Like many of my patients, I have found it challenging to get good Primary Care. When my family and I moved to the suburbs, we found that most practices were closed to new patients. When we finally joined one, both my wife and I found it difficult to gain access to appointments when we needed them. Being mostly healthy, we often bypassed Primary Care and instead relied on the occasional urgent-care visit.
This year, though, my cholesterol check was overdue but was told my doctor couldn't see me for three months (and I didn't want to play the doctor card to cut the line). So I ordered my own labs and thought I would try my luck with a direct Primary Care (DPC) practice.
I inquired with a local practice and later spoke to the doctor about his practice and fees. Furthermore, as a new patient, I was given the choice of paying for the initial evaluation in full ($160) in lieu of a committing to the DPC enrollment ($50/month). I appreciated the flexibility and scheduled my first appointment.
The waiting room in the converted colonial was tranquil and unhurried. It was refreshing to see the practice's fees posted for all to see, the way more of health care should work.
I've suffered from mild hyperlipidemia since my vegetarian days as a med student. And despite losing 25 pounds on an LCHF diet, my LDL of 180 had not budged. Numerous internists have advised me to eat less fat and get more exercise, neither of which have had an impact on my LDL. I've also been advised to try a supplement (red yeast rice), start a cholesterol blocker, or start a statin. With no personal risk factors or family history of cardiovascular disease, I took all of these recommendations with a grain of salt (an ion whose health risks have also been downgraded since my days in medical school).
My labs also begged the question: how pathological were my numbers to begin with? An insurance physical in 2015 revealed a different set of norms for the metabolic profile, against which my numbers were virtually normal. (I have to assume that life insurance actuaries know what they're doing, especially since their long-term profits depend on their calculations.)
I finally met my new doctor and we embarked on the requisite history and physical, albeit this one in an exam room with a giant fireplace. After reviewing all of my information, I was afraid he was going to coax me to abandon my LCHF ways. Instead, he opened up a new door for me to double down on harnessing the power of ketosis.
"Have you heard of intermittent fasting?" he asked. He went on to say that intermittent fasting could not only curtail LDL, but might also prevent other chronic ailments of modern living.
There are several methods of intermittent fasting, all of which help the body achieve a temporary but prolonged state of ketosis (with key metabolic features being insulin and IGF-1 suppression). The one that particularly appealed to me was circadian fasting, or time-restricted feeding (as this seemed to be the easiest to implement). I read up on the research of Satchin Panda, Ph.D., who found that mice that ate within an 8 to 12-hour window seemed to avoid developing hyperlipidemia, diabetes and obesity, even without caloric reduction. (His research has even compelled his mother-in-law to become a convert.) Early human studies have backed up Dr. Panda's results, which begs the question—are we only supposed to eat during daylight hours? Is ordering dinner at 9:00PM on my Seamless app, even though it's "healthy," contributing to my downfall? I quickly swapped out that app for Zero to track my fasting hours.
DPC physicians get criticized for narrowing their patient loads by 80% and providing the luxury of improved access, when that time might be better spent providing care to others. Though it's currently a small but growing movement, there are signs that DPC practices like this can lower physician burnout, improve patient outcomes and lower overall health care costs. In addition, startups like Iora Health, Parsley Health, and Forward, with tens of millions of dollars in venture funding, are banking on this type of subscription model.
While it's true an annual physical through my insurance plan would have been free, I found this DPC visit to be worth it for the increased convenience and access. But the biggest difference was that I was given a set of tools to better understand my physiology make a potentially high-yield change in my behavior. Were all of my previous physicians excellent? Yes. Did they have the extra time to have a personalized health conversation? No. As physicians, whether we work for large hospital systems or as private practitioners, it's a useful reminder that the foundation of the word doctor, from the Latin docere, means to teach.
Note: No one should implement intermittent fasting, or other drastic dietary changes, without first consulting their own health care provider. Also, the DPC doctor featured in this essay was not aware of the essay at the time of the visit.
Vatsal G. Thakkar, M.D. is a Clinical Assistant Professor of Psychiatry at the NYU School of Medicine. He is also the founder and CEO of Reimbursify, a startup in the out-of-network reimbursement space. You can follow him on Twitter: @VatsalThakkarMD. He is a 2018-2019 Doximity Author.