Hello and welcome to another episode of All The Hacks, a show about upgrading your life, money, and travel. Since it's the beginning of the year, I know many of you, myself included, are thinking a lot about how we can upgrade our health this year. To help make that possible, I wanted to invite Dr.

Jordan Schlain on the show. Jordan is a physician, entrepreneur, publisher, and healthcare systems designer. He was one of the early pioneers of concierge medicine and is still a practicing primary care doctor through his practice, private medical. I heard Jordan talk about optimizing your health at a conference last year, and I have been so excited for this episode ever since he agreed to come on.

He has such a wealth of knowledge on health and longevity, and we're going to try to cover as much of that as possible, including how you can start taking your health into your own hands, what to look for in a primary care doctor, what kinds of tests and diagnostics might make sense to consider, how to think about things like sleep, diet, and exercise, and a lot more, including some of his best health hacks.

So let's jump right in after this. (upbeat music) Jordan, welcome to the show. - Thank you, glad to be here. - So I'll kick it off. What do you think the state of our current healthcare system is right now? - 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 gonna get better sometime soon, but it's been 20 years that people have been saying we're just about to turn the corner, but we're dealing with a massive cruise liner that turns incredibly slow because there's so many vested interests.

The intellectually honest framing is this is a health insurance system. It's not a health care system. It's 85% about money and 15% about care, and a lot of hospital CEOs will say, well, no margin, no mission, which is a great thing for a capitalist private market company to say, 'cause if they don't make money, then they do go out of business.

The thing is, is healthcare, unlike finance, unlike travel, unlike consumer electronics, you can map out the supply chains, you can map out the choke points and the efficiencies, and you can really streamline stuff, but healthcare was never designed for scale. It's always local. There's a local person. Very few hospitals have a national footprint, so fundamentally, they have different buyers, different supply chains, different plans, different states, different regulations, so it's not an ecosystem.

It's a frico system, which is you can't peel back the onion and get other layers of an onion. You may get a tomato in there, you may get a grapefruit. Like every time you peel something back, there's things in there that are legacy systems that were built upon. They're not streamlined and thorough and simple in the way that most other industries are.

So the state of the system today is it's kind of like an every person for themselves, and you're reliant on the insurance world. Everybody has insurance. But I'll say that if you're a person that wants to get good healthcare, well, it's local. You have to look around and what's there.

There's not a lot of choice in medicine. You have free will when you have your wallet to go buy what you want, and healthcare, I call it tethered will. If you have a big cut on your arm, you don't get to go shopping to which store to go to.

You're going to go to the closest one. You're not even paying for it. So it's not even your resource. This is called in economics, the principal agent problem, where you pay a third party, they pay somebody else. So the person that you're receiving the good or service from, you didn't pay.

They don't feel aligned necessarily because you put your hardworking money into it. It may be your employer's money. I would say one of the biggest problems is this principal agent problem. But going back to the story with your headache, so then you see the doctor, they give you some morphine in the ER because it's a terrible headache.

Then you go home and the morphine wears off. You still have your headache. So you just went to go get something, and you came back, and it's not better. Or it's 50% better. Now you have to figure out what to do. So you call your primary care doctor, that's a two-week wait.

So then you ask Dr. Google and he or she basically comes back with that could be cancer. So now you're super anxious, right? And so the whole system is not designed. There was no designer. It's a patch on top of a patch on top of a patch where the money continues to flow through multiple middle people that like take their sliver of the money.

And it's not getting any better to answer the question. I've been building my model outside of the existing system, trying to create a new design. Like I've designed this and we'll get into that later from scratch, which is how do you honor both the doctor and the patient and the data in an elegant way to try to achieve the best outcome the fastest.

And I should only get paid on that. And I want the person to pay me for that. Now if they need an MRI, that's what the insurance is for. I should help them get the best MRI place. I should be the one to be their quarterback around how to receive that care.

But really what the Affordable Care Act did, and I think this is lost on most people, is it set the incentive for the doctors or the medical groups or the people that own the medical groups to get a fixed amount of money per problem. For example, right now if you have a heart failure, and maybe we could take the guy Demar Hamlin as an example, right?

He's a young healthy guy. He had a cardiac arrest. This is for those of you who don't know, NFL football, primetime Monday Night Football the other night, he fell down and they were doing CPR. I'll use him as a quasi example, but this isn't gonna be exact. The place that he gets taken care of says, "Hey, for everybody with a cardiac arrest, you get $10,000 to get him out of the hospital and get him home." It used to be, "Hey, every day he stays there, you get $3,000 in the ICU, you get all the money you want, whatever prescription you write, you get paid for." So the sicker you get or the more transactions there are, the more money the system gets.

So there's no incentive to get that guy out fast. Now the doctors, my people, we of course are healers. We want this guy to get better. We want him to get better fast. We want to make all the right decisions at the right time for the right reason. The truth is there's this overlay of, "Hey, if we keep him here a little bit longer," I'm not saying that...

I think Cincinnati has got an amazing hospital system that they would do that, but in a lot of systems that you don't hear about where there's no oversight, they'll just keep somebody there for days and there's not a financial incentive to get them healthy as fast as possible. So the Affordable Care Act created this thing called the Accountable Care Organization, which is we're gonna start going with specific conditions and saying, "This is the money you get." The incentives will be aligned around good outcomes yield good incomes.

Right now, it's bad outcomes yield good incomes, sadly, for the healthcare industry. And I think that is a fundamental problem. And there are so many middlemen, Chris, that make a little vig off of that dollar when you don't do well. From the person that sells gloves to the person that has the billing software, there's so much waste and fraud.

I would say train AI on fraud and you probably save a ton of money because it's just there in spades. I would say one other thing is that with the advent of digital health, now you have fragmentation of medical specialty things. So if you wanna go get a SIBO test 'cause you think you have bacterial overgrowth 'cause you have some bowel problems, you can go online and order a SIBO test, okay?

You get the results, they'll tell you what to do and you're managing SIBO, which is like a condition of gas bloats and cramps and can cause fatigue. So you have this fragment and no one's orchestrating everything. So now you have little windows of things that you can solve. But John Muir, who is a famous explorer naturalist in America, and I'd say he said, "When you tug on a single thing in nature, you realize it's connected to everything else." And in medicine, what I can tell you is if you have SIBO or if you have migraines or if you have whatever, eczema, there are probably multiple factors that need to come together to help solve that without pills, without injections, without interacting with the medical system.

There's so much that you can do on your own. I like to say, how do you become independently healthy? And ultimately, health is what you can do for yourself. And what healthcare is, when you can't do it for yourself, you must reach out to somebody that can help you navigate the kind of the thicket of the healthcare system.

It sounds like the providers are less incentivized financially to do whatever they think might be the best thing because the insurance company is the payer, you have this principal-agent problem. There are certain treatments, by the way, that will most likely be covered and won't. So to recommend someone do something that they probably can't afford or won't get covered by their insurance is probably not going to happen.

But you don't even know that a priori. You can recommend something and only later do they find out it's not covered. And then that patient has to go back to the doctor and say, "That wasn't, again, no design, no elegance. It's a shit show." And then kind of highlighted that the most important thing might be that everything in your health seems connected.

So this idea of your primary care physician seems as important as it ever was. But at least in my personal experience, it's been tough to find someone in the conventional medical care system that's covered by my insurance that actually wants to play that role of discovering what's wrong and trying to figure it out and being aware of all the latest medical research and all that.

So I guess maybe the question is, there's one end of the spectrum, which you've started your own practice, which is not accessible to everyone, but gives you that quarterback that can kind of go through that process. What are people who are not at the point that's the right fit for them?

