Things I Wish My Patients Knew-Can Adults Have ADD?

I think they can. In fact I think I have some of it-the tendency to be easily distracted by details, to let my mind wander even in the midst of a critical conversation, and to have chronic difficulty tracking with a lecturer. I've learned to work around it, to keep good notes, and to ruminate information and manipulate it in my brain so I can remember. Since I've been reasonably successful academically I know that having some ADD tendencies does not neccessarily make a diagnosis or guarantee failure at life. I'm not significantly impaired by it.
However,research into the neuroscience of ADD clearly confirms the presence of a brain disorder that trumps dismissive diagnoses like "lack of willpower". Studies convincingly show that the cluster of symptoms called ADD can and do have a powerful impact on the lives of adult individuals just as they do on children. The majority of children who are diagnosed with ADD do not grow out of it, and have persistent dysfunction as adults. But for some reason we (general public and doctors) are more dismissive of folks who just "can't seem to get their act together".
The price to those adults who actually have ADD  is steep. They are much more likely to drop out of highschool (17% vs. 7%), to not obatin a college degree (19% vs.26%), and are more likely to have been fired or  to be unemployed. When compared to age-matched controls they have a higher rate of teen pregnancy (37 fold increase!), higher divorce rates ( 28% vs. 15%), and higher rates of both motor vehcile accidents and DUI. There are also significant mental health consequences- higher rates of depression, social anxiety, and alcohol and substance abuse.
Not to say that all adults who have some of these troubles have ADD. But a significant number of them do, and treatment may be life-changing for them. This can be one of the most rewarding aspects of practicing medicine-to help diagnose, and then to successfully treat, a condition that has nearly ruined someones life.
Do you have it, or know someone who may have it? Here's a useful, nonbiased website that has lots of  information: http://adhdaware.org/links.htm.
The bottom line is that not everyone who lives a disorganized life or who does not listen well neccessarily has something wrong with them. And many who may actually qualify for the diagnosis of adult ADD based on testing are not signifcantly enough impaired to need treatment. But some ADD adults live tragically impaired lives which could be made so much better with proper diagnosis and treatment. I just wish they knew!
John K. Frederick, MD

Summary from a Medical Conference- Things I Wish My Patients Knew

 

Once or twice a year I attend a medical conference in order to stay current and effective.  What strikes me this year at the Dallas conference of the Texas Academy of Family Physicians is the rapidity of the advancement of medical knowledge! The sheer volume of new information is sobering.  The  task of staying properly educated and informed and transferring that critical knowledge to my patients is a daunting one.

One of my good patients kindly chastised me this week for not blogging often enough. I am honored that he enjoys my writing. So, for the next few weeks I’ll use this space to tell you what I  learned.

The first and most striking issue is hard to talk about, but timely and important. Cancers of the tongue and throat, all categorized as oropharyngeal cancers, are appearing at an epidemic rate! The old paradigm is that such cancers most often occur in older men who drink and smoke. But this is no longer true. Now the most common cause of cancer of the tonsil and tongue is Human Papilloma Virus(HPV). That’s right, the sexually transmitted disease. And it is occurring in ever younger people of all socioeconomic classes. The squeamish part next. The increased rate of this cancer directly parallels the evolution in sexual practices that have occurred on our society over the past 40 years. The risk factor most strongly associated with this cancer is a history of performing oral sex, or oral-anal contact. That’s because the tonsils in the back of the throat are fertile ground for this virus. What’s truly frightening is that confidential surveys confirm that oral sex is now a popular activity amongst even kids as young as early teens. Genital HPV is the most common sexually transmitted infection (STI) in the United States. About 20 million Americans ages 15 to 49 currently have HPV. And at least half of all sexually active men and women get genital HPV at some time in their lives. Yet many young people mistakenly think oral sex  is a “safe” sexual practice. That likely explains why this cancer is at epidemic levels.

Human Papilloma Virus exists in multiple forms, called types. The most virulent is type 16 (HPV16) which also causes the majority of cervical cancers. What once was a cancer of the pelvis and parts below the belt have now become an epidemic of the mouth and throat.

