When I started my Direct Primary Care practice, I was driven by two things: finding autonomy in medicine, and finding energy for what I prioritize outside of being a doctor. My own creativity. Health and wellness. My relationships with family and friends.
My creativity found an outlet in sculpting this practice. Balancing work and life turned out to be just as tricky as it had been in corporate medicine.
As an employee, I vacillated wildly between altruism and narcissism. I'd give everything one moment: accept the double book, go long on an encounter, log in late to chart, skip lunch. Then I'd clamp down in protest the next: yell about an administrator, cut a patient off, walk out with unfinished work, treat myself to a lavish meal.
In solo practice, every facet of the business is something I get to build from scratch. The task list never ends, and because I love it, it's easy to get lost in it. If I'm not careful, I'll sacrifice a workout to polish a social media post, or miss dinner with my wife because I stayed late building a software integration.
So hard boundaries are a must.
Wednesday mornings
When I opened on June 1, one of those boundaries was already set. Every Wednesday morning, rain or shine, my wife wanted me on a hike.
We mapped out routes we'd never done through Rocky Mountain National Park and Roosevelt National Forest and the front range, all 40 to 60 minutes from home, ranging from about five to ten miles with modest elevation gains of up to 1,500 feet.
There's some context here. My wife is a nature junkie. She majored in rocks (and dance) in college. I, on the other hand, failed geology my first semester. She's a wilderness herbalist, trained to recognize medicinal plants in the wild and prepare them as tinctures and infusions. I kill plants by looking at them, and I cannot tell osha from poison ivy.
She'd been asking me to hike with her for years. Until this summer, I mostly went along on Mother's Day, on her birthday, or when we were already camping. Cell phone in hand, begrudgingly.
The first time up Bear Peak
Four years ago, on her birthday, we summited Bear Peak: an eight-mile hike in south Boulder that takes you 3,000 feet up into the sky, through Mordor, which is how it feels to traverse the Flagstaff Fire burn scar when you’re a little more than halfway there. Afterward, she told me that about three miles in, she'd listened to how hard I was breathing and thought, if he has a heart attack up here, how will I get him down?
It killed us both. It was a tough one for her too, even though she'd been doing it on her own for years, on her birthday, at the crack of dawn. That hike landed in the middle of what I can only describe as a downward trend in my health.
Mind you, I'd long valued physical fitness. I was never what anyone would call outdoorsy, but in my 30s I learned you have to use it or lose it. I trained for and finished a few triathlons (and I didn't even finish last!). I loved my mountain bike. I ran the Bolder Boulder every year. And I spent several years yo-yo dieting: losing 35 pounds in six months, gaining it back over a couple of years. I was the living embodiment of the failure of short-term restrictive dieting, and every year running got harder.
Medical training and employed medicine made it tough to stay in shape in my 40s. I didn't have the time or energy for wellness the way I had in my 30s, especially during residency, working 80-hour weeks in the hospital. As a corporate doctor I started strong, hitting the treadmill in the clinic gym every lunch. Within a few months I was charting and working my inbox through every free moment I wasn't with a patient, and for several years I almost never ate away from my desk.
What I used to tell my patients
I had plenty of patients my age in the same circumstances. A cursory workup of their cholesterol and blood sugar, maybe with a glance at thyroid function or vitamin D, always produced the same advice:
You're prediabetic. You're at risk for cardiovascular disease. Do better with your diet. Exercise more. Take this statin. Take this metformin. Take this vitamin D, and for God's sake, get some sun.
Also, your thyroid is normal. Lucky you!
No, I will not check your testosterone. Testosterone supplementation causes prostate problems and heart disease. Okay, fine, let's check it. See? It's normal. Yes, it's on the very, very low side of normal, but it's normal. Supplementation is not indicated. It causes prostate problems, including enlargement and cancer, and also heart disease.
Good day, sir. I SAID GOOD DAY.
What the evidence actually says
Let's look at that last one.
"Normal" testosterone is defined by looking at a cross-section of the population. A widely used harmonized reference range for adult men runs from about 264 to 916 ng/dL, and the American Urological Association uses 300 ng/dL as its cutoff. A diagnosis of testosterone deficiency requires symptoms plus at least two low morning tests, drawn a few weeks apart.
Most of the men who came to me asking about testosterone had levels between 250 and 350, right at that line. For years I felt justified sending them on their way, because that's what my peers did. Supplementation was considered vanity medicine, not worth the time we'd otherwise spend treating serious chronic disease.
The fears behind that habit haven't held up well.
