Optimizing Your Health: Diagnostic Tests, Sleep, and Longevity

00:00:00.000 | I think we often think that the body and the mind are different things, but they're the same thing.

00:00:05.920 | That's like saying my computer screen and my computer chip in the thing like are different.

00:00:11.120 | Well, they are, but the output is that like one breaks, the other one, you know, you need both.

00:00:15.280 | And so the brain is what can cause inflammation in the body by stress or by angst or by not sleeping

00:00:22.080 | well or by having bad eating habits or by drinking too much because you're stressed. So this level of

00:00:27.200 | stress kind of goes down with social integration because you know your people, they call your

00:00:31.360 | bullshit in a way that you kind of come to tolerate and realize that you need people to

00:00:38.480 | guide you and to be sounding boards so that you're not just, you know, looking for more

00:00:44.560 | likes on Twitter or, you know, getting super bummed out when you get like a criticism.

00:00:48.400 | Hello and welcome to another episode of All The Hacks, a show about upgrading your life,

00:00:53.360 | money and travel. Since it's the beginning of the year, I know many of you, myself included,

00:00:57.760 | are thinking about how we can upgrade our health this year. To help make that possible,

00:01:01.920 | I want to invite Dr. Jordan Shlain on the show. Jordan is a physician, entrepreneur,

00:01:07.440 | publisher and healthcare systems designer. He was one of the early pioneers of concierge

00:01:12.400 | medicine and is still a practicing primary care doctor through his practice private medical.

00:01:16.960 | I heard Jordan talk about optimizing your health at a conference last year and I've been excited

00:01:21.680 | for this episode ever since he agreed to come on. He has such a wealth of knowledge on health

00:01:27.040 | and longevity and we're going to try and cover as much of it as possible, including how you can

00:01:31.920 | start taking your health into your own hands, what to look for in a primary care doctor,

00:01:36.480 | what kinds of tests and diagnostics might make sense to consider, how to think about

00:01:40.400 | things like sleep, diet and exercise and a lot more. So let's jump right in after this.

00:01:51.120 | Jordan, welcome to the show.

00:01:52.240 | - Thank you, glad to be here.

00:01:53.680 | - Yeah, so I'll kick it off. What do you think the state

00:01:56.880 | of our current healthcare system is right now?

00:01:58.640 | - Oh, it's bad. It's as bad as it's ever been and I think there's a lot of hype that it's

00:02:04.080 | going to get better sometime soon, but it's been 20 years that people have been saying we're just

00:02:09.920 | about to turn the corner, but we're dealing with a massive cruise liner that turns incredibly slow

00:02:17.280 | because there's so many vested interests and the way I like to, like the intellectually honest

00:02:23.040 | framing is this is a health insurance system. It's not a health care system. It's 85% about

00:02:30.000 | money and 15% about care and a lot of hospital CEOs will say, well, no margin, no mission,

00:02:35.360 | which is a great thing for a capitalist private market company to say because if they don't make

00:02:42.320 | money, then they do go out of business. The thing is, is healthcare, unlike finance, unlike travel,

00:02:51.120 | unlike consumer electronics, you can map out the supply chains, you can map out the choke points

00:02:58.000 | and the efficiencies and you can really streamline stuff, but healthcare was never designed for

00:03:03.920 | scale. It's always local. There's a local person, like hospitals, very few hospitals have a national

00:03:08.960 | footprint. So fundamentally they have different buyers, different supply chains, different plans,

00:03:14.560 | different states, different regulations. So I don't call it an ecosystem. So I think if

00:03:18.960 | you're going to do FinTech, you go, ah, I'm striped. I know exactly where to go in and find

00:03:22.720 | the problem that everybody has. And if I could just solve that, I unlock tons of potential for

00:03:29.760 | efficiency and cost savings. In medicine, it's not a freeco system. I mean, it's not an ecosystem.

00:03:35.680 | It's a freeco system, which is, you can't peel back the onion and get other layers of an onion.

00:03:44.000 | You may get a tomato in there. You may get a grapefruit. Every time you peel something back,

00:03:48.160 | there's things in there that are legacy systems that were built upon. They're not streamlined and

00:03:54.240 | thorough and simple in the way that most other industries are. So the state of the system today

00:04:00.640 | is, it's kind of like an every person for themselves, if you're a system and you're

00:04:05.120 | reliant on the insurance world, everybody has insurance. But I'll say that if you're a person

00:04:17.440 | that wants to get good healthcare, well, it's local. Like I said earlier, you have to look

00:04:22.800 | around and what's there. There's a new kind of cadre or cohort of consumer looking healthcare

00:04:32.560 | clinics, primary care. Primary care is great, but then you have behind the primary care,

00:04:38.000 | you have specialists. Most specialists and most primary care practices now, by the way, 80%

00:04:42.640 | are owned by either hospitals or insurance companies. So when you go to a store and buy

00:04:50.240 | something, well, first of all, you're going to trade a resource, which is called your credit

00:04:53.920 | card and your bank account. I'm going to trade this resource for that iPhone. And when you do

00:05:00.000 | that, you have to ask yourself, well, how much money do I have in my pocket? And which iPhone

00:05:04.640 | can I afford? When you make that transaction, you get the iPhone right now. So there's no

00:05:11.040 | delay in getting the good that you used your resource to get. And you have choice. You can

00:05:17.840 | decide not to buy that iPhone. You can buy an Android. You can buy the Google Pixel. You have

00:05:22.320 | tons of choice. There's not a lot of choice in medicine. You have free will when you have your

00:05:27.200 | wallet to go buy what you want. In healthcare, I call it tethered will. If you have a big cut on

00:05:32.240 | your arm, you don't get to go shopping to which store to go to or ER. You're going to go to the

00:05:38.160 | closest when you're bleeding. But imagine you had a terrible headache and it was like, "Oh my God,

00:05:43.120 | I'm incapacitated." And you go somewhere and you're not shopping for the best headache clinic

00:05:48.880 | because you've got a terrible headache. You must do something now. Or in the near future,

00:05:54.240 | you don't have choices. You're not even paying for it. So it's not even your resource.

00:05:58.880 | This is called in economics, the principal agent problem, where you pay a third party,

00:06:03.840 | they pay somebody else. So the person that you're receiving the good or service from,

00:06:08.240 | you didn't pay. They don't feel aligned necessarily because you put your hardworking

00:06:13.840 | money into it. It may be your employer's money. So I would say one of the biggest problems is

00:06:19.040 | this principal agent problem, the macro. But going back to the story with your headache,

00:06:23.520 | so then you see the doctor, they give you some morphine in the ER because it's a terrible

00:06:26.560 | headache. Then you go home and the morphine wears off, you still have your headache.

00:06:30.080 | So you just went to go get something and you came back and it's not better, or it's 50% better.

00:06:36.160 | Now you have to figure out what to do. So you call your primary care doctor,

00:06:39.520 | "Oh, that's a two-week wait." So then you ask Dr. Google and he basically comes or she basically

00:06:48.000 | comes back, "Well, that could be cancer." So now you're super anxious. And so the whole system is

00:06:53.440 | not designed. There was no designer. It's a patch on top of a patch on top of a patch where the

00:07:02.720 | money continues to flow through multiple middle people that take their sliver of the money.

00:07:07.920 | And it's not getting any better to answer the question. I will say that I was involved with

00:07:15.920 | Obamacare and I think a lot of people, I was invited to the White House because I've been

00:07:19.120 | building my model outside of the existing system, trying to create a new design. I've designed this

00:07:26.320 | and we'll get into that later from scratch, which is how do you honor both the doctor

00:07:31.760 | and the patient and the data in an elegant way to try to achieve the best outcome the fastest?

00:07:40.400 | And I should only get paid on that. And I want the person to pay me for that. Now,

00:07:45.280 | if they need an MRI, that's what the insurance is for. I should help them get the best MRI place.

00:07:52.000 | I should be the one to be their quarterback around how to receive that care. But really what

00:07:59.440 | the Affordable Care Act did, and I think this is lost on most people, is it put the onus or it set

00:08:07.280 | the incentive for the doctors or the medical groups or the people that own the medical groups

00:08:13.120 | to get a fixed amount of money per problem. For example, right now, if you have a heart problem,

00:08:21.440 | a heart failure, and maybe we could take the guy Demar Hamlin as an example,

00:08:25.920 | right? He's a young, healthy guy. He had a cardiac arrest. This is, for those of you who don't know,

00:08:30.560 | NFL football, primetime Monday Night Football the other night, he fell down and they were doing CPR.

00:08:35.520 | So I'll use him as a quasi example, but this isn't going to be exact,

00:08:39.920 | is there is the place that he gets taken care of says, "Hey, for everybody with a cardiac arrest,

00:08:45.920 | you get $10,000 to get him out of the hospital and get him home."

00:08:50.960 | It used to be, "Hey, every day he stays there, you get $3,000 in the ICU,

00:08:55.680 | you get all the money you want, whatever prescription you write, you get paid for."

00:09:00.080 | So the sicker you get or the more transactions there are, the more money the system gets.

00:09:04.640 | So there's no incentive to get that guy out fast. Now the doctors, my people, we of course are

00:09:11.360 | healers. We want this guy to get better. We want him to get better fast. We want to make all the

00:09:14.960 | right decisions at the right time for the right reason. The truth is there's this overlay of,

00:09:19.840 | "Hey, if we keep him here a little bit longer," I'm not saying that I think Cincinnati's got an

00:09:25.760 | amazing hospital system that they would do that. But in a lot of systems that you don't hear about

00:09:29.920 | tucked away in Nowheresville or like middle of, there's no oversight, they'll just keep somebody

00:09:35.840 | there for days. And there's not a financial incentive to get them healthy as fast as

00:09:40.320 | possible. So the Affordable Care Act created this thing called the Accountable Care Organization,

00:09:46.000 | which is we're going to start going with specific conditions and saying, "This is the money you get."

00:09:51.360 | So a couple of friends of mine, one guy from Anthem, which is an insurance company. He was

00:09:55.440 | their chief strategy officer, teamed up with a doctor, another friend of mine, Clive, and another

00:10:00.480 | business guy who ran healthcare systems said, "Hey, let's create a primary care practice." It's

00:10:05.760 | called Village MD. "And let's just go get these accountable care contracts." So we will take in

00:10:12.560 | Houston, 5,000 people, and rather than bill transactional, whatever we bill, the sicker

00:10:17.920 | you get them, our money we make, we're going to take a fixed amount from the insurance company,

00:10:21.600 | and that's all we get. So now all of a sudden, they're hyper-focused on prevention to prevent

00:10:26.960 | problems from happening. And they'll even pay for you to get an Uber driver to take you to the

00:10:30.560 | appointment if you don't have the money to do it. They'll send a meal that's healthy to your house

00:10:35.680 | after you got discharged from a heart problem, so that at least they have some control of

00:10:40.560 | preventing you from winding back in the hospital for yet another expensive admission.

