Do you take insurance for the Deep Dive?

We are a Direct Primary Care practice. We do not bill insurance for our time, which is why we can spend 90 minutes with you instead of 12. We do, however, use your PPO insurance for the labs and imaging (MRI or CT). You get the best of both worlds: concierge attention plus insurance coverage for the heavy lifting.

Can I do just the Deep Dive without becoming a member?

Yes. We offer "The Executive Audit" as a standalone service for those who have a primary care doctor they like but want a higher-level strategic review. Most patients who do the audit eventually convert to membership because they realize what they have been missing.

Is this just biohacking?

No. Biohacking is n=1 experimentation with unproven tools. This is engineering. We use validated, rigorous metrics (ApoB, VO2 Max, DEXA) drawn from the highest-quality longevity science and primary literature.

How long does a Deep Dive appointment take?

The full Deep Dive is 90 minutes. That includes a focused exam, a full review of your labs and imaging, and a strategy session where we build your 12-month plan together. Most patients also schedule a 30- to 45-minute follow-up 4 to 6 weeks later to refine the plan.

What labs are included?

Standard Deep Dive labs include a complete metabolic panel, full thyroid panel (TSH, Free T3, Free T4, reverse T3, antibodies), fasting insulin, HOMA-IR, ApoB, Lp(a), hsCRP (high-sensitivity C-reactive protein), HbA1c, fasting glucose, complete blood count, ferritin, vitamin D, B12, and homocysteine. We add sex hormones, advanced cardiometabolic markers, or genetic tests based on your goals.

How is this different from other executive-physical or lab-testing services?

Many broad lab-panel and "executive physical" services offer a lot of tests but limited physician time, and some lean on nurse practitioners or default to selling supplements. We are physician-led with a capped panel size, and we anchor every recommendation in standards-of-care medicine plus longevity science.

What if my labs come back alarming?

Surprises are why we do the Deep Dive. If we find an early sign of metabolic dysfunction, lipoprotein risk, or hormonal imbalance, we walk you through the data, build a plan, and follow up at 4-, 8-, and 12-week intervals to track changes. We have your back through the entire process.

Do you do Deep Dives for couples or families?

Yes. Many patients book back-to-back Deep Dives with a partner so we can map shared genetic and lifestyle risk. We tailor each plan individually but coordinate when it makes sense (for example, sleep environment, kitchen strategy, family fitness goals).

Why is fasting insulin a better early warning sign than HbA1c?

Fasting insulin reflects how hard your pancreas is working to keep glucose normal. It rises 5 to 15 years before HbA1c starts climbing. By the time HbA1c is in the pre-diabetic range, you have already had years of metabolic damage. Catching the rise in insulin gives us a long runway to course-correct.

How does ApoB compare to LDL-C and non-HDL cholesterol?

ApoB measures every atherogenic particle (LDL, VLDL, IDL, and Lp(a) all carry one ApoB protein each). LDL-C is a calculated estimate of cholesterol mass inside LDL particles, and non-HDL cholesterol approximates particle burden. Multiple studies (CARDIA, MESA) show ApoB is the strongest single predictor of cardiovascular events.

What is HOMA-IR and why does it matter?

HOMA-IR is the Homeostatic Model Assessment of Insulin Resistance. It uses fasting insulin and fasting glucose to estimate how insulin-resistant you are. A value above 1.5 suggests early resistance, and above 2.5 confirms significant resistance. It is one of the cheapest and most useful metabolic tests we run.

Why do you measure Cystatin C in addition to creatinine for kidney function?

Cystatin C is filtered by the kidney like creatinine but is not influenced by muscle mass. Athletes and bodybuilders often have elevated creatinine that looks like kidney dysfunction but is just muscle. Cystatin C cuts through that confusion and gives a cleaner estimate of kidney filtration.

What does Lp(a) actually do, and why is it usually missed?

Lp(a) is a genetic variant of LDL with an extra protein that promotes plaque, inflammation, and clotting. About 1 in 5 people carry elevated levels. Standard insurance protocols do not routinely test it because there has historically been no targeted treatment. New Lp(a)-lowering drugs (pelacarsen, olpasiran) are in late-stage trials, which makes early detection more useful than ever.

How accurate is at-home VO2 Max from an Apple Watch?

The Apple Watch estimates VO2 Max from heart rate and pace data using a proprietary algorithm. It is usually within 10 to 15% of a lab measurement, but can overestimate fitness in lean adults and underestimate in heavier athletes. We use it for trend tracking and confirm with a metabolic cart when we need precise zones.

What is the difference between visceral fat and subcutaneous fat?

