Our Process & Age Restrictions

Devon: [00:00:00] Hi everyone. This is Devon Meadows. Today I talked to dr D about a few things. We talk about some of the processes behind our practice nor Cal ADHD and what types of things Dr. D is doing as he’s dispensing medication and treating our patients, we learn a bit about treating children as well as elderly people that have ADHD. We also talk a little bit about the regulations and the department of justice and why some of these things are in place and what they look like for a practice that is treating ADHD.

[00:00:48]We’re still working on the format of this show. So if you have any suggestions, please ping us, comment on our episode on our website, and give us suggestions or ask questions. There’ll be a link in the show notes to the episode page, which is on our website, norcaladhd.com. So without further ado, here we go.

[00:01:12] So as far as, the process of treating ADHD goes, It’s kind of, it’s in depth. It’s, it’s regulated I noticed there’s a lot of hoops that you’re jumping through all the time. What does that mechanically look like on your end?

Dr. D: [00:01:29] Sure thing. So the requirements on me as a physician are, administrative and the biggest administrative requirement is to do a pharmacy check pharmacy background check through the Department of Justice, the California Department of Justice, not the, uh,US Department of Justice. California has set up a system called CURES and CURES stands for, Controlled substance Utilization Review and Evaluation System.

Devon: [00:02:16] Ooh

Dr. D: [00:02:16] Controlled Utilization Review and Evaluation system.

Devon: [00:02:19] It’s a doozy. These naming conventions on a lot of these he’s big medical organizations.

Dr. D: [00:02:26] And they try. They did it. So it’s you know you got a nice act acronym that’s appropriate, CURES.

Devon: [00:02:31] Yeah,

Dr. D: [00:02:32] So it is now a law that, physicians are required to do this background check pharmacy background check in the CURE system before writing a prescription for what’s called a scheduled medication.

And there are three schedules that, can be freely prescribed. And those are scheduled two through schedule four. Schedule one is for experimental medications only and as infamous because cannabis is presently a schedule one substance. Ironically, Stimulants are scheduled two substances. So they are, the most highly regulated of the freely prescribable medications in the United States in general, and in California specifically. The scheduling is set at the federal level. The laws regarding how I utilize scheduled medication are set at the state level.

[00:03:43] So, much of the administration involves when a patient, first of all, multi-month prescriptions are no longer permissible and, automatic refills on scheduled medications are no longer permissible. So every month the patient must formally make a request for a refill of their medication and then there’s a huge amount of administration that goes on behind that. The requests cannot be made by phone. it’s impossible to leave a voicemail. Well, you can do it, but we will just ignore it. The request has to be made in writing in our secure encrypted messaging system. It is completely private and nobody can see it.

[00:04:29] So the request is made in our messaging system. At that point, I will look up, our last conversation, over the past, you know, two, three days or a week. I will read that and bring myself up to speed.

I will look in one of our other software systems to see if, there’s anything outstanding. My quality assurance specialist, Ms Arlene Yarber keeps track of documentation and whether you’re up to date on your physical and labs when you make the request. So, I review her notes. I look at if there’s any outstanding items I’ve written in any of the other systems.

[00:05:07] I have an excellent team. Devon, you know, you manage this team. We are both so grateful. I’m grateful for you. And we are both grateful for the people we have. We have Ms. Rina and Ms. Karen who are just awesome.

Devon: [00:05:20] We have an awesome team.

Dr. D: [00:05:22] Yes. And so they do all the background check and make sure, everybody’s up to date on their billing and everything’s a copacetic.

[00:05:29] And so then I query. the person making the request in the CURES system, and then I actually write out the data from that query into the encrypted messaging system in our internal field. It’s a, it’s not visible to, the person who I’m helping, but it’s visible to the team. So I write out the data of that query.

[00:05:54] And then I go into another software system we use and electronically order the refill requested. Then, everybody is always assured after that has happened because I will always say, in all caps, “RX IS DONE” somewhere in the body of my responding message. And that’s a person’s assurance that I have sent it. Now many times because pharmacies are overloaded and it, there’s a lot of labor involved with them pulling down prescriptions from their system they will say, “Oh, Dr Dismond didn’t send that prescription.”

