The Latest update

Premier Update
Lots has happened since my last blog. We've now hired two new doctors here. Dr. Wil Foadey is a graduate of the Brackenridge family medicine progam here in Austin, and brings a spark of youth and vigor to our clinic. Wil is an interesting fellow- raised in Africa under trying circumstances, multilingual, and unmarried. That sets him apart from most of us. Dr. Cheyanne Casas originally came from San Antonio with a long stop in Chicago for much of her medical training and early career. She and her husband just relocated here, and he is a radiation oncologist. She brings a breadth of practice experience including some special interest in nutrition and obesity. This makes 10 family medicine doctors which is just the right number for the new medical village.

The village (currently being called Southwest Medical Village) has experienced the inevitable delay that comes along with dealing with city rules and regulations. We expect ground will be broken very soon so that we may occupy those new digs late this year. We have a full plate of specialists now signed on to join us so that that building should become a medical destination for the folks of south and southwest Austin.
We have also been delighted to add Caapital Family Practice clinic located in Westlake to our growing network. They have made  an excellent addition, and are busily learning our electronic health records system. We expect to have an  additonal network location in Dripping Springs this summer, and hope to expand in BeeCave, and possibly in Buda in the next 6-12 months.
Only bad news is no fishing recently! May try to arrange a trip for smallmouth bass back to Minnesota next fall if this network development job slows down.

Catch up with us

It;'s been awhile since I've written. In all honesty I misplaced my password, and the reset procedure seemed daunting. But I finally figured it out, and thought it was time to present a brief overview of what we've been up to.
We changed our name, and now have two affiliated clinics, one in Oak Hill (Dr. Dawson), and one in BeeCave (Dr. Gabriel). We will announce another larger affiliation this week that will increase our number of doctors from 9 to 13! Our model and message are catching on, and we've now had serious discussions with several other small family medicine clinics who want to know more about our plans. I expect we may be twice a large by this time next year!
Our building project (now named Southwest Medical Village) is moving along, albeit slowly. Building permits are hard to get it turns out. We now have recruited a full slate of specialist to join us in the building which will be located near William Canon and Vega, and hope that this village approach helps solve the triple problems of cost, access, and convenience. We hope to occupy this new and innovative site by fall of 2013.
Internally we've added personnel, and had some leadership accession. Our CEO is Rich Steinle, and he has been invaluable in managing all this on multiple different fronts. Dave McCormick joined us recently, and is a hybrid COO and CIO. He has recently begun our front office transformation from a traditional " doctor centered" model to one that emphasizes patient access and convenience. We now try to answer the phone by the second ring, and hold times when they do occur have consistently been less than 15 seconds. Give us a try and see if it works!
We've progressed toward earning the badge of Patient Centered Medical Home(PCMH), which will help us participate in anticipated changes impending from Obamacare/ACA.
Dr. Kevin Spencer has been anointed president of our medical group, and has taken much of the day to day management so aptly done previously by Dr. Greg Marchand. I now serve as managing partner of network development. Yep, you likely will start to see Premier Family Physicians (PFP for short) and our symbol of little blue men in other parts of town and the greater Austin area soon.
We have a new doc now, Dr. Matt Brimberry, who has been an excellent addition is a real patient favorite already. Dr. Andy Weary decided to shift gears and move his practice to a Spanish speaking clinic south of us. He's always wanted to do that, and we are thrilled that the time is right for him. We have tentatively hired another doc to fill the gap, and we will announce that soon.
Big things are happening, and we'll try to keep you updated. We value your input and suggestions for keeping us on track to serve you better! Dr. Frederick

The View From the Other Side of the Glove

I have been out to discredit the routine use of the screening digital rectal exam (DRE) for years. My first experience was vivid and eye opening. The setting: England Air Force base in Louisiana. The circumstances: getting my pre-training Air Force physical. I was young (20), and I had no idea what I was about to go through. I was vigorous, healthy, and had absolutely no symptoms of anything, except perhaps too much cockiness.  A pre-flight physical before flight school – sure, no problem! I remember very few events about this exam other than one – after completing a myriad of forms, I was ushered into a room where a bored doctor asked me to drop pants and bend over. I was too shocked to not comply, and before I knew it I was in a world of hurt.

Fast forward to today. Now I know better – there is basically no screening value to performing DRE on healthy young men. Because I have some knowledge of military culture, I’m sure that traditional exam was a vestige of days gone by when “one size fits all”-medicine was the rule.

As a medical student learning the art of physical exam and the importance of being thorough, we were taught that everybody needed a DRE—well, almost everybody. The only clinic where this was not a required part of the medical database was the psychiatry ward. And that’s the way it should be, because it is critical to train young doctors to be diligent and complete in their evaluations.

In today’s medical world, doctors vary in their opinion as to when a patient needs a DRE. For instance, some still maintain that a pelvic examination is incomplete without a DRE in order to access the deeper structures of the female pelvis. The same goes with prostate cancer screening – DRE is always mentioned in conjunction with the PSA blood test. We are now advised to have a lengthy and detailed discussion of the relative merits of prostate cancer screening with men.  But if we’re realistic, we know that most men will choose to dodge the finger if given the choice! The number of additional cancers found because of an abnormal DRE in men with low PSA levels is estimated to be limited. 