The only good news-the Human Papilloma Virus vaccine includes protection from HPV16. The results of studies of populations of vaccinated young people show a remarkable degree of protection from cervical cancer and genital warts. By extension experts project that the vaccine will also prevent many oral cancers as well.

Nonetheless conversations with parents regarding administering this vaccine to their kids can be awkward. Nobody expects their kids to ever be involved with this kind of activity, so “they shouldn’t need it” the argument goes. But what about potential future sexual partners, or future spouses with a secret past?  There is also mounting worrisome evidence that this infection can also be spread by open mouth kissing. Think your kid will never do that?

The HPV vaccine has recently been recommended by the FDA for both males and females starting around the 10^th birthday. Most insurers who have covered this vaccine in the past only for females will now likely cover it for males as well.

As a parent I understand there are moral, ethical, and even political arguments for and against giving your kids this vaccine. But let’s remember this vaccine is not about sex, it’s about cancer, a bad, disfiguring, painful, potentially deadly cancer.

Here’s what I and my wife have told our four kids already-sex is a special bonding relationship that should be reserved for your lifelong spouse. That is the safest way to keep such horrible things like cancer of the cervix or throat out of your future. We have also taught them that mistakes happen, and we are all capable of making bad choices.

We have chosen to vaccinate all of our kids.

John K. Frederick, MD

Who Will Be Liable

The coming change for doctors is payment reform. For patients, could it be liability reform?
There is about to be a tectonic shift in how medical care is delivered, paid for, and controlled. Over the course of the next two years, if projections are correct, doctors will be forced to line up in teams (accountable care organizations or ACOs for short) for the purposes of efficiences and cost savings. These same forces likely will shift the equations of how clinical decisions are made.Those ACO derived efficiences that may save money are also supposed to free doctors to used evidence based medicine to make clinical decisions. Thats not how we make decisions now. Currently we collaberate with patients, hear their story, examine closely, make a provisional diagnosis, then talk through evaluation and treatment choices with the patient. There may be factors that influence us to move forward with more agressive evaluation that might be clinically called for. An example might be a middle aged man who sprains his back, doesn't get better in a few days, comes to the doctor mainly because he's worried his persistent pain may represent something more serious like cancer. While the chances of that are remote, he and his doctor may choose to go ahead and get the back xray at day 4 of pain just for reassurance. Not so with evidence based medicine. You see, good, scientifically based studies show that 98% of low back pain gets better  within 2 weeks regardless of evaluation and treatment choices. That's evidence. So, with evidence based medicine, the doctor or ACO Gods may choose to not allow xrays for this patient until or if he has waited two weeks for it to get better. A money saver, true, because if this evidence is forced on a large population of patients, thats alot of xray dollars saved. But what if the patient is an exception, and actually does have cancer. Right now the fear of potential lawsuit influences doctors to shade their plans in the direction of patients desires just in the remote chance cancer is present, thereby dodging any liabiity. With coming reform, as long as a doctor performs within evidence based guidelines, he likely will be exempted from laibility regardless of the outcome. Is this a good change?

I Am A Football Fan, But Should I Be

 

I admit it-I am a fan. I grew up right in the middle of college football.My father was a football coach, first at the highschool level, then college, for all of my youth. I played, my brother played (and eventually played at the collegiate level), and my Dad spent all his time coaching, recruiting, and scouting. I have many fond memories.
As a doctor now I see the downstream effects, and I ponder the wisdom of encouraging youth to pursue football as a hobby.

