Tag: Family Doctor

Knee Cap Pain


16 April 2019

Hi, thank you for coming back for the latest edition of Beyond Primary Cares blog; where I highlight healthy and fun recipes, healthcare news, advice for medical conditions, as well as how membership for care works! Dr. Jeff O’Boyle is the owner of Beyond Primary Care, which is a new approach to family medicine and addiction medicine that creates the time and space your healthcare deserves. Beyond Primary Care serves patients in Ann Arbor and throughout Washtenaw, Livingston, and Wayne County.

The primary purpose of the blog is to introduce healthy lifestyle concepts and answer common questions I receive from patients that I believe are important. I want to start discussions that will help educate, benefit, and improve your well-being. 

Knee Cap Pain

In this post I am discussing a common condition that I see at my clinic: knee cap pain. Knee cap pain can present itself multiple ways that may not always be muscular in nature, so you should always check with your doctor before starting any treatment. However, a common reason for knee pain is patello femoral pain syndrome (PFS), where the knee cap begins to increasingly track to the outermost part of the leg bone (femur) with movements such as walking, going up/down stairs, and squatting (pretty much any movement when someone bends their leg). Improper tracking of the knee cap can mechanically be due to a number of problems, and can be years in the making or due to a single traumatic event.


Your quadriceps muscles are key to many movements and activities that you do. The group is made up of four muscles (a “quad”) – rectus femoris, vastus lateralis, vastus intermedius, and vastus medialis obliquus (the VMO). All four then run down to your knee and they join together, becoming a single tendon that surrounds your knee cap (patella). This tendon then continues down to connect to the knee bone (tibia) of your lower leg.

The VMO Connection

The VMO contributes to running, jumping and nearly every other basic movement, because together with your other quad muscles, it’s a powerful knee extensor along with pulling the knee cap to the inside. Anytime you push off the ground, your VMO is involved. It’s also an important knee stabilizer—a critical function that’s often overlooked. The other three quad muscles are either neutral or pull the knee cap to the outside. If you don’t have a developed VMO that can hold its own compared to the other quad muscles, you may experience tracking issues which leads to the vicious cycles of knee pain.

Minimize the Pain and Swelling

Minimizing pain and swelling can be done via an interdisciplinary approach with ice-packs and non-steroidal anti-inflammatory drugs (NSAIDs). Consider using ice-packs over the affected area, fifteen minutes at a time, two to three times a day. No heat, as this only will exacerbate the pain/inflammation cycle. Next, consider NSAIDs as these have anti-inflammatory properties and are used widely for musculoskeletal disorders. Select NSAIDs, such as ibuprofen and naproxen, are available over-the-counter.

Identify your VMO

In a relaxed, seated position with your legs out in front, place a rolled-towel under your knee. Next, feel your VMO by placing your fingers just above your knee cap on the inside aspect of your leg. Extend your leg by bringing your knee cap down into the towel. The extension of your leg should occurring slowly (like 5 seconds), over just a small range. When you do this you should feel the VMO contracting under your fingers. This should be your first exercise. 

Access Range of Motion and Build Flexibility

The first step in improving your situation is going be be determining if you have tight muscles as lack of flexibility can disrupt both the timing and contraction of muscles that will ultimately lead to more pain. From a balance standpoint, a tight muscle may limit the range of motion through which an opposite muscle can move (example of opposite muscles include rectus femoris/glute). Learn what you can about stretching, then find specific flexibility builders such as hip and ankle muscles.

Tape the Knee

Taping the knee is very easy and has been validated by research to help improve the nervous system firing of the weakened VMO muscle. Purchase some athletic or kinesio tape. To apply the tape, place the tape on the outside of the affected knee and pull it across the knee cap inward making sure you have enough pressure that you see a little skin fold crease as you do this. 

Stabilize & Build Strength

Once your swelling has subsided and pain is improving, you need to start with simple non-weighted stability exercises to regain integrity of the joint. Consider one-legged standing exercises. As you progress, start with non weighted strengthening exercises such as lunges, step-ups, and squats. Lastly, if at any point treating your knee becomes too complicated, talk to your doctor about a prescription for physical therapy. 

Free Up Cashflow In Your Budget


4 April 2019

What are some ways to help free up cashflow in your budget? How about healthcare through Direct Primary Care?