Where should they start? Great question. So my framework in general for every person is, first of all, do you know everything about yourself? Biologically and physiologically? What do you know? Do you know what your blood pressure is? Do you know what your cholesterol is? Do you know what your family history is?

Do you know what your genetic susceptibility to things are? What do you know? And what do you not know? A lot of people don't want to know. "No, no, no, no, no, no, no. I don't see it. I'm just going to live my life." And blah, blah, blah. Great.

They're gambling. And if you're young and healthy and there's nothing wrong in your family, probably pretty safe bet nothing bad is going to happen to you. But then you always read in the paper about the sporadic person with nothing wrong and they just died of whatever, or they got cancer at 35.

Those are the headlines that scare people, but they're true. And why would you not, with not a lot of investment, learn everything you can about yourself to make informed, proactive decisions to keep yourself optimized and not have to use the healthcare system for the rest of your life, if you could?

If you wanted to walk through someone who maybe is thinking right now, "I haven't really taken my health seriously. What should I go and either do myself or ask my doctor to help me do?" You could go to quest.com, which it's a lab. By the way, anything I mentioned here, no conflicts of interest for me.

I don't have any vested interest in anything. But Quest Labs and line up the 10 other competitors to them, you can go online and order blood tests and some states and cities will come to your house, they'll charge your insurance, they may charge you a convenience fee to do it online, who knows.

By the way, just a thing that I found, I have no affiliation with this company, but I was looking at some tests that I wanted to run that weren't covered by insurance. And there's this site, ultalabtests.com, which basically sends the same order to Quest at like a third of the price.

So if someone doesn't find something covered, I just went to Quest and got the exact same test done, but it was just less expensive. I'm not sure how that whole system works. Well, look, I mean, the dirty little secret here is when I have a patient who like, let's say lost their insurance, doesn't have insurance.

And I say, go to Quest and order a cholesterol test, it could be $200. But if I order it under my account, it's like $20. So like there's massive margin here because there's opacity and no transparency in this system, even MRIs. I don't want to get ahead of ourselves, but let's just say you wanted to do the most thorough baseline understanding of who you are in the world, right?

And you were willing to spend a chunk of change just to get to know yourself. Well, one of the things that you would consider is getting a brain MRI with a brain MRA. And I'll tell you a story about a guy that I did that on, and it turns out something happened to him.

So I'm so glad we had a baseline test to compare it to, because otherwise you're flying blind. The problem with doing tests like that, a lot of doctors will say, well, you're going to find things on there that don't mean anything. Like if you did an MRI of a spine of every 50-year-old, they all look like shit.

And then everyone, oh my God, I'm falling apart. No, that's just natural aging, but we haven't calibrated normal to not normal yet. It's like everything's abnormal if it's not perfect. But at age 24, it's perfect unless it isn't, but everything decays over time. So the MRI that I would order on somebody that really wanted - the MRA shows you the blood vessels, like three-dimensional blood vessels of your brain, because if you have an aneurysm in your brain, the typical way you find out about them is on autopsy.

Your aneurysm burst and then you fell down and unless you're close to a hospital, you're dead. They're very rare, but you catch them on some people. But if you ordered that MRI and you walked into the place, it could be $10,000. If I order it through my system, like through the private pay, it's $400.

You get the same outcome, you're just like getting hoodwinked by something you didn't even know. So that's the opacity factor that a lot of people have been trying to tackle, but there's a whole lot of people that don't want that opacity to be known because it's going to expose all these facets of the shenanigans and the chicanery that goes on behind the scenes to make the profits.

But to answer your question specifically, what would you do if you were a regular person that just wanted to know? So you do like what's called a CBC, a complete blood count. You want to know what your immune system looks like. Do you have enough blood in the tank?

There are some women that because they have heavy periods, they're anemic and they don't know it, but they have low energy and they don't know it. So you'd want to like get a baseline on where you are, whether you're anemic or not. You'd want to get like a chemistry panel.

And again, these are all like almost archaic, but they're the standard of care. You'd want to get your cholesterol and there's like a basic cholesterol, then there's a cardio IQ test, which is a much more sophisticated cholesterol test that will tell you your APO and your LDL fractionations and all sorts of bits and pieces that will give you a little more color on should you be concerned or not.

From a blood work standpoint, I like to check at least once your Westergren sed rate, which it's a very nonspecific test, but it shows what level of inflammation there is in your body. Again, it's a crude inflammatory marker. And I'll just pause and talk about something called inflammation. The more inflammation you have in your body, chronic inflammation, the faster you age.

So one's goal in life should be to have a body that's not inflamed inside. Now when you cut your finger or you bang up your something, you see the inflammation visible. But when your whole body's subclinically inflamed, which can be caused by great stress from a bad relationship, it could be caused by untreated subclinical Crohn's disease, or we could talk about a lot of things.

You're just aging faster. You will have problems later in life. And so if you try to go to your future self, what would you want to know today? So the sed rates one, there's something called an HS, high-sensitivity CRP, cardioreactive protein. Again, another measure of inflammation. These are all, I'll call blood test 1.0.

There's a whole new set of tests, Chris, we can talk about, metabolomics, proteomics. There's all these new companies coming online that are creating much more sophisticated, much more sensitive tests. Those still cost 500 bucks because they're new startups and they don't have scale yet, but those will come down.

If you're over 50, there's a cancer test called GRAIL. It's called gallery, checks for 42 types of cancers. It's 960 bucks right now, but you have a family history of cancer, I recommend you probably do that every year. I just caught a 38-year-old guy with a mother and a grandmother with stomach cancer.

I checked him at 38, colon cancer, positive, stage two, surgery, chemo. He just got his test back yesterday, cancer-free two years later, saved his life. You don't normally get a colonoscopy until you're 45. So he's 38. He would be dead by the time of his first colonoscopy. So you have to like risk adjusting.

Who are you? What are the tests that you should get? You should know what your blood pressure is. And by the way, checking your blood pressure one, does it count? The real way to understand what your blood pressure is, you have to check it 17 times at different times of the day in one month.

Put them on a spreadsheet, average them out, that's your blood pressure. What should it be? It should be below 120/80 most of the time. If you just went on a run, had coffee, had sex, got in a fight, it can be higher. That's normal. Your blood pressure is supposed to get up to be high because we have a lot of resilience in our system.

But at baseline, at regular, it should be like 120/80 or less. So those are some basic blood tests. A lot of this stuff has to do about what age you are and what your risk factors are. So if you got a family history of heart disease, my mom had a heart attack or dad, something like that, then you're going to want to like start doing these tests earlier.

And if you have high cholesterol and a family history, you should think about something called a calcium score, which is a CAT scan that gives you a lot more data on whether the cholesterol - because remember, there's different genetic types of people. Some people can have high cholesterol all their life and never have a heart problem.

Some people can have like moderately high cholesterol and have a heart problem. So you have to identify which one are you in the world. Like you're not like everybody else. You're unique. Part of it's your family history, part of it's your genetics and part of it's your lifestyle or health style.

And so, how you exist in the world depends on the probability that one of these things that could happen does happen. So those are some baseline testing, just simple blood tests, blood pressure. I would say check thyroid, gland, a TSH, that's a basic blood test. Just a good one time to know.

Men should probably be getting PSA checks and prostate exams after the age of 50 on somewhat of a regular basis. If there's a family history of getting prostate cancer in their 50s, then you should start doing that much earlier. Like again, the blood test. But a lot of these things require both experience and math.

And the good news is with AI right now, pretty soon you'll be able to plug in all sorts of stuff about yourself and it'll tell you what tests you should do. And if those tests say this, then you should do that. So that's kind of this future. The question is, how do you execute that?

I'll share one example. So I used and now partnered with this company InsideTracker. And it's basically do blood work and they go in and share you a lot of the data about where's the standard range, what's your range, what are recommendations from our team of researchers that say what you should do, link out to the research.

