Episode Transcript

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Daniel Lobell: (00:00)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs. Hello and welcome to the Doctorpedia podcast. I’m your host Daniel Lobell and I’m honored to be joined on the line today by Dr. Barry Shibuya. How are you, Dr. Shibuya?

Dr. Barry Shibuya: (00:33)
Doing great. Daniel. Nice to meet you.

Daniel Lobell: (00:35)
Nice to meet you too. You have a very unique last name. Can you tell me where that comes from?

Dr. Barry Shibuya: (00:42)
Shibuya is a Japanese last name.

Daniel Lobell: (00:46)
What does it mean?

Dr. Barry Shibuya: (00:49)
That’s a very good question. To tell you the truth, I really don’t know. [Laughs.]

Daniel Lobell: (00:56)
Well maybe I gave you some homework. [Laughs.]

Dr. Barry Shibuya: (00:59)
Yeah.

Daniel Lobell: (01:00)
I’m always fascinated by those things. My last name Lobell is French. It means ‘the beautiful’ – I think I live up to it. [Laughs.].

Dr. Barry Shibuya: (01:07)
Oh, awesome. [Laughs.]

Daniel Lobell: (01:09)
It’s a little bit of a braggadocious last name.

Dr. Barry Shibuya: (01:12)
Yeah. Cool.

Daniel Lobell: (01:14)
So you are doing it right, my friend. You’re out in Hawaii, right?

Dr. Barry Shibuya: (01:18)
Yes. This is where I’m originally from, born and raised, and I just moved back here a little bit before the COVID pandemic struck. Before that, I was living and working in California, mainly Northern California, San Francisco bay area.

Daniel Lobell: (01:37)
So you went from one resort area to a better resort area?

Dr. Barry Shibuya: (01:43)
[Laughs.] Well, one could put it that way, I was actually in the east bay of San Francisco in a city called Fremont.

Daniel Lobell: (01:49)
Okay.

Dr. Barry Shibuya: (01:50)
I don’t know whether you’re familiar with that area, but it’s the East Bay, not actually in San Francisco itself.

Daniel Lobell: (01:57)
Okay. I’m not sure what that means. Are you saying it’s not a nice area or it is a nice area? I’m not sure.

Dr. Barry Shibuya: (02:03)
No, it is. But when you say San Francisco bay, I think people have a preconceived notion of actually living in San Francisco, but there’s a lot of people who live in surrounding communities around the peninsula bay area. So I’m literally across the bay, east of San Francisco.

Daniel Lobell: (02:22)
Got it. Which Hawaiian island do you live in?

Dr. Barry Shibuya: (02:28)
I live in the main one, Oahu, which is where I was born and raised. Since coming back, it’s changed dramatically. I grew up here, and lived here for about 30 years before I left to go to school in LA. But since coming back, it’s just been an eye-opening experience to see all the changes that have occurred since I left in about 2000.

Daniel Lobell: (02:55)
I’m very curious to hear what these changes are.

Dr. Barry Shibuya: (03:00)
Well, it’s become much more developed. There are a lot of “transplants”, especially from California who are changing the physical work landscape in Hawaii. I live in a new development area called Kaka’ako, which, when I was growing up, was mainly an industrial warehouse area, but now it’s a new area where all these high-rise condos are being built and a lot of new restaurants and shopping centers are being developed. So it’s really changed and there’s good with the bad – the development is nice, but like anything, traffic and increases in costs of living come along with it.

Daniel Lobell: (03:50)
And they’re killing the beauty of the island, the natural beauty.

Dr. Barry Shibuya: (03:54)
Yeah. You can still drive 30 or 45 minutes out of town and get the natural beauty, but nothing compared to the neighboring islands or what I had envisioned of the neighboring islands, that I used to visit when I was a child.

Daniel Lobell: (04:13)
Yeah. So not too many people I know can tell me much about life in Hawaii. So I’m going to pick your brain a little bit about your childhood there. Obviously from our perspective, our life is normal, no matter where we are, but with the broader perspective you now have from having lived elsewhere, what do you think made growing up in Hawaii unique and different?

Dr. Barry Shibuya: (04:42)
Well, it was quite safe. It’s a small island. I think now we’re 1.2, 1.3 million people but when I was growing up, there were under a million. And because of that small community sense, it was a common saying that you need to be mindful of what you say, how you act, because you may either know someone or be related to someone, which I find to be quite true in a small community. And I think it changes not only how people act, but also how they treat each other on a day-to-day basis and their philosophy of life in general. Living in the mainland was a great eye-opening experience. You can hop in a car or take a short plane ride, without traveling five hours across the Pacific and you can then go to a totally different place, experience new cultures, new foods, new ideas, new ways of living.

Dr. Barry Shibuya: (05:54)
So that was really exciting and you didn’t have to worry so much about knowing or bumping into people that you had already known or met before. So that was a big change, growing up in Hawaii versus going to California. I really valued and cherished the additional opportunity that was provided by moving to the mainland. I did my undergraduate and medical school and internal medicine doctor training in Hawaii and so the first time I actually left to be on my own and be away from my family was when I went to LA to do my specialty training in rheumatology.

Dr. Barry Shibuya: (06:46)
And so I jumped at the opportunity and was really, really grateful to be able to experience that and loved it so much that even though I was planning on coming back to Hawaii to practice after specialty training in LA, the plan for me was different. I moved from Southern Cal, was going to USC and I was living in Pasadena and then I relocated to the San Francisco bay area and established my home base there and had my own practice there for almost close to 15 years before starting deciding to come back home.

Daniel Lobell: (07:31)
Was it COVID on the horizon that inspired the move back?

Dr. Barry Shibuya: (07:37)
It was for personal family reasons, I just had my son and basically all of my family was in Hawaii. So I wanted him to be able to have something similar as far as a childhood experience because my brother, his kids, my sister and her kids, my parents are still fortunately both healthy and grandma and grandpa can see and interact with my son. So it was really a personal decision. It was difficult because I had a very successful practice there. People were very surprised that I closed it up and moved back, but if I had to choose it and do it all over again, I would do the same thing because being around family and having and knowing who these people are on a regular basis – you can’t put a price on that. That’s really invaluable. And I really think my son is fortunate enough to be thriving because of that. So I’m really, really grateful for that.

