Direct Primary Care: Access Problems in Today’s Clinics

On By Dr. Scott RennieIn Healthcare System & TechnologyLeave a comment

When I talk to patients about how they access care, I hear a lot of frustration with the way primary care is delivered today. People describe having to wait weeks for a routine appointment at a clinic owned by a large corporation. They tell me they freeze up when they see a copay, even for simple follow-ups. And they often end up sitting in urgent care lines for something that should have been sorted out by a doctor who knows their story.

That experience is not unique. Many traditional primary care clinics are now owned or managed by big health systems and private equity firms. Those organizations run medicine like a business, with incentives tied to volume and billing rather than the patient’s whole-person health. That often means large patient panels and shorter visits. It also means that, with limited appointment slots and competing demands, a visit may not come soon enough when someone needs timely care.

Direct primary care (DPC) grew out of that dissatisfaction. In the simplest terms, DPC is a model where patients pay their doctor a flat membership fee, usually monthly, for direct access to routine and preventive primary care without billing insurance for every visit. You don’t see a copay or deductible for that visit the same way you do in the traditional system. What you pay upfront buys you ongoing access to your clinician for check-ups, chronic disease management, urgent but non-emergency care, and preventive services. It’s a direct contract between you and your doctor, not a third party like an insurer in the middle.

One of the most striking differences between DPC and a corporate primary care clinic is access. In a typical insurance-based practice, panels can be very large. Physicians might have multiple thousands of patients, which contributes to long waits for appointments and brief encounters when you finally get in. In contrast, many DPC practices purposefully keep panel sizes smaller, sometimes by orders of magnitude, so patients can get same-day or next-day visits and more time with the physician.

That difference matters to patients trying to manage chronic illness or catch problems early. I’ve had patients tell me they opted for DPC after a night of struggling with a new symptom and knowing that at an urgent care clinic they would only get episodic treatment. They want someone who sees the full picture of their health year after year, not someone who treats symptoms in isolation.

That contrast between DPC and urgent care is important. Urgent care excels when a child’s flu symptoms spike at 3 a.m. or when someone twists an ankle. It’s great for acute, episodic problems, and you don’t need an appointment. But those clinics are not set up to build a longitudinal understanding of you as a person: your past medical history, your family health history, your social context, your chronic disease patterns. Urgent care providers are trained to stabilize and treat the immediate issue. They rarely have time or the patient record in front of them to integrate your whole story into a care plan.

Direct primary care, on the other hand, puts continuity and relationship first. If you see your doctor regularly, they come to know your lab values alongside your life stressors, your diet, your work, and how your family affects your health trajectory. They can tailor plans accordingly, and they are available when you need guidance early on, often avoiding a need for more costly or fragmented care later.

Here is a hypothetical, not an actual patient encounter: a persistent cough that won’t clear up. In urgent care, a patient might get evaluated and sent home with instructions to rest or a prescription for symptomatic relief. In a DPC clinic, the doctor can say “let’s see you today,” review the full chart, adjust chronic meds if needed, and schedule a follow-up next week. That continuity can make the difference.

DPC is not perfect for everyone. Membership costs money, and that cost has to be weighed against sporadic traditional visits, though many patients find that predictable pricing encourages them to seek care early instead of waiting for a problem to become urgent. It doesn’t replace insurance. Hospitalizations, specialized care, and emergency services still need coverage of their own; DPC handles primary care, not surgeries or specialist procedures. Geographic access is a real constraint too. Not every area has a DPC practice within reach, and for some patients that alone rules it out.

Advocates of DPC argue that the financial predictability and relationship-based care improve satisfaction. Members appreciate straightforward pricing without surprise bills. Physicians appreciate less paperwork and more clinical time with patients.

The model works best for primary care needs alone. It doesn’t cover everything, and patients should pair a DPC membership with adequate insurance for catastrophic events.

Where I think the DPC pitch oversells itself: it markets convenience as though it solves a shortage problem. A membership fee doesn’t create more primary care doctors in a region that doesn’t have any. It only helps if a DPC practice already exists within reach.

I ran a concierge practice in 2010 and 2011, before anyone was calling it direct primary care. Patients felt less rushed and more heard, and that part was real. They call or message with early symptoms and get help quickly. That often prevents minor issues from becoming major ones. It’s a different rhythm of care, one that reflects the old-fashioned doctor-patient relationship many of us went into medicine to preserve. If a patient values that kind of access and ongoing partnership, and understands the limits of what DPC covers, it can be a powerful option that keeps them healthier and more engaged with their care.

Scott Rennie, D.O.

Sources

American Academy of Family Physicians (AAFP)

https://www.aafp.org/family-physician/practice-and-career/delivery-payment-models/direct-primary-care.html

Direct Primary Care Coalition

https://www.dpcare.org/what-is-dpc

National Academies of Sciences discussion mentioning DPC models

https://nap.nationalacademies.org/read/26183/chapter/5

Access, wait times, and problems in traditional primary care

Merritt Hawkins Physician Appointment Wait Time Survey

https://www.merritthawkins.com/news-and-insights/thought-leadership/survey/physician-appointment-wait-times/

Association of American Medical Colleges primary care shortage data

https://www.aamc.org/news/press-releases/aamc-report-reinforces-physician-shortage

Corporate ownership and consolidation in healthcare

American Medical Association on private equity and consolidation

https://www.ama-assn.org/delivering-care/public-health/what-doctors-should-know-about-private-equity-medicine