But that's one thing I did and I did the genetic profile there so they can kind of adjust things based on what they learn about your genetics. So that's one option that I've used and we partnered with. So you're talking about genetics vis-a-vis like a health problem. There's another set of genetics coming online.

And by the way, there's a company called Invitae. They're one of the bigger ones. They do the panel of I don't know how many genes, but they check for genes that like tell you what your probability of getting something is, which then can inform what your surveillance program should be.

So they've got a good panel. But then there's a company, again, I'm just gonna name various companies, called Oneome, that does pharmacogenetics. So what's that? Because of COVID and because a lot of mental health issues, a lot of people are taking antidepressants or anti-anxiety drugs. We can talk about psychedelics later because a lot of people are doing that too.

But we can tell you through, again, this science is, I'll say 75%, but it's better than 0%. So a lot of doctors will say, "I'm not gonna do that test because it's not 98%." I'm like, "Well, would you take 75% over zero? Right now, when someone is depressed, I'll try this drug.

Oh, that doesn't work. I'll try that drug. Oh, that doesn't work. I'll try that drug." Well, with pharmacogenetics, they can kind of look at the processing power of your enzymes with respect to certain genes, and they can tell you, "Hey, this drug is probably not gonna work as well because it's cleared so fast," or, "This drug will work better." So if you're gonna embark on a kind of pharmacologic adventure to try to solve a problem, this is called precision medicine, we're getting better at being able to pick the right drug the first time.

And that's through this venue called pharmacogenomics, which is, again, still new. The existing medical system is very slow to move, like I said at the beginning at the top of the podcast, and a lot of doctors won't do it. A lot of insurance companies won't pay for it because the proof isn't there yet.

And so, they usually require five years of proof and data to do the analysis to show that this cost has a future cost benefit. And that's kind of the... Which by the way, you want that science and you want that rigor. In technology, it's move fast and break things.

And in medicine, it's move slow and don't hurt people. So we do want it to move slow a little bit, but every 120 days, Chris, there's a new major breakthrough in medicine that like most of the medical field won't like know about for 10 years because they're so busy with the innovations from the last five years.

There's this natural lag that any doctor has, or any clinic has. I hold myself out and we hold ourselves out as there's no lag. All these companies are presenting to me. Every other week, I've got kind of a speed dating type of companies present to my group of six of our doctors and we kind of like, "Does it pass the sniff test?

Is it valuable to patients? Is it not like super expensive? Does it work? And then what is the science? And is it peer-reviewed? Is it validated?" There's a lot of people hawking a lot of stuff that's like super on the margin and on the bubble. And there's a ton of gurus, especially in the longevity space, talking about how if you just take this or do that, like off you go.

But there's no proof. There's just no proof. So I generally think about just to go to that place really quick, everything should be looked at through the lens of safety and efficacy. And if it's safe and it's proven safe and there's ways to prove that things are safe or not, and it's not yet proven to be efficacious, thinking longevity, well, take a flyer.

You're just gambling with your money, right? Why not? Like maybe it works, maybe it doesn't. But if you are going to do something that doesn't have a safety profile that is like really robust, I mean, this is your body, this is your health asset, this is your life. If you're going to take a flyer and gamble on the safety piece, because by the way, if we're not sure it's safe, we're not sure if it's effective, then you're gambling with your health.

I call that short brevity or long brevity. It's not longevity, it's long brevity. You are just kind of hoping that it works. My philosophy is, hey, wait a couple of years, let the science tell you the story. Don't rush into gambling with your health because if it does work and you missed it by two years, okay, that's two extra weeks when you're like 99 to 99 and two weeks old.

Like right now, you don't want to be mucking up with your system that can make it 99 to like maybe you make it to 82 because you created all this other problems. My job is to look at the science and I'm not well loved by a lot of people because I'm not making money on anything.

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Let's run through a couple of the lifespan things and just get your take on them. One of the most well-proven and well-known things for longevity is social integration, is having healthy relationships that are repeated in long-term. Are you in a book club? Do you go on walks with the same people?

We often think that the body and the mind are different things, but they're the same thing. That's like saying my computer screen and my computer chip in the thing are different. Well, they are, but the output is like one breaks, the other one - you need both. And so the brain is what can cause inflammation in the body by stress or by angst or by not sleeping well or by having bad eating habits or by drinking too much because you're stressed.

So this level of stress kind of goes down with social integration because your people, they call your bullshit in a way that you've kind of come to tolerate and realize that you need people to guide you and to be sounding boards so that you're not just looking for more likes on Twitter or getting super bummed out when you get like a criticism somewhere.

I just also did a podcast with Eric Verdon, who's the CEO of the Buck Institute on how to live to 95 super healthy, and we go through a number of different strategies to do that. Spoiler alert, it's not rocket science right now. He's doing a lot of research on stuff molecularly, cellular senescence, mitochondrial decay, telomeres, oxidative stress.

They're doing a lot of that research, but he'll even tell you we're not there yet. And then there's stem cells. And I think when we think of longevity, we have to think about like, well, my eyes may age faster than my heart. My liver may age faster than my kidneys.

So longevity is like almost organ-specific and most people don't think like that. But the spoiler alert is, and a study came out literally, I think it was yesterday. A big study over lots of years and lots of people that water, hydration - by the way, we all know this.

Everybody knows that like, as my father used to say, the solution to pollution - I see you drinking now - the solution to pollution is dilution. Water is a critical aspect of life and if you stop drinking for three days, you're dead. Let me just put a really fine point.

If you stop drinking for three days, you're dead. If you stop eating, you can go on a hunger strike for a month or longer before you're dead. Without water, you're dead in three days, which is why all these people in the hospital are getting IVs and they never die.

You stop the water, they're dead. You go out in the forest, there's all these animals out there that you can't see and can't hear if you're camping and there's animals dying everywhere. You don't hear screams. You don't hear moans. They're not in pain. Why? Because the body has come up with a very elegant mechanism for death by no water.

As soon as you start not drinking, what happens is your kidneys which filter all the stuff in your body, the level of nitrogen in your body which normally gets filtered, the more you drink, the more nitrogen goes out. I mean, sodium and chloride, there's all sorts of things the kidney does, I'm being simplistic here.

But the levels of nitrogen start to go up in your body, they get more concentrated. They're not being diluted, they're being concentrated. So, the higher the nitrogen is, if you've ever had nitrous oxide, you kind of get whoa, kind of numb and happy. It's the same thing. So, when you stop drinking, you start to get like kind of - it's like a morphine-like state where you kind of get happy and numb and things are kind of gleeful.

Now, not to suggest that if you've got like terrible pain and stop drinking, like that's a solution. But people at the end of life that aren't like suffering with any painful thing, like they stop drinking and then they die. And it's a very kind of dignified biological process that like biology has figured out for a long time.

They don't want death to be super painful. I say they, I don't know who they is, but like nature, biology. So, hydration is like a really important thing. And so, how do you know if you're drinking enough? They've got smart cups, they've got like all this new gadgets. Hey, real simple.

If you're not going to the bathroom three times a day or more while you're awake, you're not drinking enough. And you don't need to overdo it. I think you should always have a glass of water around, you know, you shouldn't be chugging, you should be drinking. And I think the part two to that is alcohol.

Like we know alcohol is a pro-aging substance. So, if you're one of these anti-aging people and you drink alcohol, well, then you're going to take some silver bullet pill that you heard about from somebody and then you're going to go out and have like a bunch of cocktails and go to Vegas.

You actually have to like think long-term and what these episodes of alcohol does. But if you are going to drink alcohol, which most people do, glass of wine, put a glass of water in front of it and put a glass of water after it because then you're diluting the alcohol's impact because alcohol dehydrates you.

