209. What Actually Matters for Longevity: Visceral Fat, VO2 Max, Muscle Mass, and Insulin Resistance | Sam Robinson, DO

0:00 Welcome to Medicine Redefined. I'm Dr. Ultima Sharajah. And I'm Dr. Darsha. Let's put the hell back in healthcare. Today, we're joined by Dr. Sam Robinson, a board-certified family medicine physician and founder of Altura Health, a longevity-focused direct primary care practice in Folsom, California. After years of practicing in the traditional insurance-based healthcare system, Dr. Robinson came to believe that preventing chronic disease requires more than annual checkups and 15-minute office visits. And I'm sure that's not the first time you've heard that. His practice is built around affordable, evidence-based preventative care, giving patients more time, more personal guidance, and a greater focus on the lifestyle interventions that have the biggest impact on long-term health.

0:47 But as our conversation unfolds, it becomes something much bigger than longevity medicine. We dive into one of the biggest questions facing healthcare today. How will artificial intelligence reshape the practice of medicine? We discuss whether AI will replace physicians or empower them, the future of direct primary care, wearable technology, and why prevention, not reaction, may ultimately define the next generation of healthcare. Please welcome Dr. Sam Robinson to Medicine Redefined. If you're a high performer who wants a clear plan for longevity, performance, and staying active with fewer setbacks, I'm now seeing patients through my telemedicine practice who are finding health and performance. I'm opening a limited number of founding member spots at refininghealthrx.com.

1:31 All right, let's jump in. Why are family medicine doctors the true longevity experts? That's a great question. Yeah. Yeah, so I'm a family physician. I've been a physician for nine years, practicing an evidence-based space, an insurance-based practice for six years. In my training, we spend a lot of time in the hospital. We spend a lot of time in the clinic, and we spend a lot of time working with patients on preventing disease. And so I love that question. That's a really good question. Why are they the perfect longevity doctors? Family doctors have seen patients at the worst part of their disease, and so they know when and how they really should intervene before it happens.

2:18 And that's why preventive health is such a big part of family medicine. And it should be, I think it needs to be a much greater part of it. So there aren't many people who haven't heard about the term longevity medicine nowadays. So let's say we found this one person living under the rock. How would you describe it? Longevity medicine, in my opinion, is advanced health optimization to prevent the things that are likely going to kill you and the things that are going to ail you later in life. So chronic disease. So we talk about the four things that are likely going to kill you if you don't die of some freak accident. And that's cardiovascular disease, metabolic disease, cancer, and a neurodegenerative disorder like Alzheimer's.

3:01 I want to dig into each one a little bit more. And, you know, the reason I started with that question, it's funny because as longevity becomes more popular, different people have different definitions. And even your response with respect to end-of-life care, my initial thought was, well, why not palliative medicine? Then you pivoted to preventative medicine. And that, again, to my knowledge, I think, I think there, that might be a subspecialty occupational health and preventative medicine, but there are a lot of fields who do that. And so of course our bias is we're physiatrists and we take care of people from the cradle to the grave. And what we're dealing with are issues where it's the aging population.

3:44 And so we'll see that. And we're dealing with every single system. And ultimately what I came to, the conclusion that I came to over the last couple of years as I've just much like yourself. So, you know, you and I have been going to, won some flag football championships together. Yeah, we did. And so we've shared these interests, but I think everybody's looking at the longevity problem and it's such a big nebulous problem, but we're looking at it from our own lens. And so I started out really narrow with respect to musculoskeletal health. I got broader and I think I still am, but I'm starting to get narrow again because I think... maybe that's what's going to be more beneficial.

4:25 Because when the cardiovascular doctor is starting to talk about PMOS, it's maybe not as beneficial as when they're talking about coronary heart disease. And You, and I guess I'm saying this after listening to a bunch of different people really get excited on social media about, quote unquote, staying in your lane, you know, talking to physician colleagues about not talking about nutrition. It's like talking about nutrition with your patient is not your lane. That's a dietician's lane. I'm like, I don't know how the hell we can even do that. Like, this is an opinion. This is a popular opinion. And so by that metric, then I can't be talking to him about sleep and I can't talk to him about exercise because that's not my lane. That's what a personal trainer is for, right?

5:05 And so I don't want to go off too much of a tangent, but I think that the longevity problem is really interesting because the lens really matters. And I guess you've highlighted that your lens is really to prevent those big four horsemen, if we can use that term. Mm-hmm. Yeah. Where do you think that, I want to take this from an evidence-based lens because you use that frame. Where do you think the evidence is strongest with respect to being able to prevent or mitigate the risk of, I think that's a better term, that's going to have the most benefit down the road in terms of delaying your lifespan and healthspent? Yeah, I think that right now there's a lot of clinics and a lot of companies that are trying to hijack.

5:51 They're trying to hijack I think there's a lot of clinics and there's a lot of companies that are trying to hijack the term longevity. And they're not necessarily using evidence-based ways, but they're using treatments that make them the most money. And the reality is the evidence-based ways for prevention may not make a clinic the most money. And it's pretty simple. It's just mostly I think that people have a hard time sticking with it. And physicians in general, they don't have a lot of time to spend on it. But in my world, so my clinic at Altara Health, we're built around four major pillars. And so number one is decreasing the visceral fat.

6:34 Number two is improve cardiovascular fitness. Number three is improve your strength and muscle mass. And number four is optimizing your internal health. And so that would be like the biomarkers, the labs, and all that stuff. But like, is there a way to down to, I don't know, building some sort of expensive treatment around this? I guess you could, but there doesn't have to be. What people mainly need is guidance. And if we need medications, we can use medications. And they need a little bit of skin in the game. They need to actually move forward with actually implementing the plan that is set forth to them.

