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Raphael Buck

Change your state, change your life. 
How to not miss your penalty shots in life.
  
Same moment. Different state. Different destiny.
 
You can often predict whether a player will miss or score 
a penalty before the ball is kicked just by the walk.
 
Player 1  
Shoulders tense. Jaw tight.  
Focus: “Don’t miss.”  
Meaning: “If I fail, I let everyone down.”  
The body contracts. The shot hesitates.  
Often miss.
 
Player 2  
Body loose. Breathe steady.  
Focus: “Pick the corner.”  
Meaning: “This is my moment.”  
The body expands. The movement flows.  
Often goal.
 
Same distance. Same pressure.  
Different state. Different result.
 
 
WHAT IS A STATE?

The concept popularized by Tony Robbins is simple:
State is the combination of three elements:

1. Physiology  
Posture, breathing, movement. 
The body influences the mind.

2. Focus  
What you pay attention to. 
Threat or opportunity.

3. Meaning  
The story you assign. 
Failure or training.

Physiology shapes focus.  
Focus shapes meaning.  
Meaning drives action.  
Action drives results.

  
WHY it matters
 
Decisions Improve  
Emotional state influences risk perception 
(Lerner et al., 2015). 
 
Energy Drives Execution  
Performance follows physiological activation. 
(Jamieson et al. 2010)
 
Identity Is Reinforced  
Repeated emotional states shape self-perception
(Damasio, 1994).
  
  
WHAT actions to take 
  
1. Activate Your Body
  
Before important conversations or decisions: 
move. Stand tall. Deepen your breathing. 
Elevate intensity for 60–120 seconds.
Body leads mind
  
2. Direct Your Focus
  
Ask better questions.  
Not: “Why is this difficult?”  
But: “What is the opportunity here?”  
Focus creates feeling
  
3. Reframe Meaning
  
Events are neutral. Interpretation is not.  
Replace “This is a problem” with “This is training.”  
Meaning shapes reality
  
4. Interrupt Fast
  
When you feel contraction, catch it early. 
Stand up. Walk. Reset breathing. 
Disrupt the loop
  
5. Create Rituals
  
Elite performers anchor peak states through routines: 
music, movement, visualization, breath. 
Build your own pre-performance ritual.
Ritual creates reliability
  

FINAL thought
  
Circumstances are rarely under your control.
Your physiology is.  Your focus is.  Your meaning is.


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Design a life that works for you 🔥
Raphael

Change Your State - Change Your Life

First Principles - Relationships. 
Why great relationships are not about you but about the other person and what you build together.

Lady Randolph Churchill, Winston Churchill’s mother, 
once attended two dinners with 
two different British prime ministers.

After the first dinner she remarked:
"When I left the table, 
 I thought he was the most brilliant man in England."

After the second dinner she said:
"When I left the table, 
I thought I was the most brilliant woman in England."

The first man impressed her.
The second man made her feel valued.

Great relationships when 
others feel seen, valued, and understood.

 
WHY it matters

Happiness
Quality relationships are the strongest 
predictor of long-term happiness 
(Waldinger & Schulz, 2023).

Health
Strong relationships significantly increase 
longevity and physical health
(Holt-Lunstad et al., 2010).

Resilience
Supportive relationships buffer stress and 
improve psychological resilience 
(Cohen & Wills, 1985).

 
WHAT actions to take

Five First Principles on Relationships

1. Trust
Trust grows through reliability and psychological safety. 
Keep your word, be consistent, listen without judgment,
and assume positive intent. 
Principle: Create psychological safety.

2. Understanding
Seek to truly understand the other person’s perspective, 
emotions, and aspirations. Ask thoughtful questions, 
listen carefully, and show genuine curiosity. 
Principle: Seek to understand first.

3. Appreciation
Express appreciation regularly. Notice small efforts, 
acknowledge strengths, and say thank you often. 
Principle: Show sincere appreciation.

4. Shared Meaning
Build experiences, rituals, and goals together. 
Travel, traditions, family habits, and common 
projects create shared memories and direction. 
Principle: Build something together.

5. Repair
Conflict is inevitable. What matters is repairing 
quickly. Apologize early, lower tension, and focus on
understanding rather than winning. 
Principle: Repair quickly.


FINAL thought

The secret of great relationships is surprisingly simple:
Make the other person feel bigger.
As writer Maya Angelou famously said:

“People will forget what you said, people will forget 
what you did, but people will never forget 
how you made them feel.”

Design a life that works for you 🔥

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Raphael

First Principles - Relationships

Be a Free Spirit. 
Live by choice, not convention.

I find it fascinating what drives people 
to live their lives as they do.

