The Default is Decline: How Performance Medicine Builds Resilience Before You Need It
The Full Listener's Guide
🎧 In This Episode
We sit down with Dr. Rich Joseph, a Harvard-trained physician and founder of VIM Medicine, to explore a radically different approach to health.
Instead of waiting for disease to strike, Rich introduces us to Performance Medicine - a proactive model that builds resilience before you need it.
We dive into why the default trajectory is decline, how to catch drift before it becomes dysfunction, and why managing your health requires the same intentionality as managing your wealth.
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Function Health - Health data platform
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The default is decline. Left alone, our bodies tend toward disorder. Building resilience requires intentional energy input across physical, metabolic, and emotional domains.
Drift happens imperceptibly. Most of us don’t notice the slow decline in capacity until it becomes dysfunction or disease. Rich makes the case of doing the work to catch drift upstream with objective metrics.
Health is a strategic asset. Like wealth, health requires proactive management. We can’t outsource our health to a 10-minute annual physical anymore - we must become agents of our own wellbeing.
❤️🔥 A Deeper Dive
Big Ideas
Performance Medicine redefines “performance” as presence, not productivity
We usually think of “performance” as athletic achievement or work output. Rich defines it much more broadly: “Your capacity to bring energy and attention to what matters most to you in your life.” This reframes health not as vanity metrics or optimization obsession, but as the foundation for showing up fully in the moments that matter - whether that’s playing Go Fish with your kids or training at the gym.
The second law of thermodynamics applies to your body
A closed system left untouched will tend toward disorder. While we’re not technically closed systems, the principle holds: entropy is always working on us. Our modern environment accelerates this decay. Fighting entropy requires targeted, dose-dependent energy input: the right stimulus plus recovery leads to adaptation.
Drift → Dysfunction → Disease is a continuum most of us miss
Traditional medicine diagnoses disease in binary terms: you either have it or you don’t. Functional medicine has done important work defining dysfunction - brain fog, autoimmune conditions, gut issues that don’t fit neat diagnostic boxes. But Rich’s work goes even further upstream to catch drift: the imperceptible decline in capacity that happens when you’re “still pretty fit” but objectively declining year over year. Most of us are swimming in our own water, unable to see the slow erosion until it’s too late.
Cardiovascular disease shouldn’t exist, but it’s still our number one killer
Six in ten Americans have at least one chronic illness. Over 90% are metabolically unhealthy. Cardiovascular disease kills more people than anything else. The tragic part? We have all the tools to eliminate cardiovascular risk - but most people don’t know their risk until the most common symptom appears: sudden death. Being fit protects your metabolic health, but cardiovascular risk is heavily genetic. You need to know your ApoB particle count and family history.
Movement is the essential prescription, but not the only one
Physical training serves as a medium to enhance stress management, self-discipline, delayed gratification, comfort with discomfort, and appreciation of process over outcomes. These are critical competencies in our frenetic, distracted, dopamine-seeking world. But building the optimal body requires all the tools available: training, nutrition, sleep, recovery metrics, medication when appropriate, and addressing the areas of life that have atrophied. Don’t be dogmatic. Use what works.
Reflection Questions
What areas of your life are experiencing drift right now? Where are you “swimming in your own water,” unable to see the slow erosion of capacity because it’s so imperceptible day to day?
Are you treating health as a strategic asset that requires proactive management, or are you outsourcing it to your annual physical? What would it look like to become a true agent of your own health?
Do you know your family health history? What did your parents, grandparents, and siblings succumb to? This is often the most important predictor of your own risk.
Where are you minoring in the minors? What health noise are you paying attention to (supplements, biohacks, optimization tactics) while ignoring the major signals (cardiovascular risk, metabolic health, physical capacity)?
Is training an anchor or a crutch for you right now? Does it provide capacity for what matters most, or has it become an identity you’re rigidly clinging to at the expense of other priorities?
Practice Opportunities
Get your dashboard baseline
Schedule a DEXA scan to measure muscle mass, bone density, and visceral fat
Get your VO2 max tested
Request an expanded lipid panel including ApoB and Lp(a)
Check fasting insulin (more upstream than A1C or fasting glucose)
Consider a coronary calcium score if you have a family history of heart disease
Track HRV and resting heart rate consistently
Conduct an N-of-1 experiment
Rich emphasizes that we’ll never have randomized controlled trials for everything we want to optimize. Learn to run structured self-experiments:
Identify what you’re trying to correct or improve
Determine if there are objective metrics to track
Establish a baseline
Make one change at a time
Measure the effect
Decide: keep or discard
Application Framework
Step 1: Understand your risk
Don’t wait for symptoms. Get comprehensive testing that includes:
Physical capacity metrics (VO2 max, strength, balance, functional fitness)
Metabolic markers (fasting insulin, visceral fat, metabolic flexibility)
Cardiovascular risk factors (ApoB, blood pressure, family history)
Recovery and daily inputs (HRV, resting heart rate, sleep quality)
Step 2: Manage risk with all available tools
Don’t be dogmatic. If you have high blood pressure or high ApoB, don’t walk around with unmanaged risk while you “try lifestyle changes first.” Use medications to manage risk now, then work on lifestyle factors, then potentially peel back medications later. Being willing to take supplements but not medications makes no sense — they’re both exogenous substances you’re putting in your body.
Step 3: Build frameworks, not rigidity
Before taking on any new therapy, supplement, or protocol, ask:
What am I trying to correct or optimize?
Do I have objective biomarkers to measure effectiveness?
Where is this sourced from? Is it safe?
How will I know if this worked or didn’t work?
Step 4: Train for adaptive capacity
Movement is the essential prescription. Physical training builds:
Stress management
Self-discipline
Delayed gratification
Comfort with discomfort
Appreciation of process over outcomes
Train across all domains: aerobic capacity, strength, muscular endurance, anaerobic capacity, balance, and stability.
Step 5: Confer resilience in other domains
Your job is to help yourself grow in different domains so you don’t atrophy. If you’re not growing, you’re atrophying. Where else besides physical training do you need to intentionally input energy to fight entropy? Relationships? Purpose? Emotional health? Mental stimulation? Don’t let those areas drift.
Step 6: Become your own agent
The days of outsourcing your health to a 10-minute primary care visit are over. Build your own health dashboard. Learn to synthesize and contextualize data. Partner with practitioners who have the time, tools, and training to help you catch drift before it becomes dysfunction. Take ownership.
Key Takeaways
The default is decline. Entropy is always working on us. Fighting disorder requires intentional, dose-dependent energy input.
Performance Medicine catches drift upstream. Don’t wait for disease. Track objective metrics over time to see imperceptible erosion before it becomes dysfunction.
Health, like wealth, requires proactive management. You can’t outsource your health anymore. Become an agent. Build your dashboard. Run structured experiments.
Cardiovascular disease is the silent killer. Being fit protects metabolic health but not necessarily cardiovascular health. Know your ApoB, Lp(a), family history, and blood pressure. Use all tools available - including medications - to manage risk.
Movement is medicine, but not the only medicine. Training builds physical and psychological resilience. But don’t be dogmatic. Use all available tools to build the optimal body and life.
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