. So pain can be related to an amputation, which... or an accident, a trauma That is not my field. But pain can also be from inflammation and something causing swelling, which is in my world.
So understanding that [00:13:00] pain doesn't equal pain in every situation. Mm-hmm. Right. The word doesn't mean the same thing. And so taking time to tease that out, I think fibromyalgia is a great example. We think of that as a neurologic sort of hyperreactivity syndrome, where the nerves are not communicating appropriately for patients.
Whether that's tied to an underlying autoimmune condition or tied to a another thing is important to distinguish, because how do we treat the underlying issue triggering that syndrome or triggering that response? And so it was really uncovering what they're trying to say with the words they're trained to tell us.
Right? "I come to the doctor when I don't feel good." Well, what does that mean? Is it a stomach thing? Which could be back pain, which could be something else entirely, anxiety, depression. Could be anything, right? like again, mental health, not feeling well, is it something that's, [00:14:00] physiologically we can change and manipulate?
So I think you really have to, in order to understand what the patient's saying, it's, "Tell me more. Tell me what that means." Mm-hmm. 'Cause I have people who come in and they're like, "Well, I'm flaring." And it's like, "But what does that mean to you? Are you flaring because you haven't really had good sleep for the last three days 'cause you have a deadline at work and you're not sleeping well?
Or did something really happen where you missed two months of medication and you're truly f- you know, your disease is now active?" And so we have to get at the bottom of what the patient's trying to actually tell us, and their words might not be our same words that we're- Mm-hmm ... taught to hear. Yeah. I've had a just as an example that always pops into my head when somebody says something like this.
I've had patients come in, it's like, "What's going on?" "Well, you know, Frank really did it this time." I'm like, "So we just met," " And I don't know who Frank is." And what you're saying is that when people use words like flare or I'm having [00:15:00] an episode or whatever, they know what that means, but we have to, we have to kinda be introduced into their world.
And unfortunately, we do it back to them, right? Because we say, "Oh, you're having a fibro- an episode of fibromyalgia," but they might not know what that means. Or your labs are normal, and they're like, "Well, I don't feel normal. They can't be normal." Exactly. And then there's the whole unpacking of that.
It's like we were checking for this specific thing, and the normal labs mean you don't have that specific thing, which means that we still don't know what's causing the problem, but it doesn't mean there's no problem. And that's really helpful. And, and I know one of the things with fibromyalgia has always been, for s- for so many years, certainly while I was training, there was still debate over whether it was a real disease.
Um, I hear that a lot now with functional, functional neurologic disorders or with chronic fatigue syndrome is still kind of out there. And, you know, the fact is that the, these, these words that we use in medical terminology are defining a group of symptoms that happen over and over again to lots of people.[00:16:00]
De facto, if people are experiencing them in the same pattern, in the same way, they're real. We don't know what's making it happen. We don't know why somebody experiences it and somebody with the same setup doesn't experience it. Yeah. But it happens. That's real what's shaping that reality is still outside our understanding.
Exactly. So this is where I wanted to poke the bear, which is my next question. So I refer out to all the specialties for all the things, including rheumatology, and I, I have a love-hate relationship with your specialty. I know. I actually thought about specializing in rheumatology after residency. I was a Med-Peds doctor, so that, you know, you're looking for like, well, how do I bridge that sort of transitional care?
And there's a Med-Peds rheumatologist in Pittsburgh who I did some training with who I really liked. And I decided against it eventually, but what I loved about rheumatology was this, this incredible understanding, like you described, of all these systems interacting with one another. So it felt like a specialty that wasn't a specialty because it was still dealing with the whole body.
Yeah. And these pediatric onset [00:17:00] diseases like JRA, ju- juvenile rheumatoid arthritis or juvenile inflammatory arthritis. I've got to get my terminology right and explain it for the audience, But it, these were things that somebody would have in childhood and continue to have into adulthood.
In fact, one of the fellows that I worked with in med school on my rheumatology rotation had JIA when she was 12, starting when she was 12, and her experience as a patient was what led her to med school in the first place. So I'm starting with that background, this tremendous respect of being able to help people out.