Hi, thank you for coming back for the latest edition of Beyond Primary Care’s blog; where I highlight healthy and fun recipes, healthcare news, advice for medical conditions, as well as how membership for care works! Dr. Jeff O’Boyle is the owner of Beyond Primary Care, which is a new approach to family medicine and addiction medicine that creates the time and space your healthcare deserves. Beyond Primary Care serves patients in Ann Arbor and throughout Washtenaw, Livingston, and Wayne County.

The primary purpose of the blog is to introduce healthy lifestyle concepts and answer common questions I receive from patients that I believe are important. I want to start discussions that will help educate, benefit, and improve your well-being. 

Today, I’m glad to welcome guest blogger, my friend Dennis LaVoy. Dennis and I co-authored this piece about freeing up cashflow through Direct Primary Care (DPC).

Who is Dennis LaVoy?

Dennis LaVoy is the owner of Telos Financial, a fee based, holistic financial planning firm located in Plymouth, Michigan specializing in serving young professionals and families. Dennis is a Certified Financial Planner (CFP®) professional and a Chartered Life Underwriter (CLU®) founded Telos to provide financial advice and uses his experience, knowledge, and expertise to help families and individuals in Ann Arbor, Detroit, and across the country achieve their financial objectives.

He went to school at Eastern Michigan University where he graduated Magna Cum Laude while receiving his degree in Finance. He has worked 10+ years as a financial advisor and opened his own firm, Telos Financial in February 2018. 

We’re going to discuss some of the financial incentives for using a DPC model.

What could using a DPC practice mean for my budget? 

Health insurance coverage is a very personal decision each family must make on their own, considering their personal values, tolerances, geographic location, and needs. Direct primary care is a membership model of health care that works well in conjunction with a High Deductible Health Plan (HDHP), commonly referred to as ‘catastrophic insurance.’ Combining a DPC membership with a HDHP addresses the main drivers of increasing cost in healthcare, such as the patient being seen in a timely manner, being proactive about your health, and ancillary medical costs (medications, labs, imaging). This allows individuals and families to have extra money on-hand every month, often saving thousands of dollars per year. So, if this type of insurance aligns with your values and tolerances, it can mean big monthly savings for your family versus a higher premium insurance arrangement.

How would it work?

Hospital systems and insurance-based clinics have higher costs for many medical services and their prices do not reflect the true cost of services even after insurance negotiations. When eliminating the costs of using health insurance, many patients can find equally effective and far more affordable options for their healthcare needs.

For example, let’s say your family is pretty healthy overall and have a high premium/low deductible health insurance policy that you pay a lot of money towards every month, where your monthly premium is $1,600, or $19,200 per year.* You believe you are not extracting enough value from your insurance, but still want coverage for those ‘what if’ scenarios. 

Switching to a HDHP insurance plan combined with a DPC membership still means you have that insurance for those ‘what if’ scenarios, but now also you have virtually unlimited access to your doctor where they can focus directly on you and not the middleman (insurance companies). Your new monthly insurance premium is $718*, and by enrolling in a DPC practice for as low as $130** a month you will have $750 in savings every month, or $9,000 per year.

*These figures were obtained by providing realistic information to ehealthinsurance.com to compare health insurance rates for 2 adult non-smokers along with 2 children for comparable health insurance plans that are compliant with the Affordable Care Act (ACA), commonly referred to as Obamacare. 

**This figure was obtained by combining the rates for adults and children at Beyond Primary Care, Ann Arbors only direct primary care practice.

Financial Savings and Opportunities

Combining a DPC membership with a HDHP can save families and individuals thousands of dollars per year where this arrangement is appropriate. Because Direct Primary Care provides so much in a membership, it is gaining national attention for the associated cost savings. A testimonial to this national attention is Consumer Reports listing Direct Primary Care as a top five smart money move in 2019 saying “joining a DPC medical practice will give you around-the-clock access to your doctor and could save you money on primary care.” 

With a couple hundred saved each month, that is money you can have working for you- not the health insurance companies. An extra $9,000 may allow you to create an ‘emergency fund,’ pay off loans, or even invest for the future. 

A $750 savings per month could build a substantial investment portfolio over time. I always recommend working with a financial planner to decide how best to invest for your family, but depending on your income, goals, and life situation, you could also save to a Roth IRA, Traditional IRA, or to a non retirement investment account. 