[00:06:33] So I assure you I have and what I can do when required, if you ping me saying the pharmacist didn’t send it, I then go into my a secure, encrypted,medication ordering system and pull down all the metadata, including a response from the pharmacy’s computer saying, yep, we got this prescription. I will actually put that in the message. And you can shove it in the pharmacist face and say, “See, I’ve I told you so!”

Devon: [00:07:03] I’ve noticed happens quite a bit.

Dr. D: [00:07:05] yes, it does. And so it’s very empowering for the person. Going to the pharmacy because they have something actually they can shove in a person’s face, and it’s very impossible for the pharmacist, pharmacist to then try and argue with, the person making the request, which they would otherwise do if they weren’t armed with this information.

[00:07:27] It’s like, no, no, he didn’t even have to call your doctor. He’s like, metadata. So, um, that’s, pretty much from soup to nuts. How prescriptions are requested and filled.

Devon: [00:07:40] so I used to get medication from a doctor. This was a really long time ago. Like when I was, when I was younger. I don’t think I had to go to the doctor every month to get a refill at that time. Is, is that a, is that a newer thing that every month, there’s sort of a touch point required.

Devon: [00:07:57] There’s no automatic refills. You said

Dr. D: [00:07:59] That’s correct. scheduled medication. There should be some kind of interaction. and doctor set this up in various ways. you know, it goes all the way from the cynical and jaded, you know, we, doctors are not. We can appear not to be the greatest people. We, we start out always wanting to try to help people, but, you know, circumstances in our very frail egos get in our way.

[00:08:26] And the cynical and jaded of us will have patients come in just for the sake of billing for increasing revenue. And I think a lot of people have experienced this. They come in and it’s like, geez, dude, you maybe said three words to me. It took two hours out of my day. I had to wait for ya. And then when you came in, you hardly looked at me and said three words and then walked out and you’re charging me for a full on office visit.

[00:08:49] So that’s the most cynical and jaded experience. Other conscientious doctors, if we, if we went only think about the positive thing, it’s just a check in.

[00:08:58] It’s more critical with things like opiates If a person looks like they’re, you know, disheveled and nodding out with blown open, uh,I’m sorry, pinpoint pupils and they’re like nodding in the course of the conversation, it’s like, okay, something’s going on here.

[00:09:15] I don’t have to worry about that. As you know, Devon, we’re pretty picky with the patients we accept. So everybody is a, if you’re, if you are someone that the team and I are helping, you’re a pretty solid person. You’re respectable. You’re reliable, trustworthy, and so we don’t have to treat you like a criminal, so we don’t have to worry about that.

[00:09:36] But yeah, I do. I’m with refills. I do, check-ins. many of the times I use a variety of systems. One, favorite one of mine is the world health organization wellbeing index. And so, folks will fill that out and it’s a nice, reliable snapshot on wellbeing. So yeah, that’s my check-in.

Devon: [00:09:57] Yeah, I’ve noticed there’s all types of different check-ins. I’ve seen some people talking to you every day and some people not as often. it’s interesting. We’ve never said any kind of like messaging limit on people either. I see you talking to a lot of these people. Sometimes every day or two when they’re messaging you.

[00:10:20]which is weird for this particular type of treatment, I think. I don’t think anyone’s used to that. There it’s, it’s usually just medication management and go to the doctor and sign a form and leave kind of a thing. I feel like people are used to.

Dr. D: [00:10:37] yes.

Devon: [00:10:38] I really appreciate it. I learn a lot. I learned an awful lot from people being generous about what’s happening in their lives and um,their concerns while taking medication. But most of all because we have such a great. Um, group of people we help. It’s all really wonderful, positive news.

Dr. D: [00:11:02] You know I have a front row seat to miracles I just love it I really, I’m so grateful to have to be in this position. Very grateful Some patients use the messaging system as a diary. And they, you know, we, we have this agreement and they use it as a diary. They’re not really talking to me. They’re just jotting down their own, ideas and thoughts.

