What 52 Looks Like

At my 30th reunion with the University of Rochester's Class of 1996 — about eighty of us back out of a class of a thousand — there was a lot of midlife talk.

We're basically all 52 this year, and strategizing our way through various approaches to hormone replacement and weight loss. Our cohort is approaching this moment with a strange and specific historical context.

In November of 2025, the FDA removed the boxed warning from estrogen-containing hormone therapy products — the black box that had framed estrogen, for more than two decades, as something that raises breast cancer risk. The agency concluded the risks had been overstated, and the new labeling includes age-specific guidance noting that women may see long-term benefit when therapy starts within ten years of menopause. (The endometrial cancer warning stays on systemic estrogen-only products, and plenty of oncologists have pushed back on the change. This isn't settled; it's moving.)

Testosterone replacement, meanwhile, is all over TikTok. And the FDA held a public workshop in September on testosterone use in menopausal women — the comment docket is open until October 19, which means anyone reading this still has time to tell them what their experience has been. The studies that appeared to link testosterone to heart disease have been substantially debunked.

Root-cause and functional approaches to prevention are gaining traction in concierge clinics, where doctors and APPs are focused on longevity and healthspan. A lot of us are looking at our aging parents with real worry — the ones still with us are weathering strokes, cancer treatment, heart problems, and the compounding weight of chronic disease — and quietly wondering how much of that was inevitable.

And Direct Primary Care has grown 837% in this country since 2017. Most of my classmates had never heard of it. The ones who had assumed that, like most concierge practices, it was financially out of reach.

What my classmates are actually doing

Many of my peers have access to concierge doctors. If not, they subscribe to Midi Health for menopause hormones, or get GLP-1 medications through Hims or Hers. Others see chiropractors or pharmacists — who have no prescriptive authority — for care of actual medical conditions in a functional setting. All of this sits on top of whatever doctor they can see in primary care under their insurance plan.

So I asked around. How's your doctor? Are you being taken care of?

The answers were remarkably consistent. A lot of people didn't know their PCP. Others described them as "fine" — meaning not much happens beyond five minutes of face time at an annual physical, where their complaints get absorbed into the general category of aging rather than treated as features of manageable disease, or as signals that the midlife transition is worth a real conversation.

We know about peptides. We don't know how to use them, or when — and almost nobody who's heard of them has a qualified source to ask. The information arrives through a podcast, a gym, a supplement retailer, or a clinic that sells them. None of those has any obligation to tell you no.

The hormone prescribers and the GLP-1 clubs offer lifestyle coaches, and virtual appointments with prescribing physicians where appropriate. But nobody is building a relationship with these providers, who exist largely to sign orders and supply the counseling required when a patient needs to talk to a doctor.

The exception, which is the part that matters

There were classmates who spoke warmly about their doctor. Real affection — the kind you have for somebody who knows you, who remembers what you were dealing with last year, who you'd call first.

Without a single exception, they were paying for that relationship outside their insurance. Nearly always a concierge practice. Nearly always because they happen to be able to afford one. And several of them got there by leaving a practice that sounded exactly like what everybody else was describing.

So satisfaction with primary care hasn't vanished. It's been repriced as a discretionary purchase, available to the people with the means to make it.

I'd ask you to sit with that for a second, because it's easy to read everything above as doctors are failing people, and that isn't what I found. The thing everybody else described missing is not gone. It's behind a paywall most households can't clear.

Which is why I care about what this costs, and not only about how it works.

The shared experience

Everyone at that reunion had some version of the same story.

Not needing much from your PCP until suddenly you did — and then being told your physical wasn't the venue to raise additional concerns. Watching insurance premiums become one of the largest line items in your household budget, and still not being able to get in when you needed something.

Being told there was no need to check your hormone levels. Or that you were too young for hormone replacement. Or that estrogen causes breast cancer. Or that testosterone causes heart disease. Or that your thyroid labs were normal, when most of them had never been drawn.

And all of us, at some point, seeing an alternative provider because we couldn't get something done inside the system.

Who I'm doing this for

What stayed with me after the trip was a reminder of exactly who I built this practice for.

I opened a Direct Primary Care practice focused on midlife care because this is where all of my friends are in their lives. They can't all see me — but there are people like them everywhere, and until I expand my license into other states, I'm learning everything I can and working with the people I can work with.

Metronome Family Medicine has added a hundred members to the thirty-three who signed up on day one. People are finding the practice on Google, through ChatGPT, or from a current member or a neighbor who ran into me somewhere around town.

I also knew I'd need to prioritize my own health to be ready for the coming years, however many I get. I want to maximize my ability to enjoy them and move through the world the way I always have — even if it's a little slower than it was ten years ago. What I've been picking up from colleagues, educators, and mentors in functional medicine and hormone optimization has genuinely transformed how I approach preventive care, and I'm still fired up to share it with men and women who want one primary care doctor on their team as they move into midlife.

What this is not

Let me be clear, because this gets flattened constantly: this is not a hormones for everybody, weight loss for everybodypost.

I'm here to point out that most conventional primary care is still massively behind the times on hormone replacement — and that testosterone for women remains genuinely controversial in a lot of circles.

I'm here to note that GLP-1 medications are completely unaffordable for most people without insurance, which tends to decline coverage until the burden of metabolic and chronic disease makes them unavoidable. And that the research on their use in alcohol use disorder, other addictions, and as anti-inflammatory agents may never get serious consideration inside systems-based care.

I'm here to tell you that expensive concierge metabolic services are not doing more for your thyroid than your primary care doctor is capable of doing.

And I'm here to say plainly that consensus and widespread adoption of treatment protocols for hormone optimization, thyroid optimization, and peptides all remain in grey areas — and that those grey areas warrant serious conversations about what we do and don't know before anybody takes them on.

But somebody has to start that conversation.

I want my peers and me to be able to have it in primary care, where one doctor can follow through on all of it. I want it to happen in DPC, where my doctor is actually reachable.

I founded Metronome Family Medicine and I'm shaping it into the kind of practice I'd want for myself.

Maybe it's the kind you'd want too.

Brian Juan, MD, FAAFP — University of Rochester, Class of '96. Meliora, baby!

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.