The Power of Compound Interest

$750 per month is a lot of money for many families. Over time, it can be hugely impactful for long term financial. Let’s further play out the scenario in this example and you have a family of 4 and that you were able to invest $750 per month at 7% growth. 7% is an assumption based on a balanced portfolio, as a point of reference, the S&P 500 from 1937-2017 (90 years) averaged 10.4%. Further, let’s assume in this example the family of 4 is two adults aged 30 and they’ll save for 12 years (Let’s say until the kids move on). 

In this example, at the end of 12 years or age 42 for the adults, you would have saved a total of $108,000 and the account would be worth over $175,400! If they didn’t save another dime after that, the account would be worth over $1,000,000 around their age 65 and 3 months. If they were able to continue the $750 per month savings, when they reached age 65, the account would be worth $1,532,591 on a total investment of $315,000. The numbers really speak for themselves and really demonstrate the power of compound interest. 

Why wouldn’t I do this?

DPC is not available locally in all communities. If you do not utilize healthcare services on a regular basis or when you do, you are just looking for one-off visits or one-time services, DPC probably is not the right fit. As always, it is something you have to consider personally.

If your employer provides a ‘comprehensive’ high premium/low deductible policy, DPC may not initially be advantageous. Still, consider bringing up DPC to your human resources leaders and incorporating into your benefits package. A partial, or fully self-insured model in conjunction with DPC has been show to result in a 30-60% reduction healthcare expenditures. 

The views expressed are my own opinions and do not apply to every situation. Your situation may vary so make sure to consult a professional for advice prior to making any decisions.


Financial planning should take into consideration all your needs and wants, review costs and tolerances, and educate yourself about the options. To learn more about financial planning, Dennis LaVoy, CFP®, CLU®, or Telos Financial please check out his website at https://telosfp.com/. If you believe Dennis may be a good fit for your family and you live in the southeast Michigan (or really anywhere), call him today at 734-468-3050.

These examples are for illustrative purposes only, not indicative of any specific investment product. Material discussed herewith is meant for general illustration and/or informational purposes only, please note that individual situations can vary. Therefore, the information should be relied upon when coordinated with individual professional advice.

Dr. Jeff O’Boyle of Beyond Primary Care is not affiliated with FSC Securities Corporation.

BPC Good Eats: Tomato Basil Parmesan Soup


2 March 2019

Hello and thank you reading my blog at Beyond Primary Care and trying the BPC Good Eats recipes. This featured recipe is a Tomato Basil Parmesan Soup. These recipes are my attempt, in a way, to bridge that Doctor’s adage of “Eat Better & Exercise More.” In this post, I will showcase a healthy meal made on a budget, my pictures are pretty decent, and that is how I got into this food endeavor.

Tomato Basil Parmesan Soup Slow Cooker
Adapted from: 365 days of slow cooking
Prep time: 15 minutes
Total time: 35 minutes + slow cooking time

2 (14 oz) cans diced tomatoes, with juice
1 cup finely diced celery
1 cup finely diced carrots
1 cup finely diced onions
1 teaspoon dried oregano or 1 Tablespoon fresh oregano
¼ cup fresh basil
4 cups chicken broth
½ cup flour
1 cup grated parmesan cheese
½ cup butter
2 cups half and half
1 teaspoon salt
¼ teaspoon black pepper

1) Add tomatoes, celery, carrots, chicken broth, onions, oregano, and basil to large slow cooker.
2) Cover and cook on low until flavors are blended and vegetables are soft.
3) About 45 minutes before serving, take the vegetables out of slow cooker and add them to a blender until smooth. If you prefer a chunkier texture you can leave it as is or just blend some of it. Return blended veggies to slow cooker.
4) Meanwhile, in a saute pan over low heat melt butter and add flour. Stir roux constantly with a whisk for 5-7 minutes. Slowly whisk in 1 cup hot soup. Add another 3 cup and stir until smooth. Add all back into slow cooker.
5) Stir and add the Parmesan cheese, half and half very slowly, salt and pepper.
6) Cover and cook on low for an additional 30 minutes or until ready to serve.


Avoid the Sneeze Pee


18 January 2019

Adult Guide to Urine Incontinence

At my family medicine clinic, Beyond Primary Care, located in Ann Arbor Michigan, I see a fair number of individuals who experience urinary incontinence. Urinary incontinence is when urine leaks, from a number of causes, that becomes frequent or severe enough to be a problem. Incontinence happens in men and women. Unless I specifically ask some individuals, some may think that incontinence is an unavoidable part of getting older or a known consequence of child birth. I wanted to tell everyone that urinary incontinence can be addressed with both non-medication and medication intervention. In this guide, I talk about non-medication treatments.

