Why I Broke Free From the Healthcare Machine
As a child, I dreamed of becoming a physician.
I envisioned building relationships with patients, understanding their unique needs, and providing thoughtful, individualized care. As I pursued the long journey through medical training, I discovered that connecting with my patients provided the greatest meaning and satisfaction.
When I began practicing primary care, I hoped to maintain those connections. Instead, I found myself trapped in a system that prioritized efficiency over relationships.
The Reality of Traditional Medicine
Every patient encounter felt rushed. I tried to take my time with each person, but with 15–20 patients scheduled daily, I had just 20 minutes — often less — for each appointment. After getting patients settled in rooms, the actual conversation lasted mere minutes.
Patients would say, “One more thing,” and I’d have to respond, “We don’t have time for that today. You’ll need to make another appointment.” That response made me feel terrible.
I wasn’t providing the care patients deserved, and I wasn’t satisfied with my work.
The Moment Everything Changed
Over time, the administrators at my practice chipped away at each doctor’s autonomy. Then came a pivotal moment — a new policy about working in urgent care — when I realized I had become just a cog in a machine.
There was no recognition of the importance of continuity between doctor and patient. Everything was reduced to a numbers game, focused on efficiency and shifting patients to urgent care where they saw providers who didn’t know them.
That day, I called a colleague who had left the practice and asked, “What am I doing here?”
Her advice was simple: “Hang up and call Barry Rotman.”
A Luxury We All Deserve
Many people perceive concierge medicine as a luxury, and I agree. It is a luxury — one we all deserve.
Concierge care makes the doctor-patient relationship special again, transforming healthcare from transactional to relational.
Some patients tell me they already have a great relationship with their doctor in a traditional practice. That’s wonderful, but it’s the exception, not the rule. That doctor is likely bending the rules or pushing against the system to provide that level of care. Even then, what patients think is great care could be better in a concierge model.
This belief is so strong that I use concierge care myself. I’ve seen both sides of medicine, and I know which type of care I want for my health.
How Concierge Medicine Benefits Patients
The most obvious benefit is time — not just time spent face-to-face with patients, but time spent behind the scenes.
I can call specialists about my patients, coordinate with radiologists about imaging studies, and dig deep into the minutia of all facets of their health.
Time also allows me to practice what I call medicine 2.0 and 3.0, with more flexible appointment types. I can schedule quick phone calls, video visits, or Zoom meetings.
This flexibility helps meet people where they are and work on their specific goals.
The Evolution of Medical Care
Medicine 1.0
This is the conventional healthcare system — waiting for a problem, then treating it. It’s reactive medicine that leads to poor health outcomes with little emphasis on prevention.
Medicine 2.0
This approach manages chronic issues while taking major steps toward prevention.
We work to prevent cancer, neurodegenerative disease, and cardiovascular disease — still the number one killer in the United States. We examine family history and personal factors to create individualized prevention plans.
Medicine 3.0
We take prevention and high-quality care and add innovation, technology, and community. We build on a good model to make it great.
Addressing What Matters Most
In traditional care, doctors lack the time to address issues like stress management, even though stress impacts everything from sleep to exercise to heart rate variability.
In the concierge model, we have time for these conversations. We can develop tailored strategies for stress management that fit into each patient’s busy life.
Traditional medicine stays surface-level. There’s no opportunity to uncover that stress might be the root cause of multiple symptoms. In concierge care, we can dig deeper.
What Motivates Me Every Day
The most rewarding aspect of practicing concierge medicine is the bond I form with each patient. This connection gets me up in the morning and keeps me going.
It’s hard to help patients if you don’t know them well. Now I have the privilege of truly knowing my patients and providing care that addresses their unique needs.
Today’s Takeaways
Having a doctor who knows you personally, coordinates your care, serves as your cheerleader, and helps with both small issues and nebulous health challenges isn’t just life-changing — it can be lifesaving.
By joining Banner Peak Health, I’ve met my original goals as a doctor: to be present for my patients and to practice quality medicine joyfully. I now have the time to care for the whole person and honor each patient’s individuality.
I’m thrilled to have begun this new phase of my career.
Pneumococcal Vaccine Schedule for Adults: Which Is Best for You?
The medical community used to believe vaccinating infants and young children was more important than vaccinating adults.