7:18 And so what we do in our clinic is we assess the visceral fat with a DEXA scan, which is the most accurate way. I mean, other than an MRI, but an MRI takes to do the whole body MRI, it'd take a couple hours, and it's just not very practical. Number two is we do a VO2 max test, and the VO2 max test, this is what's interesting about this test, is not only those that have a higher VO2 max score have a lower risk of cardiovascular disease and dying of heart disease, but they have a lower risk of dying of anything. And then number three is we can assess their muscle mass with a DEXA scan, but we try to make gains with their workout program.

8:00 And then we do some pretty extensive lab testing. So is it, are we doing these really advanced treatments that cost thousands of dollars? No. But it definitely is the most meaningful, right? And I would say that when someone approaches the word longevity, there's certain treatments that are probably going to affect 90% of your longevity. And then there's other treatments that probably affect maybe five. And a lot of those treatments are the ones that make money. Maybe this is a good time for us to introduce you to the listener. Tell us a little bit about your background.

8:40 You said you found the medicine. How did you get to put energy into solving the longevity problem from your angle? Why are you here? Passionate about this. Altura Health. Tell us a little bit about your clinic. Yeah, so I was in the insurance-based space for a while. I had 2,200 patients. I filled up very quickly and... I kept getting patients added on to my panel. It got to a point where I was booked out 13 weeks to see a patient. If one of my patients wanted to see me, they'd call up, and I was 13 weeks booked out. We had about 15, 20 minutes with each patient. And if, you know, in family medicine, patients come in with about five to eight problems at a time.

9:23 And then we want to throw in a little bit of preventive medicine as well. A lot of those problems would actually mesh pretty well with prevention. Like, how is your exercise? How is your diet? What are you doing from a cardiovascular standpoint, from a strength training standpoint? Things like that. You know, what are you doing to lose weight? But it just was not feasible to practice the way I wanted to practice and make really good results and improvements in these patients in the 15, 20 minutes I had with that. And so I decided to start this clinic where it was built around a concierge style, a direct primary care style where patients pay a monthly.

10:03 And I'm able to bring my patient panel from $2,200 down to about $300. And I spend 45 minutes to an hour with the patient. I have more time with them if they send in messages. I can write them back. I can call them. I include tests like the DEXA scan, the VO2 max, and I spend time working with them on a plan of how to improve this. I mean, so much to the point where I practice, we've got a little, you know, we've got some exercise equipment and I can just show them exercises to do right now. We're not a gym, but I'm just saying like to the point that I can show them that. I can actually spend the time. That's one of the most amazing things. How many doctors do you know have the ability to show them workout exercises to do at the gym or at home?

10:49 So I became really passionate about preventive health because I have seen people that if we can get in front of the disease, we're going to have a lot less problems later on. You know, I mean, one example, right? We, in family medicine, insurance says we can screen for diabetes with a fasting glucose or an A1C. Okay. Medicare doesn't even let us screen for diabetes with an A1C. You have to have a high glucose level before you can order an A1C. I didn't know that. There's Medicare. There's so many different coding issues. It's nuts. You got to make your, you got to play around it. Do you think that's a regional thing, Sam?

11:30 Cause you're in Southern California, right? I'm in Northern California, so I'm in Southern California. Medicare is federal, so it should be one system. But for example, if you get a fasting insulin on somebody, you can calculate something called a HOMA-IR, and we can start to see insulin resistance about 5 to 15 years before it even shows up as high sugar in the labs. And so, you know, we can get those levels, we can start to make prevention way before a lot of damage is done. Just experimenting, just practicing in this way, I don't use the term experiment, we're actually practicing medicine, but just practicing medicine in this way led me to be inspired to create a clinic where we can spend a little bit more time on this.

12:21 But, you know, we talked about preventive health, occupational health. It's not, that's the thing, that specialty is not preventive health on an individual basis. It's more like you've got a company that needs to make some protocols for health for their overall team, for the overall workforce. But preventive health is not. It's also like from a society standpoint, right? Population health. What can we do? You're dealing with immunizations, vaccines, which is important. But from an individual standpoint, the preventive health experts are the family docs. But you get one physical per year. And it's probably only going to be 20 to 30 minutes.

13:02 And it's a very small amount of labs that you're getting. And that one physical per year is just not enough to make meaningful change. Yes, we catch a few things, but it's not enough to make meaningful change. Every visit where a patient visits the family doctor, that should be a preventive health visit, okay? They need to catch things early in every visit. So that's essentially why I created this clinic so that I could bring my patient panel down to a lower level. I can spend a little bit more time with patients and I can order the tests that I really want to order. Yeah. Sam, I want to touch on the socioeconomics of longevity. You mentioned, this has been top of mind for me ever since the buzzword longevity has gone out there.

13:47 And, you know, anytime there is an exciting field that has been created, I would say, right, this is not something new. We've always known whatever, however you're practicing is kind of the basics to what works, right? Good nutrition, good sleep. a stress reduction. So it's funny how we actually have to market that now. But anytime a new field emerges, there's always opportunity, right? And you're going to see that in this, what we call a K-shaped economy, where the wealthy becomes wealthier and there's now a disparate gap. I guess I'm curious to what is your ideal patient like? Because to me, when we look at AI, we look at the tech, and we look at what longevity can do, It's always been those with disposable income, I guess, that can really kind of experiment on themselves, use AI, buy different technologies.

14:29 In the last year, how many more red light therapy companies are there? How many more sleeping, cooling companies are there? It's endless. So I'm curious about your ideal patient or who comes to you when you're talking about chronic disease. Are these patients already having chronic disease? Are they people that are coming to prevent? Talk to me a little bit about that. Yeah, that's a great question. I would say, and I can talk about even the demographics too. I mean, these are mainly patients in their 30s, but all the way up into their 80s. I would say that the socioeconomic is someone who would invest in their health enough to spend more than $100 on a gym membership, right?

15:11 So I'm not saying that my patients all spend $100 on a gym membership. There are gym memberships that cost $30. And they're great gyms, but I'm just saying if you're motivated enough to maybe want something a little bit more out of your gym, then you're probably motivated a little bit more enough to go to a doctor that's going to work with you on these things. So my program is actually very affordable compared to programs like this in the Bay Area and in SoCal. I would say mine is about a third of the cost. But that's on purpose. That was my first impression going to your website. In my head, I'm almost like, man, how is this guy surviving being in California with your prices?

