And just seeing that doctors on the large part, not living exemplary lives even though we’re seen as authorities on wellness. And so part of what I do with students i……, You know, Melissa is graduating soon from Yale, a wonderful university as a PA. And they get four weeks of behavioral health rotation. And so I try to give them four weeks of wellness. And the question I ask myself is how can I impact them the most in those four weeks to whichever field they decide to go in, it can increase their own wellness and what they contribute into the world of wellness and more holistic evaluation of their patients.

Dr Manon (04:46):

So what I’m hearing you say in this case too is that the constraints of the system make you basically manage drugs, but the needs of the patients are larger than the management of drugs alone. There’s a real, bigger need for more time, which the structure of the system makes it very difficult. And so when you’re training your you’re hoping to get this, the emphasis or the understanding of the wellness component, which you have found is so necessary.

Dr Manon (05:32):

Am I understanding that correctly?

Dr Manuj Nangia (05:35):

just one difference, which is management of people, whole people versus management of drugs. I know our training is geared towards the deductive reasoning and differential diagnosis. And then we need find that diagnosis. And then we look at symptoms and we’re trained to use medications to treat those symptoms to get rid of symptoms. And so in treating the whole person, right, this is a shift that I know medicine is going to be making and I’m just contributing towards that shift, which is focusing more on their wellness, optimal living versus deductive, getting rid of depression. How do I get more wellness in my life and what’s blocking me from there and how to do that in a limited amount of time.

Dr Manon (06:33):

I was trying to emphasize the limited amount of time, you know, cause it’s a, it’s in the integrative types of settings. Obviously you can have like a naturopathic doctor deal with nutrition because obviously nutrition impacts your gut health impacts, you know, all of your mental health as well. Right? So the thing is you really need a bigger team, but then it leaves you with managing drugs because most people are not in a position to manage drugs. And so many people are on so many drugs. You know, when I started my practice in, in Nova Scotia people are on like eight to 10 drugs. And you know, at that time they didn’t even have in the pharmacies, they had no way of knowing if you didn’t, if you wanted something, you could go to a different pharmacy down the road because there was no centralized records whatsoever.

Dr Manon (07:34):

Right. So people were on contradictory medications for their general health, but you know, psych, psychiatric health that they had, like it was, it was really crazy to see how it was just left completely open and quite dangerously. So that was in my experience. So I’m really glad to see that there’s, I think you’re right we are towards a trend that there has to be complimentary connections between what we eat and, you know, the context of our wellness, the context of health and what our support networks, all of that absolutely matters to a patient. So Melissa, I wanted to ask you, what is your experience so far in your studies and then coming into practice? What are you seeing or observing?

Mellisa (08:33):

Pa,s are generalists. And so our training is 13 different rotations in all the different fields of medicine. And then we have three electives. So right now I have the good fortune of working under Dr Nangia. And so in my behavioral medicine, as he said, it’s four weeks and it, and it is very short, a PA education is a very quick education. Our program’s two and a half years. So I’ve seen a little bit of a lot of different things and what you guys are speaking to as far as, you know, the focus on medication management and the time spent with patients and how the billing and just this system is set up. You know, not, not to point the blame at anybody, but it’s, it’s difficult to, to envision, which I had. The idea is going into PA school of being able to treat the whole person and do exactly the things that dr Nangia is trying to do in his practice.

Mellisa (09:28):

And so it, it’s, it’s definitely been an honor to witness this, that it actually can be done. And the struggles that, that, that you go through and, and how the staff works together to accomplish this. And even if daily you’re faced with the challenges of billing and the amount of time that you’re allowed to spend with patients, I’m still looking to treat them as individuals and to come up with treatment plans specific to them. And I think part of that is seeking a balance in our lives. And that’s something that dr Nangia and his wellness center really focuses on. I think a big key to our health is balance, you know, whether that be work or life or spirituality or all the different factors that we consider important as humans. And something we’re facing now, of course with the pandemic, you know, being able to be social creatures is something that’s, we’ve had to rely more on technology for that aspect of our lives.