00:10:44.640 | So the accountable care organizations, of which they're starting to proliferate,

00:10:49.600 | I think that in five to 10 to 15 years, you'll see a lot more of them. The incentives will be

00:10:54.480 | aligned around good outcomes yield good incomes. Right now, it's bad outcomes yield good incomes,

00:11:01.440 | sadly, for the healthcare industry. And I think that is a fundamental problem. And there are so

00:11:08.400 | many middlemen, Chris, that make a little fig off of that dollar when you don't do well.

00:11:13.520 | From the person that sells gloves, to the person that has the billing software, to the person that

00:11:19.920 | pick all the things that take a little micro sliver of money out of the dollar that that

00:11:24.720 | person of care got. There's so much waste and fraud. Because I would say train AI on fraud,

00:11:35.280 | and you probably save a ton of money. And I'll say one other thing is that with the advent of

00:11:39.040 | digital health, of which I was on the front edge of that, started a company about 15 years ago,

00:11:43.600 | is now you have fragmentation of medical specialty things. So if you want to go get a SIBO test,

00:11:55.360 | because you think you have bacterial overgrowth, because you have some bowel problems, you can go

00:11:58.240 | online and order a SIBO test. You get the results, they'll tell you what to do. And you're managing

00:12:02.720 | SIBO, which is like a condition of gas bloats and cramps. It can cause fatigue. It's a well-known

00:12:08.560 | thing. Working its way through the literature to become a medically established thing.

00:12:12.720 | Or if you have another condition, if you have a headache, you can go to the headache clinic,

00:12:21.840 | online headache clinic. If you have this, so you have this fragment and no one's orchestrating

00:12:26.880 | everything. So now you have little windows of things that you can solve. But John Muir,

00:12:33.200 | who is a famous explorer, naturalist in America, and I'd say said, when you tug on a single thing

00:12:38.960 | in nature, you realize it's connected to everything else. And in medicine, what I can

00:12:44.480 | tell you is if you have SIBO, if you have some, or if you have migraines, or if you have whatever,

00:12:51.600 | eczema, there are probably multiple factors that need to come together to help solve that

00:12:58.240 | without pills, without injections, without interacting with the medical system.

00:13:02.960 | There's so much that you can do on your own. I like to say, how do you become independently

00:13:08.320 | healthy? And ultimately health is what you can do for yourself. And what healthcare is,

00:13:16.160 | when you can't do it for yourself, you must reach out to somebody that can help you

00:13:20.880 | through navigate the kind of the thicket of the healthcare system.

00:13:25.680 | It sounds like the providers are less incentivized financially to do whatever they think might be the

00:13:33.280 | best thing because the insurance company is the payer, you have this principal agent problem.

00:13:37.200 | You know, there are certain treatments, by the way, that will most likely be covered and won't.

00:13:42.800 | So to recommend someone do something that they probably can't afford or won't get covered by

00:13:48.880 | their insurance is probably not going to happen. But you don't even know that a priori, like you

00:13:52.880 | can recommend something and only later do they find out it's not covered. And then that patient

00:13:56.720 | has to go back to the doctor and say that wasn't, I mean, again, no design, no elegance. It's a

00:14:03.120 | shitshow. And then, you know, you kind of highlighted that the most important thing

00:14:07.680 | might be that everything in your health seems connected. So this idea of your primary care

00:14:11.440 | physician seems as important as it ever was. But at least in my personal experience, it's been tough

00:14:18.720 | to find someone in the conventional medical care system that's covered by my insurance that, you

00:14:24.480 | know, actually wants to play that role of like, you know, discovering what's wrong and trying to

00:14:29.440 | figure it out and being aware of all the latest medical research and all that. So I guess maybe

00:14:34.080 | the question is, there's one end of the spectrum, which you've started your own practice, which,

00:14:38.880 | you know, is not accessible to everyone, but will gives you that quarterback that can kind of go

00:14:43.280 | through that process. What are people who are kind of not at the point that that's the right

00:14:48.240 | fit for them? Where should they start? - Great question. So my framework in

00:14:53.200 | general for every person is, first of all, do you know everything about yourself,

00:14:59.200 | biologically and physiologically? What do you know? Do you know what your blood pressure is?

00:15:03.760 | Do you know what your cholesterol is? Do you know what your family history is? Do you know

00:15:06.960 | what your genetic susceptibility, the things are? What do you know? And what do you not know?

00:15:12.880 | And I think there's an honest, like, a lot of people don't want to know. No, no, no, no, no,

00:15:17.360 | no, no. Like, I don't see it. I'm just going to live my life, you know, and blah, blah, blah.

00:15:20.800 | Great. They're gambling. And, you know, and if you're young and healthy and there's nothing

00:15:25.680 | wrong in your family, like, probably pretty safe bet nothing bad's going to happen to you.

00:15:29.600 | But then you always read in the paper about the sporadic person with nothing wrong and they just

00:15:32.960 | died of a whatever, or they got cancer at 35. And I think those are the kind of the headlines that

00:15:38.080 | scare people, but they're true. And why would you not with not a lot of investment, learn everything

00:15:45.120 | you can about yourself to make informed, proactive decisions to keep yourself optimized to not have

00:15:54.480 | to use the healthcare system for the rest of your life, if you could. If you wanted to walk through

00:15:59.040 | someone who maybe is thinking right now, I haven't really taken my health seriously. What should I go

00:16:04.000 | and either do myself or ask my doctor to help me do, you know, obviously.

00:16:08.320 | By the way, you could go to quest.com, which I think is it's a, it's a lab. I'm not, you know,

00:16:12.720 | by the way, anything I mentioned here, like no conflicts of interest for me. Like I'm not,

00:16:16.960 | I don't have any vested interest in anything. But quest labs and, you know, line up the 10

00:16:22.400 | other competitors to them. You can go online and order blood tests and they'll some, some states

00:16:26.720 | and cities will, they'll come to your house. They'll charge your insurance. They may charge

00:16:30.080 | you a convenience fee, you know, to do it online. Who knows. By the way, just a thing that I found,

00:16:35.280 | I have no affiliation with this company, but I was looking at some tests that I wanted to run

00:16:38.960 | that weren't covered by insurance. And there's this site ulta, U L T A lab test.com,

00:16:43.600 | which basically sends the same order to quest at like a third of the price.

00:16:47.520 | So if someone doesn't find something covered, I just went to quest and got the exact same test

00:16:52.080 | done, but it was just less expensive. I'm not sure how that whole system works, but.

00:16:55.920 | Well, look, I mean, the dirty little secret here is, is when if I have a patient who like,

00:17:01.040 | let's say lost their insurance, doesn't have insurance. And I say, go to question,

00:17:05.040 | order a cholesterol test. It could be $200. But if I order it under my account, it's like $20.

00:17:10.240 | So like there's massive margin here because there's opacity and no transparency in this system.

00:17:16.560 | Even MRIs, if you want to like, let's, okay. I don't want to get ahead of ourselves, but let's

00:17:21.600 | just say you want it to do the most thorough baseline understanding of who you are in the

00:17:27.520 | world. Right. And you were willing to spend a chunk of change just to get to know yourself.

00:17:32.000 | Well, one of the things that you would consider is getting a brain MRI with a brain MRA.

00:17:38.480 | And I'll tell you a story about a guy that I did that on and it turns out something happened to

00:17:42.400 | him. And so I'm so glad we had a baseline test to compare it to because otherwise you're flying

00:17:45.920 | blind. The problem with doing tests like that, you know, a lot of doctors will say, well,

00:17:50.880 | you're going to find things on there that don't mean any. Like if you did an MRI of a spine of

00:17:56.080 | every 50 year old, they all look like shit. And then everyone, oh my God, I'm falling apart. No,

00:18:00.480 | that's just natural aging, natural aging. But we haven't kind of calibrated normal to not normal

00:18:07.040 | yet. It's like, everything's abnormal if it's not perfect. And, but at age 24, it's perfect unless

00:18:11.840 | it isn't, but they, everything, you know, decays over time. So the MRI that I would order on

00:18:19.200 | somebody that really wanted the, the MRA shows you the blood vessels, like three-dimensional

00:18:23.600 | blood vessels of your brain. Because if you have an aneurysm in your brain, the typical way you

00:18:29.600 | find out about them is on autopsy. You, you know, your aneurysm burst and then, you know, you fell

00:18:34.560 | down and, you know, unless you're close to a hospital, you're dead. They're very rare. I mean,

00:18:40.800 | but you, you catch them on some people, but if you ordered that MRI and you walked into the place,

00:18:44.880 | it could be $10,000. If I order it through my system, if you just like through the private

00:18:49.760 | pay, it's $400. You're just like getting hoodwinked by something you didn't even know.

00:18:55.920 | And that's the opacity factor that really, I think is a, a lot of people have been trying to tackle

00:19:01.040 | that, but there's a whole lot of people that don't want that opacity to be known because it's going

00:19:05.120 | to expose like the, the, you know, all these facets of the shenanigans and the chicanery

00:19:11.520 | that goes on behind the scenes to make the profits. But to answer your question specifically,

00:19:15.600 | what would you do if you were a regular person that just wanted to know? So you'd want to know,

00:19:20.240 | you do like what's called a CBC, a complete blood count. You want to know what your immune system

00:19:24.880 | looks like. Do you have enough blood in the tank? There are some women that, that because they have

00:19:28.960 | heavy periods, they're anemic and they don't know it, but they have low energy and they don't know

00:19:32.640 | it. So you'd want to like get a baseline on where you are with your, you know, your, whether you're

00:19:38.000 | anemic or not. You'd want to get like a chemistry panel. And again, these are all like almost

00:19:43.280 | archaic, but they're, they're the standard of care. You'd want to get your cholesterol and

00:19:48.160 | there's like a basic cholesterol. Then there's a cardio IQ test, which is a much more sophisticated

00:19:52.960 | cholesterol test that will tell you, you know, your APO and, and your LDL fractionations and

00:19:59.280 | all sorts of bits and pieces that will give you a little more color on, should you be concerned or

00:20:02.800 | not. From a blood work standpoint, I like to check at least once your sed rate, your Westergren sed

00:20:11.200 | rate, which is just, it's a very nonspecific test, but it shows what level of inflammation there is

00:20:20.880 | in your body. Again, it's a crude inflammatory marker. And I'll just pause and talk about

00:20:25.600 | something called inflammation. The more inflammation you have in your body, chronic

00:20:29.040 | inflammation, the faster you age. So, so you want to like, you know, one's goal in life should be

00:20:35.520 | to have a body that's not like inflamed inside. Now, when you cut your finger or you bang up your

00:20:39.520 | something, you see the inflammation visible, but when your whole body's subclinically inflamed,

00:20:44.800 | which can be caused by great stress from a bad relationship, it could be caused by,

00:20:49.200 | you know, untreated, you know, subclinical Crohn's disease, or, you know, we could talk

00:20:53.600 | about a lot of things. You're just, you're just aging faster. You will have problems later in

00:20:58.160 | life. And so if you try to go to your future self, what would you want to know today? So,

00:21:01.200 | so the sed rates one, there's something called an HS, high sensitivity, CRP, cardioreactive protein,

00:21:06.960 | again, another measure of inflammation. These are all, you know, I'll call blood test 1.0.