15:52 I mean, absolutely amazing. Yeah. And it's been great. And I think that for the most part, I've received a lot of good feedback too on that. I've had multiple patients come in and say, and your prices are just spot on. They're great. I think that It's, I would say a lot of my patients actually at open enrollment, they lower their premiums by like three to 500 bucks to choose a little cheaper option. And then they pay not even the full difference, but a little bit of the difference to me. And they're getting a little bit more out of their health care because my program not only includes the consults with me, it includes all the tests.

16:35 And it doesn't include medication costs, but I can still submit things to insurance. Just because I'm not working in an insurance, just because I'm not billing insurance doesn't mean that I can't order a test, order a referral, order an imaging, or even order a medication that insurance won't pay for. I'm still a doctor, I still have an NPA, I still have a license. I think that's actually a big misconception people have, just to clarification, is that if you're working with a direct primary care, direct specialty care, the medication, you have a separate prescription program. Almost every single insurance has built that in. And they have their own pharmacy benefit manager. We've done a whole podcast on that.

17:15 We can plug that in for people if they want to take a listen to how that system works, which is its own problem. But yeah, that's important for people to know too. For any of my patients that want to me, for me to be their primary care doctor, it's just a little extra per month. Out here, we have a lot of Kaiser patients. Kaiser is an HMO. It's harder for me to be their family doctor because they truly, Kaiser will not pay for labs and imaging and all that stuff unless the Kaiser doctor actually orders it. But the patients still come to me for their longevity program, for my longevity program, they feel like they're gonna get way more out of it.

18:00 And so they're coming to me for their preventive health, but then they go to Kaiser if they have a problem. The other interesting thing is, You touched on something really important. It's like sometimes there is, it's not the lack of knowledge or lack of information per se. I mean, we are flooded with the information. I think you touched on something and the concept that came to mind is adherence. It's hard to get these people to, guys, you know, something important, right? You're talking about this concept of adherence. And oftentimes I find, especially when you're talking to people who have interests, right? That ideal patient, the avatar that you described, who's willing to invest in their own health. And I love that you said that. They're an advocate for their own health.

18:41 And they're an active participant in their own health. Because they're investing in their own health, they will take the time to either use their favorite AI, go to Google, whatever it is, have discussions, and try to seek that knowledge. It's the implementation part that's hard. It's the execution part that's sometimes hard. You also said having skin in the game. I guess my question for you is, Where do you think that us physicians, a lot of folks who are pivoting through the DPC, DSC space, maybe even concierge medicine, the longevity space in general, how are we providing value for them that's actually really moving the needle? I think that the needle will move for those patients.

19:24 I think that the more people that join the DPC model of primary care, I think the needle will move for them because they're invested in it. They're actually putting money towards it. And so when they go to the doctor, what I have found is when they go to the doctor, when the doctor come, you know, when they come up with a plan together, they usually adhere to that more. When I was working in an insurance-based practice, I would say that most of my time was spent motivating the patients. Now, I don't have to motivate patients. They are motivated. That's why they signed up with me. And now I just get to work.

20:05 I just get to give the recommendations. I get to do the tests. I get to explain the tests. And then I get to come up with a plan. And that's what's really exciting. And today, people are obsessed with data. There's so many wearables out there, but they just need a little bit more guidance. You know what I mean? And yes, there's a lot of AI out there, and I think AI can help. And could you DIY what I'm doing? Yes, absolutely. Would everybody do it? Not necessarily. Well, I think they probably couldn't because you need prescription power. You need, we need a license.

20:45 You need somebody to be able to order this stuff for you, right? A lot of the looking under the hood that you had spoken about, you're not going to do that without working with somebody who has a license, who's going to be able to do it right for you. And then the other thing is, okay, let me go back. It's like, could you, maybe, should you, probably not? Because you said you're looking at all these things in detail and it's making sense of those, I think is really, really, really important. I'm sorry to kind of cut you off there, but I also wanted to make sure that I put that in there because this is something I think about a lot, Tim, is like as I'm thinking about opening up my own practice in a DSC model and I'm still working for an employer where I see a lot of patients and there are pros and cons, I think, to both spaces, but I've had enough people who've made the jump just like you and enough people who've come on here who've made the jump and some have had really positive experiences, others have had not so positive experiences.

21:39 And there are enough people who are talking about how to leverage these LLMs to be able to synthesize this information for them. But then the execution piece is something that I just, I really find... that they don't know. And the other thing is, like, Darsh and I have talked about this, things that I don't have domain-level expertise, like deep expertise on, the other ones are phenomenal, right? But the problem is, I just don't know whether they're actually phenomenal or they just sound phenomenal. Because I will give it a very, I would consider elementary concept about strength and conditioning or from programming because I will routinely use book, cloud and GPT for my programming, just giving it all my constraints and creating something longitudinally.

22:22 And it does a bad job. Something that in 2011 with an exercise science degree, I was doing a pretty good job. And despite having a 1 million token context window with all these things have, I don't really know what that means in terms of human brains. Like I don't know how many tokens our brains can hold. there's a comparison, but it seems to forget these constraints all the time, like all the time. And then I find myself yelling at it all the time, which is another thing. I'm told I shouldn't do that in case when they do take over, they'll remember I wasn't nice to them, but I digress. And you and you're welcome and be polite. Please, please. Yes. Yes. So sorry, I don't want to cut you off, but I, but I did want to put that in there because I, like, I think that it's a misconception.

23:04 I think that society is, is, No matter where you go, there is a subset of people that are searching for something more. You know what I mean? They want a physician who's going to spend a little bit more time with them and explain a little bit more. And the best thing to do is to have physicians that are good at what they do be there for those people when they demand it. Everywhere, you're going to find those people. What I have found is some of these people, they end up in the wrong spot. And they could have ended up with a physician who uses evidence-based decision-making.