Speaker 6 (10:26):

But I have seen some incredible, amazing things in my education that have just touched my heart. How doctors such as Dr Manuj Nangia…. PAs and NPS that have preceptored with me, have worked with patients and helped patients. And that’s one of the reasons I wanted to be a PA with so that I could make a difference in people’s lives while also supporting my own life and my family’s life. And so yeah, my education has been very encouraging and heartwarming and I haven’t chosen a specific field yet, but definitely behavioural medicine is near and dear to my heart because I was worked in corrections and mental health for about nine years. And so yeah, that’s something that I’m familiar with and that even in my personal life, I have a very strong interest in evolutionary psychology. So …..

Dr Manon (11:22):

So,what got you, because part of what I’m covering in this podcast is what brings people into this healing profession? On what levels of, what was it for you that started this whole journey?

Mellisa (11:38):

Well I served 10 years in the military as a medic and it was kind of a natural transition for me to go into PA. That’s kind of the expected next step. And I would love to stay a medic. But the civilian equivalent is EMT and I just wanted to do something a little differently. So PA sounded like the right step for me. And doing a career later in life, considering doing a longer education that an MD read require is something that didn’t sound as reasonable to me at my age. So the, the shorter education and the continuing of my current path in the military and I, as far as being in the health field, you know, there’s, there’s all these reasons that, that we have for why we want to be in the helping field and specifically medicine in, in, in our lives. I had a mother that passed away of cancer and my dad had many years Parkinson’s and just taking care of both of them is, is, yeah, that, that also brought the field of medicine closer to my heart.

Dr Manon (12:55):

And what about for you, Dr Manuj What was the….inciting and then we’ll talk about balance. because I, I’m very interested in what you have to say about what was the, the thing that brought you into this field.

Dr Manuj Nangia (13:09):

You know, I don’t really know, to be honest. I had a vision of it since I was little. My parents, unlike some, you know, Indian immigrant parents, mine didn’t really push any particular field. Maybe that’s why I was more open, toit. But as I got older I also saw that there were some practicalities. I love the sciences and I didn’t want to be a researcher and I don’t know how much of it was compassion based to be honest. I know that some of it had to do with I decided that I’m going to do this and so I’m going to do it and I wanted it to be a heart surgeon. That’s what I wanted to do all the way until my third year of medical school when I did six weeks in LA County general hospital of trauma surgery. And at that time I didn’t want to do five years of surgery because my life went right before my eyes. And you know, I was not sleeping. This is right. As they were limiting the hours to 80 hour work weeks, it was almost the same year that they started limiting that. And so people weren’t even following it. And so yeah, I’m not really sure how the journey got me here. But yeah, I’m glad I’m here now.

Dr Manon (14:38):

Well, I mean everyone has their, their journey and thanks for being so transparent about it, but, so what, but for a psychiatrist to go into integrative wellness, what was there, what happened that made you realize that we need a bigger perspective on health and wellness? Like what was, there people that you helped that you realize that there were limitations or what was the thing that made you realize we need to have a bigger balance? A bigger view?

Dr Manuj Nangia (15:15):

you know since I was in my residency at USC LA County, I saw a big emphasis on medications and that the faculty were getting sponsored by pharmaceutical companies and they were coming into our schools and giving us these lunches. And, you know, I think common sense showed me that there’s, there’s bias in how we’re practicing. And there was not that much support on the therapy side and how much therapy was learned. It was very didactic versus experiential process learning. And that’s what made me shift to work with David Burns who’s just a great teacher and just brilliant therapist. It was all hands on. It’s like learning basketball by playing basketball versus reading about basketball. So everything changed. And I think that’s how I started my career was questioning. And that question led me to, to to go and try something and then seeing the results. There’s four spectacular and that same went towards alternative and complimentary medications. You know, I, I had a mentor, another mentor at Stanford, maybe because I was so close to a learning hub. You know, James Lake who’s really you know, someone who’s been leading our field in integrative you know, psychiatry as, as a mentor early on. So I think a large part was influenced by questioning and then finding mentors in those realms. And just the influence I got from that. And the doors that opened up and what I saw.

