Aiming for Optimal Health: Getting started on my personal journey

In the years since completing my formal medical training, I have frequently been confronted with the fact that most* of the treatments I was trained to administer are focused on controlling already existing disease processes. Rarely was there an expectation that I would be helping a patient optimize their lifestyle with prevention of disease being the end goal. I think about some of the statements of those who served as my teachers, remarks about "non-compliance" or patients needing to "take the initiative" and "make changes on their own" because the amount we could accomplish in the very limited time we actually spent together at each office visit would never create change. They were rather resigned to this. And I was starting to feel the same. 

(*I say "most" because I also perform osteopathic manipulation as part of my practice and this hands-on healing modality is something I often use to help restore optimal body structure and function.)

In the fall of 2022, a few things happened that started to shift my mentality dramatically. The first, is that I had suffered a violent assault from my former domestic partner a few months prior and was experiencing a tremendously difficult time moving beyond this trauma and loss of the associated relationship. In an effort to pursue my own healing, I was trying to re-engage with modalities that had served me in the past and decided to register for a 200-hr Yoga Teacher Training to get reconnected with my practice. The second occurrence that pushed me to become more focused on my own health, is that I noticed my clothes were no longer fitting properly. I established with a new PCP and went for a wellness visit for the first time in many years as I reckoned with the fact that I was now solidly middle aged. I was surprised getting on the scale and finding my weight was 10lbs higher than I'd ever known it to be before. No wonder most of my pants were feeling snug, if I could even get them on in the first place. 

Applying my doctor-brain to myself and considering what advice I would give to a patient, I knew I had to make some changes. It was essential for me to deal with the trauma for what it was so that I could escape from the emotional paralysis it had on me. With respect to the added weight, I could accept it as a fact of life in getting older and buy new clothes - which actually seemed viable given that I still wasn't considered overweight by BMI or even an "unhealthy" weight by any medical standard. Or, I could recognize what I see so often in my patients was slowly happening to me too and start to make some changes to keep it from getting out of control. 

A statistic I had come across in my training, is that adults in the United States gain an average of 2lbs of weight every year. Two pounds on its own may not seem that significant and could easily be ignored or taken as a small fluctuation that any one of us may have during the course of a week just due to things like hydration status, menstrual cycles, bloating, etc. But what I cared about was that 2lbs continuing to build, becoming 10lbs in 5 years or 30lbs in 15 years. I know with a certainty that losing 10lbs is a lot easier than letting it go and later trying to lose 30lbs, so I concluded that I needed to take this seriously and lose the weight. 

In mid-December 2022, I began tracking my calories. I decided to use an app called FatSecret as I had learned about it a few years prior as part of a research study that I think was actually looking at the effects of meditation on lifestyle habits. The reason I preferred it to other apps I was aware of is that the free option was rather robust, it felt far less commercialized and less emphasis on trying to push their paid features (though there are some of these available). I used the in-app calculator to determine my RDI in order to achieve slow weight loss. My personal goal was 1-2lbs a month to allow my body to also gradually adapt to this change rather than get to goal quickly and struggle to maintain it. At the outset, I was tracking my caloric intake and expenditure through activity, but really wasn't attempting to modify what I was eating in any way other than to cut myself off if I was at / near / over my limit for the day. 

An additional change I started to incorporate around this same period was time-restricted eating. A lot of attention has been paid to the concept of "intermittent fasting" though the interpretations of what that is and how to utilize it vary widely. For me, my aim was to try to optimize my metabolism in line with circadian cycles and cut out eating late at night. In particular, I was working frequent overnight shifts at the hospital and eating while at work was a pretty normal thing because these are lengthy 12-hour shifts. But I came across a study that indicated night shift workers weigh on average 11% more than our peers who follow the same diet but are working during the day. That was all the evidence I needed to know that the night shifts were working against me. Being unable to change my work schedule, I knew I had to change my consumption patterns instead. On the nights that I worked, I was frequently up during the day as well either seeing clinic patients or attending to tasks at home on the weekends, so it wasn't difficult to shift calories to earlier in the day. I would deliberately cut myself off and stop eating prior to going in to work around 6pm. Initially, it was absolutely challenging to consume nothing but water during those shifts. But gradually, my body adapted and I can honestly say that I no longer feel hungry during my overnights until I'm finishing up around 7am and I'm ready for breakfast as usual. 