So, the concentration of alcohol molecules in your body is higher an hour after you drink it than it was before. So, if you drink lots of water before and after, it doesn't get a chance to concentrate and cause problems. Sleep, super important one. I wear an Oura ring and I see you do too.

I measure my sleep every day. I've been getting 90s scores on both ends since January 1st when I stopped traveling and my goal is to keep above 90 like all the time. I have patients that are like, "Yeah, I'm in the 60s, I think it's great because I was in the 40s." And I was like, "Holy moly, 40s?" I think a lot of people think that like I'll sleep when I'm dead, I'll have plenty of time for that but the truth is if you don't sleep now, you're going to die much sooner and so you'll have less time.

And one of the hacks for me is I need eight hours of sleep. In fact, I got like almost nine last night but you should figure out when you want to wake up and you should set your alarm clock to go to bed. You should never set your alarm clock to wake up because when you set your alarm clock to wake up, in that last hour while you're waking up naturally, your cortisol levels which is an inflammatory stress molecule is going down and right before you wake up naturally, it's at the lowest point before you wake up and when you wake up, the world turned on and it spikes.

So, your cortisol level always does this huge jump when you wake up because the world just turned on and now you have to like figure stuff out. So, ultimately, you want that cortisol level to be at the lowest before you wake up because if it's high before you wake up and it spikes, it just got much higher, the upper magnitude got higher.

So, I like to let people wake up naturally. Humans are the only biological species on the planet that artificially interrupt a critical biological process, no bueno. And also, there's something called the glymphatic system in the brain which clears out all the metabolic junk from all the activity from the day before.

You want that to go through its entire process. I think waking up is a multifactorial process which the brain feels like it cleared out enough stuff. Your cortisol level is nice and low, your circadian rhythms are this, it's time to wake up. So, sleep is critical. Diet is obviously super critical.

What does that mean? Michael Pollan said, "Eat real food, not that much." And there's a big study on time-restricted eating today that came out. I generally don't eat breakfast. I've never eaten breakfast. If I have a breakfast meeting, I will, but I generally - I'm not hungry in the morning, my coffee kills my appetite, I have one cup of coffee and then I may have a cup of green tea throughout the day, I'll generally eat at 1 or 2, have a relatively small lunch, mostly vegetables, maybe a little fish and then I'll have my dinner which, you know, and stop eating at 8.30.

But the truth is you should not eat things in a package. If it's in a package, it's probably processed and probably not the greatest thing for you. It's almost impossible to do that. So, I think if you are eating things in a package, look at the ingredient list. If it's a lot of ingredients, probably not good.

If they're ingredients you can't pronounce or know, probably not good. And in general, the hack I have is like one apple is 70 to 90 calories depending on the size. It represents 50% of the dietary fiber you need in a day and your microbiome which lives in your intestine which is a separate organ that we have, feeds off of fiber.

So, you'd rather give your microbiome, your friend that helps you live because it makes 80% of the serotonin in your body or 90% which is the happiness molecule. So, if you don't feed your gut, it's hard to be happy. If you don't - I mean, if you put a bunch of chemicals and crap in your gut and cause it to get angry, you're probably not creating an environment for your best self to emerge through more serotonin, less dopamine environment.

So, I like to tell people apple, like if you want dessert or if you're hungry and you see a snack, eat an apple, eat two. You will not be hungry afterwards. You will not want to eat anything after two apples, you're just full because fiber slows everything down. So, diet is really important.

I think there's a lot of movement towards no wheat, gluten-free. I think there's going to be some science that comes out about that in the next couple years that that's probably better for you, but probably based on genetics and then exercise. Exercise is also the other pillar of longevity and by the way, exercising outdoors, much better than indoors.

Even taking walks outside, the pheromones from trees lower your cortisol level, lower your kind of inflammating process. So, people that have Pelotons and they do their one hour of hardcore inside and then they go work, better than nothing, but I would encourage you to get on a bike and go outside.

Just take a walk or a jog. Obviously, if you live in a big city and it's freezing outside, do the Peloton. I do push-ups in the morning, I do sit-ups. My exercises, I don't have a one-hour intensive thing, I just do micro things and studies have shown that three to five minutes of intense exercise a couple times a day is as good as anything else in terms of what it does to your body in terms of resilience and restorative function and longevity.

So, those are the shortcuts on the longevity thing. Then there's of course, all these supplements that people can take. There's people doing NAD drips. There's companies that do those all over the country, not proven. There's IV drips. I'm like, does your stomach work? Drink. If you're hungover and you just can't drink a lot, then sure, IVs are going to restore your fluid balance probably a little bit faster.

But if you actually drank water while you were drinking your cocktails, you wouldn't need the IV drip. So, do you want to be proactive or reactive? What is the approach that you want to take? Who do you want to be in this world and how do you want to think about your long-term health?

- So, I want to go back quickly to diet. I think we all know that processed foods, not good for you. Sugar, I assume you would say, is not a great thing to be consuming a lot of. Does that mean there's no place for it? - Great question. So, my rule is, you think the 80/20 rule, the Pareto thing, I think it's probably 95/5 or 90/10.

I have a total sweet tooth. You know, when I was growing up, I had Twinkies. I was growing up in the '70s in California and my mom, before she got like all natural and stuff, it was like, "Yeah, have one of these and Froot Loops and Captain Crunch," but I had my apples and bananas and everything else.

So, in general, and I started a non-profit called Eat Real, which is all about preventing kids from getting sugar. We're changing the menu of the largest fast food chain in the United States, which is our public school system. And by the way, by removing chocolate milk out of school, and we did this in the East Bay in the Bay Area, we eliminated 10 pounds of sugar in one child's body per semester.

Now, just think about that. Just making chocolate milk to milk. So, 10 pounds of sugar in a kid is doing absolutely no bueno. So, like sugar should be, to me, for dessert, but you can't have dessert at every meal. Like dessert can't be your main course, your appetizer, and by the way, bread is sugar, but it's not processed refined sugar.

It is a carbohydrate. It will go through an oxidative process that looks like sugar, but just not as corrosive as fructose and all these other high fructose things. So, for dessert last night, my wife made this amazing pasta squash soup, and I was like, "I need my dessert." So, what did I do?

I got raw coconut shavings, no sugar added. I got some dark chocolate chips, which are almost little sugar, and I got some peanuts and a fig. I chopped it all up, put it in a little bowl, and that was my dessert. And it was all natural. It was a very sweet.

It was incredibly sweet, but it was tons of fiber in there. And I love my sorbets, so don't get me wrong. I will cheat. If someone's got a great sorbet, I'll have it. If there's an amazing chocolate fudge thing, I'll have it. If there's an amazing cookie, there's a restaurant called Spruce around here.

The Spruce cookies, oatmeal cookies are amazing. I think they're like 1,500 calories per cookie though. So, I think you just have to be mindful of like - and by the way, I used to eat whole Spruce cookies like 10 years ago, and now I realize, "Holy shit, those are loaded." I'll just have a few bites.

So, have your dessert, but you'll still have it. But yeah, I'll still have it from time to time, but I'm much more mindful of - let me eat it. If I have a sweet tooth, let me eat an apple. That will kill my desire for more sweets because apples are pretty sweet, but all that sugar is attached to fiber.

To illustrate one point, which I think is fascinating, one of my buddies is a researcher did a study in Oakland, California. He went to an inner city school, got two 14-year-old African-American kids, both like six feet tall, told them not to eat dinner. Show up to school and we were going to experiment with food.

They showed up at 9 AM and one of them was told, "Drink this 16-ounce glass of orange juice. Glug, glug, glug, glug, glug. Drink it." He's hungry, grown guy, growing boy. Now, here's a Big Mac, the large fries and a big milkshake. Ate the whole thing, all of it, no problem.