Clearly there are times and circumstances when DRE is critical to an accurate diagnosis. Rectal bleeding or pain, for instance, or a change in bowel habits suggesting a rectal or colon cancer would necessitate an examination of the rectum. Also, an unexplained anemia can be a sign of bleeding in the intestinal tract, so checking the stool for traces of blood by DRE is quite important.

The question really is whether routine DRE for the purposes of screening is helpful or important. On the one hand, DRE is easy(for the doctor anyway), low risk,  and inexpensive to perform. While there may be a random surprise diagnosis made by routine DRE, those would be few and far between, especially if the systems review is honestly and completely negative. So if the patient has a trusting relationship with the physician and honestly reports no unusual symptoms, then DRE is very unlikely to be helpful. Furthermore, how many men and women demure from regular check ups for fear of DRE?  Humorous parodies of patients enduring DREs are widespread and influential. We’ve all been subjected to the juvenile quips from those whom we are approaching with index finger extended. I can’t prove it, but I suspect unspoken fear of DRE is the basis for declining routine physicals for a significant number of adults.

Given that the most common killer of Americans is cardiovascular disease, we would do much better to selectively perform DRE only on those patients who have a positive systems review, especially if both colon cancer and prostate cancer screening by colonoscopy and PSA is up to date. Wish I would have known this when I was 20!

Let's Work Together

After reading a recent Wall Street Journal article entitled “What If the Doctor Got It Wrong,” I began thinking about how both doctors and patients equally contribute to the undermining of good healthcare. The article’s critiques focused on specialists such as pathologists and radiologists who, by a single diagnostic pronouncement, may drastically affect a patient’s ultimate outcome. In these tense situations, it is very important that a correct pathologic diagnosis be made, and these specialists have only one chance to get it right. Hence, as the article says, second opinions are critical when there is any doubt. To their credit, many specialists are now consistently creating pathways to ensure accurate diagnoses in these critical cases by obtaining second opinions from other doctors.

For those of us in primary care, the potential for a disastrous and life-changing misdiagnosis is just as likely, but perhaps not as frequent. Faced with large volumes of daily interactions, we often see diseases and acute illnesses in their earliest stages. Vagueness of symptoms and a sparcity of specific revealing physical findings is the rule for primary care physicians, and we are often faced with making our best educated guess. It is rare that someone walks through our door with a clear and unequivocal diagnosis.

I like to think of an illness or chronic disease as an unwinding story with twists, turns, and occasional surprises, so that the final chapter cannot be known by one who has read only the first few pages. While most of what we see in the office ends “happily ever after,” sometimes that is not the case. Nobody like surprise bad endings. Physicians and patients must read along together, because as the plot ripens more of the ending can be predicted.

I believe that there needs to be an easy and collaborative process of ongoing reevaluation as events of an illness unfold—as more details are known, more can be anticipated. If an illness that looked benign in the beginning seems to be evolving into something more serious, more evaluative steps may be taken such as lab tests or various x-rays. And this can be accomplished at the appropriate pace.

So how do both physicians and patients undermine this process? 

Physicians and other primary providers often create barriers to access. In our desire not to be overwhelmed, we put processes and people between us and our patients. Phone trees, messaging machines, rapid-fire appointments, and poorly-trained office staff create inaccessibility that undermines our need to stay abreast of an evolving illness. In the harried frenicity of our daily professional lives, we often fail on our side of the unspoken agreement with our patients: in return for being given the status of a trusted guide, we pledge to walk with the patient until the illness is resolved or controlled. If they can’t access us, we can’t know what is happening.

What’s more, our current medical record system requires such high levels of security that it is often inaccessible and useless for the purposes of information exchange. Nobody knows where the story began or what turns it has already taken. We have also failed to create a seamless and timely backup system for when we simply can’t be available. This has led to increased dependence on the busy, expensive, and often inefficient emergency room system as the backup of choice. Because most physicians think much alike, it should be easy for us to pick up the illness storyline when another physician has stopped for a respite, as long as he/she is aware of what has transpired before.

Patients have some culpability, too. Hesitancy to tell us all of the facts, failure to explain specific worries or fears, or poor listening skills make that collaborative relationship difficult for physicians to maintain. Too often patients devalue that relationship by trading it off for the expedience of “quick clinics.” Trust is built on repetitive interaction, not from quick fixes and drive-through health care.

Often patients’ expectations are too high. After all, most acute illnesses and injuries are benign and self-limited, typically resolving on their own. Give your doctor permission to tell you that. Also, one of the inevitabilities of the human condition is aging, and the slow and inexorable decline that we all face can be slowed, but not stopped. Take this into account.

Another frequent complaint of physicians is that patients do not show respect for doctors’ schedules and timing. It is not uncommon for patients to deliberately (or through poor time management) choose to update their physician about their condition at odd hours, thus undermining the physician’s desire to maintain easy availability. Have you ever been treated grumpily by a physician on call? No excuses, but sometimes those late calls feel unnecessary and intrusive. Take time to think about the importance of your health issue before calling your doctor at 3:00 am. Of course sometimes it just can’t be helped.

Much of what has happened to complicate a close working relationship between patient and physician is systemic. Medical care is just too expensive (affecting patients), and disparate information systems and payment systems have made it much too complicated (affecting physicians). I hope that new forms of communication (email for instance) lead to a simpler, more effective and efficient way for us to walk through life together. In the meantime, for those of you who honor me by allowing me to be your physician, keep me posted, hopefully during working hours whenever possible!

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?