[00:11:26] And we have an agreement that, um, if I see something worth commenting I do. And it’s just delightful. I, I learned so much, so very grateful.

Devon: [00:11:38] it’s been a long time coming since we started this. Now at least it feels like it’s been almost two years. You, so you were doing primary care for a very long time before this.

Dr. D: [00:11:49] Yes, yes I was.

Devon: [00:11:51] Um What I’m curious, what types of things have you picked up or learned at this practice that you, that you didn’t know before?

[00:12:04] Like what have you learned in treating, you know, hundreds of people with ADHD that, um, you know, maybe it wasn’t so obvious when you were doing primary care.

Dr. D: [00:12:13] Well, that’s a good question. so there’s, there’s a fund of knowledge that establishes competency and, uh. The fund of knowledge for competency to, help someone with the phenotype. It’s actually not that big. The amount of knowledge you have to know. I mean, of course you already have to be a physician and versed in the appropriate things obviously. But, beyond that then the amount of knowledge one needs to help somebody with this phenotype is actually quite small. And so just to just to do the job It’s not that big big of a deal and so I think cooking is a good example. It’s like to, to cook a meal. Just any meal. The fund of knowledge required is not that large, but to make a really tasty dish, you know, okay.

[00:13:13] A good example is spaghetti. So somebody will cook the noodles and they’re not paying attention to how long the noodles are cooked. They’re just like, okay, it’s been in there for 15 minutes. I’m sure they’re done. Drain them and throw them out, throw them on a dish, and then, take a can canned mixed up or a jar of mixed up sauce, heated up and put it on there.

[00:13:33] Boom, you’re done. And you know, you can get some really good. pre-made sauces. And you know, that’s like, it’ll satisfy your, your craving for a noodles and a red sauce or a white sauce.

[00:13:48] And then on the other extreme is, cooking the noodles just right for a particular dish. And then a hand and making a sauce, which, I’ve been fortunate enough to, grow up with some, uh,old country Italian families.

[00:14:06] And then when I moved to San Francisco, I was fortunate enough to be right smack in a, a block that was entirely composed of gentle Veasey. And so I made friends with a lot of the italian chefs. It takes all day to make a good red sauce. Literally, it takes all day. And so I’m with their tutelage. I’ve learned how to do that and all my God, the difference when I’ve done it for people from these generous people teaching me how to make a good red sauce on good noodles.

[00:14:37] Oh my God. It’s like you’re never going back to anything in a jar So it’s the same way with caring for patients in general, especially for something that’s so fundamental to how a person operates in the world beyond the fund of knowledge is a lot of, wisdom and experience that only comes from trial and error.

[00:15:00] And I’m really blessed that, this is the only thing I do so I can really focus on, being better. In my mind is always trying to be better for patients. I’m just not sitting on my butt and just collecting, you know, collecting, uh,fees. I’m trying to be better. I periodically, I want to say at least once a month do a, a journal check to see if there’s any, peer reviewed thinking, I don’t so much.

[00:15:26] You know, you helped me, Devon, with the stuff that’s kind of out there in the ether sphere or whatever in the ethers. That’s floating around online, but I rely on peer reviewed sources. and you know, there’s not a whole lot of movement, you know, as you know, Diva five came out and that, that created a little buzz.

[00:15:42] So I did all the reading with regard to that. I subscribed to both science and nature. And so, every once in a while there’ll be a really interesting research findings directly or indirectly related to attention. But yeah, so it’s all of that. Goes into me being a better assistant for people who want help with the phenotype, their phenotype.

[00:16:11] That all goes into it. So just as a quick, quick recap to bring it all back. Fund of knowledge to get up on it, to be able to do it. Like to be competent, do it really small. and it’s just years of learning to really make that really nice, dish for a person. Some people like a lot of garlic, some people not so much.

[00:16:31]some patients want a lot of personal interaction. I’m there for that. Uh, some people not so much. They just need guidance on their medication. And, you know, you know, this, we see the whole range of. Interaction, but it’s all about that learning how to do, all that better.