The second kid came in and we gave him six gigantic oranges - not I, he gave them - and said, "Peel them and eat them." He couldn't eat the sixth one, he was full. Six big oranges. Those six oranges is what made that orange juice for the other guy.

So, by eating sugar with fiber, you fill up. Your stomach's a bag and when you wake up in the morning, your bag is like a paper bag that's not opened. As soon as you start filling up the bag with food, there are stretch receptors in the stomach that send signals to the brain, "Hey, we're filling up here.

Slow down." So, just stretch will signal slow down, not hungry, kill appetite, in addition to the quality of the food. But six oranges is a ton of mass. So, I'm in the habit lately of when I'm hungry or for something sweet, I'll have an apple and an orange and then I am no longer hungry.

And so, it's my hack to get all the sugar I want and you can't eat enough fruit. By the way, one other story is Dole pineapple in Hawaii. You've seen these big Polynesian Hawaiians, they're massive, they're like sumo wrestlers. Before Dole came in, those people ate pineapples naturally in Hawaii, no diabetes anywhere.

As soon as Dole came in and made pineapple juice, diabetes pandemic amongst the Hawaiians because they took the fiber out of it and they just made it the juice. So, I say no juice, juice of no bueno. I mean, there's all these green juices now, okay, whatever. Like why don't you just eat the food that the juice is made of?

Like you could do that if you wanted to, but if you just know the time, take the juice. But all those juices have honey, cane juice, it might as well be a Coke without all the hardcore chemicals. You got like the kale and you got all these things that look bueno and feel good about, but it's still got tons of sugar that's not connected to fiber.

Okay. Let's say you got 12 cookies sitting in front of you and you know you're going to eat them. It's better to eat one a day or 12 on one day and nothing for the next 11 days? It's much better to eat one a day. Imagine you're in your car and you want to go fast.

You could go first gear to 4,000 RPM, second gear to 4,000 RPM when cars had stick shifts. But the 12 cookies is taking your car in first gear to like the red line all the way to the end and it just stresses the system. Because once your blood sugar goes up with all those cookies, what happens is there's so much sugar in your blood that your body goes, "Okay, the red lights start flashing.

We need to lower that sugar." So in order to lower that sugar, we're going to make a bunch of insulin. Insulin then your pancreas makes insulin and your insulin shoots up. And when insulin shoots up, insulin is the key that unlocks the little holes in your blood vessels to let sugar out of the bloodstream and go into cells.

So when your insulin spikes, insulin is an inflammatory thing. It's like creating inflammation for your whole body. So by going to 12 cookies, you've just caused this huge glucose spike. That's the other thing I would recommend people who are curious and you've probably done this is the continuous glucose monitor.

What causes your sugar to spike? And everyone's slightly different. I found that when I ate kimchi, my blood sugars went down. I love kimchi. By the way, fermented foods are always good for you. Pretty much good for your gut, good for your health. People underestimate and they don't eat enough fermented foods, pickles, all these things.

But a continuous glucose monitor will tell you the truth about what's going on when you do things. So some people work glucose monitors for long periods of time. My thesis is wear it for a month, eat lots of things, try lots of challenges. But if you see a big spike in something, you should try to avoid that food.

Or eat an apple before you eat that food and eat it again and see if the spike happens. The apple will slow down the absorption because the fiber just slows down absorption of sugar. I say an apple or some other high fiber thing. I signed up for Levels Health and used it for a month, which is a continuous glucose monitor startup that has an app.

I use Levels too. I did it for a month. The thing about Levels and all these companies, they want you to wear them forever. And it's just like, yeah, no. If you don't do enough challenges over a month, then maybe you need to wear it longer. I think every minute that you're focused on your health obsessively, you're not focused on your life.

And the reason we're here is to enjoy our life. Health is freedom. And if we're focusing on something for a long period of time, we lose sight of like the broader purpose. I like to get people who are like hyper freak, quantified self people to like step back from the ledge and stop trying to measure things.

There's a control freak component to that, I must know everything so I can control everything. Guess what? Get the heuristic, get it and then change your behavior and then go maybe do it again in a year, see if it helped. But you're not going to notice any material difference month to month or year to year by continuing to do this stuff.

Is there anything on the supplement side or things people should be taking every day that have nothing to do with specific health concerns? So supplements are an interesting category. They're called supplements because they are supplementing something, right? So let's look at the word itself. If you know that you're deficient in vitamin D, then you should take vitamin D.

And a lot of people are. They think they get a lot of sun, doesn't matter. If you're deficient in vitamin B12 or folate or iron, you should supplement things that you're deficient for. In general, the human body is really good at taking the food that you eat, assuming it's not chemicals and it's food, and processing all the nutrients, micronutrients, metals, everything, and incorporating them into the body.

If you take something on a daily basis - so I take vitamin D on a daily basis, but my vitamin D, it's on the bubble of like 30 if I do nothing. I want it to be 50. There's just a lot of evidence that there's a lot of benefits to having your vitamin D a little bit higher.

So I'll take it every day, even though mine's ostensibly normal. There are people that take all sorts of vitamins every day, but as soon as you take those vitamins, your pee is really yellow or your pee changes color. It's because that's the color of money. That's the green dollar that you paid for, it just turned into yellow pee.

And so like you're just peeing money out. So there's not a real benefit of taking vitamins every day, but because it's under the category of generally recognized as safe and the marketing machine there is amazing and the vitamin and supplement business, I don't think there's a lot of high value in it if you have an amazing healthy plant real food-based diet.

You will get everything if you eat healthy food. If you don't and your diet is kind of crappy, then you should probably go get tested and see what you're deficient in and where you need help and then try to tailor your supplementation to that. But I don't think there's any good fundamental use case for taking something just because.

There's a lot of religion around this, people like believe, "Oh, my aunt takes like 20 vitamins every day. She's been doing it for 50 years". No evidence there. There's literally no data to support taking that. On the longevity side, there's this thing called NAD, which a lot of people are taking and going back to safety and efficacy, there's lots of brands out there.

One of them is TruNiagen and I'll only surface that one and not all the other ones because they've done the safety profiles. They know that it's safe, they've done the homework. They'll tell you like they can't prove to you that's going to make you live longer, but theoretically in mouse and in worms and maybe in dogs, like they seem to have a less oxidative stress on their mitochondria.

So if it's safe and we don't know if it's effective, well, we're just spending money and dealer's choice. Then there are other ones that haven't have a safety profile and claim the same things based on the same studies, no safety, then you're kind of gambling with your health. Like why would you do that?

The vitamins are generally recognized as safe, so that's just spending your money on something. I would say if you're spending money on supplements, you should take that money and find a doctor that's going to be in your corner to prevent things from happening or when the shit hits the proverbial fan.

Unless you have a medical condition, then yes, sure, there are supplements you should take. But if you're a healthy person, there's no real data. - You did mention in Hawaii something about a toothpaste. - There's lots of organs in your body that require some attention and if you have any gum disease, like some people have, some people don't, your dentist should tell you if you have some recession.

Because gum disease, by the way, leads to inflammation and endotoxins in your teeth, which can make your heart problems worse faster. So if you have a calcium score of two and really bad teeth, your calcium score will go up. If you have gum disease, your calcium score will likely go up faster than if you didn't.

So I sadly, I don't know why, my buddy who was a dental guy said, "Hey, just floss the ones you want to keep." And 15 years ago, I kind of laughed at him and now I regret not flossing regularly because it matters. So there's something called MyPaste, M-I-P-A-S-T, which is kind of a special toothpaste that you use after your toothpaste that helps with gum health.

We just talked about gum health. We could go to iHealth. There's 99 other versions of things that you could do depending on what the issue is, if there's a problem. And then of course, if I just flossed, I wouldn't have that problem. Then there's the proactive things you can do to prevent things.