Health Affairs on private equity and physician practices

https://www.healthaffairs.org/do/10.1377/hblog20230207.10575/full/

New England Journal of Medicine perspective on private equity in healthcare

https://www.nejm.org/doi/full/10.1056/NEJMp2102339

Urgent care role and limitations

Urgent Care Association patient education

https://www.ucare.org/patients/what-is-urgent-care

Agency for Healthcare Research and Quality on primary care continuity

https://www.ahrq.gov/ncepcr/primary-care-measures/continuity.html

Direct Primary Care outcomes and structure

Journal of the American Board of Family Medicine review of DPC

https://www.jabfm.org/content/28/6/793

Health Affairs article on DPC patient experience

https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05032

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Unlabeled blister pack of six white oval antibiotic tablets beside a plain paper pharmacy bag on a kitchen table

I hear it almost every day now. “I think I just need a Z-Pak.”

On By Dr. Scott RennieIn Infectious Disease, Other Diseases and ConditionsLeave a comment

Sometimes it’s phrased as a question. Sometimes it isn’t. In telemedicine especially, many patients request azithromycin by name within the first minute of the visit. The symptoms are familiar. Runny nose. Congestion. Post-nasal drip. Scratchy throat. Maybe a cough that started yesterday. No fever. No shortness of breath. No focal findings anyone could reasonably point to as bacterial.

But they’re convinced the Z-Pak will help them get better faster. They’ve taken it before. It worked last time. Or at least they felt better a few days later and connected the dots.

This didn’t happen by accident.

Azithromycin earned its place in outpatient medicine because it was easier to tolerate than older antibiotics like erythromycin, had fewer drug interactions than clarithromycin, and came packaged in a way that felt efficient. Six pills. Five days. Done. The Z-Pak became a symbol of modern medicine that didn’t slow you down.

Over time, it also became the antibiotic people expected.

In telemedicine, that expectation is even stronger. There’s no exam table. No stethoscope. No labs. No chest X-ray down the hall. The visit is brief by design. When a patient feels sick and wants something tangible, the Z-Pak becomes the path of least resistance. Prescribing it can shorten the encounter. It avoids a long explanation. It reduces the risk of a bad review. It keeps patient satisfaction scores high. It keeps supervisors and clinic managers happy. Everyone moves on to the next visit.

I understand why this happens. I’ve seen it from the inside.

But convenience doesn’t make a treatment safe or appropriate.

Azithromycin does not treat viral infections. It does not help the common cold. It does not clear post-nasal drip. It does not shorten the course of uncomplicated upper respiratory infections. When patients feel better after taking it, they almost always would have improved anyway.

What it does do is expose people to real risk.

Azithromycin can prolong the QT interval. That matters. QT prolongation can predispose patients to dangerous heart rhythms, including torsades de pointes and sudden cardiac death. This risk is higher in people with underlying heart disease, electrolyte abnormalities, or those taking other QT-prolonging medications, but it is not zero in otherwise healthy adults. Large observational studies have shown an increased risk of cardiovascular death during azithromycin treatment compared with other antibiotics or no antibiotics at all.

That risk is invisible to patients. They don’t feel their QT interval getting longer. They just know they want something to help them feel better.

Antibiotics also carry more familiar side effects. Nausea. Diarrhea. Abdominal cramping. Yeast infections. Rashes. Allergic reactions. These are not rare, and they are not trivial when the medication wasn’t needed in the first place.

Then there’s resistance. Every unnecessary antibiotic course applies selective pressure. Azithromycin resistance is already a growing problem in common respiratory pathogens. When we reach for it reflexively, we make it less useful for the patients who actually need it.

The harder part of these visits is the explaining.

It takes longer to walk someone through why their symptoms are viral. Why time, fluids, nasal saline, antihistamines, or intranasal steroids actually help. Why rest matters. Why antibiotics won’t fix inflammation or mucus production. Why feeling miserable does not automatically mean something dangerous is happening.

It’s much faster to send a prescription.

But faster is not better medicine.

I get patients asking for Z-Paks every day that I work in telemedicine. It’s so common that it happens at least once a day, if not three or four times a day. One example sticks with me. A patient requested a Z-Pak for congestion and sinus pressure that had been present for two days. No fever. No facial pain. No worsening course. When I explained why antibiotics wouldn’t help, they were frustrated at first. We talked through what sinus infections actually look like and when antibiotics are appropriate. We discussed symptom control instead. Two days later, they messaged to say they felt better and were glad they didn’t take an antibiotic they didn’t need.

That outcome required time. It required education. It required saying no.

Not every visit goes that smoothly. Some patients remain disappointed. Some leave poor reviews. That pressure is real, especially in high-volume telemedicine environments.

But prescribing antibiotics to keep the peace comes at a cost. It shifts risk onto the patient. It shifts harm into the future. And it reinforces the idea that medicine should always offer a pill, even when the best treatment is patience and support.

Azithromycin became dominant because it was easy. That same ease is why we need to be more careful with it now.

Scott Rennie, D.O.

Sources:

Ray WA, Murray KT, Hall K, Arbogast PG, Stein CM. Azithromycin and the risk of cardiovascular death. New England Journal of Medicine. 2012;366:1881-1890.

Sax PE. How the Z-Pak Took Over Outpatient Medicine. Substack lecture notes and essay.

Svanstrom H et al. Use of azithromycin and death from cardiovascular causes. New England Journal of Medicine. 2013;368:1704-1712.