00:21:13.040 | There's a whole new set of tests, Chris, we can talk about metabolomics, proteomics. There's all

00:21:18.080 | these new companies coming online that are, that are creating much more sophisticated, much more

00:21:22.640 | sensitive tests. Those still cost 500 bucks because they're new startups and they don't have

00:21:28.320 | scale yet, but those will come down. You know, if you're over 50, there's a cancer test called

00:21:33.760 | Grail, it's called gallery, check for 42 types of cancers. You know, it's, it's 960 bucks right now,

00:21:42.480 | but, you know, if you have a family history of cancer, I recommend you probably do that every

00:21:47.040 | year. I just caught a 38 year old guy with a mother and a grandmother with stomach cancer.

00:21:51.360 | I checked him at 38, colon cancer, positive stage two, surgery, chemo. He just got his test back

00:21:56.880 | yesterday, two cancer-free, two years later, saved his life. You don't normally get a colonoscopy

00:22:01.920 | till you're 48, 45. So he's 38. He would be dead by the time of his first colonoscopy.

00:22:07.280 | So you have to like risk adjusting, who are you? What are the tests that you should get?

00:22:12.160 | You should know what your blood pressure is, you know, and by the way, checking your blood

00:22:16.160 | pressure one, does it count? The real way to understand what your blood pressure is,

00:22:19.680 | you have to check it 17 times at different times of day in one month, put them on a spreadsheet,

00:22:24.000 | average them out. That's your blood pressure. What should it be? It should be below 120 over

00:22:29.200 | 80. Most of the time, if you just went on a run, had coffee, had sex, gotten a fight,

00:22:33.280 | it can be higher. That's normal. Your blood pressure is supposed to get up to be high

00:22:36.880 | because that's, we have a lot of resilience in our system, but at baseline at regular,

00:22:40.960 | it should be like 120 over 80 or less. So those are some basic blood tests. You know,

00:22:47.680 | a lot of this stuff has to do with what age you are and what your risk factors are.

00:22:50.960 | So if you've got a family history of heart disease, my mom had a heart attack or that,

00:22:55.680 | you know, something like that, then you're going to want to like start doing these tests earlier.

00:22:59.280 | You know, and then if you have high cholesterol and a family history, you should think about

00:23:05.280 | something called a calcium score, which is a CAT scan that gives you a lot more data on

00:23:09.680 | whether the cholesterol, because remember, there's different genetic types of people.

00:23:15.440 | Some people can have high cholesterol all their life and never have a heart problem.

00:23:18.480 | Some people can have like moderately high cholesterol and have a heart problem.

00:23:21.680 | So you have to identify which one are you in the world? Like you're not like everybody else.

00:23:26.240 | You're unique. And it's part of it's your family history, part of it's your genetics,

00:23:30.320 | and part of it's your lifestyle or health style. And so how you exist in the world depends on

00:23:37.040 | the probability that one of these things that could happen does happen.

00:23:42.800 | So those are kind of some baseline testing that like just simple blood tests, blood pressure,

00:23:47.440 | you know, I would say check thyroid gland, TSH. That's a basic blood test. That's just a good

00:23:53.840 | one time to know. Men should probably be getting PSA checks and prostate exams after the age of 50

00:24:01.360 | on somewhat of a regular basis. If there's a family history of getting prostate cancer in

00:24:05.520 | their 50s, then you should start doing that much earlier. Like, you know, again, the blood test.

00:24:10.240 | But a lot of these things require, you know, both experience and math. And the good news is with AI

00:24:16.240 | right now, pretty soon you'll be able to plug in all sorts of stuff about yourself and it'll tell

00:24:19.440 | you what you should do right now, what tests you should do. And if those tests say this,

00:24:23.200 | then you should do that. So that's kind of this future. The question is, how do you execute that?

00:24:28.320 | I'll share one example. So I used and now partnered with this company,

00:24:34.000 | InsideTracker. And it's basically do blood work. And they go in and share you a lot of the data

00:24:40.240 | about, you know, where's the standard range? What's your range? What are recommendations

00:24:44.400 | from our team of researchers that say what you should do? Link out to the research. I'm really

00:24:49.840 | happy because they just added ApoB, which I think is something that from my research, at least,

00:24:54.400 | because my biggest health issue is in the cholesterol, you know, lipid family is that

00:24:59.120 | ApoB is something that seems like hasn't made its way to mainstream medicine yet,

00:25:02.720 | but is important. So I'm excited they just added that. But that's one thing I did. And I did the

00:25:07.520 | genetic profile there so they can kind of adjust things based on what they learned about your

00:25:12.160 | genetics. So, you know, that's one option that I've used. So you're talking about genetics vis-a-vis

00:25:18.960 | like a health problem. There's another set of genetics coming online. And by the way,

00:25:22.720 | there's a company called Invitae. They're one of the bigger ones. They do the panel of, I don't

00:25:27.440 | know how many genes, but they check for genes that like tell you what your probability of getting

00:25:32.480 | something is, which then can inform what your surveillance program should be. So they've got

00:25:37.760 | a good panel. But then there's a company, again, I'm just gonna name various companies, called

00:25:42.000 | Oneome, O-N-E-O-M-E, Oneome, that does pharmacogenetics. So what's that? So because of

00:25:50.400 | COVID and because a lot of mental health issues, a lot of people are taking antidepressants or

00:25:55.200 | anti-anxiety drugs. We can talk about psychedelics later because a lot of people are doing that too.

00:25:59.120 | But, you know, we can tell you through, you know, again, this science is, I'll say 75%,

00:26:05.600 | but it's better than 0%. So a lot of doctors will say, "I'm not going to do that test because it's

00:26:10.160 | not 98%." I'm like, "Well, would you take 75% over zero? Like right now, when someone is depressed,

00:26:17.600 | I'll try this drug. Oh, that doesn't work. I'll try that drug. Oh, that doesn't work. I'll try

00:26:20.320 | that drug." Well, with pharmacogenetics, they can kind of look at the processing power of your

00:26:26.080 | enzymes with respect to certain genes, and they can tell you, "Hey, this drug is probably not

00:26:31.600 | going to work as well because it's cleared so fast, or this drug will work better." So if you're

00:26:36.000 | going to embark on a kind of a pharmacologic adventure to try to solve a problem, this is

00:26:42.640 | called precision medicine, we're getting better at being able to pick the right drug the first time.

00:26:48.160 | And that's through this venue called pharmacogenomics, which is, you know, again,

00:26:52.880 | still new. The existing medical system is very, very slow to move. Like I said at the beginning,

00:26:59.840 | at the top of the podcast, and a lot of doctors won't do it. A lot of insurance companies won't

00:27:03.600 | pay for it because, you know, the proof isn't there yet. And so they usually require five

00:27:08.800 | years of proof and data to do the analysis to show that this cost has a future cost benefit.

00:27:15.920 | And that's kind of the - which by the way, you want that science and you want that rigor so that

00:27:21.120 | you're not like, you know, in technology, it's move fast and break things. And in medicine,

00:27:25.280 | it's move slow and don't kill people, or don't hurt people. So we do want it to move slow a

00:27:30.400 | little bit, but every 120 days, Chris, there's a new major breakthrough in medicine that like most

00:27:37.200 | of the medical field won't like know about for 10 years, because they're so busy with the

00:27:41.200 | innovations from the last five years. Like, so there's this natural lag that any doctor has,

00:27:49.200 | or any clinic has. I mean, I hold myself out and we hold ourselves out as there's no lag.

00:27:54.080 | All these companies are presenting to me every other week. I have a, you know, kind of a

00:27:59.520 | speed dating type of companies present to my group of six of our doctors. And we kind of like,

00:28:04.480 | does it pass the sniff test? Is it valuable to patients? Is it not like super expensive? Like,

00:28:10.480 | does it work? Is it, you know, how do we, you know, and if, and what is the science?

00:28:14.240 | And is it peer reviewed? Is it validated? Is it, you know, there's a lot of people hawking a lot

00:28:18.960 | of stuff that's like super on the margin and on the bubble. And there's a ton of gurus, especially

00:28:23.440 | in the longevity space, talking about how, if you just take this or do that, like, you know,

00:28:27.920 | off you go. But there's no proof. There's just no proof. So I generally think about

00:28:36.320 | just to go to that place really quick, everything should be looked at through the lens of safety

00:28:41.200 | and efficacy. And if it's safe and it's proven safe, and there's ways to prove that things are

00:28:46.480 | safe or not, and it's not yet proven to be efficacious, speaking of longevity, well,

00:28:53.200 | take a flyer. You're just gambling with your money, right? Why not? Like maybe it works,

00:28:57.600 | maybe it doesn't. But if you are going to do something that doesn't have a safety profile,

00:29:04.240 | that is like really robust, I mean, this is your body, this is your health asset, this is your

00:29:08.320 | life. If you're going to take a flyer and gamble on the safety piece, because by the way, if we're

00:29:14.560 | not sure it's safe, we certainly know, we're not sure if it's effective, then you're gambling with

00:29:19.040 | your health, right? And then I call that short brevity or long brevity. It's not longevity,

00:29:25.120 | it's long brevity. You are just kind of hoping that it works. And my philosophy is, hey,

00:29:34.880 | wait a couple of years, let the science tell you the story. Don't rush into gambling with your

00:29:39.680 | health because if it does work and you missed it by two years, okay, that's two extra weeks when

00:29:46.240 | you're like 99 to 99 and two weeks old. Right now, you don't want to be mucking up with your system

00:29:54.960 | that can make it 99 to like maybe you make it to 82 because you created all this other problem.

00:30:01.280 | My job is to look at the science and I'm not well-loved by a lot of people because

00:30:05.840 | I just call out like I'm not making money on anything. Everyone else is making money on the

00:30:10.000 | things that they're pitching. So it puts me in opposition in some ways to the things that are

00:30:16.480 | being pitched. Let's run through a couple of the lifespan things and just get your take on them.