And also the respect because you guys understand immunology, which is hands down the most arcane part of medical science. It's worse than the kidney by far. And- And the hardest to understand ... you love like butter. It's your bread and butter, and that's, you know, I, take my hat off to you. On the other hand, I regularly run into problems when I refer somebody to rheumatology because I think they have something that is a clearly defined condition in that realm.
And they don't quite meet [00:18:00] the EULAR, which is the European Rheumatology Society, or ACR, which is the American Society of Rheumatology, now it's the College of Rheumatology, criteria for that particular condition, and they end up coming back to me, as you said "Oh, you should go back and see your PCP."
They come back empty-handed, and I, I still don't know what to do any more than I did three months ago. So help me understand how we can do a better job of helping people who aren't doing well, as you said, who are flaring or who are having these particular problems, but who are obviously, you know, not doing well somehow, but they fall into this gap.
And it's like, you know, going to step on the subway car and you miss and you fall into that little gap. Yeah. And so they're not diagnosed with rheumatoid arthritis or lupus or some other clear-cut condition, but they still clearly have something wrong. What are you and I both missing, and how can we help I have my version of the story. Okay. So I think a lot of it is, you know, again, going back to training, we're trained to follow guidelines or we're trained to look at [00:19:00] criteria within a, a realm, right? And so what is the probability that you meet that clinical criteria? In rheumatology, we debate all the time that the criteria are too far into the active disease- category, meaning we're waiting too long to define these conditions. And that's my philosophy, is that if we catch it early, right, do we have to let the patient actually have full-blown proteinuria from their lupus nephritis? Like how bad- Mm-hmm ... do things have to be? Right. So if you are- Lu- lupus, by the way, is the non-cancer disease that I hate more than any in terms of what I've seen happen to people with it.
Oh, yes. So like- Yes ... the earlier I can get it diagnosed, the better, and I've had such a hard time with some of my patients who have turned out to have lupus, getting them- I know. I know ... getting them care. And I... It just breaks my heart to hear those stories. But I think a lot of it is just persistence, and if you're not necessarily in a geographic partnership, so to speak, of a rheumatologist who tends to be more open-minded about [00:20:00] diagnosing and treating earlier, it's just keep the patient going back.
As much as they feel like they're turned away, there will eventually be a defining moment where that person then has to essentially pay attention. So as frustrating as that is to just keep doing something where you're not getting results, that's one way. Mm. The other way is, you know, and I think this is becoming more popular in medicine, is developing a network of people who have multiple state licenses and can do telemed, and who can be an advocate or a sounding board of, you know, "I'm really struggling with what else to order to show somebody this."
I just had a conversation with a few colleagues yesterday about how we can work with neurologists to help when we are struggling, when our meds aren't working, how do we show a neurologist or a neuromuscular neurologist, "I need help for this disorder." Like inborn- Mm-hmm ... errors of metabolism, like we're not really the best trained at identifying those, but they exist.
And so It [00:21:00] is kind of understanding, again, going back to language, that, that common language that both people speak that defines the thing. Mm-hmm. The broad answer to that is I'm finding clinically when things don't make sense, the patient probably has gout, and it's becoming the biggest mimicker of everything.
You know, we're taught lupus is the mimicker. We're taught- Mm-hmm ... oA, everybody has osteoarthritis. Well, gout is becoming the biggest mimicker. So that is something that's often not necessarily uncovered because we rely on a blood test to help us define that or a swollen joint that we can aspirate to define that.
So I'm finding gout in people with uric acid levels in the threes, but clinically on imaging- ... they have urate deposition. So from a fundamental standpoint, when things don't make sense, go look for gout. I was not expecting to learn a diagnostic pearl. I was looking for, communication skills, inspirational language.
This is really cool and Now you'll probably find a lot more gout in [00:22:00] your clinic population, even in females, so behind the scenes I can help you navigate that, but- Awesome ... I, I do think a lot of it is, you know, we, we have to... The creative docs, so to speak, the ones who are catching these things and just instinctively know something isn't right, have to develop that kind of creative network of like, who can we turn to to really help us understand what to try?