Subcutaneous fat sits under the skin and is mostly cosmetic. Visceral fat sits inside the abdominal cavity and wraps around your organs. Visceral fat secretes inflammatory cytokines that drive insulin resistance, cardiovascular disease, and certain cancers. A DEXA scan or InBody machine separates the two.

How do you decide who needs a coronary CT angiogram?

We use a combination of family history, ApoB, Lp(a), inflammation markers (hsCRP), blood pressure, and any chest symptoms to estimate cardiovascular risk. For patients with intermediate or high risk who want clarity, a coronary CT angiogram (often with Cleerly analysis) shows soft and calcified plaque directly. We refer to Penn or Jefferson for the imaging.

How is hormone optimization handled in the Deep Dive?

We test full sex hormone panels (testosterone, free testosterone, SHBG, estradiol, DHEA-S, and sometimes LH and FSH) along with thyroid and cortisol patterns. Hormone replacement is data-driven and anchored to symptoms, not to internet protocols. We do not chase supraphysiological numbers.

Will a Deep Dive identify cancer risk?

The Deep Dive is not a cancer screen, but it surfaces patterns associated with cancer risk (chronic inflammation, metabolic dysfunction, low fiber and protein, alcohol burden, suspicious imaging findings). For high-risk patients, we coordinate Galleri multi-cancer tests, mammograms, prostate MRIs, or colonoscopies through specialists at Penn, Jefferson, Temple, or Main Line Health.

How does sleep architecture testing work?

Wearable data (Oura, Whoop, Apple Watch) tracks heart rate, HRV, respiratory rate, and movement to estimate sleep stages. For patients with persistent fatigue, snoring, or witnessed apneas, we order home sleep testing (WatchPAT or Lofta) to look for obstructive sleep apnea. Untreated sleep apnea is one of the most reversible drivers of fatigue and cardiovascular risk.

What is the role of genetic testing in the Deep Dive?

Targeted genetic testing (ApoE, MTHFR, Lp(a), hereditary cancer panels) can sharpen risk assessment and personalize treatment. We do not order broad whole-genome panels by default because the clinical signal-to-noise ratio is still low. We add specific tests when the result will change your plan.

Do you take insurance for the Deep Dive?

We are a Direct Primary Care practice. We do not bill insurance for our time, which is why we can spend 90 minutes with you instead of 12. We do, however, use your PPO insurance for the labs and imaging (MRI or CT). You get the best of both worlds: concierge attention plus insurance coverage for the heavy lifting.

Can I do just the Deep Dive without becoming a member?

Yes. We offer "The Executive Audit" as a standalone service for those who have a primary care doctor they like but want a higher-level strategic review. Most patients who do the audit eventually convert to membership because they realize what they have been missing.

Is this just biohacking?

No. Biohacking is n=1 experimentation with unproven tools. This is engineering. We use validated, rigorous metrics (ApoB, VO2 Max, DEXA) drawn from the highest-quality longevity science and primary literature.

How long does a Deep Dive appointment take?

The full Deep Dive is 90 minutes. That includes a focused exam, a full review of your labs and imaging, and a strategy session where we build your 12-month plan together. Most patients also schedule a 30- to 45-minute follow-up 4 to 6 weeks later to refine the plan.

What labs are included?

Standard Deep Dive labs include a complete metabolic panel, full thyroid panel (TSH, Free T3, Free T4, reverse T3, antibodies), fasting insulin, HOMA-IR, ApoB, Lp(a), hsCRP (high-sensitivity C-reactive protein), HbA1c, fasting glucose, complete blood count, ferritin, vitamin D, B12, and homocysteine. We add sex hormones, advanced cardiometabolic markers, or genetic tests based on your goals.

How is this different from other executive-physical or lab-testing services?

Many broad lab-panel and "executive physical" services offer a lot of tests but limited physician time, and some lean on nurse practitioners or default to selling supplements. We are physician-led with a capped panel size, and we anchor every recommendation in standards-of-care medicine plus longevity science.

What if my labs come back alarming?

Surprises are why we do the Deep Dive. If we find an early sign of metabolic dysfunction, lipoprotein risk, or hormonal imbalance, we walk you through the data, build a plan, and follow up at 4-, 8-, and 12-week intervals to track changes. We have your back through the entire process.

Do you do Deep Dives for couples or families?

Yes. Many patients book back-to-back Deep Dives with a partner so we can map shared genetic and lifestyle risk. We tailor each plan individually but coordinate when it makes sense (for example, sleep environment, kitchen strategy, family fitness goals).

Why is fasting insulin a better early warning sign than HbA1c?

Fasting insulin reflects how hard your pancreas is working to keep glucose normal. It rises 5 to 15 years before HbA1c starts climbing. By the time HbA1c is in the pre-diabetic range, you have already had years of metabolic damage. Catching the rise in insulin gives us a long runway to course-correct.

