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Paper City recently made an article about AlereMD that truly captures the essence of what this dream is about.

In a medical world obsessed with optimization, and adding shots, IVs, and pills as a way to wellness, we believe the best technology can still be a careful history, physical exam, and a stethoscope, while leveraging all the tools to get to the bottom of what is troubling the patient. That means high tech imaging, thorough labs, and AI as a reference.

Patients don’t get free B12 shots – they get artisanal sourdough bread sticks and cooking lessons.

AlereMD aims to bring a dignity and humanity back to the doctor’s craft, to crate a superlative patient care experience.

Come by for a complementary meet and greet with the Doctor. We are always just a call away.

There was a time, that a primary care clinic stood out as an essential element of a community. You had a butcher, a general grocer, a hardware store, a post office, a law office, and a doctor’s office. There was the bar, restaurant, theater, and the coffee shop. It was seemingly uncomplicated. A doctor spent years getting trained in a certain skill set, found a market that seemed to have a need, hung up a shingle, and simply practiced their craft.

What makes it so that today, a primary care doctor, family medicine or internist, cannot hang up a shingle and call a clinic their own? In my neighhborhood, there are 6 coffee shops that are within a 10 minute walk from my house. One would think that with one or two alone, the market is adequately saturated. Yet, there they are, each with their own take on what a coffee shop should be.

The case for the small clinic

Centralization creates single points of failure. My belief is that this applies to healthcare like it applies to the food chain, and other domains.

What is the need for a healthcare group to have all of their hundreds, or even thousands of physicians, ideologically aligned? In my view, community needs are as unique as individual personal needs. Doctors must exist in an environment where they can approach public health problems in unique ways. We used to be trained to familiarize ourselves with the individual, and to understand why perhaps their health concern doesn’t fit a certain pattern.

The failure of public health, and lung cancer is expensive

Smokers don’t care that if they get lung cancer, it is going to be very expensive to treat, much like people who drink 2 liters of Dr. Pepper a day, don’t mind that the rest should foot the bill for Ozempic to treat their Type 2 Diabetes. That is just the real world.

Doctors should not be soldier’s on the frontline of public health initiatives proposed at the scale of a nation or a state. It is more productive to work on the health needs of the individual or small community.

Spending 15 minutes to ask a patient if they have had a mammogram, colonoscopy, pap smear, fallen, feel depressed, live alone, or smoke, has proven to be abysmal to the patient experience. When a patient feels sick, we should talk about why they feel sick. We shouldn’t waste time getting hung up on “social determinants”.

Hanging up the shingle

Physicians need to be empowered to wrest away the power of large groups. Much like the coffee shop and the law firm, we have the power of the free market on our side. We must go back to seeing patients as individuals, with unique personalities, unique flaws. And, us physicians need to approach their needs, their illness, with our individual personalities and expertise. We need to be empowered to take a chance, and hang up a shingle.

Losing your job doesn’t mean losing healthcare access.

Today, a new generation of doctors are going out on their own and providing options for people who are uninsured. They are offering cash pay options, and some don’t even accept insurance at all.

It is a legitimate growing marketplace, where the government “healthcare marketplace” has fail to deliver on the idea of affordable care for all.

I speak with Chris Haines on his show the Haines Direct Pod about some of the options out there, so you never feel high and dry when you don’t have insurance.

The Fallacy of the 15 Minute Clinic Visit

The 15 minute time slot for clinics is a modern concept, rather than a deeply rooted medical tradition. In fact, the concept does not even predate me.

Observe how other professionals work – like lawyers on retainer. Some thing just take as much time as they need to take. Lawyers charge by the hour to read and write emails, make letters, and charge for the use of their paralegals and office supplies.

Nature knows no kings, and nature does not respect our artificial constructs of time

When a patient presents to the clinic to visit their doctor we have to get a story from them. Sometimes the story is well articulated to us, sometimes it is written on their clinical appearance. However, more often than not, the journey to the diagnosis is twisted, if we can even get there.

Even the most educated people may struggle to articulate the symptoms they feel, which leaves us to work as translaters for bodily symptoms. This means trying to extract meaning from phrases like “I just don’t feel right”.

As a physician servicing a hugely Spanish-speaking population, I must contend with their unique time perspectives. It may take up to 3 times to ask “Por cuanto tiempo”, before you get an actual time answer instead of “oooof, hace tiempo”.

Chronicity

My uncle Boli is a genius man. He is a lawyer in Panama, but he understands human disease like a doctor does. He taught me early in my career that chronicity, the way symptoms play out over time, tell the diagnosis. I learned that this is crucial to extract from the clinic visit. This timeline is often more important than labs or vital signs.

Two major issues interrupt the understanding of this aspect of the disease process in the context of the modern, rigidly structured clinic day. One problem is that this chronicity is as important looking forward as it is looking back. When I have asked the patient all of the immediate questions, and done the physical exam I could fit into the 15 or so minutes, they must get on their merry way. Unless they are hospital bound because they are unstable, we must shuffle them along.

This 15 minute visit, may have taken weeks or more to get. Not only that, the next 15 minute visit is likely to be months away. However, their shortness of breath may start to creep up in the 48 hours after the visit. Or the rash suddenly appears. Or, they realize they forgot to mention the supplement they started taking for weight loss.

None of that seems to matter in the modern clinic. The patient may luck out and get in when another patient cancels, but, otherwise, they will just follow up when they can follow up. They don’t get to follow up when they need to follow up.