With respect to physical activity, I got back into the habit of some amount of regular exercise most days. Most often, this was vinyasa yoga as I was simultaneously going through my teacher training program. I had videos that I followed along with as part of my course but would also do self-guided practice as my additional goal was to get stronger and with greater endurance as a few months later we would have an intensive week of at least twice daily practices and I wanted to feel capable of participating at a high level throughout. My additional go-to for exercise was using a rowing machine at home, usually no more than 15-20 minutes at a time. I appreciate this as an energy intense full-body workout that is also low impact, offers resistance, and allows you to really accomplish a lot physically in a compact period. 

The initial loss was slow going and even though that was my stated plan, I think it is still so common to get wrapped up in the numbers and wondering if what you are doing is really working. It took me a solid 3 months to achieve and sustain the first 5lbs of weight loss, remaining very diligent with my tracking, activity, and time restricted eating. I kept up the daily tracking for another 3 months thereafter (so 6 months total) at which point I had achieved a sustained 7-8lb weight loss. Although this was only half of my original goal, I also realized I could be really happy sustaining at this weight. I was pleased with the physical changes in my body and my clothes were fitting again without the need to buy new pants. Tracking was feeling burdensome and by this time, I already had a pretty good idea of the caloric content of the food I consumed regularly without having to input anything, so I transitioned over to autopilot on that front. I kept up the time-restricted eating, even on the days I don't work overnights, deliberately aiming to stop consuming any calories by about 7pm to allow for at least a few hours to metabolize before bed. My physical activity fell off a bit, though I do still make time for structured exercise at least 2-3 days each week. And I am happy to say that 18 months later, I have sustained this weight. 

Interestingly, it was only through the process of trying to lose weight initially that I eventually started to look more carefully at my lifestyle habits as a whole and my food intake with a greater eye towards optimal nutrition and chronic disease prevention. Within my tracking app, there are breakdowns for macro-nutrients that I started to pay attention to, realizing I was rarely hitting their pre-populated goal ratios for Carbs - Fats - Protein in my daily intake. Additionally, in trying to counsel patients and friends about what I personally did, I became a lot more aware of the barriers for how an approach focused solely on calories in / calories out really isn't hitting the mark for most people. This also drove me to exploring more about nutrition science, impacts of our diet on chronic disease, and the integration of our modern understandings with the ancient practices of Ayurveda. 

I plan to write about more of these concepts in detail over the next few weeks along with my personal experience trying to make additional lifestyle changes and the challenges I have encountered. I know the amount of information out there can be incredibly overwhelming, so it is my hope that seeing the imperfect journey and struggles of even a seemingly "healthy" physician may make it all feel a little more accessible. 

This is a topic I really enjoy discussing with people and am constantly learning more about myself, so please feel free to reach out or post any comments or questions you may have for me. 

Breaking away from the limitations of yoga asana practice

Like many people in the United States, my first introduction to yoga was through studio classes. More specifically, at a studio that specialized in heated power vinyasa flow. Think sweaty people moving through a sequence of poses in rapid progression, attempting to synchronize our breath with the movements and if we were really on fire that day, to those around us as well. From the outset, I recall that my classmates all appeared to be relatively fit and flexible - and seemingly physically capable of WAY more than I could handle in those early days. But I committed to trying to get on the same level, went to as many classes I could possibly squeeze in during my initial 30-day "trial" period (paying for it with student loan money felt extra motivating), and it quickly turned into a regular part of my routine I continued to prioritize for a long time thereafter. 

Interestingly, over those first few months of becoming a yoga student, I noticed everyone seemed to be aiming for increasingly "advanced" postures. Amping up their athleticism with inversions (thinking headstands and handstands) or ever more challenging balances and bends. Unfortunately, at that time, I noticed it only in as much as I was becoming part of it. If someone around me was elevating the level of difficulty, then it gave me something to reach for and I absolutely wanted to do it too! 

Fast forward 10 years with a good amount of personal and professional experience later and I now look at all of this entirely differently. The COVID-19 pandemic and some other personal factors completely took me away from studio classes, which I know was such a common experience it even precipitated many total studio closures. However, for some time before that, I was already relying much more on my individual practice rather than class instruction largely because some of the satisfaction I used to get from those classes had evaporated. 