23:51 And so I do think that people also just, they want to be heard. And they'd like a personalized plan to them. And even if the plan wasn't that much different than the last patient, at least you listen to them and verify that, yes, this is the right plan. This is what we want to do. And I think that goes a long way. There's a lot behind motivation. People still want a human touch. And I've thought about not to like transition to AI and medicine. But will it take over medicine? Yes. Will it replace doctors? I do not think so. I have had multiple people tell me that it's going to replace doctors.

24:32 I don't think it's going to. Let's take a plane, for example. Does the pilot fly the plane or does AI fly the plane? AI does like 90% of it. Okay? But are you going to get in a plane that doesn't have a pilot? I'm not going to. Okay. I mean, I wouldn't know if there wasn't a pilot up there. Yeah. So, like, you could tell me. But could you translate this argument to, like, self-driving cars then? Maybe you could. Maybe you could. I don't think the stakes are as high with a self-driving car as a plane. But... I mean, you're still talking about lives, Sam. Yeah. No, it's true. It's true.

25:13 Not in many lives at once, maybe. Maybe. but maybe, you know, I, I, I, yeah, I agree with you. This is not a conversation that we necessarily thought that we were going to step into, but it's an important one to have. because, I don't know if you know this, but I work with a lot of trainees, I work with medical students, I work with residents. Mm-hmm, same here, I've got, I work not as much with residents, but I definitely work with med students and PA students. Yeah, so I think about this a lot, and these are questions that they will ask me. One of our interns just started, she's a first year medical student, shout out to Haritha, and we have these deeper conversations about what the future looks like. I mean, for one, you wanna be prepared. the change has, it's been more rapid now than ever.

25:54 But two, like anxiety is a very real thing. It's like, am I really going to put all this energy, put this time, this sacrifice to get to a future that was promised to me? I mean, that's what happened a lot to our generation in general by the boomers that they had promised. These people, oh yeah, go to college, get a degree, take out a lot of student loans and then you're going to have guaranteed jobs waiting for you. And then 15 years later, like psych? Psych. yeah, you can't afford a house now because they're really, really expensive and because of inflation, all of these things. And so medicine's an interesting thing that I wonder if that something similar's gonna happen. So this is where I think that we need to come together, either come together or we need to grow some brains. That's the problem is we were expected to be handed a nice job.

26:40 We were expected to be handed a nice salary and a nice lifestyle. That's not how life works in any industry. You know what I mean? Look, we went to med school. We got the education. We went to residency. We got the experience. Now we need to go out into the world and we need to actually work. OK, we need to work for what we need to work for the patients and do right by them. And if we do that, then the patients will come to us. So so this is what I will say is right now I'm seeing a movement where potentially these health systems are starting to to maybe replace doctors with a protocols. Right.

27:21 Why are we letting that happen? So here's a question. Why let the administrators replace doctors with AI? Why don't the doctors replace the administrators with AI? Okay. And that was what I found when I started my own practices. I was like, this is actually, we can, the business side of medicine can be very automated with AI. That I think that the return to private practice is, Like we're in a revolution. We're about to embark on a revolution right now. And I think doctors are going to be able to start their own practices more now today than ever because of AI.

28:01 I have a couple thoughts on this. I guess I'll just. Darsh is so excited. He's shaking. I can tell. I'm just. My mind's going a bunch of places. Let me ask you this. What would it take for you to change your mind to say AI should replace doctors or will replace doctors in the future? If humans stop being humans. So what I mean by that is humans want interaction. They crave so much a physical touch and eye contact and just emotional cues as to someone of my same species is listening, paying attention and helping me and guiding me.

28:45 Let me ask another question, not to bring religion and politics into this. replace religion and the leaders in religion and politics. I'm not saying that medicine's the same way, is the same thing, I guess, but I'm just, I'm being a little facetious here by saying that there's so much more to medicine than just information and treatment. And I've seen it because patients keep crawling back and saying, I need more. I want to ask an immediate question after a doctor answers my first question. They want true understanding.

29:26 And could they get that from AI? Maybe, but it's going to take a lot of work on their part. And people are busy. So what would it take? I would say it would probably take a generation of people that aren't that do not care about human relationships. Interesting. It's very interesting to me because I think I often find myself seeing on the other side of this where AI is taking care of the patient almost 99, 100%, but the human is the one to control the AI, almost like a fleet. Like you have a fleet of AI doctors that you are then having their own silo or specific way, right? You have one AI that could do cardiology, you have one AI that could do nephrology or whatever it might be. And I got this idea from listening to a podcast, the founder of Zapier, I forget his name, but how much he's building out agents and how he thinks that's what the commerce world is going to look like.

30:17 I know Mark Cuban came out with a tweet, Altamash, I don't know if you read this and I don't know if you've seen it, Sam. Yeah, it's on LinkedIn, yeah. Yeah, so I'm just going to read it real quick because I think it's just a good talking point too. It's a little long and he's a little jumbled, but I'll try to do my best. So he tweeted, human doctor to patient. You just puked. Let's find out why. An AI. Nothing AI can't see and reason in real time. Human doctor sees patient collapse. Does CPR. AI. Nothing AI can't see or do CPR. Human doctor sees patient. Discusses patients with other doctor who knows patient and discuss the fact that a parent was beating the shit of a patient. Shows empathy. Adapts care residents. AI, nothing.

30:57 No doctor knows what will happen to a patient when it steps in their office. They have a real-time identification and response skill set that AI can't and won't have. SDOH will always matter, which I believe stands for Social Determinants of Health, will always matter. I don't see a world where AI has judgment and can know the outcomes of its decisions without a human in the loop. I'm obviously not a doctor, but there will be no point where real-time observation, communication, and context won't matter. A human can't consume and remember all the data and information AI can. So AI will always have value. Every single one of us has more variables in our body than can be quantified, let alone identified and defined. Once we can identify them all, or at least enough, AI will be able to personalize responses for specific issues.