Your Anatomy

The bladder is a hollow sac (like a balloon) with muscular walls. It sits behind the pelvic bone. The bladder is part of the urinary system, which includes two kidneys, two ureters, a bladder, and a urethra. The kidneys take waste and water out of your blood to make urine. The urine travels down your ureters to the bladder. When you’re ready to urinate, the urine empties through the urethra.

What is Average

It sounds like kind of a lot, but, depending on how much liquid you drink, peeing roughly 8 times during the day is average. Even though it’s annoying, getting up once to twice during the night is also considered normal. Most bladders hold about 2 cups of fluid (473 mL). A classic excuse among the frequent pee-ers: “I just have a small bladder!” Turns out, there’s some truth to that seemingly odd refrain. Anatomically, everybody can be different, just like some people are tall and some people are short.

Turn Perception into Measurements

If you’re irked by how much time you spend atop the throne, consider keeping a diary to chart your bathroom breaks. When you actually tally up your trips, what feels like a lot might be totally normal. Again, most bladders hold about 2 cups of fluid. If you’re going to the bathroom frequently and producing less than that, that may not be normal.  And yes, you should actually measure. Grab a container and see if you’re hitting 1.5 to 2 cups.

Existing Medications &  Other Causes

  • Take a look at your existing medications. Medications may lead to incontinence. As example, diuretics (water-pills) used to treat high blood pressure can cause the kidneys to make a lot of urine really quickly. Review your medications with your doctor. 
  • Diabetes: If you’ve ruled out other causes, there’s a chance your constant peeing is due to diabetes. If your blood sugar’s high, the kidneys won’t be able to process all of it, and some can spill into the urine. That sugar will essentially pull more water out of you, so you’ll be generating more pee. 
  • Urinary Tract Infection:  Signs of an infection may include pelvic pain, increased frequency, increased urgency, and possible blood in the urine.
  • Pelvic Support and Urinary Tract Problems: The pelvic organs are held in place by supportive tissues and muscles. Problems occur when these tissues are stretched, weakened, or altered by stool impaction, pregnancy, childbirth, abnormal growths, fistulas, or aging.

Treatment to Avoid the Sneeze Pee

Keep Drinking Fluids. Understandably, if you spend a lot of time thinking you have to pee, you might be inclined to dehydrate yourself just a touch. If you don’t drink as much, you won’t have to go as often, right? Turns out this way of thinking is bladder sabotage. When you drink less, the urine becomes more concentrated, and the more concentrated it is the more irritating it can be to the bladder, which can trigger the sensation that you have to go more often.”

Timed voids. The good news for the small bladdered is that you can train your bladder to hold more fluid. If you give into the urges too often, you are training the bladder not to hold as much (Just don’t hold it so long that it starts to hurt). You could be inadvertently doing this if you’ve preemptively started emptying your bladder more frequently in just-in-case scenarios, like in hopes of warding off leakage, say, before a workout.To train your small bladder to bulk up, implement “timed voiding”:

  • Urinate every 30 minutes for two days, whether you have to go or not.
  • Add 15 minutes to the regimen: Urinate every 45 minutes for two days.
  • Keep adding 15 minutes to this regimen, until over time you have trained your bladder.

Hitting the (pelvic floor) gym. The stronger those down-there muscles, the easier it is to hold urine in. It’s better to learn how to use your muscles to tighten the pelvic-floor area. Yes, we’re talking about Kegel exercises. If you don’t already know, the exercises are performed by tightening and releasing the muscles you’d use to stop the flow of urine without moving anything else in your body. Find your pelvic muscles by tightening the rectum as if trying not to pass gas or pinching off a stool. Done best after emptying the bladder. Tighten and hold for up to 3-5 seconds, then release and relax 5 seconds. As muscles get stronger, progress to 10 seconds. Do these exercises 10-20 times a session, 3 times a day. Remember to breath normally. It may take 4-6 weeks to notice results.

BPC Good Eats: Pizza Dough


16 January 2019

Hello and thank you reading my blog at Beyond Primary Care and trying the BPC Good Eats recipes. This featured recipe is a Pizza Dough. These recipes are my attempt, in a way, to bridge that Doctor’s adage of “Eat Better & Exercise More.” In this post, I will showcase a healthy meal made on a budget, my pictures are pretty decent, and that is how I got into this food endeavor.

