What I learned at America’s most advanced doctor’s office

It was on my second visit to Forward Health, after the doctor told his giant wall screen to pull up various problems with my genetics, that the penny dropped. Or rather, four giant pennies. Because to deal with each issue, he kept recommending the same four courses of action.

“You’re just telling me I need to do these same four things over and over, and it’ll pretty much cancel out whatever faults exist in my DNA?” I asked the doctor, who nodded vigorously. And that’s when my concept of what a doctor does in the 21st century changed, forever.

Let’s back up. I wrote about Forward earlier this year as an example of what the future of U.S. healthcare could look like if we get our act together; this story is what I took from my experience when I visited as a patient over the course of three months. Forward, now in 17 cities around the U.S. and expanding rapidly, is focused on “reinventing” the doctor’s office with new technology. It also has an obsessive focus on preventative care — pay the $149 monthly fee, get as many visits as you like plus a lot of helpful nagging from the full-featured Forward app.

The monthly fee is a pretty penny, to be sure. One Medical, another primary care network, charges $200 a year. Even though that’s not counting the complex One Medical system of copays and deductibles, which may disincentivize you from making multiple preventative care visits, Forward is clearly the premium option.

Forward is making a couple of bets with its $1 billion valuation; firstly, that it can bring the price down over time by scaling up its technology, its physician training program, and its number of offices. And secondly, that enough of us realize that preventative care isn’t just nice to have; in many cases, it’s how you stay alive. As the CDC has found, up to 40 percent of deaths from the top 5 causes are preventable.

To that end, Forward believes in bringing every piece of information about you into its arsenal. You’re asked to upload your genetic data from 23andMe, and given a test for the DNA service if you haven’t done one already. You’re asked to share all the data you’ve gathered in your Apple or Android Health apps. Which, in 2021, I’m surprised physicians don’t automatically ask about. Why wouldn’t any decent doctor dealing with smartphone-toting, gadget-loving patients want to know their data and its patterns? What, am I taking blood pressure readings at home twice a week for funsies?

The first Forward visit is a barrage of data acquisition, starting at check in. You stand on a body monitor that takes your temperature, blood pressure and pulse via the fingers, checks your pupils, and spins you around for a weight and body fat composition analysis similar to the literal black mirror I reviewed. That’s a prelude to a blood draw for a test done speedily on the premises. No sooner has your doctor arrived in the exam room than the giant screen springs to life with dozens of readings from the blood test; mine appeared in under 15 minutes. Immediately, it zeroed in on my one abnormal reading: slightly elevated fasting glucose.

The bloodwork results themselves were just a prelude to what turned out to be a two-hour interview. The doctor put every aspect of my health under the microscope, probing until he dug up stuff I’d kind of forgotten about myself. (Restless leg syndrome? Sure, on and off, a few years back.) I was heartened to find there were plenty of questions on the mental health side of the equation, too. Forward treats all kinds of stress, depression, and anxiety as seriously as those stone-cold killers deserve.

That giant wall screen, by the way, may be the creepiest part of the Forward experience. That’s because it takes transcription — not the kind that is automatically generated by voice recognition, but the kind produced by trained medical stenographers who are listening in on every session. Is that creepy? Your medical mileage may vary. But if you’ve read this far and liked the idea of connecting your smartphone Health app, you’re unlikely to be fazed by faceless people listening in. At a certain point, you just have to trust that a doctor’s office has your best interests at heart.

And I will say, it worked as intended. The doctor, unencumbered by notebook or laptop, was able to maintain focus on his patient at all times. The screen’s transcription, which only appeared for notes the doctor wanted to make, literally kept us on the same page. If you’ve seen the canonically bad doctor’s handwriting, you’ve probably wondered if they’re making a fair summary of the meeting. I know for a fact the stenographers nailed it.