It Isn’t Speed Dating

The state of a person’s health, and the understanding of why they may be ill, is not of trivial concern. This isn’t speed dating, though the hospital administration complex, prioritizing easier patterns to measure, insist on making it so. There are enough stories of missed diagnoses to have me nervous. It simply unrealistic to get the diagnosis right every time, when nature is going follow the rules of nature, and not the admin’s mandated time slot.

My other inspiration is my grandfather, Carlos Pedreschi. He was a small town doctor in the Panamanian highlands. I can’t imagine he would stand for this trend.

Doctors must demand time with the patient. Not 15 minutes. Not 30 minutes. Not 45, but, the right amount of time.

Know why you eat what you’re eating?

• A person asks for only egg white in their scrambled egg at the deli.
• Another orders the grilled chicken breast instead of the fried.
• A person asks for Diet Coke over regular, to accompany their meal.
• Another buys skim milk for their family at home.

People are buying “organic” labeled food as a reflex these day, but what does organic even mean?

A patient told me one time that they avoided gluten because they heard it was a poison that was put in the food to make people sick.

They all think they are making a healthy food choice. But, what is health food?

Government Guidelines Want to Say they are Health Food

Health food is largely a modern lens that we apply to food. Whereas in the past, we relied on family and ancestral knowledge to almost intuitively know what food nourished and sustained us, today there is only confusion, and trends that change every 6-12 months.

So the USDA and DHS will tell us, right?

The question is, who are they really serving?

The government and the largest producers of food in this country move in lockstep.

This is the lobby effect we see all across the board in government. This is how lunchables and chocolate milk becomes health food. This is why you buy protein water today.

One year, California marks coffee as a carcinogen. The next year, a headline reads “Coffee drinkers you’re in luck, you will avoid alzheimers”.

Enter the Healthfluencers

Everyone wants to be the final word on health food. And, in a nation where we have lost so many of the traditions of the meal that ensures true, seasonally approriate, and made-from-scratch meals, we fall for them again and again.

They move the goal posts. Cholesterol is bad, then it is good (sort of). Sugar destroyed civilization, but then it is ok.

The food producers are always two steps ahead in the game, so you feel that you are always on the cutting edge of food science with the shiny package you buy. The grocery store opens up their gluten free and plant based aisles, but all you end up with is longevity mitochondria support cereal.

FERF: First Eat Real Food

Real food does not advertise itself. It does not adorn itself with flashy packaging. It does not adapt itself to the health trend du-jour.

This is as close to a moral crusade as I will get in my life. This is why I will always fight for the preciousness of a family meal and cultural and religious food traditions through my medical practice.

It is why I never argue or say what food is healthy, and instead created the food sourcing hierarchy to help you on your way to never stress about choosing what to eat, for the rest of your life.

I choose nonnas over nutritionists, sourdough demi-baguette bakers over dieticians.

I don’t eat healthy food.

The food culture in this country is in complete disarray, and it has been now for generations.

The problem is so severe, that being born in this country is a risk to your longevity – regardless of your background. Immigrants fare worse health outcomes here than they would have at their country of origin.

We are disconnected from the source of foods. We are no longer seeking it from the farms, the oceans, or the ranches.

The food is fake, my dear.

We are conditioned to trust the grocery store, while we are bathed in their fluorescent lights. We have been fooled into valuing the cost of food in dollar terms, when the actual concern is whether or not we are even getting real food in the first place.

The very definition of food has been degraded. “Spread” is butter, “nuggets” are chicken. Bread is essentially angel food cake. We seemed convinced that even water cannot simply be water. It has to be “smart” or “alkaline” or “plus”.

The food is fake.

Nutrition labels mean nothing.

The problem is beyond “nutrition”, which for me has become a bad word. There are few things which have created as much disservice to the pleasure of eating a meal as nutritionism, which imposes an unnatural and sterile lens on food. Seeing food as a combination of carbs, proteins, and fats is meant to distract and confuse.

These labels were used as a tool to destroy real food. People who deal with real food see through the nonsense.

The grandmas who make pasta from scratch, the Michelin chefs, the Korean auntie gathering ultra seasonal produce to make kimchi, and the ranchers up at the crack of dawn downing their skillet fried bacon slabs and biscuits to have the energy to get to work. The amount of protein and whether or not it is cruelty free, is a legit joke to them.

Instead of the delight of seeing all the colors in the table spread, the aromas from freshly ground spices heated on a pan, they are telling us to make a hard stop and take a picture of our food, so we can answer “how many calories is this?”, “what are the macros?”.

We need a renaissance in food.

We need to go back in time – not to some future of protein bars, powders, and those god forsaken gummies. The old book of family recipes, the farm to table star chefs, the YouTube guides, grandmas and grandpas, the sauerkraut fermenters. I truly believe they will save us by restoring the very thing that makes us human: the meal.

In the rush of a typical doctor visit, the finer details of adverse medication reactions are often overlooked and not discussed.

As concerns about fertility make rounds in the news, it is important to consider how these common drugs play a part in that concerning trend.

I’ve attached the cheat sheet you can use to bring up to your doctor here.

Spruce is the communication platform I have chosen for AlereMD. The way doctors communicate with patients is regulated, to ensure that your medical information stay encrypted and what we call HIPAA compliant.

For text, if communication is not done through Spruce, the information is considered accessible to the large phone communication companies, and the large tech companies.

This is the same for correspondence through email – not considered private.

That said, it it not strictly needed for phone calls – you can call me for your medical concerns, or the front office for non medical issues without Spruce.

Let us know anytime so we can guide you in setting Spruce up.

Charles Rismyhr, MD