31:41 But that won't happen in the next five or ten years. It's a problem similar to dealing with CTE. You can't figure out what actually happened until the patient is dead. Tell me where I'm wrong. And that sparked a whole... thread, you know, with a lot of people. But I think what he's saying is kind of what you're saying, right? Where you need a human in the loot. But anyways, I just want to kind of bring that out there because I think it's a cool talking point. Darsh, that's interesting. When you first started, I didn't think that's where you were going. I think he had maybe posts on LinkedIn or tweeted a completely different thing where he talked about... What's up? About teaching patients or having doctors teach patients to use AI? Exactly, right. So he had talked about for private practice owners, he had said, hey, if I'm a private practice owner, I'm sitting down with the patient and calibrating their AI so they can learn and after hours they can do that.

32:25 And... a physician colleague had said, clearly Mark Cuban hasn't spent any time in a room. Like, right, Sam, you've got 15 minutes in the room and you've got to go, their annual screening and stuff like that, and now you're going to sit there and program ChatGPD projects for them. Teach them how to log in. Right, teach them how to log in and do that. So, you know, I think that there is some merit to that, right? I think so. Ultimately, my take, I'm, and I know exactly what you're talking about, right? That's an MFM episode that I listened to. It was a good episode. I actually signed up for Zapier after that and I decided that wasn't valuable for me. And by the way, I think that it's super helpful. Look, open evidence is phenomenal. Every single day, if I have a question, I love to be able to collect all the evidence and just kind of get a broad oversight of what the evidence is.

33:08 But it's still valuable for me to, pick up the phone and call my colleagues to get their real world experience one-to-one, which I wanna really get an understanding of how you would define evidence-based. You've used that term multiple times today, what that means to you actually. But ultimately, what you've been talking about is coaching. And I think, Darshana, you and I have talked about this a long time ago. Ultimately, I think that physicians are coaches. And this is a one-on-one coaching relationship. What has been the limiting factor a long time in primary care in particular, like you talked about, Sam, is like you cannot have an effective coaching session within 15 minutes when you are dealing with the urgent.

33:51 You have to put out fires. That's all you have time for. Maybe even that's insufficient. And now we want to get really peeled the onion to figure out what it is that's important to you in life, why you, quote unquote, can't get out of your way to get to sleep on time, focus on your exercise regimen. Well, we really have to build this therapeutic alliance and that's not done in a 15, 10 minute visit. So that's where you need time. So if we could remove the administrative stuff like you talked about, right? So there are some LMs that are being built into or AI is being able to, into Epic at least, and I think other ones have that too. Darsh showed me one in Cerner that allows me to be able to extract a lot of the history and clean up my H&P.

34:35 Well, that's the last time I'm charting. You know, again, you have automated scribes that are listening to it. In the future, we're going to have automated scribes who are going to help put orders in, which have to be reviewed over time. And this is now leading more to the point that, Darsh, you're talking about. I do think that it probably matters a lot in which specialty we're dealing with. A lot of people have been bashing on radiology, like radiology is going to be the first one to go. It's the most logical step that one radiologist can maybe now read three times as many imaging stuff because you just have to review. Although some radiologists will argue, well, that's how you're likely to miss. And the implications of getting something wrong are so severe that it's problematic.

35:17 And so, I don't know. I find myself kind of going to the extremes and somewhere landing in the middle. I think that's usually a good place to be. But it is a conversation really worth having and for people to really sit there and explore. But I think ultimately, if I had to pick a camp right now, much closer to where you are, Sam, I don't think that therapeutic alliance can be replaced. And I think biologically, humans do have that need for connection pretty deeply, especially when you're talking about some things that require a lot of vulnerability. And not to mention, AI can't do a physical exam. There's the human connection, but there's also coordination, right? You talked about picking up the phone. You know, there's a lot that goes into primary care, for example.

36:01 You are kind of a coordinator in a way, but like you kind of, you got to know a lot about a lot. Someone told me before I started residency, they said, you know, the easiest specialty to be is a family doctor, but the hardest specialty to be is a good family doctor. Hmm. And it was just, I'm not saying that's true. I'm just saying like, it got me thinking like, there's, you gotta know a lot about a lot so that you can actually get people to the right places. You're ordering the right tests before they see the oncologist, before they see the gastroenterologist, before they see the cardiologist. So that when the patient gets to those specialists, They're not like, it would have been nice if you had this test and this test.

36:47 So I'm going to order these tests and then you come back for your second visit. No, my goal when I send a patient to a specialist is for everything to be laid out. And the specialist looks at it all and says, okay, this is what we need to do. You know? That's what makes a good primary care and a good family doctor. It's the setup, Ben. The setup is key. We can't spike the ball without a good setup. And you were in those volleyball tournaments in med school, weren't you? Yeah. Yeah, that was good times. I think we won that one, too. I wasn't good at spiking or setting up, but that's besides the point here. But I think that the doctors that don't use AI are the ones that are going to be left behind.

37:34 When new processes, when you can implement new processes that make things more efficient using AI, you're going to be way more productive and way more accurate. So my EMR that I used that I got to choose myself, not only does it have an AI scribe, but at the end of the visit, it will literally pend all of the orders that I talked. And I can review it and press sign. If I said, hey, I need to refill your lisinopril, your atorvastatin, and I'm actually gonna start you on this, and I need to order this lab, this lab, this lab, at the end of the visit, it will have penned everything, and I can literally just say sign. And it made my note for me. And if patients message in, I can actually say, hey, can you generate a response that has to do with this answer, and it will.

38:23 It's amazing. And this isn't the EMR that the hospital system chose. This is the EMR that I chose. And it will integrate. There's care quality, so everyone puts all their electronic medical records into care quality, and you can just kind of pull from it. But that's where medicine is getting really exciting, is a lot of the administrative things are being cut down, and we can actually start practicing medicine. So in some ways, it's a better time than ever. I think about your specialty, like how do you replace yours? You have to put your hands on the, family medicine, we have to put our hands on the patient, right?