There are countless explicit and implicit conventions 
about what a successful career looks like, 
what defines a great relationship, how to raise a family, 
and how to live healthily.

Many follow conventions without ever challenging them. 
They climb a ladder they never placed. 
They follow a script they did not write.

A free spirit is different.
“A free spirit is someone who is internally free enough 
to choose their life deliberately and 
brave enough to accept the consequences.”


WHY it matters

Agency
A free spirit strengthens agency 
Higher perceived control increases motivation, 
persistence, and performance under uncertainty 
(Bandura, 1997).

Coherence with What Matters
Living by chosen values increases coherence. 
When behavior aligns with intrinsic goals, well-being and 
sustained motivation rise significantly 
(Deci & Ryan, 2000).

Flexibility & Resilience
Detachment from rigid identity increases adaptability. 
Psychological flexibility improves resilience
(Kashdan & Rottenberg, 2010).


WHAT to do

1. Awareness & Detachment
List the conventions shaping your career, relationships, 
money, and health. Question each: 
Did I choose this or inherit it?
Principle: See the script

2. Curiosity
Expose yourself to alternative models of success 
and living. Read outside your field. Seek opposing views. 
Curiosity expands possibilities. 
Principle: Expand the frame

3. North Star
Define your core values, long-term ambition, 
and non-negotiables. 
Write a one-page personal constitution. 
Freedom requires direction, not drift. 
Principle: Choose your direction

4. Courage
Act in alignment even when approval declines. 
Make one visible decision that optimizes for meaning 
over optics this year. 
Freedom requires tolerating friction. 
Principle: Accept the cost

5. Discipline
Build systems that protect your autonomy: 
health routines, financial runway, deep work blocks. 
Discipline sustains freedom over time. 
Principle: Protect your freedom
 

FINAL thought
Being a free spirit is not about rebellion. 
It is about authorship.
Not escaping structure but choosing it. 
Not rejecting responsibility but owning it.

“The privilege of a lifetime is to become 
who you truly are.” Carl Jung

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Design a life that works for you 🔥
Raphael

Be A Free Spirit

Either / Or:  How to make major life decisions?
A simple question provides the right path. 

Major life decisions. Everyone faces them.  
Do I pursue this career or that career?  
Do I stay in my current job or change?  
Do I engage with this partner or another?  
Do I commit to the relationship?  
Should we get married?  
Should we have children?
  
All of these are major life decisions.
  
Some decisions feel clear; 
Others are far less obvious.  
Because they offer different paths.  
They involve trade-offs. 
Those choices can lead to regret
The regret of an alternative life.
  
I recently came across a beautifully 
simple question for navigating such choices.  
It comes from Søren Kierkegaard in Either/Or:
  
“𝗢𝗻 𝗺𝗮𝗷𝗼𝗿 𝗹𝗶𝗳𝗲 𝗰𝗵𝗼𝗶𝗰𝗲𝘀, 𝗰𝗵𝗼𝗼𝘀𝗲 𝘁𝗵𝗲 𝗼𝗻𝗲𝘀 
𝘄𝗵𝗼𝘀𝗲 𝗿𝗲𝗴𝗿𝗲𝘁𝘀 𝘆𝗼𝘂 𝗰𝗮𝗻𝗻𝗼𝘁 𝗹𝗶𝘃𝗲 𝘄𝗶𝘁𝗵.”
  
 
WHY it matters
  
Clarity
Focusing on intolerable regret simplifies 
complex choices by revealing what truly matters, 
reducing cognitive overload and indecision 
(Iyengar & Lepper, 2000).
  
Commitment
Decisions aligned with deeply held values 
create stronger motivation and persistence  
(Self-Determination Theory; Deci & Ryan, 2000).
  
Life Satisfaction
People who make decisions consistent with 
intrinsic priorities report higher long-term 
life satisfaction and lower regret 
(Schwartz et al., 2002).
  

WHAT to do 
  
1. Imagine Both Futures
Visualize both life paths in vivid detail
career, relationships, daily life, identity. 
Notice which imagined future creates 
deeper excitement or discomfort.
 