In the past year, I finally felt capable of completing a 200hr-YTT (initial yoga teacher training certification course) and chose to do it with the owners of that original studio that started me on my yoga journey. This was a very deliberate move on my part, largely because I had watched their approach to yoga transform in those intervening years too. Now, substantially more focused on what we can individually gain from yoga rather than it being treated as a primarily physical pursuit far removed from the roots of what this practice is supposed to be all about. 

Going through that 200hr-YTT, I can confidently say that I ended up doing WAY more than the required hours as every assignment or reading seemed to take me down another rabbit hole to try to learn and understand more about this ancient practice, of which asana is a relatively recent addition. I also became an avid listener of various podcasts with topics ranging from yoga history and philosophy to modern day asana teaching. But the deeper I dug and the more I learned, the less confident I felt about how I had been practicing all along, despite previously striving so hard to be the ideal student and do everything "right." 

I began to FINALLY shift how I was using asana (the physical postures many of us in the West would consider as "yoga"). Rather than treating it as an end game of achieving perfect, physically beautiful alignment in challenging postures, every movement - no matter how slight - began to take on significance. How I moved within my body, how I constricted or permitted the movement of my breath, and how my mind responded to any feelings of imperfection all held significance. And it wasn't just about my time on the mat, but it was a reflection of how I showed up in life every day (and vice versa). 

Maybe this all comes across as incredibly basic to someone who grew up with yoga as part of their household tradition or even others who just managed to grasp these concepts much earlier in their yoga journey than I. But I am truly humbled by how long it took me to FINALLY make some of these connections. And more, that I am just now getting to the point of truly "living my yoga." I am showing up better for myself and others on a daily basis, as a physician, friend, and partner. I am also finding ways to spread this wisdom with patients, largely without any asana practice at all (though I do always recommend it to those who are open to the suggestion). 

Within the past year, I did also make the conscious effort to get back to studio classes. Because within my training, it was becoming apparent that all of us could really benefit from continuing to expose ourselves to different styles and instructors rather than feeling dogmatic about the particular way we were taught or are most comfortable with. Not to mention, on this side of the pandemic, I think all of us could use a little more socialization. I found a new studio that I have been largely really happy with as it has a great vibe, supportive sense of community, and enough diversity in teaching styles that everything felt freely acceptable. Sadly, I'm noticing that same focus on increased athleticism and physical perfectionism beginning to creep in. This time though, I am hopeful that I now have the knowledge and confidence to continue practicing MY yoga, allowing my progression through asana to be the embodiment of how I am attempting to consistently live, remaining mindful and noticing all the small things to my ultimate benefit. 

Shame in abundance

Traveling back and forth to the Texas-Mexico border over the past few months has brought up a lot of new emotions for me. I'm bearing witness to things I was only reading about previously. The waves of Central American refugees who have crossed into the United States created an unnecessary "crisis," though not in the ways that many people think.

Our government has determined the solution is to treat refugees as criminals by using mass incarceration and procedures otherwise reserved for violent offenders. In the past few days it has been reported in national news outlets that Border Patrol agents are resigning at 4 times the rate with which new officers are able to be hired. This was not the job they signed up for and duties have changed dramatically from the way these positions looked in the past. The facilities used for immigrant detention are truly bursting (note the El Paso facility built to hold 125 individuals currently packing in over 800 with people physically on top of one another). The non-profit organizations stepping up to provide assistance once these families are finally released into the community are also being stretched in unfathomable ways, somehow finding meager means to keep providing as these already low resourced communities have been maxing out their charity for years while no one else was really paying attention. 

Flash forward to their next stop. Migrant families have been traveling with me on flights out of the Rio Grande Valley to Houston and I'm almost ashamed by what they will encounter there. As I myself (native-born-U.S.-citizen-super-privileged-white-lady) feel overwhelmed by IAH, I cringe to think what it must feel like for them. The place is nothing short of abundance on display. Pure excess of absolutely everything. Even the damn airport has multiple stores exclusively selling high end undergarments. As these families have nothing but the clothes on their back, a small plastic grocery bag with a few non-perishable low-nutritional-value snacks, and large envelopes with notes printed on the outside saying "I don't speak English. Can you please help me find my way?" along with their travel confirmation info. 