39:04 But I mean, you have to do a physical examination. A lot of procedures, yeah. A lot of injections, a lot of procedures, yeah. No, I think that the procedural stuff would be certainly later to go, right? You listen to a lot of these tech founders, they'll come on and AI doomers and they'll say, oh, you better become a plumber, better become an electrician. Well, I guess in medicine, orthopedics will define themselves as mechanics and I guess I'm some version of that. And so I do feel secure. But I think, again, now I'm going to pivot and go to the other side and make the argument. So I'm seeing both of you guys on my screen. It's like Darsh is on one side and Sam's on the other side. It's funny for me in my mind. I've created this, you guys are on the opposite extremes here.

39:46 I don't think three years ago, I would have even been able to imagine, maybe four years ago, that GPT or Claude, like GPT-Astro-6 just came out last week and what is, Jensen Wong's like, oh yeah, AGI is here. And I haven't really put it to the test, but I don't know. But I don't think, I would have imagined that it could do that. So just because I can't imagine that it's going to have the coordination to be able to do an ultrasound-guided injection five years from now doesn't mean that's possible. So always keep that open. I do think that ultimately where you just, what you just highlighted is where it is. That coaching relationship, it actually frees up cognitive bandwidth for us to be able to focus on what's really important.

40:28 To be able to focus on, I think why any one of us went to medicine. You'd be pretty hard pressed to find Somebody was like, yeah, I just love putting orders. That's why I went to med school. I love charting. That's, you know, that's not a thing. So yeah, it's actually, after talking about this, I'm quite excited, Sam. Thank you for that. Sam, do you think, so let me back up and put context on this. Rhonda Patrick found my fitness podcast. She had this longevity doctor or immunologist, aging researcher, doctor, I butcher this, Dr. Daria Unutmaz. So I think he's one of the consultants for OpenAI. And he says physicians who will not use or who don't use AI, it will be malpractice. Do you think that's too strong of a statement?

41:09 No. Mainly because things are rapidly changing. Recommendations are rapidly changing. We used to go search up to date. Why not just cut that search down by a fraction of the time and just get the answer? You know what I mean? I use AI quite a bit. But here's the thing is like me using AI is way different than someone who didn't go to med school to use AI. Right? Like I understand a lot of what the AI is explaining. And it helps me still make a good decision. But you know, it's interesting.

41:50 Another thought I had was, I actually encourage my patients to look stuff up on AI. It's funny because they come in and they say, they say, I know you don't like me to do this, doc. And I'm like, I've never said that. And I've actually encouraged my patients, if you're having an issue at home, go look it up on AI. Because they might actually answer the question. And you, without you having to come in for something that you probably didn't even need you know? And, because what I have found is that people that are using AI are, They're actually coming in and I'm able to diagnose things a little easier, you know?

42:31 Not that I see a lot of common colds and UTIs and little pneumonias and sinus infections. I would love to see those. It's just, that's not the reality of primary care anymore. Primary care is very complex and that's what makes it fun. I loved seeing a sinus infection. It was so nice, took no brain power. But what I'm trying to say is I actually encourage people to use AI, interact with their health. They come in better educated so that when I give them an answer, a lot of them nod and say, yeah, I actually read about that. In fact, ChatGPT even said a very similar thing. And now that you're saying it, I'm actually feeling a lot better about what it said.

43:16 A lot of patients may not use AI to validate you. They're using you to validate AI. What about fitness trackers? How do you interpret the data on those? If it's a whoop or I just got a Luna band, I know Apple Watch is a little bit more difficult to kind of extract data, but is there anything that you tell your patients in regards to the fitness trackers? Yeah, I think that fitness trackers are great for those that like them. I have a whole subset of patients that they just do not care, and it would not change the outcome if they used it. They're still gonna exercise, they're still gonna do what they're gonna do, or they're still not going to exercise, right? I find that patients that like the fitness trackers, it keeps them motivated and it works well.

44:02 But I don't think you necessarily need it to have success. So that's where it comes to individualizing the plan. But you have, you know, the physician needs to know. So I have sat down with patients and I've said, okay, let's get this set up. You got your Oura Ring. You've got, what else do you have? We're going to integrate all of this. We can use Google Health. We can use Apple Health, whatever there might be. Now we have... a lot of these calorie trackers, you can literally just take pictures of your food. And then it just calculates your calories, calculates your macros, and that makes it easy. Before, when I would have to get patients to track food and And just to give a little caveat on that, I don't think tracking is for everybody, but I think that it can help some people.

44:51 Before, they'd have to type everything in and they'd have to put in the serving size. Now they can literally just take a picture. And for the most part, it's pretty accurate. What I found is that sometimes it will underestimate on some foods and then overestimate on others. But at the end of the day or at the end of the week, it basically is the same amount of calories, whether you manually entered it or not or took a picture of it. Is there a specific one that you like? I personally like Cal AI. I like that one. And then Google Health has it as well. And it works really well. They do barcodes, but I mean, literally just the pictures. And so I'll get patients like, listen, I'm not asking you to type stuff in.

45:34 All I'm asking you to do is just take a picture of your food before you eat it. That's it. Yeah. Yeah. And they're like, okay, fine, Doc, I'll do it. And a lot of times I start off with two weeks. Like, listen, just do this for two weeks. After that, I won't ever ask you to do it again. And then just by doing it for two weeks, they get their mind reset. I would say, the phrase that I hear so much is, Doc, I really don't eat that much, and I'm still not losing weight. Okay, well, let's see exactly how much you're eating. And we do. And I would say most of the time they come back and they say, okay, I guess I was eating a lot more than I thought I was. Or they came back, they come back and say, okay, I actually did stick to the calorie goal and I did lose some weight.

46:19 But very rarely is it that patients stick to the calorie goal and don't lose weight if they don't have another physiologic disorder going on. Yeah, I mean, I think that's the perfect example, right? So to steal James Clear's third law of behavior change is... improving the, I think, the behavior response, right? And so what he talks about is reducing friction. And ultimately, we've talked about reducing friction with respect to our joy in practicing medicine or reducing friction for calorie tracking so you can hit your macronutrient goals if you're trying to optimize protein intake, maybe... not overdo it on cerebrocarbohydrates if weight loss is part of your journey or whatever you might have.