FDA Drug Safety Communication. Azithromycin and risk of potentially fatal heart rhythms. US Food and Drug Administration. 2013.

CDC. Antibiotic use in the United States: Progress and opportunities. Centers for Disease Control and Prevention.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

2026 Travel Medicine Guide: Vaccines, Antibiotics, Safety Tips, and What You Don’t Need

On By Dr. Scott RennieIn Other Diseases and Conditions, Travel, Wilderness & Preparedness MedicineLeave a comment

Travel has fully returned, and patients are planning international trips again, with a wide range of destinations and styles. On these video visits, the questions almost always start with vaccines or antibiotics. The real foundation of travel medicine is something else entirely: understanding the specifics of the trip. When I talk with someone preparing to travel, I start with where they are going, how long they will be away, what kind of environment they will be in, and whether they have a chronic condition that might change their risk. Those details matter. A medication or vaccine that is essential for one itinerary may be unnecessary for another.

The first step is confirming routine immunizations. MMR, Tdap, influenza, COVID, and varicella should be current for every traveler, regardless of destination. People sometimes think travel preparation means exotic vaccines. But many illnesses that interrupt trips are the same preventable infections we vaccinate against at home. Once routine protection is confirmed, I look at travel-specific vaccines based on destination and activities. Hepatitis A is worth adding for most international travel where sanitation varies. Hepatitis B belongs on the list for long-term travel, healthcare exposure risk, or an uncertain vaccination history. Typhoid covers travel to many parts of Asia, Africa, and Central America. Yellow fever is required for entry into several countries in sub-Saharan Africa and South America, and Japanese encephalitis matters for long stays in rural areas of Asia or frequent outdoor exposure. Ghana is the example I reach for. Yellow fever vaccination is required for entry, and travelers turn up regularly who have never had it and did not know it was mandatory. That gets sorted first, then malaria prevention if the itinerary runs rural. My view: skipping a vaccine that’s actually required for entry is the most avoidable mistake I see. It’s an easy one to catch, too, if we go through the itinerary first.

Rabies vaccination before travel is another example of something that depends heavily on the details. Someone visiting large cities in Europe for a week has almost no need for it. Someone staying in remote areas, volunteering with animals, or hiking in places where medical care is difficult to access may benefit from receiving it ahead of time. Exposure risk drives that decision, not the destination’s reputation.

Antibiotics come up frequently, and this is where expectations and guidelines often differ. Many travelers assume an antibiotic is something they should take with them in case they get sick. In reality, travelers diarrhea is the most common illness during international travel. Most mild cases respond to hydration and over the counter medications rather than antibiotics. When antibiotics are appropriate, the choice depends on symptom severity and regional resistance patterns. Rural Cambodia is the one that comes up. Travelers remember taking ciprofloxacin on a previous trip and want it again. Updated resistance data has made ciprofloxacin a poor choice there, so the plan changes, and food and water safety carries more of the load. My own bias here. I’d rather a patient carry the right antibiotic and never use it than assume hydration will be enough on a five-day trek.

For a basic travel kit, I usually start with acetaminophen and ibuprofen, which cover pain, fever, and the aches that come with viral illnesses; for gastrointestinal symptoms, loperamide and bismuth subsalicylate handle most mild travelers diarrhea, and oral rehydration salts matter just as much, since dehydration from diarrhea or heat is often the bigger problem than the diarrhea itself. If nausea or motion sickness is a concern, I’ll prescribe ondansetron ahead of time. For moderate or severe diarrhea, azithromycin or a clinician-selected alternative is the antibiotic I reach for, not something to use for every loose stool. Acetazolamide comes up for rapid ascent or high-altitude destinations. For malaria prevention, the choice sits between atovaquone-proguanil, doxycycline, and mefloquine. It depends on the region, the length of the trip, and the traveler’s medical history. Antihistamines and intranasal steroids round out the kit for anyone with seasonal or environmental triggers.

Safety planning is a major part of effective travel preparation, but it often gets the least attention; we discuss how to carry a medication list, a brief summary of medical conditions, and insurance information, along with knowing how to access care in the destination country. Food and water hygiene still matters in many regions. So does mosquito protection for illnesses like dengue and chikungunya that do not have widely recommended vaccines for travelers. For destinations with malaria risk, prophylactic medications and mosquito avoidance measures remain a core part of the plan; and for high altitude trips, preventive medications can help if ascent is rapid or unavoidable. If I had to rank these, food and water discipline prevents more sick days than any pill I prescribe. A basic first aid kit rounds this out: adhesive bandages for cuts, scrapes, and blisters; sterile gauze and medical tape for larger wounds; antibiotic ointment to prevent minor wound infections; hydrocortisone cream for itching and insect bites; alcohol or antiseptic wipes to clean a wound before dressing it; tweezers for splinters or ticks; an elastic compression wrap for sprains or mild injuries; a digital thermometer, essential for evaluating fever or illness on the road; and gloves for basic hygiene when handling a wound.

Many travelers also assume they need more than they actually do. Someone visiting Western Europe with up to date routine vaccines usually does not need any additional travel specific vaccines. Travelers often believe they need antibiotics for every trip or that malaria medication protects them from dengue or chikungunya. Which it does not. Correcting these misconceptions is, in my view, as valuable as any vaccine I give: it keeps people from paying for protection they don’t need.