How in the world can we as a nation say that we are not able to accommodate these families? Even if the numbers of immigrants we are to accept reaches the millions, how can we possibly say that we don't have enough? Because our selfishness and greed won't allow it? Because what it means to be a citizen of the United States is to be wasteful and always take more than we actually need or could ever realistically make use of? 

I watch these parents who have traveled so far, through so much uncertainty, clinging to their children, knowing that this was all for them. Not knowing what tomorrow will hold or how the next set of challenges will be overcome. No doubt already considering that they don't even know where the next meal might come from. 

I return home after each trip feeling further ashamed. And ever more desperate to change this situation. To press the true extent of my individual privilege to convince those who have the power and might be influenced that this shit has to stop. I have no idea what our collective bill for shitty detention centers is running these days, but 4 years ago it was $300 per person per day at the Dilley Detention Center in Central Texas. For that amount, these same families could be put up in a suite at an upscale hotel in pick-your-metropolis. Rather than rotting their potential away in overcrowded cells / cages / tents, let us recognize the resource that these families are. These are the scrappers - the people who have proven they can survive and thrive in anything. Let's see what beautiful things they will contribute to our society if we could only be brave enough to think beyond ourselves long enough to give them a chance.  

A widening divide: the new schism in healthcare

Although the trend has been there for a while, it's become increasingly apparent to me over the past few weeks that there truly is a schism in the evolution of healthcare in the United States. On the one hand, we have the "big boys" (e.g., large hospital corporations, insurance-backed ventures, etc.) that want to move everything towards greater degrees of automation. If we can ask the super computer Watson to give you a diagnosis, why bother with an actual doctor? Let's attempt to increase utilization of telemedicine at every turn. Farm out increasing amounts of work to support staff with intent to preserve the time of the doctor only for the neediest and most complex of interactions, no time for the mundane day-to-day of typical chronic disease. As someone who grew up with the evolution of the personal computer and feels far more comfortable seeking what I need via my handheld device versus calling an actual office to request an appointment, I'm certainly down with the convenience factor. But that's pretty much where it stops. 

On the other side of this great divide, we have the "little guys." These are the cowboy doctors who continue to bank on the utility of their education, experience, and ability. They are pushing to slim things down, eliminate the excess overhead and meaningless metrics that drive up costs and instead focus on high-touch personalized medicine. Bring the relationship between you and your doctor back to the forefront. Recognize that seeing a patient as nothing more than a series of data points up until she finally visits with you in her moment of highest need is in fact, not a great way to go about providing high quality care. Instead, it allows for greater fragmentation, lesser degrees of trust, and an erosion of the patient-physician relationship. 

The more I find myself looking at evolving trends in healthcare through this lens, the more intrigued I a about which side will ultimately prevail. On the one hand, the industrial complexity of healthcare as big business is certainly where the resources lie to continue investing and frankly, even forcing patients into these models whether we want it or not. Alternately, the cowboys are relying on the extraordinary dissatisfaction patients feel about the idea that they have become just a medical record number, a set of data points in someone's productivity metric, with little attention to how they truly feel after their interactions. 

I know that for my highest need (usually = sickest) patients, I am fearful of how much will be missed as they are forced through systems of fragmented care where the primary care physician's role is increasingly slimmed down rather than expanded to given us greater opportunity to really hear our patients, understand what is important to them, and see what is being missed. 

What will our systems of care look like when this division is complete? And which side do I want to be standing on - as a doctor or as a patient? 

Reclaiming control from the health insurance monopoly

Completing residency is a milestone in the arc of any physician's formal training. I looked towards June 29, 2018 with great anticipation for many years in advance as I knew it would finally signify the return most important thing I had given up for the privilege of my medical education: Freedom.

Yes, I'm aware many of my more senior physician colleagues don't see it this way as they've become trapped in employed positions where the productivity and documentation demands are never ending and becoming dependent on the paycheck, their decisions are still not their own. But given the less traditional path I'll be pursuing for myself, I absolutely do feel free as everything here on out is MY choice, not something mandated of me in order to get through the hoops for licensure and board certification. (The ongoing hurdles to maintain those prizes is another story for a different post.)