00:30:22.320 | One of the most well-proven and well-known things for longevity is social integration,

00:30:27.440 | is having healthy relationships that are repeated and long-term. Are you in a book club? Do you go

00:30:34.480 | on walks with the same people? Do you have like because I think we often think that the body and

00:30:39.360 | the mind are different things, but they're the same thing. That's like saying my computer screen

00:30:45.360 | and my computer chip in the thing like are different. Well, they are, but the output is

00:30:50.240 | that like one breaks the other one, you know, you need both. And so the brain is what can cause

00:30:55.680 | inflammation in the body by stress or by angst or by not sleeping well or by having bad eating

00:31:00.880 | habits or by drinking too much because you're stressed. So this level of stress kind of goes

00:31:05.760 | down with social integration because you know your people, they call your bullshit in a way that you

00:31:11.520 | kind of come to tolerate and realize that you need people to guide you and to be sounding boards so

00:31:18.960 | that you're not just, you know, looking for more likes on Twitter or, you know, or getting super

00:31:24.320 | bummed out when you get like a criticism somewhere. I just also did a podcast with Eric Verdon,

00:31:29.440 | who's the CEO of the Buck Institute on how to live to 95 super healthy. And we go through a number of

00:31:35.520 | different strategies to do that. Spoiler alert, it's not rocket science right now. I mean, he's

00:31:41.120 | doing a lot of research on stuff, molecularly cellular senescence, mitochondrial decay,

00:31:46.880 | you know, telomeres, oxidative stress. They're doing a lot of that research, but he'll even tell

00:31:53.200 | you we're not there yet. And then there's stem cells. And I think when we think of longevity,

00:31:57.280 | we have to think about like, well, my eyes may age faster than my heart. My liver may age faster

00:32:02.160 | than my kidneys. So, longevity is like almost organ specific. And most people don't think like

00:32:07.120 | that. But the spoiler alert is, and a study came out literally, I think it was yesterday, a big

00:32:12.720 | study over lots of years and lots of people that water, hydration. Well, by the way, we all know

00:32:20.400 | this. Everybody knows that like, as my father used to say, the solution to pollution, I see you

00:32:24.960 | drinking now, the solution to pollution is dilution. Water is a critical aspect of life. And

00:32:30.720 | if you stop drinking for three days, you're dead. Let me just put a really fine point. If you stop

00:32:34.320 | drinking for three days, you're dead. If you stop eating, you can go on a hunger strike for a month

00:32:38.560 | or longer before you're dead. Without water, you're dead in three days, which is why all

00:32:43.520 | these people in the hospital are getting IVs and they never die. You stop the water, they're dead.

00:32:48.000 | You go out in the forest, there's all these animals out there that you can't see and can't

00:32:51.680 | hear if you're camping and there's animals dying everywhere. You don't hear screams,

00:32:55.600 | you don't hear moans, they're not in pain. Why? Because the body has come up with a very elegant

00:32:59.920 | mechanism for death by no water. As soon as you start not drinking, what happens is your kidneys,

00:33:07.520 | which filter all the stuff in your body, the level of nitrogen in your body, which normally gets

00:33:11.920 | filtered, the more you drink, the more nitrogen goes out. I mean, sodium and chloride, there's

00:33:15.200 | all sorts of things the kidney does, I'm being simplistic here. But the levels of nitrogen start

00:33:20.080 | to go up in your body, they get more concentrated, they're not being diluted, they're being

00:33:23.840 | concentrated. So the higher the nitrogen is, if you've ever had nitrous oxide, you kind of get,

00:33:27.920 | whoa, kind of numb and happy. It's the same thing. So when you stop drinking,

00:33:32.240 | you start to get like, it's like a morphine-like state where you kind of get happy and numb and

00:33:39.120 | things are kind of gleeful. Now, not to suggest that if you've got terrible pain and stop drinking,

00:33:44.720 | that's a solution. But people at the end of life that aren't suffering with any painful thing,

00:33:51.520 | they stop drinking and then they die. And it's a very kind of dignified biological process that

00:33:58.640 | like biology has figured out for a long time. They don't want death to be super painful.

00:34:02.080 | I say they, I don't know who they is, but like nature, biology. So hydration is like a really

00:34:11.760 | important thing. And so how do you know if you're drinking enough? They've got smart cups, they've

00:34:15.280 | got like all this new gadgets. Hey, real simple. If you're not going to the bathroom three times

00:34:19.760 | a day or more while you're awake, you're not drinking enough. I think you should always have

00:34:24.160 | a glass of water around and you should always be, you shouldn't be chugging, you should be drinking.

00:34:28.080 | And I think the part two to that is alcohol. Like we know that alcohol is a pro-aging substance.

00:34:32.800 | So if you're one of these anti-aging people and you drink alcohol, well, then you're a hypocrite

00:34:36.560 | or you're not actually, you're going to take some silver bullet pill that you heard about

00:34:42.640 | from somebody. And then you're going to go out and have like a bunch of cocktails and go to Vegas.

00:34:46.560 | Like that's not, you actually have to like think long term and what these, what these episodes of

00:34:53.360 | alcohol does. But if you are going to drink alcohol, which people do glass of wine, put a

00:34:57.920 | glass of water in front of it, put a glass of water after it, because then you're diluting the alcohol's

00:35:02.560 | impact because alcohol dehydrates you. So the concentration of alcohol molecules in your body

00:35:06.800 | is higher an hour after you drink it than it was before. But if you drink lots of water before and

00:35:11.200 | after, it doesn't get a chance to concentrate and cause problems. Sleep, super important one.

00:35:16.640 | I wear an aura ring and I see you do too. I measure my sleep every day. I've been getting

00:35:24.320 | 90s scores on both ends since January 1st when I stopped traveling. And I, my goal is to keep

00:35:32.000 | above 90, like all the time. I have patients that are like, yeah, I'm in the sixties. I think it's

00:35:37.360 | great. Cause I was in the forties and I was like, uh, holy moly forties. I think a lot of people

00:35:43.920 | think that like, yeah, I'll, I'll, I'll sleep when I'm dead. You know, I'll have plenty of time for

00:35:47.120 | that. But the truth is if you, if you don't sleep now, you're going to die much sooner.

00:35:52.000 | And so you'll have less time. And you know, one of the hacks for me is I need eight hours of sleep.

00:35:56.720 | In fact, I got like almost nine last night, but you should figure out when you want to wake up

00:36:02.080 | and you should set your alarm clock to go to bed. You should never set your alarm clock,

00:36:05.760 | wake up because when you set your alarm clock to wake up in that last hour, while you're waking up

00:36:11.120 | naturally, your cortisol levels, which is a inflammatory stress molecule, um, is going down.

00:36:17.520 | And right before you wake up naturally, it's at the lowest point before you wake up. And when you

00:36:21.280 | wake up the world turned on and it spikes. So your cortisol level always does this huge jump when you

00:36:26.240 | wake up because you're, the world just turned on and now you have to like figure stuff out.

00:36:31.200 | So ultimately, um, you want that cortisol level to be at the lowest before you wake up. Cause if

00:36:36.720 | it's high before you wake up and it spikes, it just got much higher. The, the, the, the upper

00:36:40.960 | magnitude got higher. So I like to let people wake up naturally that you're humans are the only

00:36:46.000 | biological species on the planet that artificially interrupt a critical, uh, biological process.

00:36:50.880 | No way. No. Um, and also there's something called the glymphatic system in the brain,

00:36:55.760 | which clears out all the metabolic junk from all the activity from the day before.

00:37:00.480 | And, you know, you want that to go through its entire process. I think waking up

00:37:04.160 | is a multifactorial process, which the brain feels like it cleared out enough stuff.

00:37:08.480 | Your cortisol levels, nice, low, uh, your circadian rhythms or this it's time to wake up.

00:37:13.040 | So sleep's critical diet is obviously super critical. You know, what does that mean? Like,

00:37:19.440 | kind of like Michael Pollan said, eat real food, not that much. And, and, you know,

00:37:23.040 | and there's a big study on time-restricted eating today that came out. Uh, I generally,

00:37:27.840 | uh, don't eat breakfast. I've never eaten breakfast. I mean, I'll have, if I have a

00:37:31.520 | breakfast meeting, I will, but you know, um, I generally, I'm not hungry in the morning.

00:37:35.280 | My coffee kills my appetite. I have one cup of coffee. Um, and then I may have a cup of green

00:37:39.760 | tea throughout the day. I'll generally eat at one or two, have a relatively small lunch, mostly

00:37:46.000 | vegetables, maybe a little fish. Um, and then I'll have my dinner, which, you know, and stop eating

00:37:51.760 | at eight, um, eight 30. But the truth is you should not eat things in a package. If it's in

00:37:58.080 | a package, it's probably processed and probably not the greatest thing for you, almost impossible

00:38:03.520 | to do that. So I think if you are doing things in a package, look at the ingredient list. If it's a

00:38:09.040 | lot of ingredients, uh, probably not good. If they're ingredients you can't pronounce or no,

00:38:14.160 | probably not good. Um, and in general, you know, the, the, the hack I have is like one apple is 70

00:38:21.920 | to 90 calories, depending on the size. It represents 50% of the dietary fiber you need in a

00:38:27.200 | day. Um, and your microbiome, which lives in your intestine, which is the separate organ that we

00:38:32.400 | have, um, feeds off of fiber. So you'd rather give your microbiome, your friend that helps you live

00:38:40.320 | because it makes 80% of the serotonin in your body or 90%, which is the happiness molecule.

00:38:46.000 | So if you don't feed your gut, it's hard to be happy. If you don't, I mean,

00:38:48.720 | if you put a bunch of chemicals and crap in your gut and cause it to get angry,

00:38:52.080 | you're probably not creating an environment for your, your best self to emerge through,

00:38:56.880 | you know, uh, you know, more serotonin, less dopamine environment. So I like to tell people,

00:39:02.560 | apple, like if you want dessert or if you're hungry and you see a snack, eat an apple,

00:39:07.600 | eat two, you will not be hungry afterwards. You will not want to eat anything after two apples.

00:39:11.840 | You're just full because fiber slows everything down. Um, so, so, so diet is really important.

00:39:17.200 | I think there's a lot of, you know, movement towards no wheat gluten-free. I think there's

00:39:21.840 | going to be some science that comes out about that in the next couple of years that that's

00:39:25.440 | probably better for you. Um, but probably based on genetics and then exercise, exercise is also the

00:39:31.520 | other pillar of longevity. And, you know, there are some people that like, and it, by the way,

00:39:37.680 | exercising outdoors, much better than indoors, even taking walks outside the hormones from trees,

00:39:43.360 | the pheromones from trees, lower your cortisol level, lower your kind of inflammation process.