Daniel Lobell: (08:42)
It makes sense. I was just talking to another doctor on this podcast and they were prescribing spending time with family as their top choice of medication for health. I agree, spending time with my family is some of the healthiest and best time that I spend.

Dr. Barry Shibuya: (09:05)
Yeah.

Daniel Lobell: (09:07)
So you went into internal medicine and rheumatology. What made you decide to specialize there?

Dr. Barry Shibuya: (09:17)
Well, it’s really funny. Going into medicine in general, I really thought I would be helping people stay healthy and not get sick, but what I learned is that when doctors get into medical school and then decide on a specialty, internal medicine focusing on adults, we really focus on diagnosing diseases and treating diseases. We don’t spend a lot of time keeping people healthy per se, which is an interesting point of discussion, and which actually changed my practice later on. To answer your question, I really liked understanding the different potential medical problems, whether they be lung problems, heart problems, kidney problems, and so general internal medicine was great because it focused on various different disease processes. But it can be overwhelming and I realized that not only is it very difficult to be a primary care physician, but also that it’s often not well appreciated.

Dr. Barry Shibuya: (10:35)
So realizing that and understanding that, I was desperately looking to find a specialty that would allow me to focus on certain diseases or disease processes, become a little bit more expert in those areas to be able to help patients, and hopefully not be so burdened with taking care of all the potential elements that a primary care doctor needs to deal with. When I was going through my training, my colleagues were initially interested in critical care medicine or ICU medicine. And that was very interesting, fascinating. You dealt with the sickest of the sick and you really were able to help people more on an immediate basis. But I quickly realized that in order for physicians to be able to help heal the sick, they have to be able to really take care of themselves first.

Dr. Barry Shibuya: (11:44)
And so I realized that even though I was in my twenties, I could not really see myself going through the rigors of a medical ICU style practice. So I kept looking and then I discovered that there are organ disease specialties, meaning the lung, the heart, the kidney, or there are disease process specialties. So dealing with infections, dealing with cancer or what I ended up choosing was rheumatology, which is generally autoimmune or your immune system attacking various organs in your body. I liked rheumatology because at the time that I was choosing a specialty, rheumatology really was being transformed. So this was in the late 1990s. There was the first biologics or medications that we could administer for patients with chronic inflammatory rheumatoid arthritis, which is not a very common form of arthritis, but a pretty debilitating one.

Dr. Barry Shibuya: (12:55)
It really revolutionized what we were able to do for patients. I clearly still remember doing a third year elective in rheumatology during my last year of internal medicine residency training, at which point I still didn’t know what I wanted to do, but I specifically remember seeing newly diagnosed, usually young women in their twenties, thirties, forties in the prime of their lives, coming down with this really debilitating inflammatory arthritis, which made their joints painful, achy and swollen. They couldn’t take care of their partners or family, and sometimes they couldn’t even take care of themselves. And they were really, really debilitated by it. And during that one month elective, I would see their lives be transformed back to what they were before. I would see these young women come in and they’re able to walk. And then within a couple of weeks using initial standard of care therapy, but then in some cases advancing them onto what had recently been approved at that time, an injection called Enbrel or an IV called Remicade , these women were basically feeling back to their old normal selves.

Daniel Lobell: (14:26)
Is that still standard practice to use those injections?

Dr. Barry Shibuya: (14:29)
Since the late 1990s, that’s really been the primary focus as far as continued research for new biologics for new indications, besides rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis. And so when I initially signed up for the elective, I thought I was going to see a lot of old people who just complained a lot about pain. I did the elective because I said, “Well, if I’m going to do general internal medicine, I know that a lot of people come in for joint pain. So I better learn something about arthritis.” So that’s why I did the rotation initially. But going through that experience, I thought, “This is really cool.” The patients loved you because they thought you were a rock star as far as figuring out what they had and you could actually do something that changed their lives.

Dr. Barry Shibuya: (15:28)
So I was really excited about doing that. And so I applied and found a clinical fellowship at USC. I applied in my third year and I started two years later. And ever since that time, learning about what medicine and modern technology can do to help people with medications has been a tremendous tool to have in my toolbox, but after my fellowship, it was very glaringly obvious when I started my clinical practice outside of training, that that’s not initially what patients really wanted. And I specifically remember thinking to myself, every time I saw a new patient, I would tell them, “You have rheumatoid arthritis and this is how we treat it with medications.” And a common response in patients was, “I don’t really want rheumatoid arthritis” and I sat there, and started thinking about what patients were trying to communicate and my initial response was, “Well, it’s not something I’m trying to give you, it’s something that you have.”

Daniel Lobell: (16:55)
[Laughs.] Can I offer you gingivitis instead?

Dr. Barry Shibuya: (16:58)
[Laughs.] Exactly. But what I came to understand is that patients were telling me, first and foremost, “I don’t want a diagnosis of a chronic condition.” Because arthritis is usually a chronic condition, which means that if it is present for three months or longer, you cannot treat it to make it go away. And we do not have anything to prevent you from getting it. So no one really talked to me about that or taught me about that during my internal medicine and my specialty rheumatology training. This is something that I sat and thought about, because what patients were actually looking for and what they wanted guidance and help with was what they could do besides having to rely on taking a daily medication to treat their symptoms, which was completely the opposite of how I was trained as a internal medicine doctor and then as a rheumatologist.

Dr. Barry Shibuya: (18:08)
But this was actually what I had initially thought going into medicine would be about, educating, motivating, supporting patients to do it. And so with that now new knowledge of diagnosis and the medical treatment, I quickly realized that I did not have much training or expertise in helping patients get the information or support them in doing things that they were capable of doing. And so began my journey into integrative medicine which is a new field, where typically Western trained regular medical doctors who go through medical school are taught to think in a certain way. So we are taught to initially focus on the diagnosis, rheumatoid arthritis, hypertension, diabetes. We make a chronic disease diagnosis, and then we’re taught to treat it with a pill.