2. Identify the Regret
 Ask: ten years from now, which missed path 
would create the heavier regret? 
Regret reveals priorities
  
3. Remove Perfection
Accept that no choice eliminates trade-offs. 
Every meaningful path sacrifices another possibility. 
Life is trade-offs
  
4. Follow Aliveness
Notice which option feels more alive, meaningful, 
or expansive, even if it is harder or riskier. 
Growth usually lives there. 
Energy signals direction
  
5. Commit Fully
Once chosen, stop revisiting the alternative path. 
Invest your energy fully in building the life you selected.
Commitment creates meaning
  

FINAL thought
  
“Life can only be understood backwards; 
but it must be lived forwards.” Søren Kierkegaard
  
  
Design a life that works for you 🔥

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Raphael

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Either / Or - Life Decisions

My path:
Age 12: I built my first computer
Age 15: I started a small business making first websites for local orgs with HTML and JavaScript
Age 16: I learned C++ and made some primitive games
Age 22: I graduated from RPI with a degree in computer and electrical engineering and took a job that seemed cool working on designing and building a US Navy destroyer
Age 23: Finished chemo and hit remission from Hodgkin's Disease and took a hard look in the mirror
Age 25: Finished a masters in biomedical engineering at Hopkins, focusing on AI and machine learning for medical imaging 
Age 26: Had my first big win in engineering & medicine – invented a modular MRI-compatible exercise device for muscle testing and digital biomarkers
Age 27: Got into UMass medical school on my 3rd try, pursuing neuropsychiatry
Age 30: Built an electronic health record (EHR) while in medical school for a Boston-based company, my first foray into healthcare entrepreneurship and technology-enabled care models
Age 34: Built my first health-tech company, NeuroLex, using voice as a digital biomarker to detect neurodegeneration and disease earlier
Age 36: Finished residency and fellowship at University of Washington and founded a specialized dementia clinic for EvergreenHealth, applying clinical neuropsychiatry expertise
Age 37: Sold NeuroLex and helped build BrainCheck, a digital cognitive assessment technology company pioneering digital biomarkers for dementia assessment
Age 38: Founded and bootstrapped Frontier Psychiatry and grew it to 75 staff and 5k patients/month diving into innovative technology-enabled care models and healthcare leadership
Age 40: Raised a series A and transitioned to scaling mode, implementing value-based care approaches and quality improvement methodologies
Age 41: Handed off Frontier Psychiatry and Founded MedFlow, a workflow automation company for healthcare transformation and optimized care delivery systems

It's been a journey. 

My goal here is to share what I've learned in clinical neuropsychiatry, digital biomarkers, healthcare entrepreneurship, and healthcare leadership to move the needle on outcomes in healthcare, especially dementia care. Healthcare needs absolutely everyone's help to change the status quo. We need to demand better from our systems through technology-enabled care models and organizational change management.

I speak at medical conferences, corporate events, and leadership summits on brain health, dementia prevention, AI in healthcare, and building health tech companies. For speaking inquiries please send me a message.

Reza Hosseini Ghomi, MD, MSE

Her name was Gloria. 71. Retired schoolteacher.
 
Her daughter brought her in because she was "losing her mind." Forgetting words. Missing appointments. Getting confused in familiar places.
 
Her previous doctor told her it was early Alzheimer's. Prescribed donepezil. Said there wasn't much else to do.
 
When I saw her, I didn't start with a diagnosis. I started with questions.
 
When did this start? Gradually over the past year.
How's your sleep? Terrible. Wakes up multiple times. Husband says she snores loudly.
Energy level? Exhausted all the time.
Diet? Mostly tea and toast. Not much appetite.
 
I ordered labs and a sleep study.
 
Results:
 
B12: critically low at 118 pg/mL (normal is above 300)
TSH: elevated at 6.8 (subclinical hypothyroidism)
Sleep study: moderate obstructive sleep apnea, 22 events per hour
 
Three treatable conditions. All mimicking dementia.
 
We started B12 injections, levothyroxine, and CPAP therapy.
 
Within 8 weeks, her daughter called me in tears.
 
"She's back. She's reading again. She's remembering our conversations."
 
Her repeat cognitive testing improved significantly from "low" to "low normal".
 
This is not rare. I see it almost every week.
 
The most common treatable causes of cognitive decline I find:
 
Sleep apnea (the biggest one, and 80% of cases are undiagnosed)
↳ B12 deficiency
↳ Thyroid dysfunction
↳ Depression masquerading as dementia
↳ Medication side effects (especially anticholinergics and benzodiazepines)
↳ Uncontrolled blood pressure or blood sugar
 
These are not exotic diagnoses. They're basic medicine.
 
But in a system where the average primary care visit is 15 minutes, they get missed.
 
A patient walks in with memory concerns. The doctor hears "dementia." Orders an MRI. Maybe a referral to neurology with a 6-month wait. The treatable stuff never gets investigated.
 
What I tell every patient and family:
 
Before you accept a dementia diagnosis, make sure someone has ruled out everything reversible first.
 
It's the difference between a life sentence and a treatable condition.
 
Gloria is doing well. She gardens again. She reads to her grandkids.
 
She never had Alzheimer's.
 