00:39:48.080 | So people that have Pelotons and they do their one hour of hardcore inside, and then they go

00:39:52.480 | work better than nothing. But I would encourage you to get on a bike and go outside, um, you know,

00:39:57.280 | or, or, or just take a walk or a jog, or, you know, there there's other ways. You know,

00:40:01.760 | obviously if you live in a big city and it's freezing outside, like you do the Peloton,

00:40:05.680 | but you know, I do, I do pushups in the morning. I do sit ups. So my exercises, I don't have a one

00:40:10.560 | hour intensive thing. I just do micro things and studies have shown that three to five minutes of

00:40:15.520 | intense exercise a couple of times a day is as good as anything else in terms of what it does

00:40:20.880 | to your body in terms of resilience and restorative function and longevity. So those are the,

00:40:25.920 | those are the shortcuts on the, on the longevity thing. Then there's of course,

00:40:28.720 | all these supplements that people can take and, and, and, uh, there's people doing NAD drips.

00:40:34.560 | Um, there's companies that, that do those all over the country, not proven there's IV drips.

00:40:39.840 | I'm like, does your stomach work drink? Like, I mean, if you're hung over and you just can't drink

00:40:44.480 | a lot, then sure. IVs are going to restore your fluid balance probably a little bit faster. But

00:40:50.960 | if you actually drank water while you were drinking your cocktails, you wouldn't need the IV drip. So

00:40:54.960 | like, do you want to be proactive or reactive? Like, what is the approach that you want to take?

00:40:58.560 | Who do you want to, who do you want to be in this world? And how do you want to think about your

00:41:01.680 | long-term health? So I want to go back quickly to diet. Uh, you know, I think we all know that

00:41:07.600 | processed foods, not good for you. Uh, sugar, I assume you would say is not a great thing to be

00:41:12.560 | consuming a lot of, but does that mean there's no place for it? Like great, great question.

00:41:17.600 | So like my, my rule is, you know, I think the 80/20 rule was probably the,

00:41:21.680 | the, you know, the Pareto thing. I think it's probably 95/5 or 90/10.

00:41:26.000 | I have a total sweet tooth. Like I, you know, when I was growing up, I ate Twinkie. Like my,

00:41:32.080 | you know, I was growing up in the seventies, you know, California and like my mom before she got

00:41:35.360 | like all natural and stuff. It was like, yeah, have one of these and Fruit Loops and Captain Crunch.

00:41:39.760 | And, you know, um, you know, but I had my apples and bananas and everything else. Um, so in general,

00:41:45.120 | and I started a nonprofit called Eat Real, um, which is all about, uh, preventing kids from

00:41:49.760 | getting sugar, uh, which we can talk about maybe separately. We're changing the menu of the largest

00:41:54.640 | fast food chain in the United States, which is our public school system. And by the way,

00:41:58.000 | by removing chocolate milk out of school, and we did this in, uh, in the East Bay, in the Bay area,

00:42:04.560 | we eliminated 10 pounds of sugar in one child's body per semester.

00:42:09.200 | Don't you think about that? Just making chocolate milk to milk.

00:42:14.720 | So 10 pounds of sugar in a kid is doing as a absolutely no bueno. So like sugar should be

00:42:20.320 | to me for dessert, but you can't have dessert at every meal. Like dessert can't be your,

00:42:26.720 | your main course, your, your appetizer. And by the way, bread is sugar, um, but it's not

00:42:33.040 | processed refined sugar. It is a carbohydrate. It will go through an oxidative process

00:42:37.360 | that looks like sugar, but just not as, uh, corrosive as fructose and, um, you know,

00:42:42.960 | all these other high fructose things. So I, for dessert last night, I was like, my wife made this,

00:42:49.120 | you know, amazing pasta, um, and, and, and squash soup. And I was like, I need my dessert.

00:42:54.000 | So what did I do? I got raw. I like coconuts. I got raw coconut shavings, no sugar added.

00:42:59.840 | I got some dark chocolate chips, um, which are almost a little sugar. And I, and I got some

00:43:04.560 | peanuts and a fig. I chopped it all up, put it in a little bowl. And that was my dessert, you know,

00:43:09.440 | and it was all natural. It was a very sweet, it was incredibly sweet. Um, but it was tons of fiber

00:43:15.040 | in there. So I would say like, and I love my sorbets. So don't get me wrong. Like I will cheat.

00:43:20.320 | Um, if someone's got a great sorbet, I'll have it. Uh, if there's an amazing chocolate fudge thing,

00:43:26.240 | I'll have it. If there's an amazing cookie, there's a restaurant called Spruce around here.

00:43:29.920 | The Spruce cookies, oatmeal cookies are amazing. I think they're like 1500 calories per cookie

00:43:34.240 | though. So I think you just have to be mindful of like, and by the way, I used to eat whole

00:43:37.920 | Spruce cookies like 10 years ago. And then I realized, Holy shit. Those are, those are loaded.

00:43:41.520 | I'll just have a few bites. So yeah, have your dessert, but yeah, I'll still have it from time

00:43:46.880 | to time, but I I'm much more mindful of let me eat it. If I have a sweet tooth, let me eat an

00:43:52.240 | apple that will kill my desire for more sweets because apples are pretty sweet, but all that

00:43:58.640 | sugar is attached to fiber. And I, and to, and to illustrate one point, which I think is fascinating.

00:44:05.200 | One of my buddies is a researcher, did a study in Oakland, California. He went to an inner city

00:44:11.200 | school, uh, got two 14 year old African-American kids, both like six feet tall, told him not to

00:44:17.040 | eat dinner, show up to school. And we were going to experiment with food. And one of them was old.

00:44:23.760 | Uh, they showed up at 9:00 AM drink this 16 ounce glass of orange juice, glug, glug, glug, glug,

00:44:30.000 | drank it. He's hungry, grown guy, growing boy. Uh, now here's a Big Mac, large fries and a big

00:44:36.240 | milkshake. Ate the whole thing. All of it. No problem. The second kid came in and we gave him

00:44:42.080 | six gigantic oranges. He, not I, he gave us and said, peel them and eat them. He couldn't eat the

00:44:49.120 | six one. He was full. Six big oranges. Those six oranges is what made that orange juice for the

00:44:55.120 | other guy. So by eating sugar with fiber, you, you fill up, you can't, you, you know, satiety

00:45:02.080 | is not just, you know, your stomach has stretchers. Your stomach's a bag. And when you wake up in the

00:45:06.880 | morning, your bag is like, it's a paper bag. That's not open. As soon as you start filling

00:45:10.240 | up the bag with food, there are stretch receptors in the stomach that send signals to the brain.

00:45:13.920 | Hey, we're filling up here. Uh, slow down. So just stretch. Uh, we'll, we'll, we'll signal,

00:45:19.520 | slow down, not hungry, kill appetite. Um, in addition to the quality of the food,

00:45:24.560 | but six oranges is a ton of it's mass. It's a ton of mass. So I'm in the habit lately of when I'm

00:45:31.840 | hungry or, um, you know, for something sweet, all of an apple and an orange, and then I am no longer

00:45:37.520 | hungry. Um, and so it's, it's my hack to get, you know, get all the sugar I want. And you can't eat

00:45:44.000 | enough fruit by the way. And by the way, one other story is a dole pineapple in Hawaii. You've seen

00:45:50.160 | these big Polynesian Hawaiians. They're massive. They're like Sumo wrestlers before dole came in.

00:45:54.560 | Those people ate pineapples naturally on the, in Hawaii, no diabetes anywhere. Soon as dole came

00:46:00.560 | in and made pineapple juice, diabetes pandemic in amongst the Hawaiians, because they stopped,

00:46:05.680 | they took the fiber out of it and they just made it the juice. So eat the eat. So I say, no, no

00:46:10.160 | juice juice or no, no bueno. I mean, there's all these green juices now. Okay. Whatever. Like,

00:46:14.560 | why don't you just eat the food that the juice is made of? Like you could do that if you wanted to,

00:46:19.920 | like, but if you just don't have the time, take the juice, but any, but all those, those juices

00:46:24.960 | have honey cane juice. It's, you know, it might as well be a Coke, right? I mean, without the,

00:46:32.320 | all the, the, the hardcore chemicals, you've got like the kale and you've got all these things that

00:46:35.520 | look bueno and feel good about, but it's still got tons of sugar. That's not connected to fiber.

00:46:40.320 | Let's say you've got 12 cookies sitting in front of you and you know, you're going to eat them.

00:46:44.320 | It's better to eat one a day or 12 on one day and nothing for the next 11 days.

00:46:49.200 | It's much better to eat one a day. And the metaphor I'll use there is imagine you're in

00:46:57.120 | your car and you have maybe that's not, that's not for, but you, you, you, you want to go fast.

00:47:04.320 | You could go first gear to 4,000 RPM, second gear to 4,000 RPM, but when cars, you know,

00:47:10.800 | had stick shifts and you know, but the 12 cookies is taking your car in first gear to like the red

00:47:17.280 | line all the way to the end. And it just, it stresses the system because once your blood sugar

00:47:22.240 | goes up with all those cookies, what happens is, is there's so much sugar in your blood that your

00:47:27.680 | body goes, okay, the red lights start flashing. We need to lower that sugar. So in order to lower

00:47:33.600 | that sugar, we're going to, we're going to make a bunch of insulin and insulin. Then your pancreas

00:47:37.440 | makes insulin and your insulin shoots up. And when insulin shoots up, insulin is the key that unlocks

00:47:44.240 | the little holes in your, in your blood vessels to let sugar out of the bloodstream and go into cells.

00:47:51.760 | So, so when your insulin spikes, insulin is, you know, is an inflammatory thing. It's,

00:47:58.880 | it's like creating inflammation for your whole body. So, so you don't, I mean, look,

00:48:04.000 | so by going to 12 cookies, you've just caused this huge glucose spike. That's the other thing

00:48:09.440 | I would recommend people who are curious and you've probably done this as the,

00:48:12.560 | the continuous glucose monitor, like what causes your sugar to spike? And everyone's

00:48:17.200 | slightly different. I found that when I eat kimchi, my blood sugars went down. I love kimchi.

00:48:22.080 | And by the way, fermented foods are always good for you, pretty much good for your gut,

00:48:25.760 | good for your health. People underestimate, they don't eat enough fermented foods, pickles,

00:48:30.000 | you know, all these things. But a continuous glucose monitor will, will, will tell you the

00:48:34.240 | truth about what's going on when you do things. So some people work at his glucose monitors for

00:48:39.040 | long periods of time. My thesis is where for a month, eat lots of things, try lots of challenges.