Because if you get comfortable, let's say something like hydroxychloroquine, if you can do that and the patient isn't getting better, then the rheumatologist has to, come to terms with the fact that you've tried one of their meds and it's not working. Mm-hmm. Versus, you know, we're not expecting everyone to use methotrexate or use our medications, but there's...
What hap- what's happening in rheumatology across the nation is that clinics are being forced to screen referrals. So they're looking- Mm ... for lab values that are abnormal and a clinical description of something that's [00:23:00] inflammatory. So if that's not being provided, the screener, which is often not a clinician, that could be a trained MA, that could be a clinic manager, that could be somebody with, that doesn't face patients, is checking boxes saying, "This patient does not meet criteria to get into my door."
So that's happening. The second thing is once they get there, they're looking at labs that were already done and saying, "Well, you had a negative ANA. There's nothing here for me to do." So negative labs in a sense can be a deterrent, but also That's where the patient really needs to say, "Well, things have changed since I've waited the three or six months to see you.
Can we repeat things?" Mm-hmm. So I often will communicate when I'm sending a patient to a referral, I communicate to them, "If you're waiting longer than a month, ask that person, 'Can we do labs that are in your world?' Because I feel different now." Even if they feel the same, [00:24:00] I kind of coach my patients, "In order to escalate your treatment or your care, we have to progress."
Mm-hmm. "So you have to use words that sound like this is changing for you," because if you go in and say, "Well, I feel okay today," right? It's like you send the patient to dermatology w- and they don't have the rash the day they go in- Mm-hmm ... and it's like, "What can I do?" Right. But if they show up with pictures- Patients, yeah, they, they clam up, right?
And they say, "Well, I'm okay. I don't know why I'm here." And then the specialist is like, "Well, what do you expect?" Mm-hmm ... again, the common language. What do you want me to do if you feel okay?" Rather than actually sitting and talking to the patient, "Well, tell me why you were referred in the first place."
What- ... I often will ask, "Well, what did your doctor think you needed me to see me for? What did you talk about with your doctor that prompted them to say you need a rheumatologist?" Yeah. And that often will at least get the patient thinking, "Well, I was complaining that my hip was hurting," or, "I was complaining that I am...
You know, I have a itchy, scaly rash and [00:25:00] joint pain." And so the more we can get our patients on board with the referral, the more they can be their own advocate to say, "I'm not leaving this office until you at least order some testing, because I, it took me however long to get here and I'm not comfortable walking away."
And sometimes we have to hear that too, of like, "Oh, I've gotta do something for you before you can leave." And I think there's so many layers to this, right? There's the idea of waste in medicine. If you did labs and those labs were negative, why would I repeat them?
But again, the immune system evolves, so it is worth repeating because the immune system is changing. So a signal that wasn't there three months ago might now all of a sudden pop up. I do serial labs in a lot of my autoimmune patients because when they come in complaining of something that they haven't talked to me about before- Mm-hmm
it's like, well, this might be something new. I've found new markers in patients that I've followed for [00:26:00] years who I thought were stable and just coming in- Right ... for their refills, but all of a sudden that joint is swollen. I don't remember we really talked about that before. Yeah. And then lo and behold, they have rheumatoid markers, and so we have to change gears.
So I think what's hard in Rheumatology is we get into the mindset of, "I've checked you once and it's over," but that's not how rheumatology works. You check something once and then you wait, and then you talk about it some more, and you check it again, and you reevaluate. And I think that's the secret, not to just make this all about gout, but that's the secret with gout is-
you check a uric acid and it might be normal, but the patient's still complaining. Check it again and it might be now indicative of what- Sure ... you're looking for, so. Well, I'm gonna bring this back to my arch nemesis, which is lupus. I re- I remember very distinctly in second year whichever, whichever block of second year med school that I learned it in, that [00:27:00] those 11 criteria, right?
BRAIN SOAP MD, I was at- that was the mnemonic I was taught. I don't know if you were taught that one as well. No, I'm not. But you need 4 of 11 criteria to get a positive diagnosis for lupus, and they can happen at any time along the spectrum. They don't have to coexist at the same time. They can be at various points.