While early vaccination prevents infectious diseases from spreading among large populations, we now know that our ability to fight off certain diseases can decline as we age, especially in those with chronic illnesses and weakened immune systems.
One of those diseases is pneumonia, a lung infection that usually presents with fever and cough, often due to bacteria entering the lower respiratory tract and replicating.
Older and/or sicker people have a higher risk of severe pneumonia-related complications, though younger, healthier folks aren’t immune. The best pneumococcal vaccine schedule for you depends on your age, vaccination history, and underlying risk factors.
The CDC’s Updated Recommendations for Pneumococcal Vaccines for Adults
In June 2024, the CDC approved PCV21, a new pneumococcal vaccine for adults, and updated its guidelines that October.
Former guidelines recommended individuals aged 65 and over start pneumonia vaccination. Now, due to emerging data demonstrating an increase in pneumonia cases among 50+ year-olds, the CDC suggests everyone over 50 be vaccinated against pneumonia.
A Brief History of Pneumonia Vaccination
Many types of pneumonia exist. PCV21 prevents a specific type of bacterial pneumonia caused most commonly by streptococcus pneumonia. It doesn’t prevent atypical pneumonia, also known as walking pneumonia.
The first pneumonia vaccines, introduced in the early 2000s, targeted the serotypes most common among children and certain adults. Eventually, many of those serotypes disappeared because of herd immunity and the vaccination of higher-risk adults.
It’s a cycle: New strains appear, we create and administer vaccines to fight those strains, those strains are eradicated, new strains appear, etc. That’s why we’ve seen frequent updates to the pneumococcal vaccine schedule for adults and a quick succession of new pneumococcal vaccines for adults in the last decade.
The new vaccine (PCV21) contains no eradicated serotypes; only the serotypes that cause 77–85% of invasive pneumococcal infections in adults.
Natural Ways to Reduce Your Risk of Pneumonia
Aside from following a pneumococcal vaccine schedule for adults, you can reduce your risk of pneumonia by:
- Quitting smoking. If you don’t smoke, don’t start. In addition to increasing your risk of pneumonia, smoking damages the lungs, increases the risk of lung diseases like chronic obstructive pulmonary disease (COPD), and exacerbates existing chronic diseases like diabetes and heart disease.
- Practicing good oral hygiene. Regularly brushing your teeth limits the colonization of certain bacteria in your mouth. Left unchecked, these bacteria could spread to your lungs and lower respiratory tract.
- Exercising. Regular physical activity keeps your lungs in good shape. Exercise is especially helpful for patients with chronic conditions, including diabetes, heart disease, and chronic kidney disease.
- Develop a relationship with a concierge physician. It’s not enough to find any board-certified physician. Many physicians are swamped with patient panels thousands strong. They don’t have time to research all the new pneumonia vaccines introduced in the last 15 years, and they often make generic, population-based recommendations that disregard individual risk factors.A physician practicing in a concierge setting enjoys a small patient panel. He or she has time to learn about your medical history and research the best pneumococcal vaccine schedule for you.
Today’s Takeaways
While PSAs about seasonal vaccines (e.g., flu shots and COVID boosters) are common this time of year, it’s important to choose vaccines and boosters based on your individual risk — not just population-based recommendations.
For most patients who have never received pneumococcal vaccines for adults and are now eligible, PCV21 is the best choice. Meanwhile, many patients who have already received a recent pneumococcal vaccine may not need PCV21 now or in the near future.
The best way to stay healthy is to find a physician who has time to get to know your personal history and research the most appropriate vaccines for you. The doctors at Banner Peak Health make every recommendation on a case-by-case basis and are happy to answer your questions. Schedule an appointment today.
When to Start HRT for Perimenopause: A Physician’s Guide
Female patients in their forties often ask me about treatments for menopausal symptoms. When I mention hormone replacement therapy (HRT), some of them get nervous.
Because of outdated and since-debunked research, HRT has developed a stigma. Today, I’m debunking the most common misconceptions about HRT and perimenopause, including when to start HRT for perimenopause (as soon as you experience symptoms) and whether HRT is safe and effective (for many women, it is).
Understanding Perimenopause: A Process, Not an Event
While the average age for menopause in the United States is 51 (defined as going 12 months without a period), the journey to get there — known as perimenopause — can begin up to a decade earlier.