Dr Manon (16:56):

I do agree, it starts with questioning. The question is how do people start questioning? What do they need to see? You know, what is it that makes you become, you know, what I would call it critical thinker, critical, not being negative, but critical, asking, you know, asking questions so that we don’t just take the status quo as the absolute given, you know, and that really is a paradigm shift, you know? And, and to dare to to see something you’re unfamiliar with and see with open eyes, whether it has benefits or not, you know, and just to come in as what’s the expression in English? I’m like a learner, you know? Like a child, you know, what is that called? There’s an expression on child’s mind or whatever your mind, beginner’s. That’s what it is. Yeah. You know, and I think that’s very much a needed, you know? So let, let’s talk a little bit about balance. Can you, can you explain what you mean by balance for from your field? What does that mean for the, for the client, for the patient.

Dr Manuj Nangia (18:18):

So if we’re looking at our lives as a whole, we have different parts, we can break it up and how do we break it up and quantify it? And if we do do it ourselves, what are we likely to be missing? There’s actually a measurement now in our culture of measuring and data that have been validated on what is wellness? And you know, the world health organization defines it as a complete physical, mental and social wellbeing. So at first, if we’re shooting for optimal wellness, optimal physical, mental, and social wellbeing, you know, how do we break these components up into smaller parts and check for it? So we actually, I actually use a scale and we use it for our staff and the clients we’re doing therapy with to find parts of their lives that they might be missing on there might be humour scores or low or leisure scores are lower. Spiritual scores are low not getting enough sleep in nutrition. And so it just helps us figure out by the person. And then with Debbie buddy, I see whether it’s medication management or, or therapy, it’s, I inquire about the different realms and then I spend more time on one wrong that I suspect it to be low for for somebody.

Dr Manon (19:52):

Okay. And so have you from your experience with this, has it impacted the amount of medication that that is so-called needed by these patients? Like have you been able to, you know, by suggesting that they look at their nutrient intake or their sleep or their social support systems have, have you seen that, that it can impact the need for as much medication as they may have originally been on’

Dr Manuj Nangia (20:29):

That’s probably one of the most important aspects of having students come in. Most medications in my field are prescribed by primary care doctors. SSRI is and having students see a more integrated approach where a person’s having and the process of working through those symptoms to see are we going to use this medications for it or are we going to make recommendations for that. And so yeah, definitely there’s a, there’s an impact on the amount and a number of medications we use by using this approach.

Dr Manon (21:09):

it’s a systemic problem, but most medical doctors have like seven minutes with people and it’s like there’s no time to find out about everything else. And so they have inner symptoms that qualify for this in the Merck manual. And off you go, you’re going to take this and if things get worse, we’re going to, you know, then refer you to a psychiatrist, you know, which usually means more drugs, right? Maybe different drugs. But it, there’s really a gap there that, that I’m seeing from so many of them. People I’ve seen that have gone through that route and have not really had their fundamental wellness looked at there. And you know, they’re a bigger picture, right? It’s like, it really is drug pushed.

Dr Manon (22:09):

And I, and I think if you look at the infrastructure as you mentioned too, you know, it’s who’s funding what, who’s funding the schools, who’s funding the programs, who’s funding, you know, the lunches and the lunch and learns, you know, and, and I think it is, it is a systemic, bigger problem, which this pandemic is definitely pointing, you know, we, we have issues clearly systemic issues, you know, and I think as much as it has a major impact on people on the, on the personal level, I think as a system approach, it will force fundamental changes, hopefully in the right direction, you know? And do you, do you have any comments either of you on, on that statement or anything to share?

Dr Manuj Nangia (23:05):

Yeah, most of what have you seen in the past, you know, several months of doing your rotations? Perhaps if we focus on the mental health side on or you can just in general, how symptoms are managed, chronic health conditions. You know just what’s your experience?