47:01 And I think ultimately that facilitates that adherence to come right back to that thing that you talked about at the outset. So I think maybe if we bring it home for this one specific, this topic in general, it's a tool. And like any other tool out there, you can use it for good, for your benefit, or you could just use like pornography and keep talking to it over and over and over again and keep perseverating from it. To be honest with you, I've been guilty of getting into this rumination mental loop sometimes where I've had to build in guardrains and Claude is like, you've exhausted this decision is made, which is also something cool. So anything else on that, Darsh?

47:44 If not, we can kind of just talk about the, come back to the four horsemen so we can make it a little bit more actionable for people and see Sam's take on that stuff. I'm good, yeah. So Sam, I, to come back, you said cardio, cardiovascular fitness, metabolic health, visceral fat? Yeah, so visceral fat, cardiovascular fitness, muscle mass and strength, and then the internal. Internal, right, which is kind of an umbrella and it's gonna touch on all the systems. It's an umbrella, but I think that it's important. I don't think that we order enough labs in medicine for prevention. What do you think we miss out on? You know, I think that there's a lot that we miss out on, and trust me, I have sat through these lectures about trying to cut down the cost of medicine and the benefits outweighing the risks.

48:35 I understand that. And unfortunately, yes, when you order a lot of tests, you're likely to get a lot of false positives and you have to go down a rabbit hole and go spend a bunch of money and get anxiety about something that ended up being nothing. Give me an example of two or three that people will consider non-conventional. Maybe your colleagues will say, Sam, you're wasting time, you're wasting money. What are some labs? I would say that, hey, do you really need to be ordering a TPO antibody on a patient who doesn't have a TSH that's abnormal? Do you really need to be ordering a ferritin on a patient who's not anemic? So this happened last week.

49:17 I had a patient come to me. in his 50s. He came in, he's like, hey, so I had this episode, I was having a little bit of shakes, a little bit of sweats, it was kinda weird, lasted for a little bit, happened six months ago, and it went away. And then literally last month it happened twice. And I just, I don't know what that is. And now he had come in for his first consult, which for their first consult, I order a big, huge biomarker assessment of like 90 plus biomarkers. So I had this full test in front of me as he's telling me this. And for the most part, all of his tests were normal. But his ferritin was 755.

50:01 Okay? And his saturation pointed to the fact that he has hemochromatosis. He was iron overloaded. His hemoglobin was completely normal. And so I'm sitting here afterwards, and I'm, well, first of all, I was like, hey, we need to get this genetic test. We're going to get an HFE gene. I want to get a repeat test. Then you're going to go get a phlebotomy. But I'm sitting here How would I ever have arrived at a ferritin? What? His liver enzymes were normal. He wasn't anemic. His everything was normal except for that ferritin.

50:43 And I'm just like, I don't think I would have found it in the way that I was practicing before. You know, so that's just one example. I think that we could be a lot more thorough. And I think that, like, for example, Function Health, you know, it's over a, what, two plus billion dollar company right now. Patients can get a very extensive lab test for less than $400. And I think it's doing a lot of good. does it cause anxiety in certain people? Maybe. It probably gets them to the doctor. As a physician in an insurance-based practice, I had tons of patients bringing in their function health labs. And they'd be like, Doc, explain this to me. I'm like, Well, I know you came in, you have about four problems you want to talk about.

51:28 We have about 15 minutes, but yes, I'd be glad to go over all these labs with you. You know, but I think that function health really touched on something. And it's bringing out a passion that people have for their own health. It really is. I have a lot of people that are so interested in it that it makes them more interested in their own health that they're actually making changes. And so that's actually something that I've implemented in my practice. I don't use function health. I actually built my own panel that I like a little bit more. I think function health is great, but I like my panel more. And the first thing that patients do when they come to me is they get that full lab assessment and then we go over it and we identify all the deficiencies.

52:09 But what's good is they get to go over it with a doctor instead of get some AI response back, right? And they come to me and they're like, doc, my bilirubin's high. What do I do? It's okay. Everything else is normal. You probably have Gilbert syndrome. Oh, so I'm okay? Yeah, you're okay. Like most patients come in with a high belly or just other little things, you know? I give a lot of reassurance, like, don't worry about that one, that one's okay. A lot of it's like on a CBC differential. You know, like, their MCHC is high, or whatever. Like, what do I do about this? I'm like, we don't care, you're fine. And patients want to hear that, you know, they want to know that they're fine, we give a lot of reassurance.

52:54 What's your take on full body MRIs? That's a great question. I think that I'm definitely not against them. if there's a chance we could find something early, by all means, let's do it. But when I talk to patients about it, I say, listen, we're going to find something, whether it's even whether it's something that's going to kill you, whether it's something that's nothing. We're going to find something. So I want to prepare you for that first and foremost. Okay. If we order this test and if we find something that we have to go down a rabbit hole and we ended up getting a biopsy and finding out that it was benign all because of this MRI and you just spent four months of anxiety worrying about this mass that they found, are you going to regret getting the MRI?

53:49 And so I have a very serious talk with the patients before we would even get to that stage where we order the MRI. You know what I mean? And if they're like, yeah, no, I can stand it. Okay, then let's do it. If you want it, let's do it. But if a patient's like, I don't think I could take the anxiety and the stress behind that. Because I've seen it. I have seen patients just be erect. for four to six months until they finally get a final diagnosis. You know what I mean? Sam, I can see how your experience for six years as FM in the health system itself with insurance plays a big role in kind of how you think about how to help your patients now in a DPC model, right?