They can be years apart. So in that sense, I mean, lupus is a story. It's a narrative. Just that one diagnosis, I talk about illness narratives all the time 'cause I was steeped in that from the very beginning of med school. But even the disease process that everybody has in lupus is, in fact, an, an illness narrative because it doesn't all happen at the same time.
Exactly. Um, you don't have lupus, you develop It unfolds. Exactly. Uh, and I think that's really a great reminder to have you know, whether... And it applies also to, you know, th- I've a couple of patients, both from the same country as it turns out, who, when I first met them, had very obvious vitiligo with, you know, people whose base skin [00:28:00] tone was a medium brown, but who at that point were mostly pinkish white most of their face, on their hands, whatever.
And two or three years into my taking care of them, developed these huge swollen knuckles. Mm-hmm. And I checked them, and they've got both of the rheumatoid markers at the maximum level that we're able to detect, and I put them on methotrexate and they got better. And you really described an approach where I think a lot of primary care doctors are afraid to go but can go, which is you've got somebody that you're pretty sure has a thing, but they might not meet those criteria.
I'll often take the first two or three steps because after three or five or seven years of referring for the same condition, I know what you're gonna do. Yeah. Like, Dr. Panico's great, but I've seen 15 patients with her, and I know she's gonna do these three things first. So when I run out of ideas, then I'm gonna send you to her 'cause she'll know what to do next.
Um, and I think that's a skill set that a lot of us may need to get back because [00:29:00] the i- the age of being able to be a gatekeeper and just refer people, through the turnstile is clearly coming to an end. Yeah. Um- And I think you bring up a good point, too, about just being able to, you know, we kinda talk about bravery and having courage.
Being able to say, "Okay, if I try something and it doesn't work," right? With any med, whether you're starting methotrexate or you're starting an antidepressant, you have a threshold of what the patient is not tolerating. So as long as you're doing those things, you're not giving them a year supply and saying, you know, "Have a nice life.
I'll see you in a year," then it's completely within your ability to use those medications and try those things first. And we appreciate that because, again, by the time the patient gets to us, then we're ready to go onto the next thing. And so I think for a lot of people who feel nervousness about stepping, outside their realm or even if you don't have, as much available access to a specialist, you can always [00:30:00] stop something.
You can always tell the patient to stop taking a medication or give such a limited supply that there's no way they have enough refills to actually cause, damage, so to speak- Mm-hmm ... with methotrexate, for example. So- Yeah ... I think too, that's one thing that I try to encourage people-- I even do myself, I don't give more than three months of a lot of my medications because I don't want the patient to disappear with my prescription on board and have a reaction- Mm-hmm
when I can't rescue them. So we c- we have the, the capacity and power to regulate what our patients do, and can try something for a month, two months, three months, and then, you know, meanwhile you're, they're waiting to see the specialist. So I think that's completely an ap- an appropriate, position to take of I can at least do something to get them going.
And we'll do that too with a lot of things when we're trying to buy time to get them to see somebody or, or whatnot. So [00:31:00] I wanna shift gears a little bit. We talked about the difference in perspective between the specialist and the, and the primary care doctor. There's another distinction that I wanted to bring up for a second, which is that you're a DO, and a lot of us are conditioned at this point in 2026 to really kind of ignore that distinction.
You graduate an MD versus a DO program, you can go to the same residencies, enter the same specialties, apply for the same jobs. Some of my partners are MDs, some are DOs. Some of my mentors and teachers in residency were MDs, some were DOs. But I have also had students in the pre-med space who tell me they're specifically applying to DO programs because they perceive that the training is better at this exact part of medicine, of understanding people, doing whole person care, that there's something different about the osteopathic versus the allopathic approach.
A, a secret sauce, if you will. What are the ingredients of that secret sauce, if that in fact is a distinction? What does osteopathic training do to [00:32:00] create that vibe? I- it's a great question, and my husband's a DO too, and we talk a lot about this because we-- I think people who share common beliefs kind of gravitate towards something that they find attractive, right?