Pizza Dough
Prep Time: 30 minutes
Total time: 1 hour
Original Recipe

3 cups bread flour
1 (.25 oz) package active dry yeast
2 tablespoons olive oil
2 teaspoons salt
1 tablespoon white sugar
1 1/4 cup water
1 tablespoon garlic powder
1 teaspoon onion powder
2 teaspoons dried basil
2 teaspoons dried oregano
3 tablespoons honey, divided
1 cup cornmeal
1 cup unbleached flour (for rolling)

1) Microwave water in measuring cup to 110 degrees F/ 45 degree C, time varies on microwave.
2) Stir sugar into warm water, then sprinkle yeast on top but do NOT stir. Allow to sit untouched for 10 minutes.
3) While waiting, sift bread flour, garlic powder, salt, and onion powder into mixer bowl. Add 1 tablespoon honey, basil, oregano directly to bowl.
4) Once yeast/water mixture has rested 10 minutes, turn mixer to slow and add water/yeast mixture slowly. This is a little bit of an art, add to quickly or too much and your dough will be soggy and clump. Add too little and your dough will be too dry.
5) Continue mixing until dough is elastic and smooth, about 10 minutes, for last 2 minutes turn mixer to faster speed.

6) Turn mixer off, let dough sit for a minimum 30 minutes before using. If longer times are allowed, refrigerate. Ideal is 4 hours to overnight. If refrigerating, take out and allow 30 minutes to return to room temperature before rolling.
7) When ready, preheat oven to 425F.
8) Once dough has rested, spread flour over clean counter space. Place dough on counter, use rolling pin spreading and flipping dough until desired consistency. Allow to rest for 5 minutes before transferring to pizza stone or pan.
9) Place cornmeal liberally on stone or pan before transfer pizza dough. Trim to desired length (use extra dough and re-roll for pizza sticks or a smaller pizza).
10) Crimp edges of pizza with hands. Use fork and poke multiple spots at pizza dough for aeration.
11) Bake pizza crust alone for 3-4 minutes. Take pizza dough out of oven, use remainder of honey and brush ends of pizza to create flavorful crust.
12) The pizza crust is all done, top per your favorite recipe!


Neurontin, Gabapentin, Controlled Substance

Gabapentin as a Controlled Substance


10 January 2019

This past Monday, 1/7/18, the state of Michigan classified Gabapentin (brand name Neurontin) as a controlled substance (C V) as it has been increasingly been reported abused by some patients.

Gabapentin is approved by the Food and Drug Administration (FDA) to treat epilepsy and neuropathic pain caused by shingles. That is it! However, as many people already recognize it is prescribed ‘off label’ by health care providers for various reasons including including depression, anxiety, migraine, fibromyalgia, muscle and joint pain, and bipolar disorder. According to some estimates, over 90% of Neurontin sales are for off-label uses. A report by IMS health found that 57 million prescriptions for Gabapentin were written in the U.S. in 2015, a 42% increase since 2011.

Many providers, including myself, have never screened for Gabapentin abuse in the past as this medication is not tracked by the state’s controlled substance tracking system nor is it typically detectable in most office-based urine drug screens. When Gabapentin is taken alone there is little potential for abuse. Yet, when taken with other drugs, such as opioids, muscle relaxants, and other anxiety medications, there are reports that Gabapentin can have a euphoric effect.

While I see the concern for making Gabapentin a controlled substance in Michigan, it is going to be a tremendous headache for everyone. The community, hospitals, treatment facilities, and doctor offices.

Isn’t it ironic that Michigan is locking up Gabapentin (which IS affordable and has good application when used appropriately) but legalizing marijuana?

It will eventually be easier for people to smoke a joint then get Gabapentin.

Currently, a month supply at Beyond Primary Care for 300 mg (90 pills) is $4.59. The street value for Gabapentin just went up because of this classification and that makes me concerned. Hell, the CDC lists Gabapentin as a non-opioid alternative treatment for pain control. This move by the State of Michigan makes my job as a physician, patient advocate, and provider certified in chronic pain management increasingly harder to deliver affordable and effective treatment to my patients.