How does ApoB compare to LDL-C and non-HDL cholesterol?

ApoB measures every atherogenic particle (LDL, VLDL, IDL, and Lp(a) all carry one ApoB protein each). LDL-C is a calculated estimate of cholesterol mass inside LDL particles, and non-HDL cholesterol approximates particle burden. Multiple studies (CARDIA, MESA) show ApoB is the strongest single predictor of cardiovascular events.

What is HOMA-IR and why does it matter?

HOMA-IR is the Homeostatic Model Assessment of Insulin Resistance. It uses fasting insulin and fasting glucose to estimate how insulin-resistant you are. A value above 1.5 suggests early resistance, and above 2.5 confirms significant resistance. It is one of the cheapest and most useful metabolic tests we run.

Why do you measure Cystatin C in addition to creatinine for kidney function?

Cystatin C is filtered by the kidney like creatinine but is not influenced by muscle mass. Athletes and bodybuilders often have elevated creatinine that looks like kidney dysfunction but is just muscle. Cystatin C cuts through that confusion and gives a cleaner estimate of kidney filtration.

What does Lp(a) actually do, and why is it usually missed?

Lp(a) is a genetic variant of LDL with an extra protein that promotes plaque, inflammation, and clotting. About 1 in 5 people carry elevated levels. Standard insurance protocols do not routinely test it because there has historically been no targeted treatment. New Lp(a)-lowering drugs (pelacarsen, olpasiran) are in late-stage trials, which makes early detection more useful than ever.

How accurate is at-home VO2 Max from an Apple Watch?

The Apple Watch estimates VO2 Max from heart rate and pace data using a proprietary algorithm. It is usually within 10 to 15% of a lab measurement, but can overestimate fitness in lean adults and underestimate in heavier athletes. We use it for trend tracking and confirm with a metabolic cart when we need precise zones.

What is the difference between visceral fat and subcutaneous fat?

Subcutaneous fat sits under the skin and is mostly cosmetic. Visceral fat sits inside the abdominal cavity and wraps around your organs. Visceral fat secretes inflammatory cytokines that drive insulin resistance, cardiovascular disease, and certain cancers. A DEXA scan or InBody machine separates the two.

How do you decide who needs a coronary CT angiogram?

We use a combination of family history, ApoB, Lp(a), inflammation markers (hsCRP), blood pressure, and any chest symptoms to estimate cardiovascular risk. For patients with intermediate or high risk who want clarity, a coronary CT angiogram (often with Cleerly analysis) shows soft and calcified plaque directly. We refer to Penn or Jefferson for the imaging.

How is hormone optimization handled in the Deep Dive?

We test full sex hormone panels (testosterone, free testosterone, SHBG, estradiol, DHEA-S, and sometimes LH and FSH) along with thyroid and cortisol patterns. Hormone replacement is data-driven and anchored to symptoms, not to internet protocols. We do not chase supraphysiological numbers.

Will a Deep Dive identify cancer risk?

The Deep Dive is not a cancer screen, but it surfaces patterns associated with cancer risk (chronic inflammation, metabolic dysfunction, low fiber and protein, alcohol burden, suspicious imaging findings). For high-risk patients, we coordinate Galleri multi-cancer tests, mammograms, prostate MRIs, or colonoscopies through specialists at Penn, Jefferson, Temple, or Main Line Health.

How does sleep architecture testing work?

Wearable data (Oura, Whoop, Apple Watch) tracks heart rate, HRV, respiratory rate, and movement to estimate sleep stages. For patients with persistent fatigue, snoring, or witnessed apneas, we order home sleep testing (WatchPAT or Lofta) to look for obstructive sleep apnea. Untreated sleep apnea is one of the most reversible drivers of fatigue and cardiovascular risk.

What is the role of genetic testing in the Deep Dive?

Targeted genetic testing (ApoE, MTHFR, Lp(a), hereditary cancer panels) can sharpen risk assessment and personalize treatment. We do not order broad whole-genome panels by default because the clinical signal-to-noise ratio is still low. We add specific tests when the result will change your plan.

The Deep Dive: Why the Annual Physical Is Obsolete

TL;DR30-second take

The standard 15-minute annual physical was designed to catch acute illness, not optimize healthspan. The Fishtown Medicine Deep Dive is a 90-minute strategic audit of your biology that measures what actually predicts longevity (VO2 Max, ApoB, fasting insulin, body composition) and turns the data into a personal plan.

You know the drill. You wait 3 months for an appointment. You sit in a beige waiting room. You get 12 minutes with a doctor who is typing the whole time. They listen to your heart for 4 seconds, check your reflexes (why?), and order a "standard panel." A week later, you get a portal message: "Labs are normal. See you next year."

