The Crack in the Armor

Open enrollment is almost here, and with it a chance for more people to join something I'd describe as an actual revolution: the Direct Primary Care movement.

I've known about this space for a long time. As a medical student, then a resident, then a practicing physician, I was lucky enough to meet and spend time with a bunch of DPC doctors at the CAFP Foundation's Annual Summit, where family physicians from across Colorado gather for continuing education and networking. The DPC people always seemed so satisfied. They always seemed like they knew something the rest of us didn't.

Having broken through that wall and opened my own practice this year, I can honestly say I get it :)

What I didn't know

But the thing I didn't know wasn't any of the stuff you'd expect.

It wasn't how satisfying it would be to regain autonomy in a career that rewards subservience. It wasn't how having more time with patients and less time charting would make me feel like the doctor I always wanted to be. It wasn't that entrepreneurship turns out to be less difficult than it sounds. I knew all of that going in. Most of us do.

What I didn't know was how much I had been called to do this all along — that solo practice and the creativity it demands was the thing I was built for from the very beginning.

I didn't know that opening my own practice would be as achievable as it was. The list of tasks I made for myself at the start of 2026 was genuinely overwhelming. But a list is a list, and it can only ever be handled one thing at a time.

I didn't know how it would feel to have patients self-select. Everybody who has found their way into this practice and stayed seems like exactly the right person for me to take care of.

I didn't know I'd open myself back up to posting regularly on social media, or relearn website design in the era of AI.

And I didn't know how much I was capable of doing by myself. Rooming, doctoring, charting, sure. But also bookkeeping, marketing, networking, and chasing down continuing education built for precisely what I was trying to learn.

The part I lived myself

For most of my adult life I've valued health and wellness — not only in service to my patients, but in service to myself.

And I experienced exactly what I was hearing in the exam room. As a kid and a teenager I ate whatever I wanted, never exercised, and I can count on one hand the number of times I went to the gym in college. I always just fit into my clothes. Then I got older, and it got harder.

At a certain point I understood that if I didn't work to maintain or build muscle, my body would cannibalize what I had. So I yo-yo dieted. I'd drop forty pounds in six months and put it back on over two years, then repeat the cycle with some new approach to portion control or calorie restriction — each one working a little less well than the last.

Eventually I hit a wall. The weight was piling on and there didn't seem to be anything I could do to stop it.

I was watching the same thing happen to my patients. Conversations about weight often began or ended in tears, because weight is a problem most of us feel powerless to solve. And the data was grim. Diet and exercise were, at best, temporary modulators of fitness, and nearly everyone who lost weight that way seemed fated to regain it. Bariatric surgery had some genuinely good outcomes, but plenty of my post-surgical patients arrived having already regained what they had lost. Motivational interviewing never struck me as a tool equal to the size of the problem.

Set point

There's a theory that our bodies tend to defend the highest weight they've held for any length of time.

The set point model is legitimate and widely taught, though the mechanism is better described as a defended fat mass, maintained through appetite and satiety signaling, than as a literal thermostat. Lose weight, and the body pushes back: hunger goes up, fullness comes later, and energy expenditure drops.

It's an evolutionary holdover from a time when we'd eat one enormous meal and then sit in a cave all winter, starving. The brain runs some very powerful dopaminergic voodoo to get us out into the cold, foraging for plants and rabbits in the snow — or for pizza on Main Street. Cortisol, in those stressful stretches, helps us survive by making it very hard to burn through our reserves.

Diet medicine did almost nothing about the set point. Then GLP-1s arrived.

Semaglutide (Ozempic, Wegovy) and tirzepatide (Mounjaro, Zepbound) work as well as they do partly because they appear to lower that set point. The effort a person puts into diet and exercise seems to get potentiated by GLP-1 use, as the body stops treating weight loss as an emergency.

These medicines were life-changing for my patients. Eventually they were life-changing for me too.

How the supply chain actually works

For a while, these drugs were in shortage — and during that window, compounding them came into favor. To understand what that means, it helps to see how the supply chain is built.

Chemical compounds containing a drug's active ingredient are made at a federally regulated processing plant. From there they go one of two ways. They're shipped to a federally regulated factory that produces FDA-approved delivery systems — pills, capsules, vials, single-dose pens. Or they're shipped to a compounding pharmacy, which packages them into forms that are not FDA-approved. A 503A pharmacy is licensed and overseen by its state board of pharmacy; a 503B outsourcing facility registers with the FDA and operates at larger scale.

Because compounding introduces a human element, it carries more risk than brand-name manufacturing. Errors in dosing or failures in sterile processing can have serious consequences.

That said: when GLP-1s were in shortage a couple of years ago, compounding became a way to meet demand for some very desirable medicines. At my corporate employer, we were given instructions on how to order compounded medication from pharmacies otherwise unaffiliated with our organization.

The benefit to patients, beyond making a hard-to-get drug available at all, was cost. During the shortage, compounded versions often cost a fraction of what the brand-name pens did. Dozens of telehealth companies sprang up to sell into the surge of demand.

The crack in the armor

Then, as abruptly as it started, the shortage ended.

The FDA declared the tirzepatide shortage resolved and ended compounding discretion in early 2025; semaglutide followed, with 503A pharmacies required to stop by April 22, 2025. Compounding pharmacies were told to stop selling them. My own organization discouraged us from continuing with compounded medications, and patients who had finally been doing well started having their refills declined.

This seemed ridiculous to me. How could something we had been formally trained to order — something producing real benefit across a cross-section of patients who a year earlier had been hopelessly resigned to never losing weight — suddenly be subject to a moratorium?

That was a big crack in the armor of corporate medicine. Not the only one. But the first one I couldn't stop looking at.

Where that leaves my patients

The rules are narrower now than they were during the shortage. Compounding is meant for a specific patient's documented clinical need, not as a cheaper stand-in for a brand-name drug, and the FDA has proposed closing the large-scale compounding route for these medications altogether.

It's also worth saying plainly: compounded drugs are not FDA-approved. The FDA doesn't review them for safety, effectiveness or quality the way it reviews brand-name products. Which is exactly why weight medication decisions belong with a doctor who knows your whole history, not with an intake form.

So if you're paying for an online weight loss club right now, here's the short version: Metronome can replace it with a similar benefit — plus a doctor who is acquainted with the full clinical picture of who you are.

GLP-1s are a small but significant piece of the midlife puzzle. Paired with a growing willingness to practice and keep up with learning about hormone therapy in perimenopause, menopause and andropause, I think Metronome Family Medicine is the best place a lot of people in midlife can land for comprehensive primary care, preventive medicine, and functional approaches at a concierge level of attention.

So, open enrollment

As it approaches, ask yourself one question: do you have the access and the time to talk about any of this with your doctor?

If you're all set — genuinely, that's great! If you're not, consider making Direct Primary Care the cornerstone of your healthcare in 2027.

Open enrollment opens November 1. December 15 is the deadline if you want coverage starting January 1, and January 15 is the final deadline here in Colorado.

And don't forget that you'll still need a plan for financial coverage if you're hospitalized or need major surgery. A good broker can walk you through the options — bronze plans, health sharing, employer-funded arrangements for your business. If you need that broker, ask me and I'll make a referral.

If you're a physician considering DPC: reach out. Let's talk about getting you started, and I'll point you at a couple of audiobooks and podcasts that steered my ship in 2026. :)

Brian Juan, MD, FAAFP

Metronome Family Medicine is a Direct Primary Care practice in Longmont, Colorado. Learn more at metronomemd.com or book a free consult at metronomemd.hint.com.