Dr. Barry Shibuya: (19:24)
We’re trained to focus on disease diagnosis or illness, and then we treat it with a pill. And this ill pill model is not really what initially a lot of patients are looking for. But don’t get me wrong – I still help patients diagnose their condition and talk to them about what is the standard of care medical treatment primarily focused on medications, whether it be pills, injection, infusions. But, at the same time, I always try to make it a point to educate, motivate, and engage patients with what they could be doing that has been shown to be helpful in the sense of making their disease prognosis better, making it less severe. and hopefully with the goal of limiting the amount or the dose of medications that need to be taken on a chronic ongoing basis and to be able to do that, it takes a lot of time. And so what I started doing in my practice was changing the way I practiced.

Daniel Lobell: (20:44)
I read about the SENSE approach, right?

Dr. Barry Shibuya: (20:54)
Right. So that’s an acronym. The first S is for stress management, E is for exercise and N is for nutrition. The second S is for sleep and the second E is for engagement or your social support systems, like your family, like friends. And so I actually coined the SENSE approach after attending an integrative conference in Las Vegas, of all places.

Daniel Lobell: (21:33)
[Laughs.] Not the most sensible place.

Dr. Barry Shibuya: (21:35)
Correct. [Laughs.] It is kind of odd.

Daniel Lobell: (21:38)
It’s not what you think of when you think of health, but I heard that they actually have a lot of great doctors in Las Vegas.

Dr. Barry Shibuya: (21:45)
And so what I did was at the time I was running a nonprofit in the San Francisco bay called the Northern California Rheumatology Society or NCRS, and every couple years we would have a patient educational symposium. So my rheumatology colleagues and friends would get together there on a Saturday, rent out a hotel lobby or hotel room and invite people from the public to come and learn about different forms of arthritis or things that rheumatologists take care of. And I would do the wrap up, lifestyle approach with practical recommendations for them. And I was fortunate enough at that time to have the resources to videotape these presentations. So I still host them on YouTube. You go to YouTube and type in my name, Barry Shibuya and you’ll find them. And I’ve really found them to be probably the most useful and most appreciated tools that I give to my patients that I see in my practice now. The videos are long. They’re about 40, 45 minutes. And so one of my goals with Doctorpedia is to break them down into shorter bite-size chunks, to give them more piece meal because no one wants to watch a 40 or 45 minute YouTube video.

Daniel Lobell: (23:23)
There’s got to be someone who does. [Laughs.]

Dr. Barry Shibuya: (23:28)
[Laughs.] Oh yeah, some of my patients do. And to tell you the truth, I have yet to find a patient that I’ve seen in my clinical practice to which these concepts really do not apply because for people who identify and manage their stress, who are exercising, who are having a balanced healthy diet, who are sleeping well and who are engaging with people who are loving and supportive of them, they’re generally very healthy. I don’t get to see these people. I see the people when diet and exercise may not have been a priority and arthritis developed secondary to the weight gain that comes on.

Daniel Lobell: (24:16)
So is that common? Weight brings on arthritis?

Dr. Barry Shibuya: (24:21)
They go hand in hand. So if you look at our rheumatology practice because we’re dealing with joints and pain, which often impact your ability to stay physically mobile and active, if you have a bum knee and you used to run for exercise and you’re not doing anything else and you can’t run anymore because your knee is shot, it’s logical to see that weight can secondarily become an issue as you age. So I get a lot of patients coming in for knee pain, back pain, neck pain, and not only do I evaluate their specific arthritis complaint but also I always try to remember one of my rheumatology mentors: whenever she speaks, she says, “Always remember that you’re a general internal medicine doctor first,” meaning look at the whole patient.

Dr. Barry Shibuya: (25:24)
You’re not just seeing a patient with rheumatoid arthritis. You’re seeing a patient with rheumatoid arthritis who may have diabetes, depression, sleeping problems, stress issues, so you need to make your treatment recommendations that are appropriate for the entire patient. All rheumatoid patients aren’t the same, some have other medical conditions, some have stressful living situations. And so you always need to be able to customize it. And the thing that I like about this sensible approach is it allows you and reminds you to look at your patient as a whole, treat your patient as a unique individual because if you try to pigeonhole every rheumatoid patient into a certain framework as far as diagnosis or treatment, you’re going to get a lot of unhappy patients.

Daniel Lobell: (26:19)
Yeah. It’s not one-size-fits-all when it comes to medicine, of course everybody’s unique and everybody has their own set of things working in tandem, which could be disease or not. From talking to doctors, I know that there’s so many things that are cause and effect going on with every patient, that many different problems are linked to each other and one causes another causes another and it’s so different from case to case, correct?

Dr. Barry Shibuya: (26:57)
Especially when you’re talking about pain. And so one of the things that I did very early on in my actual physical practice, in Fremont was I started doing group appointments. So we would get 10 to 15 patients to come together and then we would walk them through the different topics. So you sign up for these classes. So the first class was on stress. So rather than people coming in for a one-on-one visit, they came in together as a group. And this meant that as a private practicing physician, I had to change how I ran your office because rather than a slow, steady stream coming in, a herd of patients were coming in at once. And so I vividly remember our first class on stress. They came in and we had all the staff there, helping me get some baseline vital signs, height, weight, blood pressure. And then as people trickled into the class, we actually had them fill out questionnaires.

Daniel Lobell: (28:07)
That’ll stress them out, right from the beginning. [Laughs.]

Dr. Barry Shibuya: (28:11)
It was part of the teaching for that class.

Daniel Lobell: (28:18)
For sure.

Dr. Barry Shibuya: (28:19)
So the questionnaires they filled out for me were questions related to signs of depression, anxiety and post-traumatic stress disorder. And they filled it out individually. And then I went into a 20 minute PowerPoint presentation explaining these questions: What do I mean by stress? What are different types of stress, how stress manifests, not only psychologically, but physically, what does it do to your body if it’s unappreciated, untreated for ongoing long-term basis. And then at the end, we try to give them non-pill suggestions on how you can manage your stress. And that was a great preparation for the stresses that everyone’s going through now with COVID and lockdown and everything. but after that I individually saw each of the people who came into the class and the first patient that I did on a one-on-one basis, which is kind of like their regular doctor visit.