This is not healthcare. It is sick-care administration.

At Fishtown Medicine, we do not do "physicals." We perform Deep Dives. A Deep Dive is an engineering audit of your biological systems. It assumes that "normal" is not the goal, because in modern America, "normal" is pre-diabetic, sedentary, and inflamed. Optimal is the goal.

The Gap: What They Miss vs. What We Measure

Standard medicine (Medicine 2.0) is excellent at treating trauma and acute infection. It is poor at detecting the slow, silent slide into chronic disease. Because it relies on metrics from the 1970s, it misses the warnings until the check-engine light has already entered "catastrophic breakdown" mode.

1. The Engine: VO2 Max

Medicine 2.0: "Do you exercise?" (Yes or no checkbox).
The Deep Dive: VO2 Max testing.
Why: A VO2 Max score (your lung and heart capacity) is the single strongest predictor of all-cause mortality. It tells us your functional age. If you are 40 but have the engine of a 60-year-old, we need to know now.

2. The Fuel: Advanced Metabolics

Medicine 2.0: HbA1c and fasting glucose.
The Deep Dive: Fasting insulin, HOMA-IR, and a continuous glucose monitor (CGM).
Why: Your blood sugar can stay "normal" for 15 years while your pancreas screams for help (a state called hyperinsulinemia). Measuring glucose without insulin is like looking at your bank balance without seeing your spending rate. We catch metabolic dysfunction a decade before diabetes.

3. The Pipes: Lipoproteins

Medicine 2.0: LDL-C (calculated).
The Deep Dive: ApoB and Lp(a).
Why: LDL-C measures the weight of cholesterol. ApoB measures the number of particles crashing into your artery wall. ApoB is a far superior predictor of heart attacks. And Lp(a) is a genetic risk factor that 20% of people carry, yet standard doctors rarely check it.

4. The Chassis: Body Composition

Medicine 2.0: BMI (height vs. weight).
The Deep Dive: DEXA scan or InBody scan.
Why: BMI is unreliable for anyone who lifts weights. It cannot distinguish muscle from fat. We measure visceral adipose tissue (VAT), the toxic fat around your organs that drives inflammation.

What Happens in the Strategy Session?

The most important part of the Deep Dive is not the test itself. It is the interpretation. You do not get a portal message. You get a 90-minute strategy session with your physician.

Fishtown Medicine

A 90-minute conversation with Dr. Ash. A written plan you can actually follow.

Start your intake

We put your data on the big screen and look at the trends:

"Your kidneys are filtering well (Cystatin C), but your liver is showing early strain (ALT)."
"Your testosterone is 'normal' for an 80-year-old, but you are 38. That is not normal."
"Your grip strength suggests you are losing muscle mass. We need to restructure your protein intake."

We then build a tactical plan for the next 4 quarters. We do not just say "exercise more." We prescribe "Zone 2 training, 45 minutes, 3 times per week, at 135 beats per minute."

Guidance from the Clinic

"If you want average results, see an average doctor. If you want to outperform the aging curve, you need to measure the variables that drive longevity. You cannot manage what you do not measure."

Actionable Steps for Philadelphians

Stop renting your health. Start owning the data.

Audit Your Last Labs: Pull up your last physical labs in MyChart or Labcorp. Note whether ApoB, fasting insulin, or VO2 Max appear. They almost never do.
Book a Deep Dive: Schedule a Warm Invitation Call to see if a 90-minute audit fits your goals.
Track One Metric: Pick one wearable metric (resting heart rate, deep sleep, HRV) and watch the trend for 30 days before your visit.

Scientific References

Mandsager K, et al. Association of Cardiorespiratory Fitness With Long-term Mortality. JAMA Netw Open. 2018. (The definitive VO2 Max study).
Sniderman AD. Apolipoprotein B Particles and Cardiovascular Disease. JAMA Cardiol. 2019. (The case for ApoB).
Shlipak MG. Cystatin C and the risk of death and cardiovascular events. N Engl J Med. 2013. (Why creatinine alone is not enough).

Executive Physical - the deep-dive preventive workup for driven professionals
Preventive Care - the proactive medicine approach to staying well
Longevity Medicine - Medicine 3.0 applied to your day-to-day care
Healthspan Optimization - the framework for staying healthy across decades
Functional Medicine - what functional medicine offers and where it overlaps with internal medicine

Frequently Asked Questions

Common Questions

Deep-Dive Questions

Ready when you are

Start your intake

Dr. Ash reads every intake himself, and answers questions personally - usually within a few hours.

TL;DR30-second take

This is not healthcare. It is sick-care administration.