Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Which patients with mild cognitive impairment do you consider referring for amyloid-targeted therapy?
This is an important question, as clearly, not everyone with MCI is appropriate or interested in Amyloid-Targeted Therapy. In general, I would say that the TrailBlazer trial did not change my approach to patient selection much, but it did provide more evidence that this class of drugs have a place i...
For patients over 70 with elevated ASCVD risk but no prior cardiovascular events, do you ever recommend continuing or initiating low-dose aspirin?
Yes, I might still recommend low-dose ASA for primary prevention for someone over 70 if the patient is very functional.
Which imaging features do you use when considering Normal Pressure Hydrocephalus to decide whether to proceed with large-volume LP or lumbar drain trial?
At our center, we follow the approach of the NPH clinic at the Imperial College Hospital in London.See this excellent review article for further details: Carswell, PMID 36162853.
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
How do you counsel patients on the risks and benefits of antidepressant use during pregnancy?
I always frame the decision as being between the risks and benefits of the medication vs. the underlying condition. We are always aiming for the "minimum effective dose" but "effective" is just as important as "minimum." Medications are, of course, not the only way to treat psychiatric illness and a...
How do you counsel patients on the risks and benefits of antidepressant use during pregnancy?
I always frame the decision as being between the risks and benefits of the medication vs. the underlying condition. We are always aiming for the "minimum effective dose" but "effective" is just as important as "minimum." Medications are, of course, not the only way to treat psychiatric illness and a...
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...
How do you approach adding colchicine to a patient who is on a stable statin regimen?
This is a good question and a tough situation, since the drug-drug interaction here can be as subtle as myalgias but as severe as rhabdomyolysis (rare but happens). If you can avoid long-term colchicine in this situation, it is always best. These situations (hypercholesterolemia and crystal arthropa...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...