Dr. Barry Shibuya: (29:31)
But now I had all this, the patient had information about what I was concerned about with regards to the stress and how it could manifest making their arthritis pain, worse, making their sleeping worse, making their weight gain worse … And so as I was talking, when I first entered the room, I was reviewing the first patient’s questionnaire and she was a little depressed, not really anxious, but her screening questionnaire for post-traumatic stress syndrome was positive. And as soon as I walked into the room, she began to cry and that caught me totally off guard.

Daniel Lobell: (30:13)
And now you are stressed. [Laughs.]

Dr. Barry Shibuya: (30:17)
In a good way. I thought, “This is a little uncomfortable, but we obviously hit an important nerve.” And now my challenge was to find out what was behind the tears. And so this lady who I had been seeing for about six months came to me with the usual crime, neck, back pain. She didn’t really have any severe arthritis shed a little bit on her x-rays, but her pain was way out of proportion to what my objective physical exam, blood test, x-rays were showing. And luckily at that group appointment, I had been able to convince my upstairs neighbor, who was a psychologist, to come in. And she had a particular interest in helping patients not just with stress and anxiety, but with stress and anxiety related to pain because her daughter suffered from a chronic pain condition called fibromyalgia.

Dr. Barry Shibuya: (31:25)
And there were two other patients just like this patient I’m telling you about who cried when I initially came in, because they all told me that no one asked me these questions before. And they didn’t realize that a lot of what was manifesting physically – which we, as the medical community, were calling arthritis-related pain – was actually exacerbated or primarily caused by something totally separate that we weren’t paying attention to. And so for these three patients, I referred all of them to the psychologists and each of the three of them, I saw one or two times each after that. And basically the visits were, “Thank you. This is very helpful. I’m working well with your neighbor upstairs and I really don’t need to see you anymore.”

Dr. Barry Shibuya: (32:30)
And so I thought, “Wow, I wasn’t paying attention to all of my patients’ needs.” So every time I see an arthritis patient now, I really make it a point to talk about all these SENSE topics, stress, exercise, nutrition, sleep is also a big one and who they’re engaging with. I can tell you countless patient stories, usually parents who tell me, “I’m having a hard time losing weight because I have to buy soda and chips for my kids.” And then we have a heart to heart discussion of, “Really, do you have to buy soda and chips for your kids?” It’s like, “Do your kids pay for these snacks that you have to buy for them?!” So sometimes it’s finding what not only can be helpful for the patients, but who may be sabotaging them as well.

Dr. Barry Shibuya: (33:37)
And this approach has really helped me because it’s put the fun back in medicine. I think a lot of times these days, doctors are forced to use the computer and we have to click the boxes, type everything in, we get so bogged down by the keystrokes that we forget to step back, look at the big overall picture and really see patients for the individuals who are dealing with and living their lives outside of our offices. We get to see a brief glimpse of them when they’re in our offices or on video, or phone appointments now. We don’t really understand what’s going on 99.9% of the time they’re outside of our offices, which has a huge impact on what we see or don’t see in the office. And so I really like to share that insight with patients.

Dr. Barry Shibuya: (34:41)
I do it right now through the YouTube videos. I hope to develop smaller bite-size things through Doctorpedia and also the other Doctorpedia doctors. I know that they’re changing the website, but they had a really good Stresspedia channel where different psychologists and psychiatrists talked to you about stresses and how it manifests and things like that. Because I think regardless if you’re a primary care or other specialist, we really need to be communicating better with each other and helping the patients as a whole, rather than staying in our own silos. I think medicine is very siloed now, the heart doctor focuses just on the heart and the lung doctor focuses on the lung. And we don’t really ask about other things which might be going on.

Daniel Lobell: (35:36)
Team approach is so key as the body works together. It just gets to the heart of what I was trying to say before – because the organs all feed off of one another and the body works together, certainly the doctors should be working together as well to understand the patient.

Dr. Barry Shibuya: (35:58)
And so oftentimes when I initially meet with patients, the common feedback that I get during the visit is, “Wow, this is the most thorough evaluation I have ever done.” And right now I just do telemedicine. And so I don’t have the ability to touch them, but I ask a lot of questions. I request a lot of records. And the thing that I want the listeners to understand is the disease process specialties. So that would be infectious disease. You can get an infection of your skin, you can get an infection of your kidney, your lung, your brain, you can get an infection anywhere. So although these are disease process specialties, and include infectious disease, cancer, and rheumatology, which deals with autoimmune inflammation, – they generally also overlap a lot with primary care because like a primary care physician, we need to look at the whole body.

Dr. Barry Shibuya: (37:01)
When you go to see a lung or a heart or a kidney specialist, they really focus on that disease system. I’m sure a lot of them also take into account the other organ systems, but we really have to do that on a regular basis with rheumatology, infectious disease and oncology, because we could miss stuff that could be going on. And so patients appreciate it when they get a curbside evaluation of what they’re seeing other doctors for, or may not have received an explanation of what was going on or what potentially could be going on. I commonly see patients and they get referred for ankle pain, finger pain, knee pain, and in reviewing their other organ systems, I find out they have signs or symptoms or even previous diagnoses of things that help me figure out the kind of arthritis they have.

Dr. Barry Shibuya: (37:59)
So an example is someone with a history of psoriasis, which is a chronic autoimmune skin condition: A third of patients with psoriasis can develop psoriasis-related inflammation, arthritis. And so it’s really important for the rheumatologist to know this, because if we know that, we can then determine whether or not your presenting joint complaints that fit with any of the potential five types of psoriatic arthritis, or if you have a stomach or gut condition called Crohn’s or ulcerative colitis, they can also have inflammation arthritis. So we need to be detectives. And I really enjoy that part of my rheumatology practice, because it then allows not only for education for myself, but also education for my patients as well. It’s really important that I communicate with whichever other specialists you have. So tell me who they are. I’ll send my notes to them, I’ll request their notes from them. And so we get really involved with the care coordination for the patient.