One additional far less desirous item I knew was coming down the line along with completion of my residency was the associated loss of my health insurance benefits. Although I didn't consider my plan "great" by any stretch (it was still 80/20 cost-sharing with a moderate deductible and standard co-pays), it would be considered rather plush given how crappy insurance plans have become these days. Knowing that the county had been shelling out nearly $700 each month for insurance I'd hardly utilized had me thinking quite far in advance about whether or not all of this was really necessary. 

Admittedly, I do have opportunities to access health insurance through my employer(s), though I am deliberately choosing to forgo these offers which also come with the attached strings of my working a fixed set of days and hours to "earn" it, which pretty well spits in the face of the ultimate freedom I have been seeking all these years. So I've known for a while I would be sucking it up to cover my own health insurance costs, likely making too much to qualify for any sort of subsidy but not enough for the costs to feel insignificant. 

As of this writing, I'm a healthy 34 year old woman with no major medical conditions and no plans to become pregnant, as well as no one I claim as a dependent and need to provide for beyond myself. First stop to evaluate the damage: Covered California health insurance exchange. As indicated already, I'm over income for MediCal or any subsidized plan which leaves me only with the market rate options for my area. Slim pickings there as the only insurer on the exchange in my area is Blue Shield with plans ranging from Bronze level in the $470/mo range to Platinum plans at $1000/mo with high deductible and 40% cost sharing to no deductible but a much more substantial dent in my bank account each month. Interestingly, after pricing out what these costs could potentially amount to if I had to meet my deductible and out-of-pocket max with the lowest plans, those amounts plus the annual premiums combined would actually be MORE expensive than the top tier plan in the first place, but I guess that just goes to show insurance is really a gamble and how much are you willing to take on? In a healthy year, things might not be too terrible and in a sick year... well, let's hope your savings account was pre-loaded. 

It likely hasn't been lost on anyone reading this blog that earlier this year, the Trump administration relieved us of the Patient Protection and Affordable Care Act's individual mandate which stated that all of us must prove we had insurance meeting a basic set of standards and if not, we would be on the hook for an ever increasing annual penalty to be claimed via the IRS on that year's taxes. So while this move will likely send health insurance premiums further up their exponential curve, it may also be beneficial to someone like me who is willing to stomach a bit more risk. 

Before you go thinking I'm going to totally play with fire and have no coverage for the catastrophic, I am a doctor after all, and extremely aware that none of us are immune to the unpredictable. This is where I tip my hat to the DPC pioneers before me who introduced me to health share ministries. Although this is not a new concept with many of the currently operating health shares having been around for decades, it's becoming a more intriguing option for many as we are all increasingly burdened by the high cost of health insurance premiums. Health share ministries operated by faith-based organizations were exempted under PPACA to continue their operations as is, though with required disclosures that they are NOT health insurance and should not be treated with the same expectations. 

The concept of health sharing is essentially like a cooperative or mutual insurance where individuals who pay in each month understand that their shares will be diverted to others with health care expenses at that time and with the understanding that the same will occur for you in your own time of need. Health shares are certainly more limited in their services and what they seek to cover or consider a qualifying expenses. All of the health shares also promote their religious underpinnings by having members sign statements to abide by principles of healthy living and some even attesting to your own religious convictions. 

Liberty health share is largely regarded as a the "least religious" of the various ministries and generally came with good reviews as far as I have heard among DPC docs nationally. Additionally, they have even recently started an option to reimburse members for part (or potentially even all) of their DPC monthly membership costs which I consider to be a pretty sweet deal overall. The monthly cost to partake in the top tier of Liberty's health sharing arrangement comes out to only $299/mo + a $135 joining fee with a $1000 annual unshared amount (similar to a deductible as an annual wellness visit is exempted from this). Assuming the health share remains viable over the course of the year and continues paying member claims as it has been on their most recent financial reports, total annual costs calculate out to be less than half the potential costs under the standard Blue Shield plans described earlier. 

