Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you screen for interstitial lung disease in patients with newly diagnosed polymyositis or dermatomyositis in the absence of respiratory symptoms?
I do screen all newly diagnosed IIM patients with PFTs and chest CT. This has a double purpose: establishing a baseline of lung function and, screening for lung cancer. While the patient might not have lung symptoms on presentation, respiratory involvement can manifest later on the course of the d...
What was the rationale for abrupt discontinuation of etanercept rather than gradual tapering in the SEAM-RA trial?
The main goal of this trial was to get RA patients off of therapy and to see whether they would flare or maintain remission. We didn’t expect that the ultimate likelihood of success or failure was going to be primarily related to how long it took to do that. While a gradual withdrawal of the drug ma...
How do you follow patients after SBRT for NSCLC?
When we started our lung SBRT practice almost 13 years ago, the follow up schedule was based on trying to measure the benefits and impact of the therapy in a fairly structured fashion so that we could develop expertise in understanding outcomes, radiographic changes, patient experience, and treatmen...
How do you discuss the benefits and potential risks of anticoagulation for a strong indication (e.g., atrial fibrillation with high CHA2DS2-Vasc score) with older adult patients with frequent falls?
Current guidelines from AHA/ACC emphasize that oral anticoagulants should not be withheld simply because a patient is at risk of falling.Instead, I try to manage involving shared decision-making with the patient or DPOA that weighs stroke risk against modifiable bleeding and fall risk factors( with ...
Do you consider testing and treating IDA in unexplained thrombocytopenia?
Iron deficiency often causes thrombocytosis, and in fact, probably is the most common cause of reactive thrombocytosis encountered in clinical practice. With very severe iron deficiency, thrombocytopenia can be seen. I have seen it in rare patients presenting with hemoglobin levels about 3 gm/dL or ...
Do you routinely check serum phosphorus levels after IV iron therapy?
Only before and after FCM. I hold subsequent doses if phosphorus low. There is no need to monitor with the other formulations. For people needing multiple doses of IV iron (IBD, bariatric surgery, heavy uterine bleeding, angiodysplasia), I avoid FCM.
What is your treatment paradigm for rectal cancer in the setting of COVID-19?
We haven't changed our standard recommendation: short course radiation -> 3-4 months of FOLFOX. In a very timely manner, the RAPIDO ASCO abstract was released here in May. It showed that the patients who received short course radiation -> FOLFOX had improved pCR, less disease related treatment failu...
What is the recommended follow-up/surveillance schedule following organ preservation treatment approach for cT1-2N0 rectal cancer?
Patients with stage I rectal cancer treated with organ preservation require close surveillance to rule out tumor regrowth and local recurrence that may be salvaged with radical surgery. The highest risk of recurrence is within 2 years after completion of neoadjuvant therapy and patients should be fo...
What varying approaches do you take in suicide risk assessments?
I agree with the following from Dr. @Dr. First Last: "Ultimately, no scale or method is going to be perfect. We are unfortunately bad at predicting which individuals with suicidal ideation progress to an attempt. The most we can do is gather as much information as possible about how someone is feeli...
What do you recommend as a first-line antidepressant in patients with major depressive disorder and migraines?
In my clinical practice, I have found SNRI medication, particularly extended-release venlafaxine (dosed from 37.5 mg to 225 mg), to be helpful for patients with both comorbidities. Other medication classes I have seen used to good effect include TCAs (amitriptyline, nortriptyline) and some SSRIs (se...