Combine all of this with a clear discussion of itinerary, health history, and realistic risk. Most travelers leave the visit feeling better prepared, not overwhelmed by unnecessary steps. Travel medicine should be individualized. What someone needs for a two week trip to Western Europe is very different from what is needed for remote backpacking in Southeast Asia or trekking at high altitude in Peru. Once the plan matches the destination, everything else becomes much clearer.

Scott Rennie, D.O.

Sources

CDC Yellow Book (cdc.gov)

CDC Travel Vaccine Guide (cdc.gov)

CDC Travelers Diarrhea (cdc.gov)

WHO Travel and Health (who.int)

WHO International Travel Requirements (who.int)

UPMC Travel Health (upmc.com)

TravelHealthPro (travelhealthpro.org.uk)

National Library of Medicine Travelers Diarrhea Review (ncbi.nlm.nih.gov)

Pyllola Travel Vaccines Guide (pyllola.com)

Immunize.org Travel Vaccines (immunize.org)

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Menopause Treatment by Telemedicine: How It Works

On By Dr. Scott RennieIn Menopause & Women's Health, Senior & Caregiver HealthLeave a comment

For many women, menopause care has long been an afterthought in traditional medicine. The conversation often starts late, if it happens at all. Now, thanks to telemedicine, that’s beginning to change.

Over the last few years, virtual menopause clinics have emerged to fill a long-standing gap in women’s health. Clinics like Midi Health and Menopause RX connect women directly with clinicians trained in menopause care. According to the Centers for Disease Control and Prevention, about 42 percent of women now use telemedicine, and a growing number are using it specifically for midlife and menopausal health (Pevzner, 2025; CDC, 2025).

This shift matters. Research shows that most doctors receive little or no formal training in menopause management. A 2019 Mayo Clinic report found that only 7 percent of medical residents felt prepared to manage menopause (Mayo Clinic Proceedings, 2019). Women often report their symptoms being dismissed or overlooked. In a 2025 survey of 1,000 women aged 45 to 60, nearly 71 percent said their physician didn’t adequately prepare them for menopause or discuss treatment options (Pevzner, 2025).

That’s where telemedicine can help. Virtual menopause clinics provide timely access to clinicians who understand hormonal transitions and can offer evidence-based guidance. As Dr. Sherry Ross, an ob-gyn in California, explained in a Yahoo Health interview, these platforms solve many of the problems in the current healthcare system, particularly access and education (Pevzner, 2025).

Telehealth also reaches women in rural or underserved areas where menopause-certified specialists are scarce. The Menopause Society, formerly NAMS, highlights this benefit in its educational resources, noting that virtual platforms can deliver specialized care to women who might otherwise go without it (The Menopause Society, 2025). On my own panel, roughly 25 percent of women arrive already on hormone therapy started elsewhere; most others are still looking to start when they get to me. That tells me how far this shift has already gone outside primary care.

Virtual visits handle a fairly wide range of these symptoms: hot flashes, sleep disturbance, mood changes, low libido, and mild vaginal dryness lead the list, and each of these can often be addressed through careful history, lifestyle interventions, and evidence-based hormonal or non-hormonal therapies (Pevzner, 2025).

Of course, telehealth isn’t the right fit for everyone. Complex or potentially serious symptoms such as postmenopausal bleeding, abnormal discharge, breast changes, or pelvic pain still require in-person evaluation. As Dr. Robin Noble, a gynecologist in Maine, reminds clinicians, some conditions simply can’t be ruled out without a physical exam (Pevzner, 2025).

That balance is important. Telemedicine can’t rule out postmenopausal bleeding, abnormal discharge, or a breast change over video, and it shouldn’t try to. The best virtual programs integrate follow-up visits, communicate with the patient’s primary physician, and make sure screenings like mammograms and Pap smears stay on schedule (The Menopause Society, 2025).

When colleagues ask how to steer patients toward credible virtual options, I start with licensure: is the provider licensed and, ideally, certified by The Menopause Society (MSCP)? From there, check that the clinic’s data security is HIPAA-compliant, and don’t sign on until there’s a real process for ongoing monitoring and coordination of care (The Menopause Society, 2025).

Here’s where I push back on the marketing a little. Platforms like to say virtual care “closes the gap,” but a same-day video visit doesn’t fix a residency curriculum that gave menopause a few hours of teaching total. It gets a patient to someone who knows the topic faster. It doesn’t fix why so few primary care doctors learned it in the first place.

Some version of this comes up constantly: a woman held off on raising her symptoms because she didn’t want to waste the doctor’s time. Then she gets to someone who takes the question seriously, and what she finds is reassurance and a plan. That’s the kind of access we should all want for our patients: timely, informed, and respectful of their experience.

Menopause care is finally catching up with the rest of modern medicine, and telemedicine is a big part of why.

Scott Rennie, D.O.

References

Pevzner, H. (2025, July 30). Your complete guide to getting menopause help online. Yahoo Health. https://www.yahoo.com/lifestyle/menopause-telehealth-guide

Centers for Disease Control and Prevention (CDC). (2025). Telemedicine utilization data.

Mayo Clinic Proceedings. (2019). Menopause education in residency training.

The Menopause Society (formerly NAMS). (2025). Professional resources and video library.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Why Menopause Care Is Missing From Women’s Checkups

On By Dr. Scott RennieIn Menopause & Women's Health, Senior & Caregiver HealthLeave a comment

I hear some version of the same question most weeks on video visits, patients trying to figure out whether what they’re feeling is actually menopause.