It only makes sense the repeated microtrauma to joints and soft tissues results in a wearing down process. Almost like repeatedly running over potholes in ones car will prematurely cause the shocks to wear and eventually fail, repeatedly running into other people must result in premature wear and tear of the body. I have an ex pro football player in my practice. Though relatively young, he has a "bum" knee that precludes him playing tennis with his son. Another college level player has chronic neck pain that makes long plane rides almost impossible without Vicodin. Yet another ex pro player has low back pain which makes exercise almost impossible and which has resulted in him being clinically obese. Can premature heart disease be far behind. Now there are new and worrisome data that there also may be cognitive effects of repeated blows to the head (loss of brain function)-that is why we suddenly see at the pro level a new emphasis on recovery and playing restrictions after concussion.
All this leads me to wonder. Is it possible that those parents who encourage their kids to play football are in effect increasing the likelihood of their child experiencing premature aging and death? Is there a longevity price to be paid? Could it be that football participation and repeated head trauma leads to poorer school performance, and a diminution of ones eventual academic and career achievements?
These questions may never be answered given the difficulty of gathering such long term data. I hope the answer is "no", but fear that is not the case.  My hope for football- I hope that new technology in equipment allows for better force absorption and protection of body parts. I hope that the use of size,speed,and performance enhancing drug use by athletes will be effectively banned. I hope that rules changes reduce the risk of unnecessary head and neck injury, and new blocking and tackling techniques become widely accepted by coaches and fans.
I am quietly glad my son chose tennis.
Yet thats feels so "unAmerican"...

Yelp? Yikes!

One of the shocking and sobering aspects of social media  is the vast amount of contemporaneous value judging now pouring forth from those small devices. Electronically empowered consumers rate everything. It's just part of the perceived fun of being connected. Sites such as Yelp have become a major source of consumer information for this generation, and the doctor's office is no longer immune.
We physicians are not used to such immediate and frank feedback. If you think this does not apply to you just ask your teenager what is being said about you online. But being aware of this type of immediate, empassioned, no holds-barred feedback has it's advantages. In the past the only feedback we heard mostly was negative. A patient was angry, or frustrated, or embarrassed beyond tolerance, and rather than simply walk away, a complaint was filed. Complements were rare and unexpected. These days, however, passionate analysis is just as often positive given how easy it is to offer. Also, having my clinic actively involved and overtly receptive to being "Yelped" is in itself a badge of fluence in todays wired society. This generation expects the opportunity to give this feedback, and access to such feedback is often a selling point to new patients. And who are we kidding-it is happening whether we participate or not.
The curmudgeon in me sees problems. Such electronic feedback only comes from a specific population-those young at heart with nimble thumbs. Sometimes expectations from this crowd are unrealistic and immature, and may lack objectivity. After all, medical interactions are often complex and difficult to fairly value. Just because we have to deliver some degree of bad news should not result in us being panned. Also, these brief electronic comments are completely one sided. HIPAA laws prevent any counterpoint or counter complaint no matter how justified. I've often dreamed of a website listing those difficult and demanding patients. Perhaps a flashed warning on the smart phone when one of "those" trys to enter the office. Now there's an app for us old guys!
Realistically our entrance into this sphere of consumer feedback has already begun, and inevitably will proceed at an ever increasing pace. There is no point in resisting, so we should join in. Rather than becoming overly sensitive and defensive, let's consider it an opportunity to learn and improve. Hopefully the grace we extend to our patients will flow back in our direction.

Dr. Fredericks Second Opinion: Why are we changing our name

Dr. Fredericks Second Opinion: Why are we changing our name: "Many of you probably noticed we are changing our name from South Austin Family Practice Clinic (SAFPC) to Premier Family Physicians (PFP). Y..."