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♻️ Repost if you think everyone deserves a thorough workup before a dementia diagnosis
💬 Has this happened to someone in your family? I hear these stories all the time.

Neuropsychiatrist | Engineer | 4x Health Tech Founder | Cancer Graduate | Keynote Speaker on Brain Health, AI in Medicine & Healthcare Innovation - Follow for daily insights

I'm a dementia doctor.

Here's what I'm actually worried about for my own brain at 42.

People ask me this constantly. And my answer has shifted significantly over 15 years of diagnosing and treating cognitive decline.

At 30, I worried about genetics. APOE4 status, family history, the things you're born with. Now I barely think about them. Genetics loads the gun. Lifestyle pulls the trigger.

Here's what I actually focus on now:

1. Sleep is non-negotiable
↳ 7.5-8 hours. Every night. I protect this more aggressively than any other health behavior.
↳ I use a sleep tracker once in a while, not to obsess, but to catch drift before it compounds into weeks
↳ The glymphatic system clears amyloid during deep sleep. Missing it is not neutral.
↳ When my sleep suffers, everything else degrades within two days. I can feel it.

2. I exercise for my brain, not my appearance
↳ Aerobic exercise 5 days per week. Not optional.
↳ Resistance training 5 days per week specifically because the combination outperforms either alone
↳ I stopped treating exercise as something I do when I have time. It generates the time.

3. My blood pressure is the biomarker I track most seriously
↳ Midlife hypertension is one of the most powerful dementia risk factors we know of
↳ I check mine monthly, not annually
↳ My target is below 120/80. Not because I'm anxious. Because the data is unambiguous.

4. I treat social connection as a medical priority
↳ Loneliness carries dementia risk equivalent to smoking 15 cigarettes a day
↳ I schedule relationships like I schedule clinical obligations. Otherwise they disappear.
↳ This was the hardest behavior change for me as someone who trends toward isolation and overwork.

5. I have genuine skepticism about the longevity supplement world
↳ I take nothing I cannot justify with human outcome data (I take several I've written about before)
↳ I follow the TAME trial (metformin and aging) closely. Almost nothing else in that space has my serious attention yet.
↳ Most of what people spend hundreds of dollars on monthly does not have the evidence base to justify it.

What I've stopped worrying about: crossword puzzles, brain training apps, most supplements, and whether the occasional glass of wine will accelerate my decline.

What 15 years has taught me: the boring interventions are the ones backed by evidence. Sleep. Exercise. Blood pressure. Social connection. Food quality. Stress management.

The fundamentals are not less effective because they're not new. They're the evidence base because they actually work.

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💬 What does your own brain health routine look like right now? Tell me one thing you do consistently.

I'm a dementia doctor.

And I check my blood pressure regularly.

Not because I'm worried about a heart attack.

Because new genetic evidence shows high blood pressure directly causes dementia.

Not just "associated with." Causes.

A massive study from Denmark and the UK analyzed genetic data to separate correlation from causation.

High blood pressure and obesity don't just increase dementia risk. They trigger it.

This changes everything about how I think about prevention.

For years, we told patients: control your blood pressure to reduce dementia risk.

Now we know: control your blood pressure because it's causing brain damage.

Same advice. Different urgency.

Here's what I do personally:

I check my blood pressure at home weekly. Target: under 120/80.

I track my weight daily. Not for vanity. For my brain.

I adjusted my diet years ago when my fasting insulin started creeping up. Insulin resistance is another direct cause.

I exercise 6 days a week. Zone 2 cardio. Resistance training. Not negotiable.

I'm 42. I've diagnosed over 1,000 cases of dementia.

I know what's coming if I don't intervene now.

The beautiful thing about this research: these are fixable problems.

You can't change your genes. You can't reverse your age.

But you can control your blood pressure. You can manage your weight. You can improve your metabolic health.

These aren't risk factors anymore. They're causes.

That means they're also solutions.

Start now. Not when symptoms appear.

By then, the damage is done.

⁉️ When was the last time you checked your blood pressure at home?
♻️ Repost if prevention starts with what you can control
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Citations: Nordestgaard et al.High body mass index as a causal risk factor for vascular-related dementia: evidence from Mendelian randomization analyses.The Journal of Clinical Endocrinology & Metabolism 2026.

A patient told me last month: "I retired 3 years ago and I haven't felt right since."

No medical problems. No depression diagnosis. No family history of dementia.

But his cognitive testing showed early decline.

When I dug deeper, the pattern was clear.

He went from daily interactions with 30+ coworkers to seeing almost nobody. His wife works full time. His kids live out of state. His main social activity was work, and then work ended.

Loneliness is not just an emotional problem.