On the heart. TRAVERSE, a large randomized, placebo-controlled trial published in the New England Journal of Medicine in 2023, followed more than 5,000 men aged 45 to 80 who had low testosterone and either existing heart disease or high cardiac risk. Testosterone was no worse than placebo for heart attack, stroke or cardiovascular death. In February 2025, the FDA removed the cardiovascular-risk language from the boxed warning on testosterone products. Further study is needed to look at atrial fibrillation, acute kidney injury and pulmonary embolism in the testosterone group. And the FDA added a class-wide warning that testosterone can raise blood pressure.
On the prostate. In the TRAVERSE prostate substudy, high-grade prostate cancer was rare in both groups: 0.19% on testosterone versus 0.12% on placebo, not a significant difference. Urinary symptoms didn't worsen. PSA does rise somewhat on testosterone, which is one reason it needs monitoring, and labels still say testosterone shouldn't be used in men with known or suspected prostate cancer.
So what does it do when we put it back?
The strongest evidence is for sexual function. In the Testosterone Trials, published in the NEJM in 2016, men 65 and older with low testosterone saw modest but real improvements in libido, sexual activity and erectile function, along with small improvements in mood.
Testosterone also tends to increase lean muscle and reduce body fat in men who are truly deficient, and it can improve strength, especially when baseline levels are very low.
What it didn't reliably do in those trials was improve energy or fatigue more than placebo.
It's not a fountain of youth. It's a real treatment for a real deficiency, with real benefits and real things to watch.
My turn
The year I turned 50, I had pretty much given up on losing weight and getting back in shape.
I was carrying a lot of self-judgment. For years I'd subscribed to the idea that my fitness had deteriorated because of a moral failure: a lack of willpower, an inability to will myself into a healthier body. I was resigned to my symptoms simply being signs of aging.
Then my physician and I had our first conversations about GLP-1 therapy, and I started tirzepatide. The protocol involved carefully monitoring muscle mass, hitting a high daily protein target, and lifting modest weights to prevent muscle loss.
A few months in, with modest weight loss on the GLP, we checked my testosterone for the first time. It was low, low enough to qualify me for treatment.
My doctor, who has been practicing three times as long as I have, told me about his approach: he regularly targets testosterone levels around 500-600. I've since learned that lines up closely with the AUA's own recommended target of roughly 450 to 600, the middle of the normal range. That's a stark contrast to what I'd seen from testosterone clinics and "men's health" mills, where many of my patients had levels over 1,500 on pellets with minimal monitoring, in exchange for insane per-visit fees. Doing this properly means rechecking levels, hematocrit and PSA on a schedule, and having a frank conversation about fertility, because testosterone suppresses sperm production.
Fifty pounds and a lot of lakes
A friend on her own GLP-1 weight loss journey introduced me to rucking to help with muscle preservation, so I started walking my dogs with 20 pounds on my back. By the time my wife and I were hiking this summer, I was carrying 50 pounds and all of our water every time we went into the woods.
We visited mountain lakes. Button Rock Reservoir. Ouzel Lake, the road less traveled, past Ouzel Falls, where we met the first of many moose we'd see this summer. Blue Lake, and Little Blue Lake, requiring a crazy scramble up rocks marked by cairns. Lost Lake. Brainerd Lake. Sprague Lake, which we hiked to from outside the park, only to walk into a parking lot full of people who had simply driven there. And Bear Lake, Lake Haiyaha, Dream Lake, Emerald Lake and Nymph Lake, all on the same day!
Back up the mountain
Then last week, we hiked Bear Peak again, for the first time in four years.
No crazy weight on my back for this one. This was the hike we'd trained for, and we set out to see what we could do. I carried nothing but water and layers, plus a first aid kit, a shovel and a knife, because every trailhead sign told us it was better to have them and not need them than to need them and not have them.
I felt like a million bucks. It was our first hike of the year in the rain, and soaking wet, we climbed 3,000 feet over about five miles and came back down three miles with smiles on our faces. I felt more capable than I ever had, in stark contrast to four years ago.
Now hear this: testosterone therapy and GLP-1 therapy are no substitute for eating well and exercising. They are not a magic bullet that every midlife man can shoot himself with to transform his life without overhauling how he lives. My personal journey to health and wellness is not a protocol that can be applied to everyone.
What I found was support for my own efforts to be as healthy as I can be in middle age. Everyone deserves an evidence-based look at midlife hormones like the one I got, and nobody should have to pay a testosterone clinic, or anyone who isn't their primary care doctor, to get it.
Midlife care is baked into the bedrock of what I've built at Metronome Family Medicine. If you live in Colorado and don't have support in this area from your primary care doctor, give me a call :) If you’re an employed doctor who does not get to see something as magnificent as the views in Rocky Mountain National Park at least once a week, consider direct care: DPCalliance.org and DSCalliance.org.
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 here.