Devon: [00:16:47] Yeah. is somebody ever too young or too old for ADHD treatment? Through the use of stimulants.

Dr. D: [00:16:56] That’s a great question. If you are an old fart like me, meaning over the age of 60. and this is the first time you’re considering something like this. you’re not a you’re not a good fit for me.

[00:17:10] I’m not saying you don’t deserve treatment or that you shouldn’t have treatment, but you should have a thorough STEM to stern checkup, especially your heart, for this.

And then a real deep dive. As to why you’re at this late age, you’re, you want to get this medication, and I haven’t engaged people with this and talk to them about it. And a couple of people have come through. I say, look, you’re probably not going to be a candidate, but I said, first we got to do this very deep dive, which usually takes about 90 minutes plus to do.

And then I’m going to make you go get thoroughly checked out before I will even consider helping you with stimulants.

[00:17:56] And so this, you know, we’ve only had a handful. I mean, I have fingers left over on one hand of people who have been in that situation because most people, I just flatly turned away. That the people who may not be a candidate, but you’ll still have to pay me for your time.

And they go, that’s okay. I just want to know. So I do the deep dive and, and lo and behold, very good, very compelling story of why here and why now. And so then I say, okay, you got to get all this checkout. I’m not gonna, you know, we’re not going to put you on the subscription plan if you jump through all the hoops and get thoroughly checked out and if it’s appropriate.

[00:18:33] Then we’ll start charging you for service, and then we can begin to experimentation. I’ve only had one person successfully make it through that gauntlet,

Devon: [00:18:42] Okay.

Dr. D: [00:18:43] And, yeah. And they’re grateful. They actually, they’ve just basically been hardcore denial and, just so utterly grateful for, having the chance to try stimulants to improve their life. And it’s been miraculous. And the good news is they haven’t needed a whole lot of medication and they don’t take it every day. So I feel really comfortable with that, but that’s rare. That’s incredibly rare that that’s the case.

Devon: [00:19:09] Yeah It’s surprising that you go 50 or 60 years and not treated or some, and I’ve noticed, you know, not even knowing about it is also the case for some people that kind of call.

Dr. D: [00:19:24] That’s a big part of it That’s a big part of it And then particularly if you’re not on either coast, Oh yeah This is like nobody’s talking about this And when they do talk about it it’s it’s in harsh and bad light.

[00:19:38] So and that it was precisely the case with the one person who made it through the gauntlet and has been just you know miraculously helped with treatment

They they they grew up in in the Midwest,

Devon: [00:19:56] I understand the feeling I grew up in the Midwest and, um, I kind of feel like, well, I was taking stimulants in like second or third grade, I think, and I don’t really remember the effects, but I know that once I was put on them, the side effects were really severe at that age, to the point to where, they, they had to stop.

[00:20:28] And once I stopped taking them, I was dramatically improved from even. compared to the point before I even started them, it was like I was, I was like yelling out, getting in a lot of trouble, got on stimulants, and I was like either sleepy and falling asleep or going crazy. And then when they took me off, I was sort of, I kind of like flat-lined or something.

After that, I was, I was able to adjust and understand the game of school for a person with ADHD. But, for children, It seems like such a tricky, a tricky thing. 

[00:21:06]a parent asked me questions sometimes, like on our website chat and well we don’t treat anyone under 18 and so I don’t have much to tell these people, You know, I send them to chadd.org or to a major ADHD, resource. But I, I often wonder, like, what, what those people can do?

Dr. D: [00:21:30] well, the challenge is, having a way to communicate with this young person so that they can give feedback and their dose, dosages, dialed appropriately. I don’t have any experience treating children, and I’m going to guess just from my experience with adults who come to me as a transfer of care.

This frequently happens. They are on a dose. They’re not wholly satisfied with the dose. And I asked him, did you experiment to find this? Or did somebody just write a script and say, Hey, try this. And they say it’s the latter. And I say, would you like to try and experiment to figure out for yourself what’s appropriate And they say “Well yeah let me try it” I want to say no, I can’t say confidently. When adults have been given the opportunity to experiment and figure out for themselves what’s appropriate It has never been never been the dosage they were using. Never. It’s always been something different and it’s usually less.

