Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Under what circumstances would you recommend early fecal microbiota transplantation over antibiotic treatment or bezlotoxumab in a patient with recurrent C. difficile infection?
Assuming donor stool is available, if the patient is not expected to need another course of antibiotics in the foreseeable future, I would recommend FMT.
What is your approach to treating patients with decompensated heart failure when their hypervolemia is refractory to oral furosemide?
Depending on the oral dose, it may just be a problem of underdosing or even perhaps non-adherence. We would typically transition to intermittent IV Lasix dosing with close monitoring, if minimal response, we can double the dose to try and get to the ceiling effect of Lasix, depending on the renal fu...
How do you approach managing intolerable vivid dreams as a side effect of SSRIs?
There are several distinct options I go over with patients who have this side effect. It often self-resolves, but can take a few (up to 6) months to resolve, and there is no guarantee. If the patient is willing to tough it out, I often have them do nothing. But, we are talking about it being an int...
What types of cardiac conduction abnormalities would lead you to avoid using tricyclic antidepressants?
I wouldn’t say it is a definite contraindication. But, I would want to be sure it is a longstanding patient and they are seeing a cardiologist regularly. Then, if the QTc were within reason, I would consider it; but it wouldn’t be high on my list of options.
What is your approach to antibiotic selection for bacterial species that demonstrate susceptibility to penicillins or cephalosporins on testing, but are known to harbor inducible AmpC resistance?
I follow the recommendations from the IDSA guidelines (Tamma et al., PMID 39108079). Duration of treatment does not influence my decision about whether to use a beta-lactam for organisms with inducible AmpC. For Enterobacter cloacae complex, Klebsiella aerogenes, and Citrobacter freundii, I do not u...
Would you continue or stop anticoagulation for a DVT/PE in a patient with active cancer who has completed 6 months of therapy?
This is an important question that we didn’t really have a clear answer for… until this year when an NEJM RCT was published! Mahé et al., PMID 40162636 In this RCT, patients with cancer-associated VTE who completed 6 months of full-dose apixaban were randomized to half-dose apixaban vs. full-dos...
What is your go-to non-invasive test for the evaluation of angina in the primary care setting?
Great question, but not a simple answer! In my experience, there is no "go-to" noninvasive test for the evaluation of angina in the primary care setting. That is because each noninvasive test has its own strengths and pitfalls, which must be judiciously applied in the selection process for the indiv...
How do you approach laboratory evaluation in patients with fatigue?
First search for evidence by history and physical examination for any evidence of inflammation. If there is tailor the lab workup rather than ordering tests as screening tools. ESR and CRP to start with. Anything more without a reasonable a priori likelihood of the targeted diagnosis is just asking ...
How do you counsel patients with bipolar disorder who want to breastfeed?
This is a great question! Many women desire to breastfeed their babies, and providers often encourage the initiation of breastfeeding in the immediate postpartum period. For women with underlying bipolar disorder, this decision can be more nuanced. Nursing a young infant requires multiple feedings ...
How do you approach patients who identify so strongly with being sick or with a particular diagnostic label that it makes up a significant portion of their identity?
In many cases, the point at which this question is being asked is one at which the train has already left the station, and sickness as a way of life/career has set in. Unfortunately, with functional somatic syndromes, there is data suggesting that self-rated quality of life and functioning are lower...