In reading through the various disclosures and contract documents, it is clear that the services eligible for "sharing" are distinctly limited versus what would be covered (though rarely in full) by the standard commercial plans. This is particularly true in California where we have ever increasing lists of mandatory benefits under state law. But it also made me consider - how much of that SHOULD we as a public be on the hook for covering for other individuals? Have we gone too far in what we determine to be essential medical needs when some things really are just elective or worse yet, have very poor medical evidence to back up their necessity though everyone seems to find procedure XYZ critically important to be available to everyone. One glaring gap is coverage for mental health services. Although this is not something I personally require at present and hope I will not require in the future, I also have to recognize that the vast majority of mental health practitioners don't participate in public or private insurance plans anyway so not having coverage in case a need arises may not even impact my level of access. 

So the conclusion to this now lengthy treatise is that I felt compelled to take the gamble and sign up for a health share. Unfortunately, due to a known defect in my DNA, I have an exclusionary condition that prohibits me from participating in a health share as their guidelines are currently written (despite knowing - as a physician - that this is unlikely to cause my lifetime health expenses to be different than any other healthy young-ish adult). Having now done the math and determined that this would be a good move for me at this point in my life had the eligibility requirements aligned, I would definitely feel more comfortable recommending the same to my own patients in the future.

Given my personal circumstances, I've headed back to the exchange marketplace and will be purchasing an individual Silver level plan from the ONE private insurer still listed for my county. For the remainder of 2018, this will cost me about $560 out-of-pocket monthly, a fee I may seek to have at least partially offset through one of my employers as my work schedule becomes more regular later this year. In the meantime, fingers crossed I won't have to hit the deductible I have yet to set aside funds for. And fingers crossed the premium increases to come for 2019 won't be too gnarly to my carefully plotted budget.

Although health sharing ministries are clearly not an option for everyone, I appreciate that there was (potentially) another option available to me at this time and I also appreciate the possibility to more freely move in and out of it in the future as one's future needs change. Anyone else out there taken the leap of faith with a health share ministry? Would be interested to hear any and all experiences, good or bad. Please leave a comment below! 

Wellness. When applied to health care workers and more specifically, the need for physicians to strike a better life balance, I am so very sick of hearing this term. It has become so empty and so meaningless. I admit, I even recoil a little at just hearing the word now.

I had a similar experience earlier in my life while working as a domestic violence advocate. The word then was "support" and all the good intent in the world could not restore meaning to the word. I remember one particular discussion with my boss about a statewide advocacy group offering their "support" to local shelter programs during a massive snowstorm. We were outwardly laughing about how absurd this was because the real, tangible sorts of "support" our programs desperately needed - like help shoveling out the snow drifts covering driveways and sidewalks - was not what they meant and never would be. The small things that could have had a big impact and would have meant the world to us, were never going to come.

Years removed from that situation, I cannot help but realize I've found myself back in a similar, if not even more abusive relationship with my employer. Granted, I'm a resident physician and anyone whose ever watched a medical drama on TV is surely aware that residency is a tradition of brutally long hours at emotionally and mentally exhausting labor intended to push competent physicians out at the end. But even if I can forgive the personal process I'm living through, I cannot be blind to what I'm witnessing all around me.

A few weeks ago, I was at a meeting that brought together doctors, physician's assistants, and nurse practitioners who work at the various county health department-run clinics. These meetings happen on a routine basis to give pertinent updates to all of us under one roof. This particular meeting had a different spin than normal, however, as the latter portion of the morning was to be dedicated to the topic of: Wellness.

What ultimately ensued has stuck with me for nearly three weeks now and the more I think about it, the more indignant I feel. This room packed with various highly educated and competent individuals who were dedicating their careers to care for the most underserved in our community, was at a boiling point. It was clear that the System were are all forced to operate within was wearing us ragged and tearing us apart.

Our concerns were voiced to one another. Nearly everyone in agreement, all expressing similar frustrations and angst at our inability to achieve improvement in conditions. We were asked to write out our greatest complaints and suggestions on giant post-it notes hung on the wall. To discuss in open forum thereafter so we could feel heard. The only problem was - the ones who most needed to hear these concerns, were all conspicuously absent.

Despite the reoccurring thoughts about that day I've had over the past few weeks, I had not felt the need to document the experience until now. But now, every experience that re-emphasizes those complaints rings in my head like a warning siren telling me we all need to flee and save ourselves while we still can. While we may still have some ability to save the parts of our humanity and drive to do this work that remain intact.