Why are we changing our name

Many of you probably noticed we are changing our name from South Austin Family Practice Clinic (SAFPC) to Premier Family Physicians (PFP). You may have also noticed we are growing, and now have a clinic in Bee Cave (Premier Family Physicians @BeeCave), and have associated with Dr. Mark Dawson in Oak Hill.
Here's the scoop. The massive push of the federal government into healthcare with the Affordable Care Act (ACA), also perjoritavely labeled Obamacare by some, is a game changer for physicians. Primary care doctors like us have been thrust to the front of the line and made to feel important again. There are numerous studies now that show that communities that are populated by primary care doctors have lower overall healthcare costs and better quality care than those dominated by specialists. And so the ACA has within it built in incentives for primary care doctors to lead the way, to use computers, to collaberate with other doctors in a way that they rarely have in the past. But only for those doctors who work as a team using technology and teamwork to "manage" a larger population of patients. In fact, small group practices are likely doomed under the ACA. They can't afford the costly infrastructure of computer systems, software, and  management to be able to provide such highly integrated and collaberative care. The ACA actually has pointed disincentives for those small practice doctors who resist-there are financial penalties ,for instance, starting in 2012 for those doctors who fail to use electronic prescriptions. You can't do that without being electronified, which is often too expensive and daunting a changeover for many small and solo practices.
So, our options at SAFPC were to be bought by a local hospital, be absorbed by a larger multispeciality group, or grow ourselves into an organization with adequate gravitas. Or wither and die. We debated all those, really did not like that last one, so decided to grow. As we began to plan our business strategy and talk with our colleagues in town, it became apparent that what we were building had appeal amongst lots of other small and solo doctors in the area. We've added two of the best (Dr. David Gabriel and Dr. Mark Dawson), and are in serious discussions with many more. We are not sure how big Premier Family Physicians will get. We intend and are committed to creating an organization with a small practice feel: where patients still get personalized care from one doctor; where we are easy to find and access-by email for instance, and perhaps later with other bidirectional social media like Facebook; where our doctors have time to manage the minutia, and are not scrambling to see enough patients to keep the lights on.
This Facebook business page is intended to keep you informed of our progress. We'll post informational items, and perhaps some videos of our providers. We will try not to waste your time or be too narcissistic. We hope you'll follow along!
John K. Frederick, MD
PFP@SouthAustin

The Z Pack generation

I've heard many monikers for the current young generation (generation Z, millenials). How about the ZPackers. Let me explain. The current generation is marked by a desire to push a button and get action. If you make them wait, they move on. Have a problem, then lets get a solution. Here's the problem, and now please fix it. It'd be nice if illness worked that way.

Now let's talk about the most common malady that we in primary care see in our offices-upper respiratory infections. Lets not call them "colds" (seems to unimpressive), so how about upper respiratory tract infections, or URI's for short. That is any combination of runny nose, nasal congestion, scratchy throat, loss of voice, cough, and malaise. Pick any two, and you likely have a URI. Those are nasty illnesses caused by viruses that take anywhere from 7-14 days to kick, regardless of what you do. Enter the Zpack generation. And alot of nifty marketing by Pfizer. ZPack-just roles right off the tongue, doesn't it?

What happens is about 3-4 days into one of these illnesses I see a patient who says they have a "sinus infection" (that puts the correct amount of emphasis and importance on their malady). You know, yellow snot, stuffy head, can't breath thru their nose, and perhaps now "coughing things up". Usually these folks know what they need ( a ZPack), and just dropped in to get one. Sure enough, once they start their Z pack, they are better in 3-4 more days (total illness 7-14 days). Now they are convinced that the ZPack cured them, and we have now created a huge public health problem. Not good for them personally, either.

Don'tjust  take my word. Look at the science. The scientific literature is full of large studies that should lay any doubts to rest that URIs are not caused from bacteria, but from a variety of viruses (germs that are not killed by antibiotics, and must just run their course). That same literature also concludes that antibiotics have no effect on URI. In fact we are now seeing some pretty serious health consequences to overuse of antibiotics-the most dire is antibiotic resistance from certain commonly seen, and previously non life-threatening, bateria. The biggest and baddest maneater is called MRSA (MRSA= methacillin resistant Staph Aureus). I can't prove that overuse of antibiotics has caused this trend, but I and many doctors more expert than me believe it is at least one of the contributing factors. And not just a public health issue-on a personal level it takes up to year for your colon bacteria to fix itself once you have ingested an antibiotic. Nobody knows the consequences of that,either. But they likely aren't good.

