Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend medical therapy for extensive atraumatic osteonecrosis of the femoral head to mitigate pain or prevent femoral head collapse?
This is a good question. Extensive atraumatic ON of the femoral head will probably not respond to any medical therapy; eventually, the patient will need a replacement. However, ON that is from a systemic insult (drugs, alcohol) is often bilateral so if the other hip is less affected or not affected,...
Is there a role for functional medicine approaches in psychiatric treatment?
Functional medicine is a pretty broad term that encompasses stressors underlying biological, hormonal, nutritional, and environmental impacts on a person’s health. While I am a big fan of trying to get to the root causes of health conditions, including mental health conditions, and think in terms of...
How do you approach osteoporosis screening in men?
While osteoporosis is more prevalent in postmenopausal women, it is often under-recognized in men. The risk of mortality after hip fracture is higher in men, and that risk may extend over 10 years after injury. Men who sustain a wrist fracture are more likely to have severe osteoporosis and a higher...
How do you approach osteoporosis screening in men?
While osteoporosis is more prevalent in postmenopausal women, it is often under-recognized in men. The risk of mortality after hip fracture is higher in men, and that risk may extend over 10 years after injury. Men who sustain a wrist fracture are more likely to have severe osteoporosis and a higher...
How do you titrate lithium for patients with bipolar affective disorder during pregnancy and immediately after delivery in the context of fluid shifts and changing levels?
Great question! Lithium clearance increases during pregnancy, and some women may require a dose increase to maintain therapeutic benefits. It is not my practice to prophylactically increase the dose during pregnancy, but I do recommend monitoring labs (lithium level, BUN and creatinine, and TSH) ea...
For atrial fibrillation patients with high risk of CVA who cannot tolerate full dose AC due to bleeding, do you consider low dose/extended dosing anticoagulation even if they do not meet age/GFR criteria for a dose reduction, if Watchman is not readily available as an option?
Most drugs, including anticoagulants, have a dose-response. Therefore, one could argue that even though DOACs were not studied at low doses, except in defined sub-groups such as the very elderly, using such a dose in other situations may have some benefit. The problem is that without data, we simply...
For atrial fibrillation patients with high risk of CVA who cannot tolerate full dose AC due to bleeding, do you consider low dose/extended dosing anticoagulation even if they do not meet age/GFR criteria for a dose reduction, if Watchman is not readily available as an option?
Most drugs, including anticoagulants, have a dose-response. Therefore, one could argue that even though DOACs were not studied at low doses, except in defined sub-groups such as the very elderly, using such a dose in other situations may have some benefit. The problem is that without data, we simply...
Do you have any experience with using every 2-week GLP-1 therapy instead of weekly for cost reduction strategies in patients using it for weight maintenance?
My experience is limited and anecdotal, but I do have multiple patients who did biweekly GLP therapy to stretch out their prescriptions due to coverage issues that occurred due to some insurance policy change back in March. Most of the patients had success with biweekly dosing, as the half-life of t...
How do you differentiate between hyperactive delirium and excited catatonia?
This is a highly complex distinction to make for several reasons, not the least of which is that the two conditions can coexist in the same patient at the same time. This has been demonstrated in some recent studies of mainly intensive care delirious patients, though the reported very high incidence...
How do you decide between adding oral orforglipron or starting prandial insulin in a patient with type 2 diabetes above goal on basal insulin?
This is a timely question in that it is clinically relevant, and in June 2026, the ACHIEVE-5 trial was published online in JAMA, which studied adding orforglipron to basal insulin.If the patient is judged to be significantly insulinopenic--thin, low dose of basal insulin requirement, and high postpr...