Direct Primary Care, Affordable Healthcare, Beyond Primary Care, Ann Arbor Doctor

Direct Primary Care Doesn’t ‘Cherry Pick’ Patients


4 December 2018

I recently met a doctor and self-proclaimed underserved medicine wonk who bellowed that DPC doctors ‘cherry pick’ healthier and wealthier patients, leaving the the vast majority of individuals without care and fewer doctors to choose from. Nothing is farther from the truth- Direct Primary Care is not concierge medicine. I wanted to scream (I didn’t) that this perception whereby accepting a patient’s insurance somehow improves access to health care. I wanted to point out how the health care services this doctor was providing relies so heavily on third-party reimbursement systems, costs for their medical care have likely gone up. But in the end, the before-mentioned doctor was so entrenched in the health care insurance matrix, I could only use their misconceptions to help educate others.

Direct Primary Care Doesn’t Cherry Pick Patients

Direct Primary Care doctors run their own business so that we can do what is right for a change in health care; Treat individuals the way everyone wants to be treated by giving patients the time and peace of mind they deserve. We have transparent pricing on the care for our memberships, and do not charge more for complicated patients, or management of difficult or chronic medical conditions that require more frequent trips to see the doctor. Our plans work great for anyone at any level of insurance or for individuals at any level of savings and income.

  • No insurance? Whether you have a family, or are a single working mother whose employer doesn’t offer insurance, Direct Primary Care is a great option. We provide the vast amount of medical services needed, there are no surprise bills, and contacting or seeing your doctor doesn’t mean you will have to miss work or school.
  • You have insurance but a high-deductible? Direct Primary care does offer excellent and affordable healthcare that can compliment a person’s insurance. I talked about a better plan- Direct Primary Care with Insurance earlier. Direct Primary Care focuses on decreasing their patient’s need for specialty care, ER visits, and hospitalizations by focusing on health and prevention. Doing so can (and does) reduce the need.
  • Have good, or even great insurance? Direct Primary Care universally recommends all patients have insurance. But having insurance does not mean access or longitudinal care. Having insurance without proper access is tantamount to rationing. With Direct Primary Care, we will exceed your office expectations in getting you in for your appointment with the same provider who knows you and your health- every visit.

Direct Primary Care wants to work for you. 

Opening My Clinic, Beyond Primary Care

My goal with opening a direct primary care practice was to make healthcare more affordable and accessible to everyone in the community. I have worked in the fee-for-service system, up-billing every visit to maximize insurance reimbursement (remember, costs are passed down- ultimately to the patient). I remember the conversations about patient’s prescribed blood pressure medications that cost $100 a month, and how I felt powerless to offer alternative ways of obtaining more affordable medications. I know the gut-wrenching decisions I had to make in cutting short a conversation about a patient’s knee pain because I was already a half-hour behind, offering them to return for a subsequent visit two weeks away.

At some point, my job as a family doctor in the fee-for-service system felt more like just a title and salary. After spending the better part of a decade in medical school and post-graduate training, I wanted my role as a doctor to have value. Value for providing my patients with unparalleled access to care. Value for providing my patients with transparent pricing on health care services and helping them navigate the system when needed. Value for sitting down with my patients, spending the time with them that is needed, and being there. That is the value in Beyond Primary Care.

Ropa Vieja, Family Medicine, Real Medicine, Saving Dollars

BPC Good Eats: Ropa Vieja


3 December 2018

Hello and thank you reading my blog at Beyond Primary Care and trying the BPC Good Eats recipes. This featured recipe is a Ropa Vieja. These recipes are my attempt, in a way, to bridge that Doctor’s adage of “Eat Better & Exercise More.” In this post, I will showcase a healthy meal made on a budget, my pictures are pretty decent, and that is how I got into this food endeavor.

Slow Cooker Ropa Vieja
Prep Time: 20 minutes
Total Time: 25 minutes (including 8-10 hr slow cooking)
Adapted from: Food Network

1 (15 oz) can crushed tomato
3 tbsp ketchup
1 tbsp apple cider vinegar
4 cloves garlic, minced
1 ½ tsp ground cumin
2 jalapeno pepper (with seeds), thinly sliced
2 bell peppers (1 red, 1 green), sliced ½ inch thick
1 ½ lbs skirt steak or flank steak
1 onion, thinly sliced
3 tbsp chopped pimiento-stuffed green olives, plus 1 tbsp brine from the jar
2 cups white rice, for serving
Salt and Pepper to Taste

1) Combine the tomatoes, ketchup, vinegar, garlic, cumin, jalapeno, and ¾ tsp salt in a slow cooker.
2) Add the steak, bell peppers, and onion and toss to coat.
3) Place cover on and cook for 8 to 10 hours
4) Coarsely shred the meat with 2 forks, then stir in olives and olive brine. Serve over rice.