It's a neurological one.

What the research shows:

Social isolation increases dementia risk by roughly 50%. That's comparable to physical inactivity, depression, or smoking.

The Lancet Commission includes it as one of 14 modifiable risk factors. It's not a soft recommendation. It's in the same category as treating hypertension and diabetes.

Why isolation damages the brain:

1. Chronic loneliness raises cortisol
↳ Sustained cortisol exposure shrinks the hippocampus
↳ The hippocampus is where memory formation happens
↳ Lonely individuals show measurable hippocampal volume loss on imaging

2. Social interaction is cognitive exercise
↳ Conversation requires attention, processing speed, working memory, emotional regulation
↳ It's one of the most complex things the brain does
↳ Remove it and the brain loses its most consistent workout

3. Isolation changes behavior
↳ People who are isolated sleep worse, eat worse, move less
↳ They're less likely to seek medical care
↳ Every other risk factor gets amplified

What I told my patient:

This isn't a personal failing. Your brain is responding to the absence of something it needs.

We built a plan. Weekly volunteer work. A walking group. Regular phone calls with friends scheduled like appointments.

Six months later, his cognitive scores improved. As important, he felt a lot better.

Not because I prescribed a drug. Because he rebuilt the social architecture his brain depended on.

Retirement planning should include a social plan.

If it doesn't, the brain pays the price.

⁉️ Do you have a social plan for retirement, or did you mostly plan the finances? I think this is a massive blind spot.
♻️ Repost if someone you know needs to hear this
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I prescribe exercise before I prescribe medication for most of my cognitive decline patients.

But most people are doing the wrong kind for their brain.

After 15 years as a neuropsychiatrist focused on neurodegenerative disease, exercise is the single intervention I recommend with the most confidence and the least hesitation. The data is simply stronger than almost anything else we have.

But not all exercise does the same thing to the brain. The type, timing, and combination matter.

Here's what the neuroscience actually shows:

1. Aerobic exercise is the BDNF engine
↳ BDNF (brain-derived neurotrophic factor) is the protein that drives new neuron growth
↳ A single aerobic session raises BDNF levels 200-300%
↳ Sustained aerobic exercise over months measurably grows hippocampal volume on imaging
↳ 30 minutes 3-4x per week is where the meaningful brain benefits begin
↳ Walking counts. The intensity threshold is lower than most people assume.

2. Resistance training protects differently
↳ Builds insulin sensitivity, which reduces one of dementia's key metabolic drivers
↳ Reduces inflammatory markers independently from cardiovascular exercise
↳ Shows protective effects on white matter integrity in imaging studies
↳ The combination of aerobic and resistance training outperforms either alone

3. Timing matters more than most people realize
↳ Morning exercise appears to have more durable effects on cognitive function through the day
↳ High-intensity training within 3 hours of bedtime can impair the deep sleep your brain needs most
↳ Exercise and sleep quality compound each other over time

4. The best-evidenced protocol for brain health specifically
↳ 150-180 minutes of moderate aerobic activity per week
↳ Plus 2 sessions of resistance training
↳ Spread across at least 4 days to maximize neurochemical exposure
↳ Consistency over years matters more than intensity in any single session

The patients who age sharpest in my clinic are not doing extreme programs. They are walking, lifting, and moving consistently without long interruptions for years on end.

If you are only doing one type of exercise, you are leaving brain health benefits on the table. If you are not exercising consistently, you are managing cognitive risk less effectively than almost anything else you could be doing.

The gym is the most evidence-based dementia prevention tool we have. Full stop.

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♻️ Repost if you think more people should hear this from a doctor, not a fitness influencer
💬 What does your exercise routine actually look like? No judgment here.

What is the #1 thing you can do to prevent dementia?

I just gave a talk to a group of audiologists in Binghamton, New York.

Timeless Hearing. Five locations across upstate New York. A team that genuinely cares about their community.

I told them something they already knew:

Hearing loss is the single largest modifiable risk factor for dementia.

Not exercise. Not diet. Not sleep.

Hearing.

The Lancet Commission's 2024 update made it clear. Across 14 modifiable risk factors, untreated hearing loss in midlife carries the highest population-attributable risk at 7%.

The ACHIEVE trial followed nearly 1,000 older adults for 3 years. In the group at highest risk for cognitive decline, hearing intervention reduced the rate of decline by 48%. The higher the risk, the higher the reduction, up to 62% in the highest risk group!

That's not a supplement. That's not a drug. That's a hearing aid.

Here's the problem:

Most people don't get their hearing tested until they notice a problem. By then, years of auditory deprivation have already changed how their brain processes information.