Mellisa (23:25):

I think I, my experience has been varied, but just to take some specific examples I was able to do part of my internal medicine rotations with the site that also does integrative wellness. And they do functional medicine and also nutrition. And, and in that setting, when a client’s signs up for a functional medicine appointment, they, have an hour with the doctor most times and then half hour follow ups. But when they sign up for a regular traditional Western medical appointment, they maybe have 15, 20 minutes with the doctor. And the nutrition is about the same as the functional medicine. They can have an hour and then the follow ups are about a half an hour. So it seems like the time allotment is more when you go to a more holistic approach. But I’m also finding insurance payment for, for that type of time being spent is difficult. And but it was still encouraging to see that there’s a clinic like Dr Manojis that is, is combining all these factors of the, the wellness for the patient and doing individualized treatment plans.

Mellisa (24:36):

I know that, you know, we’ve done all the different settings. So as far as emergency medicine or internal medicine or paediatrics, it, I guess it depends on, you know, and I’ve done it in different States as well, so it depends on kind of what your peers are doing and what insurance will pay. But I think it takes having this being important to you and really believing in it. And, and just kind of standing up to the system and trying, finding ways, being creative to make that happen. I mean, doctors still have to make a living. This is their job and there’s nothing unethical about that. And so being able to make money and provide for your family and pay off student loans it is valid and it’s important. And treating the patient as a whole patient and giving them the time that they need. You know, there’s, there’s creative solutions to these problems that we face and, and I think they’re important ones that we face them.

Dr Manon (25:39):

Yeah. So like, I mean, a big part and I totally agree. You know, after all the training, everyone needs to be paid for what they do. But can you foresee or do you have thoughts either of you can answer, you know, how, how a better system could be set up so that, you know, the findings that you have in your experience of wellness be more easily integrated and manageable financially. You know, how do you see any bigger picture for, for the world, but could put all of this together? You know, I’m true collaborative approach,

Dr Manuj Nangia (26:23):

what I’m doing with my kids is I’m trying to influence them at a young age to have the practice. We have Google now, right? So we can get information, we can learn things so quickly and so easily. There’s a negative part of that is the instant reward where getting used to on the other side is we have the ability to start growing into, there’s a Term expert generalist expert. So, so becoming a generalist knows the little bit of a lot of different things. An expert knows a lot about one thing. So why not be someone that knows a lot about different things about nutrition, about fitness, about relationships, about, you know, our psychology and you know, or chemistry or neuro certain. And so practitioners I think and, and kids we can start the process of questioning and finding things we’re interested in and then exploring and learning wellness……. The one that there’s so many different aspects to it.

Dr Manuj Nangia (27:38):

And you know, how much nutrition do doctors get in medical school? It’s, it’s, it’s known. We get very limited education on nutrition. And so with that limited, if all we have is a tool of medication and that’s what we know about the biochemistry and the tool, how often are we can use and implement some of these other healing strategies for our patients. So doctors becoming you know, generalist experts. And so we, we lead the way by doing it ourselves, by talking about it and perhaps by modelling it others might be interested in doing the same and we have something at our practice that we do it. We, we, we be the wellness, we be the person that we want our clients to be a priority when they’re here is their priority is to practice wellness over anything else as a part of their four weeks here.

Dr Manon (28:44):

That’s, wonderful. because I know there was a time you would go to your and doctor and they would be smoking. There’s even commercials come out, cigarettes recommended for Camel cigarettes by Doctorrs , exercise was not a thing at all. You know, so it’s, it’s interesting how, you know, definitely modelling the behavior is a huge influence.when your doctor is actually more healthy than you are, you’re like, Hmm, what are they doing? You know? So and I think as, as parents for your children as well. And it’s not just the physical health, it’s the, it’s the mental, emotional health, the relationship health, you know, how, how you are in community and in communion with other people.

Dr Manon (29:38):

You know. So, yeah. And that’s a very interesting, I, I when I did my journey, I I was actually accepted both in medical school and not Naturopathic school. And I decided to go into naturopathic school because our training is similar in the sense of the pathology the physiology, the anatomy, the the basic sciences and that understanding. But I found that it gave more breadth of solutions and more, more insight into wellness. You know, so we ha we do understand nutrition. We do understand psychology to a point. Again, we’re not specialists of any one part homeopathy, you know, all of these medicines that were sort of put down generally by the press because there’s a lack of understanding of the, the way research needs to be conducted. You know, which is another thing that’s a whole paradigm shift.