Daniel Lobell: (39:11)
I loved hearing you talk about putting the fun back in medicine, because anytime somebody’s having fun doing their job, I immediately feel like they’re doing a better job because they’re truly enjoying what they’re doing. I love the SENSE approach. I want to hone in on some things. I think you did a very good job of elaborating on the stress management, which was first S and the last E, which was the social engagement. If you can even give us little recaps or little nuggets on what you would advise people with the first E, which is exercise, the N, which is nutrition, and as you mentioned, the sleep is so important, that second S. What are some of the standard things you would tell people that are just generally good advice for those three letters?

Dr. Barry Shibuya: (40:17)
So for the exercise part, I try to stress to patients that I really want you to think about these not as temporary goals, but as things you are going to be able to keep doing. So it’s really important to find something that you’re going to be able to continue. I see a lot of people spending a whole lot of money buying gym equipment, expensive gym memberships to then only use them for a month or two. So I really try to focus on the enjoyment part for them, if they enjoy walking at the mall with their significant other, their family, great! Do that! Because I’d much rather you continue to do that, which is more economical than spending a couple hundred or thousand dollars on a gym membership or piece of equipment that’s going to be used as a clothes hanger in three to six months. So the key really is the sustainability of the activity and the enjoyment. Another piece of advice is if you usually have arthritis involving weight bearing joints, like hips, knees, back, feet, sometimes looking into water types of activities is a good alternative. Growing up in Hawaii, everyone thinks that everyone here loves the water and surfs.

Daniel Lobell: (41:46)
All the doctors are wearing hula skirts. [Laughs.]

Dr. Barry Shibuya: (41:50)
[Laughs.] Part of the reason why I never came back to Hawaii after school was because I was never really a beach person. My brother would die without being able to go to the beach. But for me, I’ve gone to the beach since coming home with my son more in the past three, four years than I’ve done probably in the previous 30 growing up here. So I’m not really a big water person, but now, as I’m getting older, I’m getting some aches and pains and tweaks and I actually appreciate swimming in the pool a lot more. And doing different types of exercises that may be easier on your joints is also a good idea. If you do a lot of impact, running, jumping, maybe alternating that, or changing to a less joint impactful exercise, like stationary bicycle or elliptical would be easier on your joints.

Dr. Barry Shibuya: (42:48)
But again, finding things that you enjoy doing is super, super important. The Arthritis Foundation has a great website, arthritis.org. They have a lot of patient-friendly exercise videos on their websites to check out. Another great resource is on YouTube. If you just type in ‘sit and be fit’, these are exercises for my senior patients. They even have exercises for people who are in wheelchairs, they focus on upper body exercises. You don’t even have to stand up to do a lot of them. So ‘sit and be fit’ on YouTube, arthritis.org for the Arthritis Foundation, friendly exercises, but really focus on things that you see yourself being able to keep doing. And you enjoy to do, doing a physical activity with someone you like being with also knocks off two birds with one stone. You can have your social engagements with your friend, your family member, as you go walking. I used to live in Fremont. I used to have a Shiba Inu. I loved to take him walking all around the neighborhood and even around the lake there.

Daniel Lobell: (44:00)
Isn’t that a Japanese dog, a Shiba Inu?

Dr. Barry Shibuya: (44:03)
It is.

Daniel Lobell: (44:05)
So you’re partial to Japanese dogs because of your Japanese heritage?

Dr. Barry Shibuya: (44:10)
[Laughs] No.

Daniel Lobell: (44:11)
I happen to love Shiba Inus.

Dr. Barry Shibuya: (44:16)
I was just fortunate enough that we had a friend in the bay area who was actually a vet and we had a get together and I mentioned, “Oh, I’m thinking about getting a dog.” And she’s like, “Hey, well, I’m actually going to do some free animal exams on a Shiba Inu next week and the guy bringing him in has a Shiba rescue.” And I said, “Are you serious?” She’s like, “Yeah.” And so that’s how I ended up rescuing my Shiba Inu.

Daniel Lobell: (44:49)
That’s so cool. I love Shiba Inus. They’re such a cool breed. They’re great, great dogs. And I think I’ve heard what you said about having to be very dominant over the dog because of how they were originally bred.

Dr. Barry Shibuya: (45:05)
Yes, they were small bird hunting dogs. And so he would go crazy in the backyard whenever he saw birds coming into the yard. I think a couple of times, he even ate a few. I really miss him. I left him there. I gave him to somebody else when I moved back here.

Daniel Lobell: (45:26)
So you rescued a Shiba Inu and then someone rescued your rescue. [Laughs.]

Dr. Barry Shibuya: (45:30)
Yeah, actually I was the third owner.

Daniel Lobell: (45:34)
Wow.

Dr. Barry Shibuya: (45:34)
He was originally from Taiwan. The owner brought him to California and then gave him to the owners that I adopted him from.

Daniel Lobell: (45:49)
So he got to know a lot of families, it’s kind of cool in a way, as much as much as it can be. You can look at it the other way. It’s like he’s gotten to live multiple dog lives in one life. [Laughs.]

Dr. Barry Shibuya: (46:03)
[Laughs.] My son keeps telling me, “Dad, when are we going to go back to California to see Kenji again?” I’m like, “Once you’re vaccinated, once we’re able to get back to California, I think that’s a great idea. We’ll definitely look him up.” So that would be my recommendations for the exercise. As far as for the nutrition, that one gets a little trickier because there are ethnic cultural ideas of “We generally eat this and not that”. So for the nutritional part, I just tell them general concepts of, “If it comes in a package and if your grandparents or great grandparents wouldn’t recognize it as food, meaning it’s not a whole food, it’s probably not the best thing for you.” That being said, I know convenience and costs are big issues here now.

Dr. Barry Shibuya: (46:54)
I tell patients, “Food is really medicine. If you make poor choices with food, you’re going to have to take pills to counteract your poor food choices. But if you invest and you eat healthier, you eat whole foods, you eat all different colors of the rainbow as far as fruits and vegetables, you limit processed foods, meats, fats, that’ll be your medicine for your body. So you won’t need to take a lot of pills later on”. There’s a lot of great cartoons out there. A lot of people with a lot of medicines go to the pharmacy to pick up their pills. I prefer to help patients to go to the farmer’s market so eating from your local farms, as far as eating or healthier, sometimes people want specific cuisine recommendations.