The brain regions that handle hearing start getting reassigned to other tasks. Social isolation increases because conversations become exhausting. Depression risk rises. The cascade is already moving.

What I told the audiologists:

You are dementia prevention specialists. You just haven't been called that yet.

What general medicine still gets wrong:

Hearing is treated as a quality of life issue. Nice to have. Not urgent.

It's not.

Untreated hearing loss is a brain health emergency in slow motion.

We went over talking points any staff member (clinical or admin) can use with referring providers and patients to make the urgency clear.

What I'm asking:

Everyone over 50 should get a formal hearing assessment. Not the free screening at a convention booth. A real audiological evaluation.

If you have hearing loss, treat it. Early. Aggressively.

The evidence is strong enough that waiting is the wrong move.

I walked away from that talk more convinced than ever. The audiologists at Timeless Hearing already get it. They're doing the hard work of connecting hearing health to whole-body health in their community.

Now the rest of medicine needs to catch up.

⁉️ When was the last time you or a parent had a hearing test? This might be the most important screening nobody talks about.
♻️ Repost if you think hearing health deserves more attention
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I wrote a a paper and a book chapter on the gut-brain axis and schizophrenia over a decade ago.

At the time, most of my colleagues thought it was fringe science.

Now it's one of the fastest-growing areas in neurodegenerative disease research.

Here's what we know:

Your gut contains roughly 100 trillion bacteria. They produce neurotransmitters, regulate inflammation, and communicate with your brain through the vagus nerve in real time.

When that system breaks down, your brain feels it.

The research connecting gut health to dementia:

1. Gut bacteria composition changes years before cognitive symptoms
↳ People with Alzheimer's show distinct microbiome patterns
↳ Less microbial diversity correlates with faster cognitive decline
↳ These changes are detectable early

2. Chronic gut inflammation drives neuroinflammation
↳ A leaky gut barrier lets inflammatory molecules enter the bloodstream
↳ These molecules cross the blood-brain barrier
↳ Chronic low-grade neuroinflammation accelerates amyloid and tau pathology

3. The vagus nerve is a two-way highway
↳ Gut bacteria produce serotonin, dopamine, GABA
↳ About 95% of your body's serotonin is made in the gut
↳ Vagus nerve stimulation is already being studied as a treatment for early Alzheimer's

What the research does NOT yet prove:

Fixing your gut will prevent dementia. We're not there.

The causal direction is still being worked out. Does gut dysbiosis cause neurodegeneration, or does neurodegeneration change gut function? Probably both, but the studies confirming causation in humans are limited.

I want to be honest about where the science is.

What I tell patients:

You don't need to wait for perfect evidence to take care of your gut.

A Mediterranean diet rich in fiber, fermented foods, and plant diversity supports gut health and has independent evidence for reducing dementia risk.

Often a probiotic can make sense.

Reducing processed food and unnecessary antibiotics protects microbial diversity.

Managing stress matters. Chronic stress disrupts gut barrier function directly.

The gut-brain connection isn't a trend. It's biology we're just beginning to understand at the level it deserves.

⁉️ Have you noticed changes in your cognition when your gut health is off? I hear this from patients all the time.
♻️ Repost if you think gut health deserves a place in the brain health conversation
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Citation: Nemani K, Hosseini Ghomi R et al. "Schizophrenia and the gut-brain axis." Prog Neuropsychopharmacol Biol Psychiatry. 2015.

Harbor Health just acquired Rippl, a dementia care platform.

This is one of the most important deals in dementia care this year.

And most people outside the industry won't hear about it.

Here's why it matters:

Harbor Health is a "payvider." They're both the insurance company and the care provider. They own the clinics and the health plan. Austin, Dallas, San Antonio, El Paso. Expanding into Florida.

They already acquired 32 VillageMD clinics in 2025.

Now they're adding Rippl's dementia platform on top.

This is vertical integration with a very specific thesis:

Dementia is one of the most expensive conditions in healthcare. Not because of the drugs. Because of where patients end up.

The emergency room. The hospital. Post-acute facilities.

When a patient with dementia becomes agitated or confused, families often have no option but to call 911. That visit costs $20,000 or more.

Rippl's entire model is built to prevent that. Identify behavioral and medical issues early. Intervene before crisis. Keep patients at home.

Harbor Health looked at this and said: if we're paying for these ER visits anyway, we should be the ones preventing them.

The bigger trend:

This is not unique to dementia.

UnitedHealth employs over 90,000 physicians through Optum.
Humana runs CenterWell and Conviva with 250+ senior-focused primary care centers.
Elevance acquired behavioral health providers and rebranded them under Carelon.

The payers are becoming the providers.