But these are investments you have to make. They're investments in time, investments in all these different things. So a lot of people, they'd rather treat the problem when it happens than spend all this time preventing something that they can't imagine could happen. So that's kind of a psychological pretzel people have to like engage in, imagining their future selves.

So we started with this, "Who are you?" where you ran through a bunch of tests, a lot of blood work, a few other things. Yeah. I think the next one that you talk about is, "How are you?" So, "How are you?" is really, "What does your life look like?" I mean, you wake up in the morning and then you go to bed, right?

And absent those moments when you're sleeping, what does your life look like? What are your relationships? I've come up with this concept called vitality signs, which is not vital signs and vitality signs are measures of your relationship with things in the world. So the relationship, so "How are you?" is like how is your relationship with your parents?

How is your relationship with your children if you have them? How is your relationship with your primary relationship, your spouse or girlfriend, boyfriend? And if you don't have a spouse, girlfriend or boyfriend, how's your relationship with the absence of that? Does that cause you anxiety? Are you cool with it?

Like because all these things are going to inform a bigger picture. What is your relationship with money? Are you obsessively trying to get more? Are you super happy with what you got? Like what is your relationship with it? What is your relationship with time? What is your relationship with your past?

What is your relationship with your vanity? Are you obsessively concerned about how you look or do you not give a shit? Like it's somewhere in between. What is your relationship with sex and love? So there's all these different components and ultimately, based on these things, we'll start to get a framework of - like if someone doesn't talk to their parents anymore, "Oh yeah, I don't talk to my parents anymore" or "Me and my sister haven't talked for years", that person's got a - there's a problem there.

There's a real problem there. Now, there's a hole in that person's life in some way or there's some deficit whether they blow it off or not, it's true. You can't skip it. You have to like acknowledge what that is. So the "how are you" is like all those things I just said from the vitality signs but more importantly is what do you do, what are your habits, what do you do that you should do more of and what are the things that you should do less of and what are the things that you're not doing at all that you should be doing.

So you have to examine your habits. So that's the "how are you" and it's your mental health. Like are you in a good state? Do you wake up happy? Do you wake up upset? All of these things kind of ladder up to your overall - I'll call it the happiness or contentedness quotient with your existence, your existential quotient.

Where are you? How are you? If I run through that thing, I'll tell you like "Oh yeah, that guy drinks a lot, doesn't sleep enough. That person over indexes on sex versus love". Whatever these things are, who you are and how you are, then set you on a trajectory.

And so, the third bucket is what is your trajectory. I have a slide that I generally show people which shows like "Here you are when you're born and here's you are when you're dead". You can go between the ages of 0 and 24, you're growing and between the age of 24 and death, you're aging.

So what is the slope of the curve of aging? Are you above normal? Are you below normal? Are you a super ager? Meaning do you age super fast? Those things can be measured based on who you are and how you are. So if you're constantly doing like a check-in on who you are and you're doing a check-in on how you are, you can kind of look at this trajectory and kind of know which one you're going to be.

You control your destiny. No one's making you do the things you're doing that you shouldn't and no one's not making you not do. It's just you get in the way of yourself and nothing screws up a great story like data, which is why I'm super happy that there's all these devices that can measure things now.

For example, there's a blood test from a company called SomaLogic proteomic test and it can tell you with like a high degree of accuracy what your four-year risk of a heart attack is. It's like a $600 test. It's a blood test. You don't need a calcium score. The world's moving to blood not scans.

So all these fancy full body scan places are like I don't see their future much and they're expensive and the technology is getting so much better with AI and blood and breath. And there's a company called Owlstone that you can breathe into and it'll tell you how your liver, your kidneys are, your intestines, the health of them through volatile organic compounds.

So, the cadence of check-ins, who am I? And then the intellectual honesty of how am I and what am I doing is what leads you on this trajectory. And if you really want to live a long and healthy life, which I think people call health span, just have to look at these things.

You can't look away. You just need to be honest about what you're doing and who you are and what you should be doing more of and whether that's diagnostic, therapeutic. Like I have a friend who's a chef who had Crohn's disease. He was on methotrexate and all these hardcore drugs.

And then one day he said, "You know what? I'm going to like radically change everything about my life." He's now off everything. All symptoms are gone and he just eats whole foods and he got off the pharmaceutical train. And Nestle, by the way, they make sugar foods and then they make diabetes pills.

So, they've got the whole ecosystem. They get you sick and then they treat you. But that's like a vicious cycle of whatever. I mean, a lot of companies do that too. For people that want to optimize their health, they just have to look at what they're - like your fork is a weapon.

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So please consider supporting those who support us. So I want to take an example from this whole process, which is personal to me, which is had high cholesterol. How high? HDL 48, LDL 155. LDL 155, that's high. And how old are you? I'm 38. Okay. So over the last few years, LDL range 138 to 155.

So I got a test, had a doctor at Sutter and it wasn't because I picked this person, turns out I had shingles and I just needed a doctor to prescribe something. They were like, "Go see your primary care physician." I didn't have one. I picked whoever had the next open appointment.

They went in, they were like, "Let's review your blood work." And they went through and the advice was, and I'm reading this quote because she sent me a note after the blood work was done for my cholesterol, she said, "Your cholesterol is 206 with HDL 48 and LDL 155.

Advise, low fat, high fiber diet. Let's repeat in a year. Take care." That was the message. My reaction to that after talking to a few friends was like, "I feel like maybe there should be more going on in this process." There's a lot more information that needs to be, yeah.

And so a couple of friends said, "Oh, you should probably go get your ApoB tested. You should go look at more data." What ended up happening, and this took two or three years because it just did, finally I found a doctor who was like, "Oh, you should go get a calcium score." I did.

Was that covered by insurance? I don't know. It was two weeks ago. So I don't know yet. The hospital that did it told me they pre-cleared it with insurance and I wasn't gonna have to pay for it. Great. But unclear. I haven't seen the payment come through. But the calcium score came back a two on one artery, zero on everything else.

So two is a real number, by the way. It's not zero. Two is a real number. You have early evidence of coronary artery disease. Yes. Now, I'm not saying that three years could have prevented any of it, but the idea that three years ago I was messaging with a doctor whose advice was like, "Hey, just kind of eat healthy and we'll talk in a year." Seems like if I were someone going through a lot of the process that you mentioned of looking at some of your data, trying to take some of these tests, trying to figure out where you're at, how do you evaluate and analyze it when you don't have access to someone like you who's maybe done a lot more of the research?

What does the average person do when they see a number? It seems high. They talk to their doctors like, "Eh, we'll deal with it later." Going back to the beginning of the conversation, a lot of the medical system we have is like, "Let's treat it when it's a problem." Like high cholesterol, young person, maybe it's not a problem yet.

But clearly, if I've had high cholesterol for five, six years and I had... Or maybe all your life. All my life. Yeah. Like, maybe we could have been doing something different. So I guess one question is just, how do you interpret these? How should someone try to find the right person?

Could you find the right primary care physician at any hospital medical practice that could be a partner here? And I just happened to have the wrong one. I don't know. So I think it starts with, if your LDL is greater than a hundred, let's just use that as a marker.

Forget about all the rest of the APO and all the rest of the everything else. If it's greater than a hundred, then you say, "How long has it been that way?" We're not starting to test kids, teenagers, because we know the parents' cholesterols are off the map. When we get new members and the parents are off, we go check the kids.

And if the kids are off, that's never been done before. Just a way to think about it before I answer the question specifically, because I think it's important. When people smoke cigarettes, we as doctors ask them, "How many years have you been smoking cigarettes and how many packs a day?" And we call them pack years.

