Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach managing nausea and GI side effects when initiating methotrexate?
There are several strategies to minimize nausea and gastrointestinal symptoms with the use of methotrexate. The medication can be taken with food, just not with caffeine. The dose can be split throughout the day it is taken such as half the dose in the morning and the other half in the evening. The ...
When and how should we be stopping GLP-1 Receptor Agonist/Dual Agonist therapy?
I usually continue for 3-4 years, the tapering down slowly over 1 year period, buy then the set point for energy expenditure and appetite likely is changed.
Do you prescribe respiratory muscle training (RMT) devices to patients with dysphagia?
We encounter dysphagia frequently in our patients with Parkinson's disease and other movement disorders. If there are any concerns about swallowing or aspiration, my first step is to refer to Speech Therapy for evaluation, and I defer to their expertise for specific treatments from there. That said,...
Do you prescribe respiratory muscle training (RMT) devices to patients with dysphagia?
We encounter dysphagia frequently in our patients with Parkinson's disease and other movement disorders. If there are any concerns about swallowing or aspiration, my first step is to refer to Speech Therapy for evaluation, and I defer to their expertise for specific treatments from there. That said,...
Do you discontinue amlodipine or use an alternative approach to manage peripheral edema when it occurs as a side effect of the medication?
Peripheral edema is a common complaint and can be exacerbated by any vasodilator therapy, including hydralazine and minoxidil. My initial approach to swelling is to 1) make sure there is no proteinuria, which can be easily overlooked in a diabetic who infrequently sees doctors; 2) assess heart and l...
What is your approach to screening for cognitive impairment in hospitalized older adults?
Upon admission to the hospital, all older adults should undergo a brief cognitive screening. This initial step helps establish a baseline and can identify previously unrecognized cognitive issues. Several tools are well-suited for this purpose; we use minicog as the screening tool at our hospital. ...
For patients with Hashimoto's thyroiditis, is there a commercially available blood test for detecting abnormalities in the type 1 deiodinase enzyme in order to identify patients who would potentially benefit from T4 and T3 combination therapy?
From a clinical standpoint, there is almost never a need for adding T3 to the therapeutic regimen of patients being treated for hypothyroidism. The exogenously provided T4 gets converted to T3 in the body. Why pay the drug companies a lot of money for something that your body will do for free? The T...
How do you approach cardiac surveillance in an asymptomatic adult who received anthracycline-based chemotherapy for a childhood cancer and presents to you without an active survivorship program?
I'm a pediatric oncologist who runs our childhood cancer survivorship program, so I generally don't take care of adults. We are a free-standing children's hospital, so we have no affiliation with an adult program. So, when I transition our pediatric oncology patients out of our program, I transition...
How do you approach cardiac surveillance in an asymptomatic adult who received anthracycline-based chemotherapy for a childhood cancer and presents to you without an active survivorship program?
I'm a pediatric oncologist who runs our childhood cancer survivorship program, so I generally don't take care of adults. We are a free-standing children's hospital, so we have no affiliation with an adult program. So, when I transition our pediatric oncology patients out of our program, I transition...
What topical therapies and procedures do you recommend for patients with atrophic acne scarring?
If the patient has hyperpigmentation, then some sort of topical lightening approach (i.e., tretinoin/kojic acid/niacinamide/Vit C/tranexamic acid, etc) or chemical peels. For the actual scarring, assuming that the acne process has burned out, the most ideal procedure depends on the particular type o...