[00:22:48] So I’m going to guess that without that, it takes all, I mean, with an adult, it takes a lot of labor with a child, oh my goodness.

[00:22:56] You know, you have to have a good conversation, framework for the parent. cause parents get so wound up so easily, rightfully so when it comes to their kids. And so, you know, it’s like a parent is not going to give good information when they’re freaking out.

[00:23:14] They’re going to be on the extreme of reporting. Oh my God. This happens all the time when in fact it happens like one in five times, but they’re just so amped up. They can’t accurately give information, so there’s a lot of labor with the parent. Then with the child, it’s like establishing a, a communication, a foundation with the child such that when the child says up, they actually mean up, and I understand it as up.

So, that, that’s involved. If all that were able,

[00:23:48]to be had, I suspect children would do very well and you wouldn’t have the experience that you had. I suspect you would have had a much better experience if all of those things were going on. Hugely, labor intensive. Most of the cases, insurance companies don’t pay for it. So it’s going to be a bespoke practice like ours, private practice like ours that can grant that.

Devon: [00:24:12] It seems like it’s really the, the experimentation portion of the process that we have is not, it’s like not something that is compatible within the general system of medicine with it, with going to your, cause we went to our primary care doctor. Um, we would kind of drive out into the city to do that. So it’s like a half hour and you kind of have to get your month’s worth of, of value out of that visit.

[00:24:41]it just doesn’t seem like the way that children are treated for ADHD in that way is it’s not, it makes it hard for an effective situation to happen.

Dr. D: [00:24:53] Yes That’s exactly right. That’s exactly right.

It’s just a bad setup. And you know, the gone are the days when a doc gets paid for the time she or he spends with the patient. It used to be that way. It’s not that way anymore. I’m actually old enough to have lived through the incomplete transformation. I’m actually, I’m blessed to have had a front row seat to it.

[00:25:17] I, am a fellow from the Kaiser family foundation, they paid for me to go to the Stanford graduate school of business at the time was the number one business school in the country many, many years ago. And, the man there, Alan Einthoven was the architect of the transition to managed care. And I actually studied with the guy.

[00:25:41] So, um, I lived through it. I was a doc at the time. I was going to Stanford and I had a busy, I was a busy, popular doctor down in San Jose and it was fee for service, straight fee for service. I got paid for my time, no questions asked. And uh, most people were happy with that cause my inclination is to spend time with people instead of throwing you out on it, you know, treat them and street them as we would say.

[00:26:08]So up to now where there is no there’s absolutely no remuneration for the quality of the interaction. None whatsoever. There’s no incentive

Devon: [00:26:19] So Kaiser put you through business.

Dr. D: [00:26:23] Kaiser. “The Kaiser Family Foundation”.

Devon: [00:26:26] Kaiser Family Foundation, what is that?

Dr. D: [00:26:28] Correct Oh, it’s a big, big foundation that does a lot of, uh. Philanthropic, public benefit type stuff. So, Yeah I’m very, very fortunate, man. 

[00:26:40]I’ve been blessed with a lot of, tremendous opportunities and I’ve met a bunch of really super people. All the folks in my Stanford class, big shout out to,my class at Stanford. Just really phenomenal people. So grateful to have made their acquaintance.

[00:26:55] I mean, these are very powerful people. A lot of them are in the news these days. And the beauty of being a classmate is I can call them And they’ll take my call. You know it’s awesome It’s really just really wonderful wonderful wonderful people. So…

Devon: [00:27:13] Oh that’s cool.

Awesome I I feel good about the chat. Thanks for talking.

Dr. D: [00:27:21] Yes yes I appreciate it Devon! Alrighty. Bye

Thanks for listening to Devon and me, Dr. D on ADHD. If you have any feedback, episode ideas or questions that you would like us to explore in an episode, please email your thoughts to podcast@norcalADHD.com that’s podcast@norcaladhd.com. You can find links and references in our show notes over at norcalADHD.com/podcast.