And so for both of us, we chose DO schools outside of MD schools because of that exact philosophy or, or I guess nomenclature, is that it was different. And for me, it was more of the idea that I wanted the most broad knowledge base. also we both went to a school, I think it's more common now, but we both went to LECOM in Bradenton, and that was one of the first small group learning schools where we had problem-based learning.
Like we, we had very few lectures, but we were- Mm-hmm ... pretty much in groups our entire curriculum. And so you really developed communication- I, I appreciate the shout-out for PBL because I, I went to Pitt, which is an MD [00:33:00] school, when they were leaning hard into PBL for the f- for the first time. Yeah, they were early- It was amazing
PBL program too, yeah. And I taught PAs at Chatham University here in Pittsburgh, which is an entirely PBL-based curriculum, so I am 100% on board. Yes. Also, you went to a school that is, while it is, was in Bradenton, Florida, is based in Pennsylvania- Yes ... so thank you for that. Yeah. Go on. Sorry, I didn't mean to interrupt.
You mean to say- Yeah, a lot of common commonality there. But yeah, so the idea that you were forced to communicate from day one, like you didn't just get regurgitated information. You had to hash it out together. You had to learn in study groups. Like it was very communal. Mm-hmm. And that's what medicine, the crux of it is, right?
We're not on an island by ourselves trying to save the whole world alone. And so it really starts with just the idea that you learn from each other and, and you're lear- again, you're learning language together. Then there's the osteopathic, like the OMM training, the osteopathic manipulative medicine, where [00:34:00] we have labs.
We'd have four hours a week of physical lab to learn the manipulation techniques, and so you have to learn body language. You have to study the way somebody moves and interacts and, hobbles and walks and stands and all those things. So whether... I don't practice manipulative medicine anymore, but the muscle memory of the way I'm looking at a patient, even when I'm out in public, it's like, oh, you can pick up like very subtle little things the way people- Mm-hmm
act, right? And so that part I think is very valuable because I'm not necessarily just there talking. I'm there talking and looking and listening and comprehending all of this all at the same time. And I'll have patients, like I'll do a physical exam and I'll have them do something else and they're looking at me like, "What are you doing?"
I'm like, "I'm watching the way you're positioning yourself [00:35:00] because I don't think it's happening where you have pain. It's happening somewhere else." And then you pick that to image or what have you, right? And so- Th- then there's the integrative. Because of PBL, you have to learn everything separately and put it together.
So you- Mm-hmm ... you don't just get a lecture where it gives you bullet points that are gonna be tested. You get the story, and then you have to intertwine that with, your anatomy, your physiology, your pathology, your histology, your immunology. Like, all of that has to blend together, which is real life.
And so- Yeah ... that's all, again, from day one. And I think, too, like we, we... You can trace back, you know, who had the first, like, nutrition course in medicine, but, but osteopaths learn nutrition ear- you know, very early on. That wasn't something that was then, like, added as a fad. And so we did a lot of stuff with gut health before it was a [00:36:00] thing, you know, when people thought everyone was crazy for thinking about, your gut bacteria.
We learned all of that, so it wasn't really, like, new news. And now, and now we're doing stool transplants to cure C. diff. Right. Yeah. And so I think just the idea that you learn how to synthesize information for what makes sense to you, and then you're, of course, tested on it, so whether or not that's correct.
But then you also learn to recover from mistakes in a different way. It's not just, "Oh, I missed a question 'cause I didn't memorize it." I had to actually understand why those pieces fit together. So- Yeah ... it's kind of just a different... Well, I'll go back to language, right? It is the same language.
We're using the same words out of the dictionary, but we're putting them together in a different way, so the sentence is a little, little different. The dialect is a little different. And then you have to acclimate once you get out. Then you have to blend it all together again in your training and- And what I can appreciate about [00:37:00] that is that the ways of learning that language are not somehow impenetrable to an allopathic program to adopt.