54:32 Loopholes that you have to think of, labs that you might do. For those providers who are now getting into DPC, longevity, concierge, but may not have that type of hospitalist or family medicine background, what are some tips that you can give them when it comes to critically thinking about how to best care for their patient, whether it's lab work, maybe some loopholes, how to kind of think about insurance and super billing, whatever you think. Yeah, I think that number one, you need to brand yourself as to what value are you giving the patient? Is it access? Is it expertise? Is it a curriculum? What is it? And brand that.

55:13 Once you've branded that, then you can kind of go from there. Like I've, I know some concierge doctors here that the way that they brand their practice is, look, we are available 24-7. You can call us anytime. We keep our patient panel down to less than 200 patients. You will always be able to reach us. And that's their brand. That's what some people just want access. You know, the way that I branded mine was I am a longevity clinic, a true longevity evidence-based clinic. If you want me to do your primary care, I will. And all of the primary care will be meshed in with the goals of the longevity program, which is nice.

55:53 And some people like that. And then I know other DPC that they're very big into potentially women's health or even sports medicine, whatever that might be. And by the way, I do a lot of sports medicine. I didn't do a fellowship in sports medicine. I did an area concentration in sports medicine in my residency. And right now I'm on the sports doctor. of our local high school football and lacrosse. And I go to training rooms every week too. And so it's just kind of a way to give back. But I have a big passion about sports medicine. But so I think they need to come up, they need to brand what they are providing and they need to just be excellent at it.

56:34 And if they're excellent at it, then the word's going to get around. They need to focus on how to be good at it. We don't have to convince too many people to be our patient if we're just really, if we're providing to the patients what they really need and want. need and what they need and what they want might not be the same, but they need a doctor who's willing to walk them through that. As far as super billing, I think super billing is a great idea. I would definitely not give guarantees. And that's why I tell patients, I say, I will give you a super bill. I'd be happy to do that. I will not, contact the insurance, I will just give you the bill and you can deal with insurance.

57:15 Whether they accept my super bill or not, that's not on me. So I always like protect myself there. But I, my advice to docs that, that want to go DPC, my first advice is do it. Don't hesitate. Like you, there is a market for people. They will find you You will get patience. As long as you focus on delivering the right product, you're going to get patience. People want it. They are so fed up. The next thing is I would say automate your processes as much as possible.

57:56 And what I mean by that is use the latest technology. EMR, the latest billing, the latest AI software integration, because you are going to be able to focus so much on medicine when everything is just automated. And do you need a medical assistant? That's a good question. And I think it just has to come down to what do you want? I have a medical assistant. I absolutely love having my medical assistant. My patients love having my medical assistant. And that's all. It's just me and one medical assistant. And we are able to provide pretty dang good care just with that model.

58:40 But, you know, there's other things you can do for medical assistants. You can outsource. You know, like MedVA, they use medical assistants from the Philippines. the labor is a lot less and you're getting good quality medical. They can do all your prior office. They can do your scheduling. They can be your receptionist. But there's a way to automate all of the administrative tasks. And that's where I'm saying, listen, as physicians, I think we need to take that power back. And then, you know, I think just have fun with it. Enjoy it. I will tell you, I didn't realize how much I was drowning in insurance-based practice.

59:21 I mean, I knew I was drowning, but I didn't realize how much I was drowning until I was in my own practice for a month, and then I was like, there's just so many things I'm not worried about. It's crazy. I mean, just like simple things. Messages, they would go through like so many hands, and then they would get to me, so by the time they got to me, it was like three to four days later, and then it takes about a day or two for me to respond. Now, I mean, just patients, the messages go straight to me. I can answer them quickly. It's easy. One of the issues that we get in family medicine too is like, right now, a lot of family doctors are paid based on production, which is fine. But the issue is, is like a lot of that coordinating care, you're not compensated for, and so you resent it, right?

1:00:07 And in direct primary care, that's what you're being paid to do. And you don't feel bad about doing it, and you don't hate it, because you only have 300 patients. You know, direct primary care practice, I think they're anywhere from three to 600 patients. You have a six to a third of the patients you had before, and so you're actually able to do it, and you feel good about it. I love it, Sam. I think that my favorite thing is this idea of turning the tables, right? I think we've talked about how over the last 25, 30 years, if the global burden, not just global, but the US burden on the economy because of healthcare spending is increased, that's because doctors are making the same amount of money since the 1970s or less, probably if you account for inflammation, actually.

1:00:53 Inflammation, that's how you know. Inflation, excuse me. And That deficit can be explained by admin. And you're proposing that we flip the tables, right? This whole conversation that we've been having, a lot of people are like, is AI going to replace doctors? And today might be the first time. Although I'm doing it and we're seeing it, it's the first time somebody actually is... is it the admin that we can get rid of who's making a lot of money and decrease that deficit? So I think from a policy perspective, that is an area really worth concentrating for us physicians. So I love that. It's a fight worth having or fighting rather.

1:01:33 And yeah, man, I'm super excited. So Altura Health, tell the people where they can connect with you. Where can they find out what you're doing? Yeah, so I'm located in Sacramento, in Folsom, actually. It's a suburb of Sacramento. So it's just Northern California, about an hour and a half from Lake Tahoe, which is a really nice place, but. So right now we've got one location. We do all the testing on site. It's great. Patients can sign up. We can actually do some virtual stuff. It's just they have to be physically in the state of California for me to do any virtual stuff. And so, but I would absolutely, they can go to my website, altarahhealth.com. That's A-L-T-A-U-R-A health.com.

1:02:14 They can sign up. They can send me an email. I'm happy to answer any questions. You can send me a DM on Instagram. Happy to answer any questions as well. So yeah, I'm pretty excited. You know, we're just trying to change how medicine is done. We want to take preventive health to the next level and just get people as healthy as we can. Love it. Appreciate you coming on, Sam. Thank you. Yeah, I really, really appreciate you guys having me on the podcast. And it's been a pleasure. Yeah, absolutely. Thanks. Thanks, Sam. Thanks for listening to another episode of Medicine Redefined. If you enjoyed this episode, please be sure to check out some of the additional resources in the show notes. Please also check out our social media platforms where you can find more content like this.

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