Here's the probem. Go to most doctors tomorrow, tell them yellow snot. "sinus infection", you get them all the time, Zpacks always work, now coughing up phlegm, yada yada. Hey, we doctors want to please,so here you go, here's the ZPack. On to the next patient. Not me-I'll tell you truth if I'm not too exhausted from the previous patient (s) with the same request.

Commonly used tactics: " I go on vacation in two weeks and don't want to be sick". No. How about "I know when I get it in my head it will always go into my lungs". Nope again. Now desperate "My roomate says all I need is a ZPack". For goodness sake, stop it!

What's the right way to go about this? Doc, I fell bad, REAL bad. Cough, congested, blowing my nose all day. Can't sleep. So ask him, "do you think I need an antibiotic"? That's right, give him permission to tell you the truth.  Perhaps he'll do the right thing and give you options. Yes, collaberate, bargain, lets try this or that, and if 14 days roll around and you are NO BETTER, then perhaps we'll give an antibiotic a try. Call me, or better yet email me. Won't cost you anything extra. And perhaps we won't use azithrmycin  AKA ZPack.  Just too strong, and we want it to really work well when we really need it like if you ever get pneumonia.  Perhaps we'll try one of the other really good ones that won't kill your colon bacteria or let your Staph get drug resistant. Yep, that would be a better way to go. Your doctor will think you're smart!
So, wash you hands frequently, keep your fingers out of your nose and eyes during cold and flu season, get extra sleep that time of year. Stay away from sick people as best you can. That's the way to do it.
Now there is a second opinion!
Dr. Frederick

Do I still need shots?

That was the question that came from my 40 year old patient here for a routine physical. My answer-yes, you still need to be aware of your immunization status, and get updated "shots" when needed. Creating immunity via an injection (such as a flu shot) offers significant protection from the bad critters (viruses, bacteria) that roam our world. Think that bottle of purel is just as effective? Have you ever anonymously watched people when they think they aren't being watched? We touch ourselves in all sorts of areas that seed our hands with all sorts of critters. Those critters are then deposited on door handles, telephones, cardoors, lunch tables-you get the picture. This should NOT make you a phobic, but should induce you to wash hands regularly, keep your hands out of your nose and eyes (a common way of seeding others, but also seeding yourselves with someone elses smarm), and get your immunizations. The scare concerning illness or injury induced by immunizations is well overblown, and can not be objectively justified. The hope that immunizations will continue to give us more and greater benefit are true. Immunzations for certain kinds of cancers already exist and have proven to work (gardasil for prevention of cervical cancer). More are on the way-my personal hope is that very soon there will be a shot for melanoma since I have a family history. Perhaps other types of cancer as well. I urge you not to be afraid!
So, make sure that you've had your tetanus shot every 10 years, get a flu shot yearly (unless you can afford to miss a week of your life). If you have asthma make sure you've had a pneumonia shot, and if you are over 65 go get a Zostavax (shingles vaccine). Ask your doc next time you see him/her to make sure you are up to date!

update on our clinic

We've been busy for the last few months deciding on a business strategy, hopefully one which will help us survive the coming changes in healthcare. We've decided to decline the offer to be bought by a hospital or large medical group. But we also do not want to become irrelevant or obsolete. So, insert drum roll here, we have decided to grow! This was not an easy decision. The doctors at our clinic have a unique and enviable chemistry, and we like working together. We genuinely love our staff and care about them as people. Growing our clinic could threaten all of that. However, much of what is coming in healthcare from the new federal healthcare law threatens clinics which are too small (see my first blog on ACOs). So, we've decided to grow, and next month hope to open our second location in the Lake Travis area. There may be a third sometime this year as well. Our target likely will be to have 20 or so providers who are part of our team within the next 12-24 months (we have about 16 now). The trick will be to grow deliberately and wisely so as to maintain our small practice feel, yet rapidly enough to qualify to be an ACO by 2012. We'll also be changing our name!
In the end we all may work for the Federal government. My guess is ACO mania will prove to be a flop, and cost savings will be inadequate to pay for increased utilization. But, that may take 10 years to play itself out, and we will continue to run the race as best we can.
Dr. Frederick