Women often come to me with vague but frustrating symptoms. Trouble sleeping. Brain fog. New anxiety. Irregular or heavy periods. Weight creeping up despite no major changes. Sometimes joint pain, palpitations, or new migraines. Many times, we both suspect something hormonal. The connection to menopause doesn’t always click right away.

Most of us were never taught to see the menopause transition as its own physiologic phase with real preventive implications, not because we don’t care. Medical training gives menopause a brief mention inside reproductive aging, with the emphasis staying on fertility, not on what happens once it ends. Patients ask me about hormone therapy, sleep, mood, or sexual changes, and more often than I’d like, I don’t feel equipped in the moment to explain what’s happening or lay out the options.

The average woman in the United States reaches menopause at about age 51, according to the Mayo Clinic (2024). The years leading up to that point, called perimenopause, can last four to eight years. Hormone levels fluctuate widely during this time. These shifts affect body temperature regulation, brain chemistry, metabolism, and cardiovascular function. Symptoms can begin well before the final menstrual period. A woman in her mid-forties may show up with new anxiety, fatigue, or night sweats. That’s an easy substitution to make instead of perimenopause, and it’s one I watch for now specifically because of how often it happens.

There are several reasons why menopause-related concerns get missed. Many women are still menstruating irregularly and do not yet think of themselves as menopausal; primary care visits are short and filled with competing priorities. The confusion that followed older studies on hormone therapy still lingers. I’d rather be direct about where I land: the newer safety data is solid, and hesitation still rooted in the old fear is outdated. Newer research from The Menopause Society and the National Institutes of Health shows clear safety and benefit for most healthy women under 60 or within 10 years of menopause onset (The Menopause Society, 2023; NIH, Office on Women’s Health, 2024).

I ask every woman in her forties about menstrual changes, hot flashes, sleep, mood, libido, and vaginal or urinary symptoms, because awareness starts with the question, not the answer. Simple questions open the door. If a patient raises the issue herself, I’d rather start the conversation than defer it to a specialist on the spot.

I lean on The Menopause Society’s practical resources and CME, and I’m working through their Menopause Society Certified Practitioner (MSCP) program myself. Reading Menopause Practice: A Clinician’s Guide or reviewing their treatment algorithms has strengthened my own confidence here. Other organizations such as the NIH, AAFP, and Cleveland Clinic also offer free CME courses and case examples.

Treatment doesn’t always mean prescribing systemic hormone therapy right away. I explain the range of choices and personalize them: for some patients that means hormone therapy, for others it’s non-hormonal medications, localized vaginal treatment, or lifestyle interventions. For a symptomatic perimenopausal patient who still needs contraception, I favor continuous combined hormonal contraceptives, since standard menopausal hormone therapy can produce breakthrough bleeding in that setting; a typical low-dose choice is ethinyl estradiol 20 mcg plus levonorgestrel 100 mcg orally once daily, often continuously. If contraception isn’t a factor, my usual starting menopausal regimen is transdermal 17-beta-estradiol 0.025 to 0.05 mg/day plus micronized progesterone 100 mg nightly, continuously, if the uterus is present. Weight-bearing exercise, protein intake, and good sleep remain foundational regardless of what else we add. My job is to know the options well enough to guide that discussion, and to know when a referral actually helps more than I can.

When menopause management becomes part of preventive care, patients feel seen and supported. It becomes a normal part of the health conversation, the same as colon screening or cholesterol management; I try to keep these discussions inside the relationship I already have with a patient, rather than routing her to someone new for something I can manage myself.

Menopause represents a turning point for cardiovascular, metabolic, and bone health, and recognizing it early is a real opportunity to prevent disease later. My honest read on where primary care gets this wrong: it’s decades-old caution about hormone therapy that the newer data no longer supports, not a lack of caring. Women deserve clinicians who treat that caution as outdated and prescribe with the confidence the evidence now allows.

Scott Rennie, D.O.

References:

Cleveland Clinic. Menopause and Preventive Care: What Every Woman Should Know. 2023.

The Menopause Society. Menopause Practice: A Clinician’s Guide, 6th Edition. 2023.

Mayo Clinic. Menopause: Symptoms and Causes. Updated 2024.

NIH Office on Women’s Health. Menopause and Heart Health. 2024.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Compounded Semaglutide and Tirzepatide: What to Know Now

On By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

When patients ask me about compounded weight loss drugs like semaglutide and tirzepatide, I take a deep breath. The topic is complicated and keeps changing. I won’t just tell patients to avoid them. They’re already looking for these options, and my job is to help them navigate the risks safely.

Dr. Beverly Tchang’s “swim safely” analogy fits well. We can’t stop people from diving into the ocean of compounded products, but we can at least give them floaties: information, caution, and tools to make better decisions. (Tchang, Medscape)

Here’s how I explain it to patients and colleagues, updated with the most recent data.

Why compounded versions exist

When semaglutide and tirzepatide injections were in short supply a few years ago, patients turned to compounding pharmacies that offered custom formulations, often at a lower price. (GoodRx)

In late 2024, the FDA ended the declared shortage of tirzepatide. (Stat News) By early 2025, semaglutide (Ozempic and Wegovy) followed. Once the shortages ended, enforcement ramped up against compounded versions. (GoodRx)

Now, compounded versions are only legal in narrow circumstances, such as when a patient has a medical need that can’t be met by an approved product. (GoodRx)

In December 2024, the FDA sent warning letters to several companies selling unapproved GLP-1 drugs labeled “for research use only.” (Reuters) Some of these contained no active ingredient, incorrect salt forms, or inconsistent potency. (Verywell Health)

Key risks and what to look for

Not all compounding pharmacies operate at the same standard. A friendly local pharmacist doesn’t necessarily mean the product is safe. Dr. Tchang’s checklist gives a good framework for evaluating any compounded GLP-1 medication. A simplified version: look for a pharmacy where the medication is prescribed by a licensed provider, there are no disciplinary actions on file, the pharmacy has been in business for more than a year, only semaglutide base is used (not a salt form), and the facility is FDA-registered or FDA-inspected; it should also be able to ship sterile drugs safely to all 50 states.