00:48:45.040 | But if you see a big spike in something, you should try to avoid that food or eat an apple

00:48:50.400 | before you eat that food and eat it again and see if the spike happens. Because the apple will slow

00:48:55.280 | down the absorption because the fiber just slows down absorption of sugar. I say an apple or some

00:48:59.360 | other high fiber thing. I signed up for Levels Health and used it for a month, which is a

00:49:05.200 | continuous glucose monitor startup that has an app. I use Levels too. I did it for a month.

00:49:09.120 | The thing about Levels and all these companies, they want you to wear them forever. And it's just

00:49:12.240 | like, yeah, no, like I don't, like after one, I mean, if you don't do enough challenges over a

00:49:18.000 | month, then maybe you need to wear it longer, but you don't, you don't need, you know, I mean,

00:49:21.440 | I think every minute that you're focused on your health obsessively, you're not focused on

00:49:26.400 | your like life. And the reason we're here is to enjoy our life. Health is, health is freedom.

00:49:32.320 | And if we're focusing on something for a long period of time and, you know, we lose sight of

00:49:37.840 | like the broader purpose here. So I like to get people who are like hyper freak quantified self

00:49:45.040 | people to like, you know, step back from the ledge and stop trying to measure things. And

00:49:49.760 | there's a control freak component to that. I must know everything so I can control everything.

00:49:53.280 | Guess what? Get the heuristic, get it kind of, and then, and then, and then change your behavior

00:49:57.760 | and then go maybe do it again in a year, see if it helped. But you're not going to notice any

00:50:02.000 | material difference, you know, dated, you know, month to month or year to year by continuing to

00:50:08.320 | do this stuff. So we started with this, who are you? Where you ran through a bunch of tests,

00:50:13.600 | a lot of blood work, a few other things. I think the next one that you talk about is how are you?

00:50:18.560 | So, so how are you is really, what does your life look like? I mean, you wake up in the morning and

00:50:25.200 | then you go to bed, right? And absent those moments when you're sleeping, what does your

00:50:29.680 | life look like? What is your, what are your relationships? I've come up with this,

00:50:32.640 | this concept called vitality signs, which is not vital signs and vitality signs are measures of

00:50:39.360 | your relationship with things in the world. So the relationship, so how are you is like,

00:50:46.560 | how is your relationship with your parents? How is your relationship with your children?

00:50:51.440 | If you have them, how is your relationship with your primary relationship, your spouse or

00:50:57.120 | girlfriend, boyfriend? And if you don't have a spouse, girlfriend, boyfriend, how's your

00:51:01.360 | relationship with the absence of that, right? How does that, does that cause you anxiety?

00:51:05.920 | Does that, are you cool with it? Like, cause all these things are going to inform a bigger picture.

00:51:09.760 | What is your relationship with money? Are you obsessively trying to get more? Are you super

00:51:13.360 | happy with what you got? Like, what is your relationship with it? What is your relationship

00:51:17.680 | with time? Like, are, you know, are you, some people, what is your relationship with your past?

00:51:24.400 | What is your relationship with your vanity? Do you, are you obsessively concerned about how

00:51:28.400 | you look or do you not give a shit, you know, or, or like somewhere in between,

00:51:31.360 | what is your relationship with, with sex and love? Like, you know, and, and so there's all

00:51:38.080 | these different components of like, how are you? And ultimately based on these things,

00:51:42.320 | we'll start to get a framework of like, if someone doesn't talk to their parents anymore,

00:51:45.680 | oh yeah, I don't talk to my parents anymore. Or me and my sister haven't talked for years.

00:51:48.960 | That person's got a, there's a problem there. There's a real problem there. Now, if that,

00:51:53.280 | that like, there's a hole in that person's life in some way, or there's some deficit,

00:51:58.320 | whether they blow it off or not, it's true. You can't skip it. You have to like,

00:52:02.800 | acknowledge what that is. So the, how are you is like, all those things I just said from the

00:52:08.160 | vitality science, but more importantly is what, what do you do? What are your habits?

00:52:12.560 | What do you do that you should do more of? And what are the things that you should do less of?

00:52:19.760 | And what are the things that you're not doing at all that you should be doing?

00:52:23.600 | So you have to examine your habits. So that's the, how are you? And it's your mental health.

00:52:29.440 | Like, are you in a good state? Do you wake up happy? Do you wake up sad? So, so the, all of

00:52:32.960 | these things kind of, kind of ladder up to your overall, I'll call it the happiness or contentedness

00:52:41.520 | quotient with your existence. You know, your existential quotient, where are you? How are you?

00:52:47.840 | And so I, you know, and that will inform, like, if I run through that thing, I'll tell you like,

00:52:51.920 | oh yeah, that guy drinks a lot, doesn't sleep enough. That person, you know, you know, over

00:52:56.960 | indexes on, on sex versus love, you know, you know, whatever these things are, you know, how,

00:53:05.520 | who you are and how you are, then set you on a trajectory. And so the third bucket is, what is

00:53:11.520 | your trajectory? Here you are when you're born and here's, you are when you're dead. And you can be,

00:53:16.880 | you can go, you know, between the ages of zero and 24, you're growing and between the age of 24

00:53:21.280 | and death, you're aging. So what is the slope of the curve of aging, right? Are you, are you

00:53:27.520 | above normal? Are you below normal? Are you a super ager? Meaning are you age super fast?

00:53:32.400 | And those things can be measured based on who you are and how you are. So if you're constantly

00:53:38.800 | doing a, like a check-in on who you are and you're doing a check-in on how you are,

00:53:42.560 | you can kind of look at this trajectory and kind of know which one you're going to be.

00:53:46.720 | You control your destiny. No one's making you do the things you're doing that you shouldn't,

00:53:51.360 | and no one's not making you not do. It's just, you get in the way of yourself and nothing screws up

00:53:55.840 | a great story like data, which is why I'm super happy that like, there's all these devices that

00:54:00.640 | can measure things now. For example, there's a blood test from a company called Soma Logic,

00:54:05.920 | proteomic test, and it can tell you with like a high degree of accuracy, what your four-year

00:54:10.480 | risk of a heart attack is. It's like a $600 test. It's a blood test. You don't need a calcium score.

00:54:15.120 | So the world's moving to blood, not scans. So all these fancy full body scan places are like,

00:54:21.920 | I don't see their future much. And they're expensive and the technology is getting so

00:54:27.200 | much better with AI and blood and breath. And there's a company called Owlstone that

00:54:31.520 | you can breathe into and it'll tell you how your liver and your kidneys are and your intestines,

00:54:36.880 | the health of them through volatile organic compounds. So, you know, the cadence of check-ins,

00:54:43.280 | who am I? And then the intellectual honesty of how am I and what am I doing

00:54:49.120 | is what leads you on this trajectory. And if you really want to live a long and healthy life,

00:54:54.800 | which I think people call health span, you just have to look at these things. You can't look away

00:55:00.320 | and you just need to be honest about what you're doing and who you are and what you should be

00:55:05.360 | doing more of, whether that's diagnostic, therapeutic. I have a friend who's a chef

00:55:10.720 | who had Crohn's disease. He was on methotrexate and all these hardcore drugs. And then one day

00:55:16.160 | he said, "You know what? I'm going to radically change everything about my life." He's now off

00:55:20.080 | everything. All symptoms are gone. And he just eats whole foods and he got off the pharmaceutical

00:55:25.120 | train. And Nestle, by the way, they make sugar foods and then they make diabetes pills.

00:55:29.600 | So they've got the whole ecosystem. They get you sick and then they treat you.

00:55:33.360 | But that's like a vicious cycle of whatever. I mean, a lot of companies do that too. And I think

00:55:38.160 | that for people that want to optimize their health, they have to - they just have to look at

00:55:44.480 | what they're - like your fork is a weapon. So, I want to take an example from this whole process,

00:55:49.920 | which is personal to me, which is had high cholesterol. How high? HDL 48, LDL 155. LDL 155,

00:55:59.360 | that's high. So, and how old are you? I'm 38. Okay. So, over the last few years, LDL range 138

00:56:09.200 | to 155. So, I got a test, had a doctor at Sutter, right? And it wasn't because I picked this person.

00:56:16.560 | It turns out I had shingles and I just needed a doctor to prescribe something. They're like,

00:56:21.040 | "Go see your primary care physician." I didn't have one. I picked whoever had the next open

00:56:24.640 | appointment. They went in, they were like, "Let's review your blood work." And they went through and

00:56:28.880 | the advice was - and I'm reading this quote, because she sent me a note after the blood work

00:56:34.080 | was done for my cholesterol. She said, "Your cholesterol is 206 with HDL 48 and LDL 155.

00:56:39.680 | Advise low-fat, high-fiber diet. Let's repeat in a year. Take care." That was the message.

00:56:44.720 | My reaction to that after talking to a few friends was like, "I don't - I feel like maybe

00:56:49.600 | there should be more going on in this process." This is a lot more information than it has to be.

00:56:53.360 | Yeah. A couple of friends said, "Oh, you should probably go get your ApoB tested. You should go

00:56:58.160 | look at more data." What ended up happening, and this took two or three years because it did.

00:57:05.520 | Finally, I found a doctor who was like, "Oh, you should go get a calcium score." I did.

00:57:09.600 | Was that covered by insurance?

00:57:12.720 | I don't know. It was two weeks ago. So, I don't know yet. The hospital that did it told me they

00:57:19.440 | pre-cleared it with insurance and I wasn't gonna have to pay for it, but unclear. I haven't seen

00:57:25.040 | the payment come through, but calcium score came back a two on one artery, zero on everything else.

00:57:34.240 | So, two is a real number, by the way. It's not zero.

00:57:35.920 | Two is a real number.

00:57:37.040 | So, you have early evidence of coronary artery disease.

00:57:40.720 | Yes. I'm not saying that three years could have prevented any of it, but the idea that three

00:57:46.320 | years ago I was messaging with a doctor whose advice was like, "Hey, just kind of eat healthy

00:57:50.960 | and we'll talk in a year," seems like if I were someone going through a lot of the process that

00:57:56.800 | you mentioned of looking at some of your data, trying to take some of these tests, trying to

00:58:00.320 | figure out where you're at, how do you evaluate and analyze it when you don't have access to

00:58:07.920 | someone like you who's maybe done a lot more research? What does the average person do when

00:58:12.880 | they see a number, it seems high, they talk to their doctor, their doctor's like, "We'll deal

00:58:16.720 | with it later," which going back to the beginning of the conversation, a lot of the medical system

00:58:21.120 | we have is like, "Let's treat it when it's a problem." And high cholesterol, young person,

00:58:26.720 | maybe it's not a problem yet. But clearly, if I've had high cholesterol for five, six years

00:58:31.600 | and I had been doing the right thing- By the way, or maybe all your life.