(Interestingly, there’s often a strong correlation between when a woman experiences menopause and when her mother did, suggesting the timing has a genetic component.)
Perimenopause isn’t a single event. It’s a gradual process that lasts several years. During this time, different symptoms may emerge, with sleep disruption often being the first noticeable sign. This is followed by what we call vasomotor symptoms: hot flashes, night sweats, and heart palpitations.
Many women also experience mood changes, including increased irritability and sometimes depressed mood.
Physical changes can include vaginal dryness and more frequent urinary tract infections. Some women also report cognitive changes, often described as “brain fog.”
Benefits of Starting HRT During Perimenopause
HRT has emerged as one of the most effective treatments for perimenopausal symptoms, particularly for managing vasomotor symptoms. Because of outdated research, most women don’t know this.
In 2002, a series of clinical trials called the Women’s Health Initiative (WHI) suggested that HRT use is associated with high risks of stroke and breast cancer. Instead of asking when to start HRT for perimenopause, women asked when to end HRT for perimenopause. Many women discontinued treatment.
However, subsequent research has largely debunked these findings, and we now have a stronger understanding of HRT’s safety profile and benefits.
When started during perimenopause, HRT offers several benefits. It can reduce the risk of depression, even in women who aren’t experiencing mood changes, and may decrease the risk of coronary artery disease when started close to menopause.
HRT has also shown promise in preventing cognitive decline and protecting the bones, reducing the risk of osteoporosis. Additionally, it helps manage genitourinary symptoms (vaginal dryness and more frequent UTIs) that can occur before menopause.
Is HRT Right for You?
Before asking your healthcare provider when to start HRT for perimenopause, consider your personal and family health history.
If you have a history of stroke, breast cancer, endometrial cancer, or ovarian cancer, avoid HRT. The same applies to those with blood clots, clotting disorders, or poorly controlled blood pressure. If blood clots are your only concern, transdermal estrogen might be an option, as it carries a lower clotting risk than oral estrogen.
Some relative contraindications include advanced liver disease and heavy or irregular bleeding during perimenopause. It’s also important to note that HRT isn’t a reliable birth control option, so if you still need contraception, consider other options.
Treatment Options
HRT isn’t one-size-fits-all. The treatment comes in different forms, including oral medications, transdermal patches, topical creams, and combinations through compounding pharmacies.
For women with an intact uterus, HRT typically includes both estrogen and progesterone, while those who’ve had a hysterectomy usually only need estrogen. Women with a progesterone IUD may not need additional progesterone in their HRT.
Testosterone therapy can be particularly helpful for specific perimenopausal symptoms, especially decreased libido and cognitive issues (brain fog, difficulty remembering names, etc.).
Alternatives to HRT
For women who can’t or choose not to use HRT, several alternatives exist.
You might manage vasomotor symptoms with medications like venlafaxine (Effexor) or gabapentin. A newer option, Veozah, is available but requires careful liver function monitoring.
You may address mood issues with SSRIs like Zoloft or Lexapro, or SNRIs like Effexor. For genitourinary symptoms, vaginal estrogen alone may be sufficient.
Some doctors might recommend oral contraceptives instead of HRT, particularly for women who experience heavy, irregular bleeding or who need contraception. While these contain higher doses of estrogen than typical HRT, they can manage certain symptoms.
Insurance and Access
Insurance coverage for HRT varies.
Insurance often covers common forms like estrogen sprays, oral progesterone, estrogen patches, and vaginal estrogen formulations, though out-of-pocket costs can still be significant. Coverage for compounded formulations is less common, but may be possible with proper documentation of medical necessity.
When to Start HRT for Perimenopause
Decide when to start HRT for perimenopause based on your symptoms and medical history.
Don’t wait until symptoms become severe or hurt your quality of life. If you think you might be experiencing perimenopausal symptoms, schedule a conversation with your healthcare provider to discuss whether HRT might be right for you.
Here at Banner Peak Health in Walnut Creek, I customize HRT treatment to each woman’s needs and preferences, whether that means choosing pills, patches, or creams. What works best for one woman may not be ideal for another, and finding the right combination often involves some trial and error.
If you’d like to explore your HRT treatment options or discuss when to start HRT for perimenopause, reach out today to schedule an appointment at our Walnut Creek office. I’m happy to chat.