Dr Manon (30:41):

But you know, it gives you that generalist and the ability to refer and collaborate, you know, with people. But it, I feel like it’s so important to go through this like sieve of wholeness before going down. It’s like, you know, I keep saying this way, if you go to a butcher, they’re not going to tell you what vegetables to eat, you know, unless they’re, you know, a fan of great cooking, then they might put the two together, but they’re going to tell you which cut of beef to buy, for example. Right. So I think we definitely are at risk with the way, at least in the Canadian system, the way everything goes to specialists before really having a full understanding of the whole person. You know? So how are in the States, cause you’re both in the, in the States, how, how does the payment structure work for you know, for seeing a psychiatrist and also so that you can extend out to this wellness approach on any level of funding or how, how does that work?

Dr Manuj Nangia (31:53):

So you have a tough condition, depression, anxiety being the most common. You see a psychiatrist, I take private insurance, the most common ones, blue cross or Cigna, United health, you know and so you have a copay that you pay. So patients will pay $20 a visit and we’re, you know, we do about 45 minutes for a new patient intake. And for the patient it’s just a, it’s one fee that they usually pay. Sometimes they have a high deductible and when they go out of network, most of the times it’s going to be cash insurance won’t cover it. But many doctors are in network for psychiatrists and mental health. Most of my colleagues are not in network. So there would be cash and most of my colleagues who are therapists are not in network. So they would have to pay cash and you know, which gets expensive sometimes $600 an hour for a psychiatrist, junior dollars an hour for a therapist.

Speaker 4 (33:02):

And so, you know in mental health, people who have the money they would see somebody who is a cash provider, namely because they usually have more experience or more skilled. And that’s just you know, it’s like there’s things we don’t talk about, but this is just the way it is. That’s the way it is. And you know, I think it’s almost like if I’m going to see a therapist that takes insurance, I don’t know what kind of quality, you know, therapies like are and how do I know how good they are. We don’t really have outcome measures or track that. And so you know, it’s kind of, that’s that’s the way the system is right now. And you know, we’re, we’re trying to do something about it several of us and we’ll see if that changes in how that changes in the future by tracking outcome data.

Dr Manon (34:01):

we have results double-blind you know, or evidence-based drug results, but that translates completely differently in practice, right? It’s not, you’re not just a doctor here’s your drug and off you go, we expect the same results it changes by everything. You know, the entire, the encounter, everything affects the impact of the drug. Right. And that none of that is measured. Right. And they think from a science based perspective, that’s crazy. You know, everything must be, and then they could see that there’s actually a lot more that goes on than the drug itself.

Dr Manuj Nangia (34:57):

Yeah. More and more of us are trying to track outcomes and we’re basically doing it ourselves.i had my students play a big role. Melissa has been playing a big role and in that we’re trying to collect data and our clients rate their mood anxiety scores every session along with their different stressors and and some of their wellness scores. And so we’re trying to correlate variables with outcomes. And the students are also inputting the they’re dosages and and they’re also inputting side effects. So what are the real rates of side effects of Prozac causing weight gain or sexual side effects and how effective is Prozac versus exercise and helping improve this person’s outcome and or spiritual scores. And so we’re, we’re collecting data and you know, it takes time to put it together.

Dr Manuj Nangia (35:54):

But as students like most are just doing a great job in this you know, and so we’re, I’m in the process of that. Some of my colleagues in the process of doing something like this, it’s just a matter of time until the pharmacy pharmaceutical industry, there’s no longer have control over the data. We have large amounts of data out there. How do we call it it and put it together and give it to the people so they can see for themselves what, where are these numbers and you know, unpublished versus public studies. And you know, the ethics on how the studies are done is that the standard is the double blind placebo control. And what if we just collect a large number of outcome data and, and see for ourselves what’s really helping people.

Dr Manon (36:43):

Mm. Well, you know, it’s funny cause my, my background is law and you know, and I’m thinking like it’s informed consent. Like what is truly informed consent when what you’re relying your information on is so limited.