You know- Right ... we've identified several things that you did that my program also did and that are spreading to more places and more ways. So- ... um, you know, hopefully we're able to take this approach, especially what you described just now of learning... You know, not learning for a grade, but learning for mastery so that you take your, mistakes or you take your low grade on an exam and actually turn that into additional learning rather than shame and- Right
Moving further and further away from your goals of whichever residency you wanna get into or whichever honor you wanna earn. So I love that. Yeah. Yeah. You also mentioned this idea of being collaborative, not being on an island, and I know that for at least part of your career, you've been a physician leader where you've been responsible for other professionals.
I am also in a position of leadership where whether it's [00:38:00] tone setting or coaching or whatever I'm really interested in knowing both for my own personal use in my day job, but also to share with the folks that are listening, how do you incorporate what we've been talking about into your role as a leader of other clinicians?
Meaning, what do you ask of other doctors, APPs, people that work for you in a nursing capacity or as an NA or pharmacists that you work with in terms of providing this kind of compassionate relationship-based care, the level of listening and understanding that you're talking about? What are, what are you expecting of other people that are partnering with you?
That's a great question, and this evolves over time. I-- right now I'm reading "Radical Candor." I don't know if you've heard of that book, but it, it really came out of Silicon Valley and about like the tech industry and how to be a manager. And they talk a lot about follow through or follow up, right?
You can, you can have a distinct teaching style where you [00:39:00] say, "Go back and try again," like, "Go back and see what was missing," or, "Go back and think about another differential," for example, like what else could it be? Or you can actually show somebody, "This is the mistake that I made, and this is how I figured it out."
So the thought process, it's teaching that how to get from point A to point B to point C to point D- in those steps rather than just giving an answer. Training somebody in rheumatology, what's the next best drug that you're gonna prescribe? Well, you have to think about what are the comorbidities, what are the risks if you prescribe drug X, what are the side effects I'm gonna be watching out for?
If that is something the patient has, I don't wanna do that thing. So I talk a lot about knowing, in rheumatology specifically, knowing what you're expecting your drug to do. What are you expecting your treatment plan to accomplish? Mm-hmm. If you can't answer that question Then we've gotta [00:40:00] figure out was that even the right-- are we on the right path?
Mm-hmm. Is that the right plan? Then- Right ... it's really going back and, okay, how are you gonna verify that's correct? So are you gonna follow up with the patient in a month? Are you gonna follow up with the patient in, you know, X, Y, Z? Are you gonna have the medical assistant reach out and ask how they're doing?
So it's that checking back in to make sure, 'cause that teaches ourselves that we're on the right track, right? I do a lot... My medical assistants roll their eyes when I'm like, "Please call the patient and see how they're feeling, with their medication." They're like, "They're already scheduled for a follow-up."
I don't care. I'll bring them back in if they're having a hard time. Mm-hmm. So a lot of that is- 'Cause that follow-up may be three or six months, and I wanna know after two weeks if there's a problem with the medication, 'cause otherwise they're gonna keep taking it for another two and a half months to their detriment, right?
Or stop it on- Mm-hmm ... stop it on their own and come back worse than when I saw them. Right. So- And stop it and not tell you. Right? Yes. Yes. [00:41:00] Yeah. So I, I think a lot of-- I don't know if I can pinpoint it to, like, one or two things- Mm-hmm ... but a lot of it just comes back to patience. I think having...
Allowing other people to blunder. No mistake is irrecover-- Well, I should be careful how I say this. Few mistakes are irrecoverable from- Mm-hmm ... if you're paying attention. So documentation, communication, right? If you're consciously trying to do the right thing and a side effect happens or a lab abnormality happens, you have to recover from that and- Mm-hmm
hopefully quickly. So- Yeah ... a lot of it just comes down to, again, we learn from our mistakes far more than we learn from our successes because we're forced to think differently- Mm-hmm ... when we make a mistake. And so I move slowly in clinic, and so when I'm with somebody training them, it's like, okay, the, the goal is not to be in and out of there so you get your notes [00:42:00] done.
Mm-hmm. Yes, that's part of the goal. But the goal is that you deliver the best in the moment with the information you're given, treatment option for your patient or options, and you decide together. So- Yeah ... it's really-- It, it goes back to, like, it's not about me, it's about them. Mm-hmm. What are they coming to us for?