00:58:34.720 | All my life. Yeah. Maybe we could have been doing something different. So, I guess one question

00:58:40.000 | is just, how do you interpret these? How should someone try to find the right person?

00:58:44.720 | Could you find the right primary care physician at any hospital, medical practice that could be

00:58:50.880 | a partner here and I just happened to have the wrong one? I don't know.

00:58:54.160 | So, I think it starts with, if your LDL is greater than 100, let's just use that as a marker. Forget

00:59:05.520 | about all the rest of the APO and all the rest of the everything else. If it's greater than 100,

00:59:11.360 | then you say, "Okay, I need to... How long has it been that way?" We're not starting to test

00:59:15.600 | kids, teenagers, because we know the parents' cholesterols are off the map. When we get new

00:59:21.840 | members and the parents are off, we go check the kids. And if the kids are off, that's never been

00:59:25.760 | done before. And just a way to think about it before I answer the question specifically,

00:59:32.320 | because I think it's important. When people smoke cigarettes, we as doctors ask them,

00:59:37.280 | "How many years have you been smoking cigarettes and how many packs a day?" And we call them pack

00:59:42.560 | years. So, if you've smoked 10 packs a day... I'm sorry, one pack a day for 10 years,

00:59:48.160 | you have a 10-pack year history. If you smoked two packs a day for 10 years,

00:59:52.800 | you have a 20-pack year history. That's the same as smoking one pack a day for 20 years.

00:59:58.160 | So, it's what is the load of this chemical, which ultimately ladders up to risk of heart disease,

01:00:05.600 | diabetes, and lung cancer. So, we think about pack... We call them pack years. So, now,

01:00:11.440 | kind of the more sophisticated lipidologists are talking about LDL years. How long has your LDL

01:00:18.080 | been high circulating through your body? So, there's LDL years. So, if your LDL is high and

01:00:24.160 | you have a calcium square of 2 and you're 38, you probably had a high LDL for a long time,

01:00:28.240 | and you don't have the genetic subtype that doesn't care. Like, it doesn't... Your body

01:00:32.320 | like actually... And again, I don't know if you smoke or there's other things that you do,

01:00:36.480 | but the first thing is like, get to some answer of, "Do I need to do something else?" And you can

01:00:43.200 | go deep into like the weeds of LDL. And I have patients that want to optimize their LDLs and

01:00:48.640 | stuff like down to the... They'll pay some doctors that like hold themselves out for $100,000 to

01:00:54.400 | optimize their LDL. And it's just like, you're optimizing 0.001% of your body. It's already

01:01:03.200 | pretty good. So, the question is, if you did her diet, like let's just say you followed her diet

01:01:10.560 | and said, "Okay, doc, I'm going to do that. When do we check it again?" And she said, "A year."

01:01:15.120 | My answer would be, "Well, I want to know if the diet story works sooner than later because I don't

01:01:23.360 | want a whole another LDL year to go by that high. So, can we please check it in four to six months?"

01:01:28.960 | But you actually have to do an honest change of your diet. And if it goes down to like 100,

01:01:36.720 | you know the answer. You know the answer. Keep your diet like that. And even if you knew your

01:01:43.600 | calcium score was a two now, and you knew that you could lower it with diet down to like 80,

01:01:51.200 | and to give you a calcium score of greater than zero, you've got to get your cholesterol below

01:01:55.040 | your LDL below 80. That's what kind of our guidelines are here. If you can't do that with

01:02:00.880 | diet, then you need to be on something. You need to be on a statin, sadly. And if you are so adamant

01:02:06.400 | about taking statins, which is basically there's a lot of different kinds, but there's an HMG-CoA

01:02:11.600 | reductase inhibitor, but that's the fancy name for the molecule. Then you can eat red yeast rice

01:02:16.320 | every day, because that's what is a statin. If you could find a way to put that in a soup and

01:02:22.640 | eat it every day, you could lower your cholesterol, your LDL that way. So, I think that whenever you

01:02:27.760 | find out something's abnormal, you have to think about, "Okay, intervention, retest, intervention,

01:02:32.240 | retest. How quickly can I find out if I can make a difference without pills?" And if I can't,

01:02:39.280 | what pill do I go on? Right? Because once you get a calcium score that's positive,

01:02:45.680 | you just know now that you're committed to not having that number go up. That number goes up

01:02:52.320 | with the LDL staying at 155. And then it goes up and up, and then you have a heart attack at some

01:02:56.720 | point in your life, and that sucks. So, you don't want that. So, these are-

01:03:01.280 | And I didn't mean, by the way, to make this about me. I just-

01:03:03.520 | No, no, no. But I think if people get into your head and hear me talk to you as though

01:03:07.360 | this is them, I think everybody can take something away from, if you get something that doesn't look

01:03:12.560 | right, doesn't feel right, then dig in. Don't let that doctor get away with, "Eat fiber,

01:03:17.840 | let's check in a year." And by the way, one thing that I realize in hindsight,

01:03:21.920 | a lot of people moving around a lot, I've probably had five primary care doctors since I graduated

01:03:28.480 | college. And I went back and looked, and it's like, I don't have my blood tests too far back,

01:03:35.360 | but I've got them about seven years back, and I've had high cholesterol for seven years at least.

01:03:40.480 | So, what I can tell you, but I had one doctor, and then I had another doctor,

01:03:44.240 | and then I had another doctor. But I had one doctor for three or four years

01:03:48.080 | at that cholesterol, but never really pushed back, said to do anything.

01:03:52.400 | But part of that's because, going back to what I was talking about earlier about the medical

01:03:58.720 | system moves slowly, we never thought ever of treating a 20 to 30-year-old or a 30 to 40-year-old

01:04:04.720 | with statins, unless they had a credible family history. I mean, there are people that have heart

01:04:10.000 | attacks in their 30s. They have crazy genetic cholesterol problems, hypercholesterolemia,

01:04:15.200 | and hypertriglyceridemia, and they can get these problems. But the medical field,

01:04:19.520 | we generally don't, we're not aggressive with younger people, because like you said,

01:04:24.320 | the system's reactive. It waits for you to get sick, and then they make a lot of money.

01:04:28.240 | They don't make a lot of money. The pharmaceutical companies make a lot of money

01:04:31.120 | on preventing the heart attack, but the hospitals, and the doctors, and the surgeons,

01:04:35.440 | and the cardiologists, and everybody in the food chain doesn't make that much money.

01:04:39.760 | From you not having a heart attack, and not to be hyper-perverse about it, but it's just the way

01:04:45.360 | the system's designed. And oh, by the way, that doctor that saw you, they're not accountable to

01:04:49.840 | your future outcome at all. And they don't know you because you're moving around, just another kid

01:04:54.480 | in the mix coming through their system, which is why I really believe that these long-term

01:05:00.560 | relationships matter. I think that everyone's trying to find the quick fix, the transactional,

01:05:05.200 | where's the chat bot for healthcare, so I can blah, blah, blah, blah, blah. I think at some

01:05:09.840 | point, but you really want someone that knows you, gets you, and is going to tell you the truth,

01:05:15.360 | and double-check on things. Is there a way you tell someone to interview? If I'm like, "Okay,

01:05:20.160 | obviously, this one wasn't a good fit. I need a new primary care physician." There's not an easy

01:05:26.000 | way to find someone that I know of. Are there questions you would ask them to try to figure

01:05:31.600 | out if they're the right fit for you? I would ask everybody, what is their perspective on prevention?

01:05:37.360 | I would ask them, what is their perspective on productivity? I would ask them how they

01:05:45.200 | hold themselves accountable to your outcome. Because a lot of doctors feel like, "Once you

01:05:50.240 | leave my office, how am I going to enforce anything? It's your life." So I would say,

01:05:57.680 | "Hey, look, I sometimes am my own worst enemy, and I'm busy. How can we do this together so that

01:06:06.160 | you hold me accountable, and I hold you accountable? Can we both hold ourselves accountable

01:06:09.920 | here?" If the answer is like, "I don't have time for that. I'm just too busy." Probably not the

01:06:14.000 | right one for you. This goes to, I think, the meta-theme here, which is the rise of what I'll

01:06:18.960 | call concierge medicine, or what I'll call membership-based medicine. In primary care,

01:06:24.560 | I'm probably one of the grandfathers of the field, because I started a concierge practice when it

01:06:29.680 | wasn't really a thing in 1998. I gave out my cell phone. I said, "People can call me whenever they

01:06:34.160 | wanted." I would follow up with people. I would use email and text in the late '90s and early

01:06:40.320 | 2000s, because I wanted communication to be the most important thing. Because you'll get the good

01:06:45.600 | outcome if you have communication. You won't get the good outcome if you don't have communication.

01:06:49.040 | Because communication is more than just data. It's holding people accountable and building trust.

01:06:55.200 | So concierge practices are basically you pay... So one medical didn't start off as one.

01:07:00.160 | They're kind of like a junior... They're like a freshman version of a concierge practice,

01:07:05.840 | meaning that... I think they charge $159 a year, but they take insurance. Then you have companies

01:07:10.800 | like MDVIP that charge $3,000 a year. There's a group called ROAMD, R-O-A-M-D. It's an association

01:07:18.720 | that I'm part of that has doctors all around the country that have doctors that are membership

01:07:24.960 | based. They can charge anywhere between $50 a month to $500 or $1,000 a month or $2,000 a month.

01:07:35.920 | It all depends on what level of investment you want to make based on what you think exists out

01:07:42.240 | there. So there are these practices out there. Some people call them direct primary care, DPC,

01:07:49.760 | direct primary care. Some people call it membership based medicine. Some people

01:07:52.720 | call it concierge medicine. Some people call it private medicine.

01:07:55.360 | But I think that one has to look at their... If you make $100,000 a year and you say, "Okay,

01:08:01.280 | I want to invest in my health." What percentage of your $100,000 will you invest in your health?

01:08:10.400 | So we know that you invest a certain amount in a cell phone and a Wi-Fi package. And we can talk

01:08:16.480 | about what you invest in technology. Everyone's got their own personal budget. I know that you

01:08:21.680 | talk about this a lot. But a lot of people will say, "Well, I have a membership to Equinox or

01:08:27.840 | to pick the gym and that's, I don't know, $60 a month. So that's $500 a year. So $500 a year is

01:08:34.480 | 0.5% of your income." I don't have a membership to Equinox,

01:08:38.800 | but I'm guessing you don't either because I'm pretty sure it's more like $100 or $200 a month.

01:08:42.400 | Okay, maybe it is. You're right. There you go. I'm not a member of a gym. I have four kids and

01:08:47.840 | I've got a gym in my house. I'm running around all the time. So even if it's $100, let's say $100,

01:08:53.360 | that's $1,200 a month, that's 1.2% of your budget. But that's not investing in your health.