Dr Manon (37:01):

You know, it’s like not only are you not told about other things that may help you because not …………..it’s not personal. It’s just that if you don’t know, you don’t know. If you haven’t researched anything else, you don’t know that there’s maybe other options for people to, to help. But you know, it really begs the question of informed consent. How much do we, does the public really, how much should they get to know, you know, and how do we control that whole part so that it’s not a one view and one perspective. The one that has so far, all the financial backing, you know, cause we all know money, you know, money is not a problem, but it’s a problem if if it’s the only way we can get information, you know, and back things up too to understand one specific perspective. Right. So that’s very interesting what you’re doing. That’s, that’s great. Have you talked about that so that other people feel inclined to follow suit and, and get results based rather than just, you know,

Dr Manuj Nangia (38:20):

Most of my colleagues I spend time with are more than a therapist side and we have similar training and they do outcome measures for every session that they’re with somebody. Yeah. I also have a colleague who I’m close with who started a clinic for children and he’s actually creating an EHR that does outcome data measurement. And so, yeah most doctors or, or you can say working really hard and at times the burnout rate is high and we’re pushing through that burnout rate. And so there, there are measures in generally what I’m seeing is just not so organized. And you know, it’s not used optimally and we’re in the process of trying to figure out how to optimally use it as well. It’s just you know, yeah.

Dr Manon (39:19):

Yeah. No, it’s yeah, I think that’s actually pointing to something that sharing that we might get people that can put this together and see this. because I think it’s so it’s so relevant, you know, to be able to share it. That’s true experience, right? It’s, it’s true outcomes. So I think that’s wonderful that you’re doing this work, you know, and it’s really hard as a, as a practitioner to do all parts, it’s impact impossible, you know? So like, Anyway, it’s really great, Melissa, that you’re helping in this project and you know, I, I’d love to get more people to understand the importance of this work and how to, to put this forward. You know, I do think as a collective mind, things will come up that, that move this project forward, you know, so that’s good.

Mellisa (40:16):

A wonderful opportunity for me as a student. I’ve only had one other, a rotation where they conducted research. And I think what Dr Manoji and what you were talking about modeling the behaviour in yourself and with your employees and your students. I can vouch for the fact that definitely our personal wellness of students is, is paramount. It’s, it’s a huge factor in our rotation. And I, I think the research that he’s doing is extremely important. In the other rotation that I had, I, I they, they actually had their own research centre that they were setting up. And then there’s also issue of financing that and the staffing to take care of that. They set up a foundation so that they could have donors so that they could have funding for these things and to have the outcome data that evidence based medicine to support diet and lifestyle changes and alternative therapies like homeopathy and herbal remedies and so forth. we don’t have the, the EBM for that. And, and I, I, that’s also near and dear to my heart that, that we go towards that. And I think modelling and getting the evidence is that the two really important things that you both have said and the financing is an issue. I mean I struggled two months at this other rotation because basically it was not covered mostly by insurance was not covered. And so people of a high SES were able to access these medical services. It was an integrative wellness center and on the one hand that just is the way it is. And on the other hand, I think, okay to the future people that have money can participate in this and get the evidence so that hopefully in the future people that don’t have the economic means can and then have insurance help or some sort of government help where they could if we have the evidence to show, look, this works,then people without means could have access to the same medical care, which they don’t know

Dr Manon (42:19):

Exactly. Yeah. And the net result of being healthy is, is totally worth it in society as well for the benefit of society. It’s not just a individual, I’m healthy, but it’s like I can then contribute more. I can, you know, it has far reaching implications because we have so many people, you know, who are off work or so sick at work that they’re not being productive. So even from the purely like financial perspective, looking at all of this is, is really important because I think it, this can positively change the world in the sense of we can really learn, you know, and that will impact future health care in a possibly in a very positive way. You know? I agree. All right. Well, I think our time is up, so thank you so much for agreeing.

Speaker 1 (43:35):

 Thank you for joining us. For more information, go to DrManonBolliger.com.