What are they asking for that we can accomplish with them? Yeah. It's funny, I just said to my, my third-year med student this morning, I said, "I'm never gonna fault a third-year med student for being slow. I am gonna be upset if they're sloppy." Yes. Yeah. That's true. So we're, I-- we're getting toward the end of our time.
I wanted to come back to something that I was thinking about when you were talking about-- when we were talking about the first question that I asked about the distinctions with, with specialists in general and then when I asked you about the criteria. I feel like one of the things that may get in the way, and I don't wanna...
I wanna be very clear. I have lots of friends who are in academic medicine, lots of friends who are doing very important research. [00:43:00] It is critical to the amazing care that we're able to provide that there is all of this knowledge out there. But I feel like s- one of the detriments of being so focused on academic medicine is that we set these criteria that are really research criteria, right?
Yeah. Yeah. You are ACR because you can't do good research on rheumatoid arthritis if you've got a bunch of people included in the study who may not actually have RA. Yes. But in the real world that you and I are working in, there are people who may have RA, who may have lupus, who are unwell enough to need help.
Yes. And whether or not they meet the research criterion isn't really all that important. It's whether or not we have something that we can do to help them. Yes. Whether or not we can make them feel better in some way. And if we use an RA medication and it works even though they don't really have RA and it doesn't hurt them, then I'm not sure that that matters.
And by the same token, like you, you have these algorithms for how you treat things [00:44:00] and well first you do this, then you do this, then you do this. If that doesn't work, you have to go to a different category of drugs. And it's evidence-based, but the evidence is based on those groups of people who strictly met the criteria- Understood
and not on the real world people. Yes. So if you don't contextualize the care, to, to borrow a phrase from, uh, from another one of the podcasts that I listen to, which is on Becoming a Healer I think it's Stanley Weiner and Stephan Cortez are the podcasters. Have to give them credit where credit is due.
And I feel like that's what you were describing here is like why are we doing this in the first place? Mm-hmm. What are we hoping to accomplish with this particular thing, and is it working? Even if it's supposed to work, if it's not working in my patient, we've got to stop and try it again. Did I get that right?
I, tell people I train with, that I work with, you know, the guidelines are what piques our interest in that disease, right? I'm not thinking necessarily about... our things overlap, so it's really hard to say exactly. [00:45:00] But psoriatic arthritis, for example, doesn't have a lab test, but it has clinical criteria and imaging diagnostics.
So if you don't necessarily have any abnormal labs but you look like RA, we traditionally call that seronegative RA. Mm-hmm. But we're also getting better at identifying antibodies that do mean RA, so there's a whole nother subset of RA that's, quote, "seronegative." But anyways If you still act inflammatory, there's still an inflammatory spectrum of something happening, whether or not there's a test to prove that it's there.
And I think that's where, again, the research helps us, but it also hurts us in real life because we're out there regurgitating, "You have to meet four out of these criteria," and the patient's suffering when you've potentially missed a whole disease because you were looking at the wrong criteria. You were- Mm-hmm
you were looking at the wrong disease. And so I think in rheumatology, and even [00:46:00] in, you know, with diabetes, right, the whole gamut of pre... what does pre-diabetes mean? How long are you a pre-diabetic, right? Mm-hmm. And so all of these sort of m- this minutia, it bogs us down in a way that ends up delaying the inevitable.
So I tell patients, "You might have a low rheumatoid factor and maybe one or two joints that are swollen, but I'm not gonna deny you the fact that you're still swollen and that you still- Mm-hmm ... have inflammation. I can't change that or ignore that once I see it. So I'm still gonna call you rheumatoid arthritis, and we're gonna go down the treatment path, and whether or not this changes or evolves- Yeah
We'll catch it together." Yeah. But when you tell a patient, "You're one point off from a diagnosis," and they're like, "Well, how do I make that happen so you believe me?" How do I get worse so I can get better? Yeah. Yeah, that's, that, that's a very bitter irony. It's like, "What do I have to prove to you- Mm-hmm
that I'm not feeling well?" Right. Yeah. I feel like that's not a hurdle people should have to jump over. [00:47:00] Yeah. So before we finish up, I know that you have some new exciting things happening in your, in your professional world. Tell me what's going on and, and how people can find out more about it.
