Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What treatments do you recommend and how do you counsel patients with postpartum hair loss?
I start with reassuring that it's fairly common to experience excessive hair shedding after pregnancy, about 3-6 months postpartum and usually peaking at about 4 months after giving birth. I counsel that many patients regain their normal hair growth over time, without any treatment. However, if they...
With the recent trials such as SELECT and STEP-HFpEF demonstrating benefits of GLP1-agonists in terms of CV risk reduction and improved exercise function, have you begun to incorporate this class of medications into routine CV health maintenance for patients with HFpEF and/or pre-existing CAD?
I would strongly support the use of this medication. The biggest challenge is insurance coverage. When would it be approved by insurance and how many hoops we will need to jump before they approve it?
What would be the differential and initial workup for tongue fasciculation?
Tongue atrophy and fasciculations, unless very severe and obvious, can be difficult to determine by clinical exam alone. I have had multiple patients who were told that they have ALS after an inexperienced examiner saw them for an initial visit and thought they had tongue fasciculations without furt...
Does the presence and location of cerebral microbleeds affect your decision for antithrombotic treatment in patients with atrial fibrillation?
That is a great question. Agree, the data is observational and no firm conclusions can be made. My practice is to consider left atrial appendage occlusion in patients with suspected CAA. In patients with hypertensive microbleeds, both resuming anticoagulation and left atrial appendage occlusion are ...
What recommendations do you provide to isotretinoin patients about delaying cosmetic procedures (lasers, fillers, botox) once they have reached their goal dose?
We basically perform any and laser procedures, even when patients are on isotretinoin if it is appropriate as far as the indication. We do tend to wait for 3 to 4 months for ablative fractional treatments, but all other treatments, such as hair removal, pigment removal, and vascular laser removal, a...
How do you approach palliative conversations about what patients can expect when deciding to stop maintenance dialysis?
I typically include this discussion with my patients as part of the discussion of what options are available to address irreversible progressive CKD (eGFR<25). I find it best to present all options for ESKD management in a balanced format and I open the clinic visits to all family and friends to sup...
How do you manage patients with end stage kidney disease and recurrent ascites who do not have any evidence of cardiac or liver disease?
This is not a common scenario but we definitely see it. More aggressive dialysis is likely the best treatment if possible not only as far as fluid removal but also as far as clearance. Recommend 4 days per week dialysis. If fluid removal is not adequate then would do large volume peritoneal taps eve...
When do you recommend electrical stimulation (Cefaly device) in patients with chronic migraine, if at all?
The Cefaly device provides transcutaneous electrical nerve stimulation to the supraorbital nerves and has regulatory approval both as an acute and preventive treatment. This device and other neuromodulatory therapies are useful in several settings for the treatment of chronic migraine: Some people ...
How do you approach patients that develop atopic dermatitis while on biologics for psoriasis?
We have a few patients on dual-biologic therapy who have features of both psoriasis and atopic dermatitis, where each is severe enough to merit systemic therapy on their own. Probably a little less now with more JAK inhibitors available, but we still have some patients maintaining on these regimens....
Is there utility to ordering biochemical screening labs for global developmental delay?
When suspected, it might be warranted to do an initial screening for metabolic disorders. Genetic testing is also a good idea, starting with a microsomal microarray and fragile X testing. Whole exome sequencing might follow and is becoming more affordable and covered by insurance.