Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you approach hormone replacement therapy for perimenopause in a patient with increased risk factors for VTE?
Like many medical choices, this decision involves weighing trade-offs—specifically, the risk of venous thromboembolism (VTE) versus the burden of severe menopausal symptoms. If we focus only on VTE risk (and set aside the trade-offs related to menopausal symptoms and the controversial issue of breas...
How would you approach hormone replacement therapy for perimenopause in a patient with increased risk factors for VTE?
Like many medical choices, this decision involves weighing trade-offs—specifically, the risk of venous thromboembolism (VTE) versus the burden of severe menopausal symptoms. If we focus only on VTE risk (and set aside the trade-offs related to menopausal symptoms and the controversial issue of breas...
How do you counsel cancer patients when they ask if they should avoid sugar?
“We don’t have evidence to support any specific diet that can either worsen or improve outcomes. I encourage a healthy, well-balanced diet with my top priority being you maintaining your weight during treatment.” Particularly for my head and neck patients, getting in sufficient calories is of the ut...
Do you typically include exercise restrictions and/or alcohol intake restrictions in routine counseling for patients with atrial fibrillation?
I counsel on adopting a heart-healthy diet, exercising regularly, limiting alcohol (reasonable amounts of caffeine likely not a big deal), quitting smoking, managing stress, and ensuring quality sleep, especially treating sleep apnea. No exercise restrictions (unless they do extreme exercise; data m...
How do you approach a treatment relationship with a patient who is non-adherent to recommendations and also is not interested in transfer to another practitioner?
This situation superficially forces a provider to sit with frustration and perhaps resentment versus skirt the issue of abandonment. Some would (or would wish to) choose the latter and be ethically content to follow rules about providing referral information and a "buffer" period of continued care w...
How would you work-up an older male patient with elevated testosterone-level-for-age?
To rule out CAH, testosterone-producing tumors, and a spurious rise due to elevated SHBG.
Should presence of coronary artery calcifications on CT/CTA be considered as presence of vascular disease on CHA2DS2-VASc score?
This is a great question, not only for this aspect but also even defining as what counts as secondary prevention vs primary prevention, etc. The short answer is that it is not clarified in CHADSVASC, but at that time, they were more using the definition of "clinical CAD," so I generally do not count...
How do you discuss the role (if there is any) of frequently weighing yourself at home for patients who desire weight loss?
The frequency of weighing is very individualized. It can be easy for people to get caught up in day-to-day fluctuations, which may not be meaningful, but could be upsetting. To identify true trends, the sweet spot for weighing frequency for most people is generally 1-3 times per week. For people wit...
Do you prefer allopurinol or febuxostat for patients with chronic kidney disease who are receiving treatment for asymptomatic hyperuricemia?
Allopurinol. For my Asian and sometimes African American patients, I consider HLA testing to make sure they are not at risk for allopurinol hypersensitivity. In which case, I will prescribe febuxostat. Most often, I find the insurance will not even cover febuxostat unless I have tried allopurinol fi...
How do you pragmatically approach a conversation about "liver detox"/"liver cleansers" when patients bring up this topic?
It's important to keep an open mind with the use of these products, as often people will want to take them despite what you might say. Having some experience with the use of these products (or at least their ingredients) will give the patient a comfort level with freely discussing their use with you...