Yeah. So I have a lot of things, um, happening. So I can be found on all social media platforms. I'm pretty busy on LinkedIn. I try to be. Um, but Dr. Brittany Penico or Brittany Penico DO, depending on the platform. I'm on Facebook, Instagram, um, YouTube, and then my website, drbrittanypenico is available as well, .com.
Okay. And we will put links to all of those in the show notes that will be up on your favorite podcast platform, wherever you love to listen to podcasts. And I just really wanna thank you for, first of all, giving me some, concrete things that I'll probably use in clinic on Monday- Absolutely.
Look for gout ... but for, for developing this. I, I particularly love your idea about building these communities of like-minded people who are differently occupied specialists and primary care [00:48:00] folks to be able to help people who are falling into those margins. Because like in every endeavor we have, the people that are on the margins are often the ones that suffer the most- Yes
and if we can figure out a way to meet them there I think that's a great success. So if that's what comes out of this interview, then we've, solved world peace, basically. We're getting there. We're trying, right? Yeah. Brittany, thanks so much for your time. Yes. I really enjoyed this interview thoroughly, and we'll talk again soon.
Sounds good. Thank you. You're welcome.
There's an old joke about Shmuel. He was the town hypochondriac. Every time you talked to Shmuel, something else was hurting him, or he thought he was having a heart attack or a stroke or cancer. Years this went on until, like everybody does, Shmuel finally died. His family went and buried him in the cemetery, went home and sat shiva, and continued to mourn him for the year.
When they went back to the cemetery the following year to unveil his headstone, they pulled back the cloth to show the epitaph he had chosen for himself. "See? I told you I was sick." Like Brittany and I discussed, the way our system works is enough to make anyone feel a little like Shmuel. Every day, I take care of people who feel like they too have to prove that they're sick, or more specifically, sick enough to need the treatment we both know will help them.
They're trying to document in triplicate that they actually have heart disease so I can start them on a weight loss drug that's proven to prevent heart attacks. They're counting the number of times they wake up gasping for [00:01:00] breath at night or fall asleep at the wheel during the day, which is worse, in hopes of getting approved for a sleep study.
They're begging to see a neurosurgeon for their slipped disc, but the neurosurgeon wants an MRI first. So I order the MRI, but the insurance wants to know whether the neurosurgeon thought they needed one. They need care for their mental health that neither I nor my colleagues can safely provide, but the higher level of care we want to access for them won't take their insurance or doesn't have space for three more months.
I'm not saying we should lie or make things up. I'm also not saying that, God forbid, people should deliberately get sicker, and I'm certainly not saying we shouldn't have boundaries. I'm not the right doctor for everyone, and I can't cure everything or treat everybody. The medicine or test that everyone wants isn't the medicine everyone should take or the test that everyone needs.
There do have to be boundaries, but there's a lot of gray areas in between those boundaries where people aren't getting help at all. Back to the calf, you [00:02:00] know, that strange ritual we talked about in the cold open. There's a suspicion that that murder occurred because the city didn't provide proper hospitality.
When the elders say, "We didn't see it," it's to say, "We didn't know they needed this thing. We'd have certainly helped them if only we had known." But the patients in the gray area suffer because we don't see them. We don't see them as belonging to us, as being our problem. If you're listening to this, you may be a clinician who hasn't figured out yet how you can help those people that fall into the gray areas.
Stick with us, with people like me, Brittany, and a lot of colleagues that you have that probably want to figure out a way through out of the city and into those gray areas. And if you're a patient who feels like you live in the gray area, keep advocating for yourself. Say, "Listen, I know I don't meet the criteria, but there's got to be something you can do for me.
There's got to be some way you can help me. A trial, a different medication, or just [00:03:00] continuing to listen, continuing to take care of me, and not saying, 'Well, it's not your heart. See you later.'" You still deserve care regardless of what's going on. Getting somebody to see the whole you and the suffering rather than the defined problem that isn't there is the first step.
Good luck. We're with you. Don't give up hope.