So if you've smoked one pack a day for 10 years, you have a 10-pack year history. If you smoked two packs a day for 10 years, you have a 20-pack year history. That's the same as smoking one pack a day for 20 years. So it's what is the load of this chemical, which ultimately ladders up to risk of heart disease, diabetes, and lung cancer.

So we call them pack years. So now the more sophisticated libidologists are talking about LDL years. How long has your LDL been high circulating through your body? So there's LDL years. So if your LDL is high and you have a calcium score of 2 and you're 38, you probably had a high LDL for a long time, and you don't have the genetic subtype that doesn't care.

I don't know if you smoke or there's other things that you do, but the first thing is get to some answer of, "Do I need to do something else?" And you can go deep into the weeds of LDL. I have patients that want to optimize their LDLs and stuff.

They'll pay some doctors that like hold themselves out for $100,000 to optimize their LDL. And it's just like, you're optimizing 0.001% of your body, it's already pretty good. So the question is, if you did her diet, like, let's just say you followed her diet and said, "Okay, doc, I'm going to do that.

When do we check it again?" And she said, "A year." My answer would be, "Well, I want to know if the diet story works sooner than later because I don't want to hold another LDL year to go by that high. So can we please check it in four to six months?" But you actually have to do an honest change of your diet.

And if it goes down to like 100, you know the answer. You know the answer. Keep your diet like that. And even if you knew your calcium score was a two now, and you knew that you could lower it with diet down to like 80, and to give you a calcium score of greater than zero, you got to get your LDL below 80.

That's what kind of our guidelines are here. If you can't do that with diet, then you need to be on something. You need to be on a statin, sadly. And if you are so adamant about taking statins, which is basically there's different kinds, but there's an HMG-CoA reductase inhibitor, but that's a fancy name for the molecule.

Then you can eat red yeast rice every day because that's what is a statin. If you can find a way to put that in a soup and eat it every day, like, you could lower your cholesterol and your LDL that way. So I think that whenever you find out something's abnormal, you have to think about, okay, intervention retesting, how quickly can I find out if I can make a difference without pills?

And if I can't, what pill do I go on? Because once you get a calcium score that's positive, you just know now that you're committed to not having that number go up. That number goes up with the LDL staying at 155, but then you have a heart attack at some point in your life and that sucks.

So you don't want that. And I didn't mean, by the way, to make this about me. No, no, no. But I think if people get into your head, like hear me talk to you as though this is them, I think everybody can take something away from, like, if you get something that doesn't look right and doesn't feel right, then dig in.

Don't let that doctor get away with eat fiber, let's check in a year. By the way, one thing that I realize in hindsight, a lot of people moving around a lot, I've probably had five primary care doctors since I graduated college. And I went back and looked and it's like, I don't have my blood tests too far back, but I've got them about seven years back and I've had high cholesterol for seven years at least.

But I had one doctor and then I had another doctor, then I had another doctor, but I had one doctor for three or four years at that cholesterol, but never really pushed back, said to do anything. But part of that's because going back to what I was talking about earlier about like the medical system moves slowly.

We never thought ever of treating a 20 to 30 year old or a 30 to 40 year old with statins unless they had like a credible family history. I mean, there are people that have heart attacks in their 30s. Like they have crazy genetic cholesterol problems, hypercholesterolemia, hypertriglyceridemia, they can get these problems.

But the medical field, like we're not aggressive with younger people because like you said, the system's reactive. It waits for you to get sick and then they make a lot of money. Pharmaceutical companies make a lot of money on preventing the heart attack, but the hospitals and the doctors and the surgeons and the cardiologists and everybody in the food chain doesn't make that much money from you not having a heart attack, not to be hyper perverse about it, but it's just the way the system's designed.

And oh, by the way, that doctor that saw you, they're not accountable to your future outcome at all. And they don't know you because you're moving around. You're just another kid in the mix coming through their system, which is why I really believe that these long-term relationships matter. I think that everyone's trying to find the quick fix, the transactional, where's the chat bot for healthcare so I can blah, blah, blah, blah, blah.

I think at some point, but you really want someone that knows you, gets you and is going to like tell you the truth and like double check on things. Is there a way you'd tell someone to interview? Like if I'm like, okay, obviously this one wasn't a good fit, I need a new primary care physician.

There's not like an easy way to find someone that I know of. Are there questions you would ask them to try to figure out if they're the right fit for you? I would ask everybody, what is their perspective on prevention? I would ask them, what is their perspective on productivity?

I would ask them how they hold themselves accountable to your outcome, because a lot of doctors feel like, "Once you leave my office, how am I going to enforce anything? It's your life." So, I would say, "Hey, look, I sometimes am my own worst enemy and I'm busy. How can we do this together so that you hold me accountable and I hold you accountable?

Can we both hold ourselves accountable here?" And if the answer is like, "I don't have time for that. Like I'm just too busy." Probably not the right one. And this goes to the meta theme here, which is the rise of what I'll call concierge medicine or what I'll call membership-based medicine.

So, in primary care, I'm probably one of the grandfathers of the field, because I started a kind of a concierge practice when it wasn't really a thing in 1998. I gave out my cell phone. I said people can call me whenever they wanted. I would follow up with people.

I would use email and text in the late 90s and early 2000s, because I wanted communication to be the most important thing, because you'll get the good outcome if you have communication. You won't get a good outcome if you don't have communication, because like communication is like more than just data.

It's holding people accountable and building trust. So one medical, didn't start off as one, they're like a freshman version of a concierge practice, meaning that I think they charge $159 a year, but they take insurance. Then you have companies like MDVIP that charge $3,000 a year. There's a group called Roamed, R-O-A-M-D.

It's an association that I'm part of that has doctors all around the country that like have doctors that are membership-based. And they can charge anywhere between, I don't know, $50 a month to $500 or $1,000 a month or $2,000 a month. It all depends on what level of investment you want to make based on what you think exists out there.

So there are these practices out there. Some people call them direct primary care, DPC, direct primary care. Some people call it membership-based medicine. Some people call it concierge medicine. Some people call it private medicine. But I think that one has to look at their - if you make $100,000 a year and you say, "Okay, I want to invest in my health." What percentage of your $100,000 will you invest in your health?

So we know that you invest a certain amount in a cell phone and a Wi-Fi package. And we can talk about what you invest in technology, got their own personal budget. I know that you talk about this a lot. But a lot of people will say, "Well, I have a membership to Equinox or pick the gym and that's, I don't know, $60 a month.

So that's $500 a year. So I invest - so $500 a year is 0.5% of your income." I don't have a membership to Equinox, but I'm guessing you don't either because I'm pretty sure it's like more like $100 or $200 a month. There you go. I'm not a member of a gym.

I have four kids and that I've got a gym in my house. Like I'm running around all the time. So even if it's $100, let's say $100, that's $1,200 a month, that's 1.2% of your budget. But that's not investing in your health. That's investing in your fitness. So I just want to be really clear.

I mean, which is a subset of your health. But if you really want to make the big investment on a doctor to have a relationship with that you can go back and forth with and really build up a rapport and then kind of a bilateral mutual transparent accountability quotient, you should ask yourself if it's all invest 4%.

If it's $4,000, you can find a lot of doctors in the membership-based world for $4,000 a year and they'll use your insurance to do the blood test, to get the MRI, the CAT scan, to send you to the specialist. So you're only paying for a quarterback. You're investing in someone to oversee it, to be your partner.

Your insurance will still be used for everything else. So that's how I would think about - and by the way, this field is growing. There was a report by Grandview where the concierge medical market is like the fastest growing field in medicine. It's the fastest growing sector in all of health and biotech and everything.