If a compounding pharmacy cannot meet these criteria, that’s a red flag. Ask directly for documentation. If they can’t provide it, walk away.

Some compounders also mix in vitamins or preservatives to make their product “different” from the brand name; that may sound harmless, but combining untested additives with peptides can change how the drug behaves. (GoodRx)

A few are promoting oral or sublingual forms of semaglutide and tirzepatide. These seem attractive for patients who don’t like injections, but they haven’t been validated in clinical trials, and absorption is unpredictable. (Omada Health)

Even small changes in formulation or dosing can interrupt treatment and cause rebound weight gain or side effects.

How I approach this with patients

When a patient says, “I found a compounding pharmacy that sells it for half the price,” I acknowledge their concern. Access and cost are real issues. But I explain that the regulatory situation has changed. If an FDA-approved version is available, that’s the standard we should use first.

I encourage patients to ask the pharmacy for their certificate of analysis, sterility test results, and ingredient source; if the pharmacy hesitates or says it’s proprietary, that’s enough reason to stop.

One patient of mine was on a compounded semaglutide microdose that wasn’t commercially available, at least as she described it to me. I never could pin down what she was actually getting. The compounder wouldn’t release potency data either. We moved her to a low-dose commercial version instead. Weight loss slowed a little. Safety and consistency improved, and I knew what was in the pen.

We also reviewed manufacturer assistance programs and insurance coverage. Many patients don’t realize that drug makers often cap out-of-pocket costs for brand medications; cost confusion is one of the biggest drivers behind compounded use.

The FDA’s BeSafeRx campaign

The FDA has an ongoing public safety campaign called BeSafeRx, designed to help patients and providers verify the legitimacy of online pharmacies and compounded drug sources; it offers tools to check pharmacy licenses, identify red flags, and report suspicious products.

It’s a good resource for anyone considering buying compounded or online medications; I often share it directly with patients so they can see what trustworthy sourcing looks like.

You can find the BeSafeRx information at:

https://www.fda.gov/drugs/buying-using-medicine-safely/besaferx-your-source-online-pharmacy-information

What’s changed recently

The REDEFINE trial (NEJM, 2025) studied cagrilintide combined with semaglutide (CagriSema) and showed about 20.4 percent weight loss over 68 weeks, compared with 14.9 percent with semaglutide alone; that kind of data will shape treatment algorithms going forward. GoodRx reports that the FDA’s grace period for compounding GLP-1s has officially ended for both tirzepatide and semaglutide, though some pharmacies still market “custom” or “non-identical” formulations, and regulators are watching closely.

Approach this without judgment if you’re a clinician. Patients are trying to find affordable solutions. And they often trust what they see on social media more than official channels; we can help most by staying informed, asking questions, and documenting carefully. Patients should be cautious for a different reason. Ask your provider to review any compounded medication before you use it, make sure your pharmacy meets every item on that checklist, and use resources like the FDA’s BeSafeRx to verify safety.

Knowledge and transparency remain the best safeguards.

Scott Rennie, D.O.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Why Weight Loss Plateaus Happen and How to Break One

On By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

Most people losing weight eventually hit a plateau. The number on the scale stops moving, sometimes for weeks, and it can feel like something has gone wrong. Nothing has. Plateaus happen because of biology: at a lower body weight the body burns fewer calories than it used to, and hormones like leptin shift in ways that increase hunger, slow resting metabolism, and make the next five pounds harder to lose than the first fifty.

Handling a plateau matters more than trying to prevent one. In my practice, we look at the medication plan, nutrition, and activity together. Sometimes the answer is moving to a higher dose of semaglutide (Wegovy) or tirzepatide (Zepbound), switching between the two, or starting orforglipron (Foundayo) if a patient hasn’t tried it yet. In my experience two patterns show up most. An early one within the first month, when patients think the medication has stopped working but it’s actually just been started low to help the body adjust rather than to drive weight loss yet. And a later one once someone’s at the highest dose they can tolerate, when exercise drops off and food choices drift back to where they started. Other times the prescription isn’t the issue at all. Small changes in nutrition, like adding more protein, cutting liquid calories, or tightening portions, can make the difference.

Physical activity plays a role too. The National Weight Control Registry has shown that people who keep weight off long term usually exercise about an hour a day. That doesn’t mean a treadmill. Brisk walking, biking, swimming, anything that raises the heart rate consistently, counts, and strength training helps by preserving lean muscle and keeping metabolism steady.

Daily habits matter. People who maintain weight loss tend to eat breakfast every day and weigh themselves regularly. They also tend to watch less television, generally under ten hours a week. None of this is a rigid rulebook. It’s structure, and structure makes it harder to drift back into old patterns.