Boiling down to the big four

The solutions are simple: Inside my Foward account’s medical plans.
Credit: forward app

By the time of the second visit, to talk over my DNA data, the Body Scanner, invisible stenographers, and big screen with all my data already seemed ordinary. On the one hand, this is to Forward’s advantage: Try going back to an ordinary doctor’s office after getting used to this! On the other, the genetic discussion kind of passed in a blur, a screen-based miasma not dissimilar to social media scrolling.

What did the doctor tell me? I have five markers in my DNA associated with higher risk of coronary artery disease. (No surprise there; my dad had his first heart attack at 40, his dad died of a heart attack in his 50s.) Less obvious flaws in my genetic code are associated with significantly or moderately increased risks of glaucoma, macular degeneration, prostate cancer, obesity, and Parkinson’s disease.

But for all the high-tech data mining, the prescription for each risk — the thing that would more than cancel out my misbehaving DNA strands was drawn from a very limited well of lifestyle changes. I’m at risk for a coronary, so I need to get my blood pressure down, so I need to optimize my diet, exercise, and sleep. To combat stress and moderate anxiety, I need to stick with the mindfulness meditation.

That’s what led to the “big four” framing that the doctor and I continued throughout the rest of my time at Forward. With every potential threat to my health, I’d ask: Dial up the big four? The doctor would nod. Diet, exercise, sleep, mindfulness. Get those four right, and barring the thorny questions of supplements and drugs, there’s little more that any doctor’s office can do for you — even one with all your latest bloodwork and DNA analysis at their fingertips.

There’s more to dig down on each of those categories, of course. A proper diet has to include good hydration (try lemon water!), no smoking, and a limited but nutritious amount of plants and probiotics in your belly. Exercise is whatever works for you, as many days of the week as you can manage, but I’m not the only person who has belatedly woken up to the joys of running. Sleep varies for everyone, but if you’re not getting at least seven hours a night, you may have a problem. And meditation can take minutes to learn but a lifetime to master.

If the solutions are so simple, why even pay for all the bells and whistles? It’s a good question, because even the most high-tech doctor’s office will depend increasingly on whether the doctor can be an effective life coach who encourages you to up your game on the big four.

The example I always return to comes not from Forward, but my regular doctor at Kaiser Permanente. I’ll never forget the day that, discussing an unrelated prescription, he managed to turn the conversation around to belly fat. “You know,” he said, “the only patients I find who can ever completely lose it are the ones who run five miles a day.”

Five miles? That’s hard, I complained. To his credit, the doctor didn’t try to cheerlead or insist. “Yup,” he said simply, nodding and turning back to his laptop. And in that moment, a switch flipped, and I decided to start running five miles a day. In the age of the big four, every patient will need a different kind of life coaching; mine turned out to be a cat-like kind of reverse psychology.

Show me skin

My third and final Forward visit was focused on a single kind of cancer screening: skin cancer. Forward has created a new kind of camera that allows its doctors to get up-close views transmitted live to the big screen. And let me tell you, especially if you’ve lived with the star damage of a state like California, it’s not a pretty sight up close. If anything is going to scare you straight on the big four, this might. It might even make you add “sunscreen” as the fifth item on the list.

And yet again, for all its high-tech flash, the skin camera was only the beginning of an ongoing process. It took snapshots of my moles, with a couple that looked like potential trouble being flagged for later surveillance. Even here, at this moves-at-the-speed-of-light office, you generally wait to see if a mole changes over time before getting it biopsied.

That’s preventative healthcare. It has to be a slow, constant, life-long process of keeping your eyes on various leading indicators, or paying a professional to do so. (Another advantage of Forward — the app nagged as consistently as a parent when I was slacking on any homework the doctor had given.) But whether or not you have the scratch to afford Forward’s $149-a-month high tech version, you know that no matter what your genetics are, the big four is the best you can do. Eat and hydrate well, sleep well, exercise well, chill well.

Are these major lifestyle changes often hard to make? Yup.