Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend vitamin K2 supplements in patients with osteoporosis?
The answer, as with most vitamin supplementations, cannot be answered with high-level evidence to support a "yes or no". A bit of background and then a brief review of available evidence.Vitamin K is thought to be important for bone health because it activates several proteins involved in bone forma...
Do you recommend checking anti-drug antibodies for patients on TNF inhibitors?
This is a very good question with direct clinical practice implications. I do not check or follow anti-drug antibodies when using TNF inhibitors for the treatment of rheumatoid arthritis or psoriatic arthritis. There are reports that suggest, on a group level, that these antibodies, if present, impa...
Has the TRAVERSE trial, which showed testosterone therapy was noninferior to placebo for MACE but raised signals for pulmonary embolism and atrial fibrillation, changed how you counsel middle-aged men who specifically cite cardiovascular safety when requesting TRT?
Results from the TRAVERSE trial have made my discussions a bit more streamlined, but I have always used a handout discussing known risks of TRT, such as infertility, testis atrophy, and erythrocytosis, and associated risks based on poor literature dating back to 2011. This trial confirmed what most ...
What treatment do you use for stroke prevention in cervical artery dissection?
Two prior RCTs (CADISS and TREAT-CAD) investigated this topic, each with distinct designs. The CADISS trial found no statistically significant difference in primary outcomes between antiplatelet and anticoagulation therapy for extra-cranial dissection. However, the TREAT-CAD trial failed to demon...
How do you approach pharmacologic management of OCD in patients with comorbid bipolar disorder, particularly when considering SSRIs or clomipramine?
This is a great question! Depending on the study you read, anywhere from 10% to 25% of patients with bipolar disorder have comorbid OCD. The challenge, as you might imagine, is that treatment with SRIs in the absence of a mood stabilizer may run the risk of inducing a manic episode. A larger debate...
How do you counsel patients/families whose goals of care are clearly aligned with a comfort-focused, end-of-life approach, but who are hesitant to formally enroll in hospice?
Hospice sounds like a 4-letter word to a lot of families! I find it important to distinguish the philosophy of comfort care vs. the benefit package associated with enrolling in hospice. Some people are able to be provided end-of-life comfort care without electing the hospice benefit, and that is fin...
How do you counsel patients/families whose goals of care are clearly aligned with a comfort-focused, end-of-life approach, but who are hesitant to formally enroll in hospice?
Hospice sounds like a 4-letter word to a lot of families! I find it important to distinguish the philosophy of comfort care vs. the benefit package associated with enrolling in hospice. Some people are able to be provided end-of-life comfort care without electing the hospice benefit, and that is fin...
How have you integrated the new HPV self-swab collection into your routine cervical cancer screening, particularly in those with prior abnormal results?
Unfortunately, the new HPV self-swab collection is not currently available in my institution, but I would definitely incorporate this into my routine cervical cancer screening if it were an option! I think the HPV self-swab option is ideal for patients who are either not amenable to a pelvic exam or...
How have you integrated the new HPV self-swab collection into your routine cervical cancer screening, particularly in those with prior abnormal results?
Unfortunately, the new HPV self-swab collection is not currently available in my institution, but I would definitely incorporate this into my routine cervical cancer screening if it were an option! I think the HPV self-swab option is ideal for patients who are either not amenable to a pelvic exam or...
With data suggesting that menopause contributes to major cardiovascular, bone, and cognitive outcomes, what changes should internal medicine clinicians make in risk assessment, HRT counseling, and long‑term monitoring for midlife women?
This is an interesting question because there are no new data about menopause as a risk factor for CV, bone, or brain health. These BMJ guidelines are very helpful and reflect a new approach to the treatment of menopausal symptoms, which is hormone therapy first. My patients usually want to try alte...