Why? Because value-based care only works when you control both the clinical delivery and the financial risk.

What I've learned from consulting in this space:

The organizations that win in the next decade won't be the ones with the best technology or the lowest cost.

They'll be the ones who integrate care delivery, payment, and data into a single coordinated system.

Harbor Health made a bet that dementia care belongs inside primary care, not as a referral to a specialist 6 months from now.

They're right.

⁉️ Do you think payers becoming providers is good or bad for patients? I see both sides.
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I was in Washington DC last week and met Dr. Oz and his CMS leadership team in person.

I went in skeptical. I left impressed.

Here's why.

Dr. Oz was not performing for cameras. He was deeply fluent in the inner workings of complex Medicare payment models, reimbursement structures, and clinical workflow challenges. He asked detailed questions and followed up with specifics.

His deputy administrator Chris Klomp left running a billion-dollar healthcare company to come fix Medicare. Not for prestige. Not for a salary bump. Because he believes the system can work better.

What they're doing at CMS right now:

1. Prior authorization reform
↳ Insurers have pledged to cut the number of procedures requiring prior auth from ~6,000 down to 2,000-3,000
↳ Common procedures like colonoscopies and cataract surgeries getting removed
↳ Real-time approvals for most requests targeted by 2027
↳ A clinical professional must review every denial

2. Pushing public and private sectors to work together
↳ CEOs from Elevance, United, Humana, Cigna, Kaiser all at the table
↳ Not just talk. Published commitments with CMS monitoring progress
↳ Interoperability standards so providers don't deal with different portals for every insurer

3. Modernizing policies that don't belong in the tech age
↳ Some insurers still require fax for prior auth requests
↳ CMS is pushing standardized electronic submissions by 2027
↳ Continuity of care protections when patients switch plans

Why this matters:

Prior auth costs the US healthcare system $35 billion annually in administrative burden. Practices hire entire staff just to fight with insurance companies.

Every hour spent on prior auth is an hour not spent with patients.

I've lived this. At Frontier Psychiatry we had staff whose entire job was navigating prior auth for psychiatric medications. Patients waited days for approvals while their conditions worsened.

The truth is, I can't help move the needle in cognitive health for the majority of people without a strong partnership with CMS.

The fact that CMS is convening the industry and holding them accountable rather than just writing regulations is different from what I've seen before.

Is it perfect? No. These are voluntary pledges. Execution will determine everything.

But the energy in that room was genuine. These are people who left lucrative private sector positions because they believe the system needs to change.

I'll be watching closely.

⁉️ How has prior authorization affected you or your patients? I want to hear real stories.
♻️ Repost if you believe healthcare admin burden is the silent crisis
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The air outside your window might be the dementia risk factor your doctor has never mentioned.

Most people associate air pollution with lung disease. The brain connection is far less discussed and far more alarming.

Here's what the evidence now shows:

1. Fine particulate matter crosses the blood-brain barrier
↳ PM2.5, particles smaller than 2.5 microns, enter the bloodstream through the lungs
↳ They cross into brain tissue directly and trigger neuroinflammation
↳ This is the same inflammatory pathway that drives neurodegeneration
↳ The brain has no mechanism to expel them the way the lungs can partially clear larger particles

2. The numbers are significant
↳ A study of 130,000 older adults found a 92% increased dementia risk with high PM2.5 exposure over time
↳ Living near a major roadway increases dementia risk by approximately 12% even after controlling for other factors
↳ The Lancet Commission now lists air pollution as one of 14 modifiable dementia risk factors
↳ It accounts for roughly 2% of global dementia cases, which in absolute numbers is millions of people

3. Indoor air is often worse than outdoor
↳ Cooking with gas, candles, certain cleaning products, and poor ventilation concentrate pollutants indoors
↳ Most people spend 90% of their time indoors
↳ HEPA filtration in bedrooms is one of the most practical and underused interventions we have

4. This is a health equity issue
↳ Communities near highways, industrial sites, and ports face disproportionate exposure
↳ The same communities often have less access to healthcare that could detect early cognitive changes
↳ Air quality and dementia risk are distributed unequally across zip codes in every major city

What you can actually do:

↳ Monitor air quality index before outdoor exercise (free apps, takes 10 seconds)
↳ HEPA air filter in your bedroom: your brain clears amyloid during sleep, clean air during that window matters
↳ Reduce indoor pollutants: ventilate when cooking, reduce synthetic fragrances
↳ Exercise in green spaces when possible rather than traffic-adjacent routes

This isn't a reason to stay indoors or live in fear. It's a reason to add air quality to the brain health conversation the same way we've added sleep, exercise, and diet.