If you hit a plateau, don’t get discouraged. Treat it as a signal to check in and adjust, not to quit. My first move is usually education, making sure the patient understands what the medication is actually doing and why the scale has stalled. If food noise is still loud after that conversation, I’ll increase the dose or add another medication, but not before we’ve gone back through lifestyle and food choices together. Whatever the starting point, there are proven strategies to get moving again.

Reference: National Weight Control Registry. www.nwcr.ws

Scott Rennie, D.O.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Binge Eating Disorder Signs and Treatment in Adults and Kids

On By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

Binge Eating Disorder, or BED, is one of the eating disorders I screen for most often in practice. Clinicians define it as repeated episodes of eating a large amount of food in a short period of time while feeling a loss of control during the episode. BED involves episodes that feel compulsive: the person cannot stop eating even when full or uncomfortable. This goes well beyond a second helping at dinner or an indulgent dessert.

The diagnostic criteria for BED require both that large amounts of food are consumed in a discrete time frame and that there is a sense of loss of control while eating. The episodes are also linked to behaviors such as eating more rapidly than normal, eating until uncomfortably full, eating when not hungry, eating alone because of embarrassment, and feeling disgusted or guilty afterward. At least three of those behaviors must be present. The episodes need to occur at least once a week for three months, cause distress, and they are not followed by purging behaviors like in bulimia.

Here’s a hypothetical that illustrates the pattern: someone sits down in the evening and works through an entire pizza and a half-gallon of ice cream in under two hours, not from hunger but because they can’t stop. They feel physically ill afterward. Ashamed, too. The cycle repeats weekly or more often. I’ve seen a real version of this on video visits. One of my patients was managing things with intermittent fasting, and it worked in the sense that the scale moved, but every time the eating window opened back up, they took in way more calories than they needed. The fast itself was setting up the binge.

Children complicate this picture. For kids under 12, researchers have proposed a related diagnosis called Loss of Control Eating Disorder, or LOC-ED (Tanofsky-Kraff et al., 2008). The issue is that children may not consume amounts of food that adults would consider objectively large, but they still experience the same loss of control. In this group, the definition focuses on the subjective sense of being unable to stop eating. The proposed criteria mirror those of BED but apply specifically to children younger than 12. The episodes still need to happen at least once a week for three months and cause distress.

Picture a hypothetical case in pediatrics: a 10-year-old who sneaks into the kitchen at night, eats snack foods quickly, and can’t stop once started. The amount might look modest by adult standards. For a child, it’s significant. What matters is the loss of control, not the portion size. Wrappers hidden in the trash. A refusal to eat breakfast the next morning. Those are often the only clues a parent gets.

Treatment is available for both BED and LOC-ED. For adults with BED, the most evidence supports cognitive behavioral therapy, which helps patients identify triggers, restructure eating patterns, and address guilt and shame. Interpersonal therapy has also been shown to help, especially when social stress is a driver. Some patients benefit from medications. SSRIs have modest benefit for binge frequency, and lisdexamfetamine is the only medication currently approved by the FDA for BED in adults. Nutritional counseling and structured meal planning are usually part of the approach.

I should be direct about where I actually fit into this picture. I don’t manage BED treatment myself. Real treatment leans heavily on behavioral health, and in my current telemedicine positions I don’t have the coordination with a therapist or eating-disorder specialist that this really requires. What I do is screen for it on video visits: ask the direct questions, name what I’m seeing, and refer out from there.

For children with LOC-ED, treatment recommendations are less formalized since the diagnosis itself is still considered research-based. The focus is often on family-based behavioral therapy, involving parents in setting up structured eating schedules and reducing situations where loss of control is most likely to occur. Addressing mood or anxiety symptoms is important, since these are often linked to eating episodes. Nutrition support is also key, both for the child and for parents trying to guide food choices. Medications are not first-line in children.

Recognizing BED or LOC-ED is important because both conditions are linked to higher rates of obesity, depression, and medical complications if untreated. Many people don’t come forward because of shame or because they don’t realize their pattern is a diagnosable disorder. Asking direct questions about eating behaviors, especially around loss of control, can uncover these conditions and open the door to treatment.

If this description fits you or someone you know, talk with a healthcare provider. Early recognition, especially in children, can change the trajectory and reduce the risk of chronic problems.

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

References:

Allison KC, Tarves EP. Treatment of night eating syndrome. Psychiatr Clin North Am. 2011;34(4):785-796. doi:10.1016/j.psc.2011.08.002

McCuen-Wurst C, Ruggieri M, Allison KC. Disordered eating and obesity: associations between binge-eating disorder, night-eating syndrome, and weight-related comorbidities. Ann N Y Acad Sci. 2018 Jan;1411(1):96-105. doi: 10.1111/nyas.13467. PMID: 29044551; PMCID: PMC5788730

Tanofsky-Kraff M, Marcus MD, Yanovski SZ, Yanovski JA. Loss of control eating disorder in children age 12 years and younger: proposed research criteria. Eat Behav. 2008;9(3):360-365. doi:10.1016/j.eatbeh.2008.03.001

Why Do I Eat at Night? Night Eating Syndrome Explained

On By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

Night Eating Syndrome (NES) is one of those conditions that many patients, and even some clinicians, overlook. NES is a recognizable eating disorder where the timing of food intake shifts into the evening and nighttime hours, distinct from occasional snacking after dinner. Patients often feel embarrassed and dismiss it as a bad habit. It has real consequences for weight, sleep, and overall health.