Dr. Barry Shibuya: (47:59)
There’s a pretty substantial amount of literature with regards to the health benefits of the Mediterranean diet. But obviously here in Hawaii, like I did an educational seminar for the Arthritis Foundation and we had one with a dietician. And so I had her talk to our community – primarily still an Asian type of community culture – about the health benefits of the Mediterranean diet. And so trying to take into account people’s cultural, ethnic food choice preferences becomes important because again, like the exercise, if you’re only gonna do this diet for a month or two, I don’t care how much weight you lose. Even if you lose 5, 10, 15, 30, 50 pounds, if you go back to eating what you were doing before that, you’re gonna rebound, gain the weight back and oftentimes even more. So did you really do yourself a favor?

Daniel Lobell: (48:57)
I’ve been down that road a bunch of times, I read these books from Dr. Michael Gregor. I don’t know if you’re familiar with him, but he’s a big proponent of plant-based dieting. I did that for a while, but even though I lost quite a bit of weight, I couldn’t sustain it. And then I put on even more.

Dr. Barry Shibuya: (49:13)
Exactly.

Daniel Lobell: (49:13)
So it’s frustrating.

Dr. Barry Shibuya: (49:15)
One of the big challenges here in Hawaii, and I understand this because I grew up here, is that people eat rice with every meal. And when I moved to California, that was something that I eventually stopped eating. So when my family would visit me in California, they would say, “Where’s the rice?” I said, “I don’t eat rice.” And they looked at me like I had moved to Mars. So for people in Hawaii where complex carbohydrates and rice becomes an issue with regards to their weight, arthritis, gout, diabetes, trying to educate them on a slightly healthier version of rice, maybe not all white rice, maybe half white, half brown rice or eventually switching out to some rice-like grains like quinoa.

Dr. Barry Shibuya: (50:15)
But again, you have to be able to customize it. For some of my patients who moved to California, but are from Hawaii, I could get them to switch from white rice to brown rice, or even try some cauliflower which you can make it into a fried rice-like dish. So making small changes that you can see yourself sustain really becomes the key. Also being able to read and appreciate food labels is super important. So we often work with a nutritionist dietician to help educate and motivate patients like that. I have countless patients where the only thing they did was cut down on the soda and juice that they were consuming and they dropped 20, 30, 40 pounds. It was incredible how much soda they were drinking a day. And as the weight came down, guess what? The arthritis pain came down.

Daniel Lobell: (51:19)
I wish that was my problem because I don’t drink any of that. I only drink water or seltzer or black coffee and I have a weight problem. I’m jealous of those people.

Dr. Barry Shibuya: (51:33)
Initially when I talk to patients who are interested in getting a hold on their weight, I say, “It’s natural to focus on diet and exercise, but although this is part of the sensible approach that I’m trying to teach you, I want you to put that aside now. And I really want you to focus on your stress and your sleep.” Because if you are stressed or not sleeping well or not sleeping enough, that can affect weight gain. And more importantly, I get worried at the patients who tell me they’re not stressed at all.

Dr. Barry Shibuya: (52:10)
I’m like, “Where do you live?” I mean, everyone was jealous, especially my friends in California, like, “Why are you gonna live in paradise?” And I said, “There are numerous studies – and I can attest to this too – that living in Hawaii is even more stressful because it’s more dense.” I think our traffic in certain areas is even worse than the four or fives on a Friday night in LA.

Daniel Lobell: (52:33)
I can attest to that from when I was visiting Hawaii. I was shocked by how bad the traffic was.

Dr. Barry Shibuya: (52:39)
Yeah. Cost of living is a factor too. Everything needs to be shipped in here, gas, food, household supplies. And you’re in close proximity to a lot of people. So the scenery is nice. We can send you a nice postcard of a nice sunset, but translating that into less stress on a daily basis is not something with which I would typically agree. But making sure that people recognize and appreciate, and there are different questionnaires of just common day to day happenings like changing jobs or moving. It doesn’t have to be something obviously glaring like witnessing a shooting or a murder or losing a loved one. Obviously those are stressful, but it doesn’t have to be one big stressful event. It could be just an accumulation of many smaller things.

Dr. Barry Shibuya: (53:44)
You then tie that in with not sleeping well. I mean, we are a cloture of not sleeping well, and that’s the perfect setup for stress hormones, cortisol going up in your body, altering your metabolism, promoting weight gain, chronic disease, etc. And so I used to look at weight as a character flaw issue and a lot of doctors still look at it that way. I really look at it as usually a stress and sleep issue with the goal and the focus of educating and motivating patients to make some of these small changes. So from time to time when appropriate screening for depression, anxiety, post-traumatic stress is really important, sometimes just giving them life events questionnaires. Over the past year, have you experienced any of these things? Because the more of these small little routine events that you don’t necessarily think are stressful by themselves, when you add it up in total, have really been shown to correlate with actual measurable chronic disease.

Dr. Barry Shibuya: (54:56)
So we periodically do that kind as well. And then for the sleep portion I’m really excited about the use of technology, and so one of the apps that I tell my patients to try is the SnoreLab app. If you go to one of the app stores and you look for SnoreLab, you can download it for free. I think you can try it for three nights. So you have to sleep by yourself, turn the app on and it’ll monitor your breathing. And it’s not the perfect test, but it’s something interesting that you can play around with. And it actually gives you a snore score. And so if your snore score is greater than 50, there is a good chance that you have a very common sleep disorder called sleep apnea.

Daniel Lobell: (55:47)
I have sleep apnea and I use a machine every night when I sleep.

Dr. Barry Shibuya: (55:53)
And so a lot of my patients either don’t know they have sleep apnea or can’t tolerate the machine so they don’t really use it. A patient I just saw yesterday had some sort of house fire in which he lost his sleep machine about five years ago and never bothered to get a new one after that. But since then, he’s gained another 50 pounds and his sleeping is worse. And he came to me because now his pains are worse. And I said, “Thinking back to when you were using your sleep apnea machine before you lost it in the fire, did you have a lot of pain?” He goes, “No.” And I said, “What was your weight like? He’s like, “I was a lot lighter.” And I said, “Well, I think your body’s trying to tell you something.” And so one of the other tips that I teach patients is think back to a point in time in your life when you were your healthiest.