My best friend contacted me this afternoon to tell me he received a phone call on his way into clinic, a mere two minutes late based on our given start time, to find out where he was an if he was coming in today. My friend is incredibly reliable and timely, particularly for a doctor. So today was an anomaly, to be sure. But the troublesome part is that rather than be met with a question about if he was okay or if anything was wrong given the tardiness is incredibly out of character for him, he was instead met with an accusation. A hard working resident physician, who plays by their rules, always goes the extra mile and accommodates without complaint was not given the benefit of the doubt. Instead, he was treated as troublesome. In this environment where there is always more work to be done than time to do it, there are never any thank yous or recognition for a job well done. There are only shaming lists of ridiculous metrics that mean nothing to my patients and nothing to true quality of care, but seemingly show something about how we're doing to other bureaucrats behind a desk somewhere.

Physicians who are able to live in ways that embody wellness, do not work in these systems. They do not cowtow to meaningless mandates and metrics that do nothing to help our patients. They have found a better way that cuts out the layers of administration and insurance that separate doctor from patient. They refuel their desire to be the physicians they wants to be by taking great care of patients and developing personal relationships where everyone can feel that they truly matter as an individual.

This is what direct primary care is all about. When people tell me that they don't think it is possible in this community or that it is just some far fetched idea that will never work, I often remind myself just how untenable our current system is. Public or private, the setting truly doesn't matter when the drivers are all the same. But to eliminate the unnecessary layers and find the holy grail of incredibly satisfied and well cared for patients with incredibly happy doctors, all for a substantially lower cost?  Proletariat Health will be about getting back to what matters. That's the real revolution.

I suspect someone would have to be fairly cut off from the outside world in order to not have heard that the United States is in the midst of an epidemic of opiate overuse and abuse. No matter which community you live in, we have been affected by what even Donald Trump has now officially designated as a public health emergency.

As I look towards the future and designing the practice that will allow me to best serve our patients, I am constantly considering what are the biggest issues our community is facing and how might we do better to address them? One area that has been quite problematic for us in Monterey County, at least since my arrival here to start residency in July 2015, is lack of affordable access to addictions treatment. Suboxone (a medication used to treat opiate addictions that is used in a manner similar to methadone but without the abuse potential) is offered in multiple clinics locally, but only ONE that I am aware of accepts MediCal for payment and routinely has a waiting list for patients seeking this service. Per the reports of my patients, other clinics are charging cash prices typically around $600 monthly, which most of them find to be financially out of reach. 

As I've been working towards obtaining my own Suboxone prescribing privileges for use at a Federally Qualified Health Center in Santa Cruz, I started considering how this type of treatment might be better incorporated into primary care and a Direct Primary Care practice in particular. Fortunately, someone else has already written an excellent piece about exactly how this can be beneficial and more financially viable for the average patient. 

Rather than charging people on a per-visit basis for the privilege of being forced to show up for added office visits just to receive one's maintenance medication, Direct Primary Care will allow me to prescribe for these patients while also treating the rest of their basic and likely interrelated health care needs. At Proletariat Health, we will choose to focus on the health and overall well being of each patient rather than seeking to nickle and dime people and generate extra revenue by requiring separate visits for each problem due to time constraints. 

Consider that many patients who currently struggle with opioid addictions initially accessed these drugs in an attempt to treat chronic pain. While we can work to stop the cycle by no longer prescribing the drugs of abuse and possibly starting treatment with other agents to control the addiction, how often does the underlying concern that created this situation remain unaddressed? 

The answer is: far too frequently. 

For a low monthly fee with no added charges for additional visits and a totally transparent pricing structure, patients can get their needs met in a more affordable manner than is oftentimes possible even with a comprehensive private insurance policy. Better yet, visits are unhurried because we aren't incentivized by volume or trying to pay the exorbitant overhead costs associated with a typical insurance-based practice. We are free to focus on our patients and their concerns rather than an insurance company's arbitrary metrics about what we should be discussing today.

This is what Proletariat Health is all about and we're thoroughly looking forward to the future. Join us and see what it's like to be part of the health care revolution.