The diagnosis of NES is based on established criteria. To meet the definition, at least 25 percent of daily food intake occurs after the evening meal or there are at least two episodes of nocturnal eating per week. These episodes are not explained by social or cultural norms. People with NES are aware of what they are eating at night, unlike sleep-related eating disorders where the behavior may happen without recall. The condition also needs to cause significant distress or impairment in functioning (Allison & Tarves, 2011).

In practice, this can look two different ways. Some patients skip breakfast, eat a small lunch, and end up consuming half their calories after dinner. Others wake almost every night around 1 or 2 a.m., head to the kitchen, and eat before they can fall back asleep. Over time, the pattern disrupts sleep and drives weight gain.

NES also overlaps with mood and sleep disorders. Patients often report insomnia, depression, or evening stress. Eating becomes a way to cope with anxiety or to induce sleep. That’s why treatment has to be more than calorie restriction. Cognitive behavioral therapy focused on both eating and sleep habits has shown promise, and selective serotonin reuptake inhibitors (SSRIs) have been helpful in some patients (Allison & Tarves, 2011). I prefer CBT-I, but in practice medications often end up being what gets prescribed. I don’t treat night eating syndrome myself. I screen for it before prescribing weight loss medications, then refer out.

The tie between NES and obesity is important. McCuen-Wurst and colleagues (2018) have shown that NES is associated with higher rates of metabolic problems such as type 2 diabetes and hypertension. Timing matters. Eating late into the night throws off circadian rhythms and glucose metabolism, so the impact is greater than just extra calories.

On a video visit, NES surfaces only if you ask about it directly. Within the past six months, one patient told me, “I can’t sleep unless I eat something at midnight.” That single line was the diagnosis: Night Eating Syndrome. We had her follow up with behavioral health.

Treatment is best when it’s individualized. Weight loss alone won’t fix NES if the underlying behaviors and triggers aren’t addressed. Collaboration between primary care, psychiatry, nutrition, and sleep medicine can make a real difference. For colleagues, the key is asking when patients eat as closely as how much. For patients, understanding that this is a recognized condition with treatment options can take away some of the shame and open the door to better care.

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

References:

Allison KC, Tarves EP. Treatment of night eating syndrome. Psychiatr Clin North Am. 2011;34(4):785-796. doi:10.1016/j.psc.2011.08.002

McCuen-Wurst C, Ruggieri M, Allison KC. Disordered eating and obesity: associations between binge-eating disorder, night-eating syndrome, and weight-related comorbidities. Ann N Y Acad Sci. 2018 Jan;1411(1):96-105. doi: 10.1111/nyas.13467. Epub 2017 Oct 16. PMID: 29044551; PMCID: PMC5788730

Wegovy and Zepbound Cash Pay Prices Without Insurance

On By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

Patients and colleagues ask me often about the cost of GLP-1 medications when insurance does not cover them. Wegovy and Zepbound are both FDA approved for weight management. Many patients run into the same barrier: their insurance plan excludes the drug entirely. In those cases, people end up paying cash, and the list price can be thousands of dollars a month.

Novo Nordisk now offers a cash pay path that changes the math for some patients. Through NovoCare Pharmacy, every Wegovy dose strength drops to 499 dollars for a 28 day supply, shipped directly to the patient’s home. This applies only when a patient’s insurance won’t cover Wegovy at all; if a commercial plan does cover it, a separate savings offer can drop the copay as low as 0 to 25 dollars, but the 499 dollar flat price is reserved for patients paying entirely out of pocket. Medicare and Medicaid patients don’t qualify. Sources: Novo Nordisk press release, August 5, 2025 (prnewswire.com), and the NovoCare savings program website (novocare.com).

I had a patient not long ago who had already tried to fill Wegovy at a local pharmacy. The pharmacist told her the cash price was over 1,300 dollars. She could not afford that. Under this new program, she can request her prescription be sent to NovoCare Pharmacy and receive the medication for 499 dollars a month instead. Still expensive. For some patients it is the only feasible way to continue therapy when insurance refuses to cover it.

Eli Lilly runs a comparable program for Zepbound. Both LillyDirect and NovoCare are really good in my experience. The paperwork is less than most insurance companies require, and both platforms are quick to get medications out to patients. I like them equally and don’t have a preference. Self pay patients can get Zepbound for 500 dollars a month, a 28 day supply, dispensed through a mail order pharmacy under LillyDirect, Lilly’s patient access platform, and shipped to the patient. The same coverage rule applies: this is for patients whose insurance doesn’t cover the drug, and Medicare, Medicaid, and other government insurance don’t qualify. Source: LillyDirect program site and Eli Lilly press announcement, August 2025.

These programs are designed for a narrow group: patients with no coverage at all, facing list prices that are otherwise out of reach.

If you are a patient considering these programs, the next step is to talk with your prescribing clinician. Prescriptions have to be routed to the designated mail order pharmacies to qualify for the flat cash price. Taking the prescription to a local retail pharmacy and expecting the same deal won’t work.

As a physician, I see how frustrating the access issue has become. Some patients with coverage pay very little. Others pay nothing. Then the next patient on my schedule that same day has no coverage at all and faces a price higher than their mortgage. These new programs don’t solve every problem. For patients paying entirely out of pocket, they make a real difference. Whether 499 or 500 dollars a month is enough is a fair question. It beats a price higher than a mortgage payment, and for now, that’s the trade on the table.

Sources: Novo Nordisk press release August 5, 2025, NovoCare savings program (novocare.com), Eli Lilly press materials August 2025, LillyDirect (lillydirect.com).

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.