Dr. Barry Shibuya: (56:52)
And then think about the five categories. What was stress like in your life? What were you doing for exercise? What was your nutrition or your diet? What was your sleep like? Who were your engaging with? Because that oftentimes can give you specific recommendations about what you were doing in the past that worked for you and manifested as the healthiest version of yourself that you can recall.

Dr. Barry Shibuya: (57:23)
For women the answer is usually, “Before I had my kids.” And often it’s before some stressful event happened: I got divorced or lost my job or moved. And so individualizing their life experience in time chronology with their chronic disease oftentimes opens up not only the patient’s eyes, but the provider’s eyes as well. You get a sense of this patient suffering from a lot of chronic diseases, but it really chronologically started when they were going through a divorce, a separation, loss of a job. Another common one is caregiver stress, parents with young kids also having to take care of their elderly parents with health issues.

Daniel Lobell: (58:29)
Parents with old kids, that’s also stressful. [Laughs.]

Dr. Barry Shibuya: (58:31)
Yes. And so It really gives you a better overall picture and allows you to empathize with what patients are struggling with or dealing with. A lot of times, the recommendations I have for patients with regards to helping them better manage their pain or has nothing to do with pills. It has everything to do with making sure they have support from Alzheimer’s Association because they’re spent, they’re having to watch mom or dad with Alzheimer’s 24/7 because no one else can help them and they’re neglecting their own health because of that. And for me, this has put the humanity and the fun back into medicine because it’s really given me a clear understanding of what each of my individual patients are going through. Now, this is not something which interests everybody.

Dr. Barry Shibuya: (59:30)
But I would say a vast majority are at least interested in the concepts of creating their own sensible lifestyle management approach. And initially, I really became conscious of it, when I was probably at my busiest time in my private practice. I was working full time running an infusion center, administering IV medications for arthritis and one Christmas, I got a Christmas card from a patient that I’d seen regularly who just fell off the map and the Christmas card went something like this. “Hey, Dr. Shibuya, I just wanted to wish you happy holidays and just tell you, “Thank you.” Now this is a patient that I hadn’t seen for almost a year. So he came from the Richmond area, which is about maybe an hour away from my office. And we were giving him an IV treatment of a medicine for his psoriasis, which is a chronic skin condition.

Dr. Barry Shibuya: (01:00:35)
And at every visit, we talked about how his psoriasis was doing, how his medicines were doing, but we’d talk about the sensible approach, how was your stress, how was your exercise. And he wasn’t really too keen on changing anything. He was busy working and enjoying life but then it was his girlfriend who was pestering him. Hey, I think you can eat better. I think you could exercise better. And so between my periodic checking in on him and his girlfriend’s nagging him on a regular basis, one day he decided to make some lifestyle changes, primarily focused on diet and exercise, but he mentioned some things about reducing his stress and sleeping better. And then he lost about 25 to 30 pounds. And what he noticed was his joint pains didn’t act up at the regular intervals that they did in the past, which required him to stay on the chronic intravenous therapy for his arthritis and his psoriasis got much better. So he was like, “If I can maintain this weight loss, I feel good, my joints are good, my skin is good. I don’t need to drive the hour to go to the office to get the IV medications for which I have to pay my portion of the insurance. So it met the quadruple aim.

Dr. Barry Shibuya: (01:02:01)
The quadruple aim is what I try to remind myself about. It’s about patient satisfaction. So he was happy. His joint pain’s better, skin is better. The outcomes were better. He’s not having to deal with chronic pain, taking chronic medications and his psoriasis is better. I’m happy that he’s happy. So I’m not stressed as well. And his insurance company is happy because he is utilizing less resources.

Daniel Lobell: (01:02:34)
When I first got that letter, I was like, “Oh no, my practice is gonna suffer. I’m going to lose all my patients because I’m going to make them all well. Little did I realize that that actually made my practice busier because he told everybody, his friends, his coworkers, his colleagues, his family members to come see me. And so I sat there and I thought, “This is what I really went into medicine for, to help people understand whatever illness that they have to the best of my ability with my medical training, but also educate, motivate and support them into being able to manage whatever condition they have, to the best of their ability with their daily choices.” If we need to prescribe pills, injections, IV, we will, and we will do it safely.

Dr. Barry Shibuya: (01:03:28)
But if we do not and can save society and patience, the financial burdens or whatnot, why don’t we do that? And so what I commonly tell patients is when you watch the video, have a sheet of paper on the left hand side of the sheet of paper, write S E NS E. And as we talk about stress management, you take notes next to the big S for my stress, my stress is caused by blah, blah, blah, blah, blah. When I get stressed, I generally tend to do blah, blah, blah, stress eat, or get angry with my kids or whatever. So you can recognize it and to manage my stress, I am going to blah, blah, blah, blah, blah. And I tell patients, you do that for each of these categories, stress, exercise, nutrition, sleep, and your social engagement.

Dr. Barry Shibuya: (01:04:24)
Once you fill all that out, that becomes your lifestyle prescription. You are your own doctor. You put that piece of paper up on your refrigerator, in your bathroom, somewhere you’re going to see it every day. And you check in with yourself every day. Did I do my stress management? Did I do my exercise? Did I do my nutrition? And I guarantee you, the more times you say yes, and you stick to your plan, if weight is an issue for you, it will get better, your pain and your other chronic diseases will get better. It’s not going to cure everything. It’s not gonna make you 20 years old again and not taking any medications, but you’re going to be healthier, happier, take less medication, see less doctors. When I started teaching the SENSE approach in Hawaii, I was writing it out for a patient that I was seeing. And she’s like, oh, your acronym is SENSEI. And I was said, “I like that even better.” So I just added an I to the end. And I like that even better because I don’t know if you know this, but sensei in Japanese means teacher.