It's expected to double or triple in the next eight years. So why is that? Because doctors want to help people and they want that principal agent problem gone. They want to be accountable to you. So if you don't like me, if I'm not doing my job, guess what? You fire me, I just lost revenue.

If I'm an insurance taking doctor and you fire me, it doesn't matter. Someone will fill that spot in a nanosecond because I've got a three-month waiting list. So I don't have to care if people like me or don't like my outcome. Someone's going to fill that insurance-based principal agent problem slot because there's no accountability.

There's no true straight line. There are dotted lines everywhere. There's no straight lines. The straight line is between the doctor and the insurance company because the insurance company can call the doctor and say, "Hey, we're not paying you that much because you're not whatever. We don't like you." And one doctor against an insurance company or the hospital system will say or the employer, the one medicals, not to knock on them, they'll tell their doctors, "Hey, we need more revenue.

So instead of seeing 14 patients a day, please see 15 patients a day." So if you're seeing 15 patients a day, that means each patient gets one less minute, which means that's one more email, one less minute, one more person. Like quality just starts to exponentially erode. I know that Roamed is going to be building a physician finder for somebody that wants high-quality private membership-based physicians this quarter or next quarter.

That's where I'd start. I don't think Yelp reviews or any of these health grades reviews are useful at all. I don't buy them because people want to go to the Apple store, not the doctor store. So when you go to a doctor store to rate somebody, like unless you're like a professional rater, you're usually there to complain.

I wasn't thinking about it when you started your practice, but it seemed like early on it was two things. It was the quarterback and the like 24/7 access, we'll come to your house kind of stuff. And what I've been looking for since is I want someone who charges enough that they have free time in their day to read some research or have someone on their staff to read research.

100%. Someone who's thinking proactively about my health, but like I can wait for someone to respond tomorrow or on Monday. That's right. So it's like that middle ground is the company that I want to see. And there are tons of them. There's nothing at scale because all the ones at scale, One, Forward, Parsley, pick the brand, they've all raised money.

So they have investors. So it becomes a profitability story versus a great healthcare story. Most of the onesie-twosie small versions of concierge medicine, it's somebody that's like, this is my business. My revenue depends on me doing a great job for you, not on somebody telling me to do more or faster or whatever.

So I think there's some consolidation in that space, but I think you have to be really clear on what drives this doctor and you want a doctor that's thinking about you when they're not in front of you, right? Doing that research, I read an article about multiple sclerosis this morning.

I have a multiple sclerosis patient and I'm like, "Hey, guess what? There's this new research, just heads up and tracking this." Nothing to do here, but like maybe in a year or two, there'll be some interesting developments. And by the way, we talked about all these costs. If your company has an FSA plan, you could put money in pre-tax each year and be able to use that for your medical expenses.

So one way, and I haven't really thought through this completely before. I'm not going to recommend it. I'm just going to throw it out there. You can't change it mid-year. So one way to force yourself to have a health budget is to just commit to put a little bit more in your FSA each year.

So maybe say, "This year, I'm going to put two grand," and obviously we're recording this in January. So it's a little late for this year. But next year, you could say, "I'm going to put two grand or three grand in my FSA." You do have to use it or lose it.

Usually, maybe you could roll over, I think this year, $650. But it'll kind of force you to try to get more serious about these things. Because if you're listening to this and you're like me, at least, it's really hard to be like, "Oh, do I want to do this test?

It costs $500." For some reason, there are things in life that it just seems like, "I grew up, medical treatment should be free. If it's not free, it seems harder to spend." It's not hard for me to buy a new iPhone, but it's really hard for me to spend $200 on my health.

That goes back to this concept of there are no consumers in healthcare. I've never seen a consumer in the ICU type of a thing. Consumers have a profile that when you want to go to the iPhone, you have all the agency, all the free will, all the power, all the resources, those decisions are yours.

When you go to the healthcare system, they're not. You've lost it all. So that's why getting a concierge doctor or a membership-based doctor is you're investing in somebody that's got your back, that's going to work with you, that's going to be co-piloting your care with you, and that's going to actually care about you and care about your outcomes.

I believe you don't go to eight years of medical school and college and residency because you want to make money. Like you're a healer. There are some people that go into finance and want to be hedge fund guys or some people that want to be artists and architects and like everybody wants to make a good living, but you don't go into medicine unless you're maybe a plastic surgeon or a cosmetic dentist or whatever, because that's where big money is, vanity.

That's healing like some psychological wound somewhere deep in your past. And so, I'll give it to them. There's some healing components there, but our world is like this is the everything person. This is like all facets of your existence and health need to be under my umbrella and I'm a healer and I want to help you and like we're naturally empathic.

We're naturally long-term. We feel bad when something bad happens, there's a bad outcome. Empathy and compassion I think are part of the frameworks for going into medicine in the first place. And I think a lot of these doctors are getting burned out. There's a huge physician burnout because these big companies, the medical industrial complex is forcing them to see more faster, check more emails, like Kaiser doctors have to check their emails in 48 hours.

They have 2,500 patients per doctor. So imagine the amount of emails with no barrier to email and they don't get paid for email. Like the Cleveland Clinic or the Mayo Clinic, I can't remember which one, they just announced a program that every email to your doctor is going to cost you 50 bucks.

So now you have to be really thoughtful. You can't just like - which I think is good for doctors because then at least there's some barrier to someone posing some crazy question with three articles to read and look at what my brother said and like Kaiser will make you respond to that, which is bananas.

These are the ways to really think about it. I think having someone in your corner is important even when you're young and healthy because you don't want to wait until you're sick. That's a hope strategy. I hope I get a good one when I'm in the ditch. You want to have somebody on your team because they can see the ditch coming.

Healthcare is super predictable. We know you were going to have a heart attack if you didn't get on top of your lipids. So now you're not going to have a heart attack. Now let's work on everything else type of thing. There's lots of ways to think about medicine. I'm optimistic about a lot of the changes that are coming.

I'm not optimistic that they're going to happen fast. I hope that I can be kind of a guiding principle. I hope people copy what I do all day long to create different versions of it and I'll say private concierge medicine, whatever. That's the way it used to be. I used to be your primary care doctor until the HMOs came in and they saw that it was a trillion dollar market and now it's got a financial boondoggle.

You gave us some good tips on what we can do to try to take some of this into our own hands, find someone that might be a better partner. I think that's really helpful. But you write about stuff. You have podcasts. Where can people stay on top of what you're learning in your practice and online?

So if you want to see what I'm reading and you want to get my point of view on what I think about the latest science because I read about five to ten articles a day is on LinkedIn. For now, I'm Jordan Schlein at LinkedIn. There's not a lot of those.

No C in Schlein. It's just S-H-L-A-I-N. I post one or two things a day on longevity and/or science that I think is compelling and interesting that people need to pay attention to. And if you want to go subscribe to our podcast, it's Inside Medicine, you can find it on Spotify and Apple.

- Or wherever you're listening to this. Right now. - Yeah. - Awesome. Jordan, thank you so much for being here. - Awesome, Chris. I am super excited. If you want to do this on the regular and pick a health topic and go deep, I'm in. - Awesome. Okay. We're definitely going to have to get Jordan back on the show because there were so many topics we just scraped the surface up.

And I think it could be really cool to do a bit of a health Q&A with him next time. So email me any questions you want me to ask for that episode. Or if you have any questions on any topic, send me those as well. I'm Chris@allthehacks.com. And to all the amazing people who've been leaving five-star reviews for the podcast on Apple, thank you so much.

I had a goal to get to a thousand reviews in 2022, but I came up a few short. So if you're on an iPhone and you find this show valuable, I'd be so grateful if you could just spend a few minutes to leave a five-star rating. If you have time to write a few words in a review as well, that'd be great.

But even just the quick rating would be so appreciated. Okay, that's all for this week. See you next week.