01:08:58.800 | That's investing in your fitness. So I just want to be really clear, which is a subset of your

01:09:03.120 | health. But if you really want to make the big investment on a doctor to have a relationship

01:09:07.360 | with that you can kind of go back and forth with and really build up a rapport and kind of a

01:09:13.520 | bilateral mutual transparent accountability quotient, you should ask yourself if it's,

01:09:18.480 | "I'll invest 4%." That's $4,000. You can find a lot of doctors in the membership-based world

01:09:23.520 | for $4,000 a year. And they'll use your insurance to do the blood test, to get the MRI and the CAT

01:09:29.840 | scan, to send you to the specialist. So you're only paying for a quarterback. You're investing

01:09:34.960 | in someone to oversee it, to be your partner. Your insurance will still be used for everything else.

01:09:42.640 | So that's how I would think about... And by the way, this field is growing. There was a report

01:09:48.880 | by Clearview or Grandview where the concierge medical market is the fastest growing field

01:09:55.840 | in medicine. It's the fastest growing sector in all of health and biotech and everything.

01:10:00.400 | It's expected to double or triple in the next eight years. So why is that? Because doctors

01:10:04.640 | want to help people and they want that principal agent problem gone. They want to be accountable

01:10:09.840 | to you. So if you don't like me, if I'm not doing my job, guess what? You fire me, I just lost

01:10:14.000 | revenue. If I'm an insurance-taking doctor and you fire me, it doesn't matter. Someone will fill

01:10:18.960 | that spot in a nanosecond because I've got a three-month waiting list. So I don't have to care

01:10:23.040 | if people like me or don't like my outcome. Someone's going to fill that insurance-based

01:10:28.560 | principal agent problem slot because there's no accountability. There's no true straight line.

01:10:35.520 | There are dotted lines everywhere. There's no straight lines. The straight line is between

01:10:38.720 | the doctor and the insurance company because the insurance company can call the doctor and say,

01:10:41.920 | "Hey, we're not paying you that much because you're not... Whatever, we don't like you."

01:10:45.920 | And one doctor against an insurance company or the hospital system will say,

01:10:49.600 | or the employer, the one medicals, not to knock on them, they'll tell their doctors,

01:10:54.240 | "Hey, we need more revenue. So instead of seeing 14 patients a day, please see 15 patients a day."

01:10:58.560 | So if you're seeing 15 patients a day, that means each patient gets one less minute,

01:11:01.760 | which means that that's one more email, one less minute, one more person.

01:11:06.160 | Quality just starts to exponentially erode. I know that Roamed is going to be building a

01:11:13.280 | physician finder for somebody that wants high-quality kind of private membership-based

01:11:18.320 | physicians this quarter or next quarter. That's where I'd start. I don't think Yelp reviews or

01:11:27.280 | any of these health grades reviews are useful at all. I don't buy them because they're just...

01:11:33.360 | People want to go to the Apple store, not the doctor store. So when you go to a doctor store

01:11:39.040 | to rate somebody, unless you're a professional rater, you're usually there to complain.

01:11:43.360 | It seemed like early on, it was two things. It was the quarterback and the 24/7 access,

01:11:51.040 | we'll come to your house kind of stuff. And what I've been looking for since is,

01:11:55.360 | I want someone who charges enough that they have free time in their day to read some research,

01:12:01.600 | or have someone on their staff to read research. Someone who's thinking proactively about my

01:12:07.040 | health, but I don't need someone who will necessarily... I can wait for someone to

01:12:11.760 | respond tomorrow or on Monday. So it's like that middle ground is the company that I want to see.

01:12:18.000 | And there are tons of them. There's nothing at scale because all the ones at scale,

01:12:23.520 | One, Forward, Parsley, pick the brand, they've all raised money. So they have investors. So it

01:12:32.480 | becomes a profitability story versus a great healthcare story. Most of the onesie-twosie

01:12:38.480 | small versions of concierge medicine, it's somebody that's like, "This is my business.

01:12:43.120 | My revenue depends on me doing a great job for you, not on somebody telling me to do more or

01:12:48.720 | faster or whatever." So I think there's some consolidation in that space, but I think you

01:12:53.760 | have to be really clear on what drives this doctor. And you want a doctor that's thinking

01:12:59.040 | about you when they're not in front of you, right? Doing that research, I read an article about

01:13:04.000 | multiple sclerosis this morning. I have a multiple sclerosis patient. I'm like, "Hey, guess what?

01:13:07.040 | There's this new research. Just heads up and I'm tracking this." Nothing to do here, but maybe in

01:13:12.080 | a year or two, there'll be some interesting developments. And by the way, we talked about

01:13:15.440 | all these costs. If your company has an FSA plan, you could put money in pre-tax each year and be

01:13:22.720 | able to use that for your medical expenses. So one way... And I haven't really thought through

01:13:28.000 | this completely before. I'm not going to recommend it. I'm just going to throw it out there.

01:13:31.040 | If you want to... You can't change it mid-year. So one way to force yourself to have a health budget

01:13:36.960 | is to just commit to put a little bit more in your FSA each year. So maybe say, "This year,

01:13:42.240 | I'm going to put $2,000." And obviously, we're going to be recording this in January. So it's

01:13:45.680 | a little late for this year. But next year, you could say, "I'm going to put $2,000 or $3,000 in

01:13:49.920 | my FSA." You do have to use it or lose it. Usually, maybe you could roll over, I think this year,

01:13:55.760 | $650. But it'll force you to try to get more serious about these things.

01:14:00.720 | Because if you're listening to this and you're like me, at least, it's really hard to be like,

01:14:05.440 | "Oh, do I want to do this test? It costs $500." For some reason, there are things in life that

01:14:10.880 | it just seems like, "Yeah, I grew up. Medical treatment should be free. If it's not free,

01:14:15.440 | it seems harder to spend." It's not hard for me to buy a new iPhone,

01:14:18.320 | but it's really hard for me to spend $200 on my health.

01:14:21.360 | Well, and that goes back to this concept of there are no consumers in healthcare. I mean,

01:14:27.120 | I've never seen a consumer in the ICU type of a thing. Consumers have a profile that when you

01:14:32.560 | want to go to the iPhone, you have all the agency, all the free will, all the power,

01:14:36.880 | all the resources, those decisions are yours. When you go to the healthcare system, they're not.

01:14:41.120 | You've lost it all. So that's why getting a concierge doctor or a membership-based doctor is

01:14:46.080 | you're investing in somebody that's got your back, that's going to work with you,

01:14:50.560 | that's going to be co-piloting your care with you, and that's going to actually care about you

01:14:54.800 | and care about your outcomes. Because I fundamentally believe you don't go to eight

01:14:59.840 | years of medical school and college or residency because you want to make money. You're a healer.

01:15:05.520 | There's some people that go into finance and want to be hedge fund guys. There's some people that

01:15:08.400 | want to be artists and architects. Everybody wants to make a good living, but you don't go

01:15:12.960 | into medicine unless you're maybe a plastic surgeon or a cosmetic dentist or whatever,

01:15:18.080 | because that's where big money is, vanity. But that's not healing. That's healing like some

01:15:24.640 | psychological wound somewhere deep in your past. And so I'll give it to them. There is some healing

01:15:29.520 | components there. But our world is like, this is the everything person. This is like all facets of

01:15:36.080 | your existence and health need to be under my umbrella. And I'm a healer and I want to help

01:15:41.120 | you. And we're naturally empathic. We're naturally long-term. We feel bad when something bad happens,

01:15:48.640 | there's a bad outcome. Empathy and compassion, I think, are part of the frameworks for going

01:15:55.120 | into medicine in the first place. And I think a lot of these doctors are getting

01:16:00.240 | burned out. I mean, there's a huge physician burnout because these big companies,

01:16:06.240 | the medical industrial complex is forcing them to see more faster, check more emails.

01:16:12.240 | Kaiser doctors have to check their emails at 48 hours. They have 2,500 patients per doctor.

01:16:17.280 | So imagine the amount of emails with no barrier to email and they don't get paid for email.

01:16:24.720 | So like the Cleveland Clinic or the Mayo Clinic, I can't remember which one,

01:16:28.080 | they just announced a program that every email to your doctor is going to cost you 50 bucks.

01:16:32.000 | So now you have to be really thoughtful. You can't just like, which I think is good for doctors,

01:16:35.920 | because then at least there's some barrier to someone posing some crazy question with three

01:16:40.000 | articles to read and look at what my brother said. And like, Kaiser will make you respond to that.

01:16:45.440 | So I think that these are the ways to really think about it. I think having someone in your

01:16:50.480 | corner is important, even when you're young and healthy, because you don't want to wait

01:16:54.320 | until you're sick. That's a hope strategy. I hope I get a good one when I'm in the ditch.

01:16:59.440 | You want to have somebody on your team long before, because they can see the ditch coming.

01:17:06.400 | Healthcare is super predictable. We know you were going to have a heart attack if you didn't get on

01:17:10.080 | top of your lipids. So now you're not going to have a heart attack. Now let's work on everything

01:17:14.880 | else, type of thing. So there's lots of ways to think about medicine. I'm optimistic about

01:17:22.320 | a lot of the changes that are coming. I'm not optimistic that they're going to happen fast.

01:17:26.480 | I hope that I can be a kind of a guiding principle. I hope people copy what I do all day long

01:17:35.200 | to create different versions of it. And I'll say private concierge medicine, whatever. I think

01:17:41.520 | that's the way it used to be. You used to pay your primary care doctor until the HMOs came in,

01:17:47.120 | and they saw that it was a trillion-dollar market. And now it's just a financial boondoggle.

01:17:52.960 | Where can people stay on top of what you're learning in your practice and online?

01:18:00.160 | So if you want to see what I'm reading, and you want to get my point of view on what I think about

01:18:03.920 | the latest science, because I read about five to 10 articles a day, is on LinkedIn for now. I'm

01:18:09.760 | Jordan Schlein at LinkedIn. There's not a lot of those. No C in Schlein. It's just S-H-L-A-I-N.

01:18:14.720 | I post one or two things a day on longevity and/or science that I think is compelling and

01:18:21.440 | interesting that people need to pay attention to. And if you want to go subscribe to our podcast,

01:18:26.000 | it's Inside Medicine. You can find it on Spotify and Apple.

01:18:30.960 | Or wherever you're listening.

01:18:32.480 | Or wherever you're listening.

01:18:33.200 | Right now. Awesome. Jordan, thank you so much for being here.

01:18:36.880 | Awesome, Chris. I am super excited. And listen,

01:18:39.040 | if you want to do this on the regular and pick a health topic and go deep, I'm in.

Optimizing Your Health: Diagnostic Tests, Sleep, and Longevity | All The Hacks Podcast