Daniel Lobell: (01:05:36)
I watched the ninja turtles. Come on. [Laughs.[

Dr. Barry Shibuya: (01:05:37)
Oh, there you go. [Laughs. ]And so the I that I teach patients about, which are not on my YouTube videos, because I discovered this later and I hope to incorporate this into some of the shorter Doctorpedia videos that we’re going to make. But the ‘I’ is “What is your inspiration or what is your motivation for making these changes?” Because oftentimes if patients can’t answer that question, it’s going to be really difficult. So when the going gets tough, you need to sit back, reflect and think about why am I doing this? The answer should not be, “Because my doctor said so.” I said, “If your inspiration is Dr. Shibuya will get mad at me If I don’t lose weight, no that isn’t going to work. You’re not doing it for me.”

Daniel Lobell: (01:06:29)
I know what mine’s going to be now that I’m my own doctor. I don’t want to get sued by myself for malpractice.

Dr. Barry Shibuya: (01:06:36)
[Laughs]. That’s a good one.

Daniel Lobell: (01:06:36)
[Laughs].

Dr. Barry Shibuya: (01:06:36)
I would encourage you to make it a little more positive or less frightful [Laughs] – that you’re going see yourself. And so I often find that people fall off the wagon and it’s normal to fall off the wagon. I do it myself. So since coming back to Hawaii, I’ve gained maybe about 10 pounds since I’ve come back because I’m raising a little one. My sleep is off. I have the food.

Daniel Lobell: (01:07:08)
There is so much food.

Dr. Barry Shibuya: (01:07:10)
Well, that is actually one of the things that keeps popping up on my feeds – how difficult it is to eat healthier are in of all places, Hawaii – the cost of fresh fruits and vegetables are much higher here. A lot of the local cultural food, as you mentioned, are processed, high in carbs, high in fat. And so if choices are limited and the cuisine choices aren’t the best, it’s not impossible [to lose weight and eat healthy], but it gets a little bit more challenging. And so realizing that and acknowledging it is important. But then with that information, making a plan to address it becomes the goal of what we try to do, not only for our patients, but also for ourselves. And so that’s what I hopefully will be able to do.

Dr. Barry Shibuya: (01:08:13)
And the big impetus for me to join Doctorpedia was to use this platform to share bits and pieces of information that people can digest in short settings but hopefully come back for more, because the one thing that I tell patients too is once you get one or two good stress reduction habits and they become automatic for you, change it up, do something different. like I tell patients about laughing yoga. So if you go to YouTube and you put in laughing yoga, there’s all these groups that get together and they just laugh. And you know, patients look at me funny, like “What are you talking about?” And I said, “Well, haven’t you heard? Laughter is the best medicine.” And they’re like, “Yeah.” And I said, “Well, there are medical reasons why laughter is important.” It makes you breathe deeply. You are getting rid of these air toxins from your body that you can exhale out by breathing more deeply, you are moving your diaphragm, which then stimulates your biggest calming parasympathetic nerve, your vagus nerve. You’re releasing these feel good endorphin hormones in your brain, which makes you feel good. But like any pill or any drug or any treatment, even laughing yoga does have potential side effects. So the only time that I do not recommend doing laughing yoga is when you have diarrhea because you will have side effects.

Daniel Lobell: (01:09:55)
Yeah. That sounds like like a problem. [Laughs.]

Dr. Barry Shibuya: (01:10:00)
[Laughs.] Yeah. So that’s probably not a good time to dial into YouTube or to join your local laughing yoga group. So stay at home, take care of the diarrhea and then you can go back later.

Dr. Barry Shibuya: (01:10:12)
I really enjoy talking about these things. I really enjoy listening to patients and even learning from patients about what works for them. because then I can share it with similar patients that I see later, especially if it’s from an ethnic group or minority that I’m not too familiar with. So even though I still live in Hawaii, most of my practice is in California. I still have a license to practice there. And so the company that I’m working with is a telemedicine company. And I’ve actually bumped into a couple of my former patients from Fremont on this platform of TeleMed2U where I practice now. And so that’s been nice as well. but I really, really enjoy this part of my practice because again, no one wants to take a pill or a shot for the rest of their lives. And frequently patients may be a little hesitant to tell the doctors “Hey, I don’t wanna take this. So I’ve been skipping or I haven’t been filling [my prescription.]

Daniel Lobell: (01:11:13)
Well, Dr. Shibuya, you sound like my kind of doctor. I like doctors that talk to you on a real level and on a very caring level and certainly doctors who are pushing you to take care of yourself and to make medicine secondary, a more holistic approach.

Daniel Lobell: (01:11:36)
I usually ask the doctors to round off the interviews with what they personally do to stay healthy, but because you covered that so well in our interview, I’m just going to wrap up by telling you I’m going to do some breathing exercises. I’m going to do some regular exercise. I’m going to eat apples. I’m going to get some good sleep and download SnoreLab. And and then I’m going to go talk to some healthy people. [Laughs.]

Dr. Barry Shibuya: (01:11:59)
There you go.

Daniel Lobell: (01:12:00)
You’re a sensible guy.

Dr. Barry Shibuya: (01:12:02)
Keep doing what you’re doing and keep laughing, keep that sense of humor. Because I really think that’s an integral part of any healthy lifestyle plan. Because my goal is to create another blue zone. So blue zones are areas of the world where people typically live to over a hundred. I started to create a blue zone in Fremont before I left. I had three or four people who were over a hundred. And it’s not just living until a certain age, it’s the quality of life too.

Daniel Lobell: (01:12:35)
Why is it called blue? What’s the significance of the color blue?

Dr. Barry Shibuya: (01:12:38)
You have some great questions. I think I have to do my research and come back to you to explain that. [Laughs.]

Daniel Lobell: (01:12:45)
Call me back and tell me why it’s blue and what your name means and we’ll have everything we need. [Laughs.]

Dr. Barry Shibuya: (01:12:51)
All right, Daniel, you got it. [Laughs.]

Daniel Lobell: (01:12:53)
Thank you so much, Dr. Shibuya.

Dr. Barry Shibuya: (01:12:56)
I had a blast. Nice meeting you.

Daniel Lobell: (01:12:57)
You too.

Daniel Lobell: (01:13:01)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs.

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