Right now, it barely shows up there.

📌 Follow Reza Hosseini Ghomi, MD, MSE for brain health content that goes beyond the standard prevention list
♻️ Repost if you think air quality deserves a bigger role in the health conversation
💬 Do you track air quality where you live? This is a habit worth starting.

I was in Atlanta last week meeting with Elevance Health leadership.

Elevance is the parent company of Anthem Blue Cross Blue Shield. $197 billion in operating revenue. 45 million members. Fortune 20.

They're investing hundreds of millions into AI and workflow automation. And they told me exactly where it's going. No other payer is more committed to using technology to improve patient outcomes and experience.

Here's what stood out:

1. Prior authorization is being automated
↳ Their Health OS platform connects provider data, lab results, and pharmacy info
↳ AI reviews prior auth requests against clinical criteria in real time
↳ They've reduced denials from missing information by 68%
↳ Goal: most prior auth decisions happen without human intervention

2. They're pushing value-based care harder than ever
↳ Their Carelon division is expanding condition-focused pathways
↳ Diabetes, hypertension, chronic pain, behavioral health
↳ They want providers who can demonstrate measurable outcomes

3. Member-facing AI is scaling fast
↳ Their Sydney app uses AI to answer benefit questions in natural language
↳ 10 million members had access by end of 2025
↳ Full 45 million member rollout happening in 2026
↳ The member experience is becoming the competitive battleground

What this means for providers:

The payers are building infrastructure to measure everything. Quality metrics. Cost per episode. Outcome data. Patient engagement.

Practices that can't demonstrate value through data are going to lose contracts. Period.

This isn't a prediction. It's happening now.

The practices that thrive in this environment will be the ones that build automated workflows to identify the right patients, deliver the right care, and document the outcomes without adding burden to their clinical teams.

That's the exact problem I built MedFlow to solve.

Not replacing clinicians. Removing the operational friction that prevents good clinical decisions from becoming consistent clinical actions.

The gap between what payers want to measure and what practices can deliver is where the next decade of healthcare transformation lives.

If your practice still relies on manual chart reviews to find care gaps, that window is closing fast.

⁉️ Is your practice ready for the payer shift toward automated quality measurement? What's your biggest barrier?
♻️ Repost if you think workflow matters more than willpower in healthcare
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One night of poor sleep increases amyloid-beta in your brain by 5%.

Not one year. Not one month.

One night.

Researchers at the NIH used PET imaging to measure amyloid accumulation after a single night of sleep deprivation. The increase was significant and measurable.

Why this matters:

Amyloid-beta is the protein that accumulates in the brains of Alzheimer's patients. Your brain clears it during deep sleep through the glymphatic system, a waste-removal network that activates primarily when you're in slow-wave sleep.

Skip that sleep and the waste doesn't get cleared.

Now multiply that by years of poor sleep.

What the research tells us:

People who consistently sleep less than 6 hours per night have a 30% higher risk of developing dementia compared to those who sleep 7-8 hours.

The relationship between sleep and dementia is bidirectional:

Poor sleep accelerates amyloid accumulation
↳ Amyloid accumulation disrupts sleep quality
↳ Which accelerates more amyloid accumulation
↳ The cycle feeds itself

Sleep apnea makes it worse:

Roughly 80% of sleep apnea cases are undiagnosed. In my dementia clinic, I test almost every patient for it. When I find it and treat it, cognitive function often improves within months.

Sleep apnea causes intermittent oxygen deprivation throughout the night. Every episode is a small assault on brain tissue.

What I tell patients:

Sleep is not optional recovery time. It's when your brain does its most critical maintenance.

If you consistently wake up tired, if your partner says you snore or stop breathing, if you need caffeine to feel functional by 10am, get a sleep study.

Treating sleep apnea is one of the highest-yield interventions in dementia prevention. It's also one of the most underdiagnosed.

Simple sleep hygiene steps that protect your brain:

Consistent sleep and wake time, even weekends
↳ Dark, cool room (65-68 degrees)
↳ No screens 30 minutes before bed
↳ Limit caffeine after noon
↳ Alcohol disrupts sleep architecture even if it helps you fall asleep

Your brain cleans itself at night.

Let it.

⁉️ How many hours of sleep do you consistently get? Be honest. I'll go first: I aim for 7.5 and usually hit 7.
♻️ Repost if you think sleep is the most underrated health intervention
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Citations: hokri-Kojori E et al. β-Amyloid accumulation in the human brain after one night of sleep deprivation. Proceedings of the National Academy of Sciences. 2018.
Sabia S et al. Association of sleep duration in middle and old age with incidence of dementia. Nature Communications. 2021.

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