Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you counsel patients who develop DVT or atrial fibrillation requiring anticoagulation when being treated with lecanemab or donanemab?
I believe until further data/studies are available, I would prefer not to use anticoagulation (at least long term) without comprehensive discussion among other treating physicians depending on the indication. The lecanemab appropriate use recommendations (Cummings et al., PMID 37357276) recommend ag...
How do you approach a patient on anti-TNF with positive Quantiferon (previously negative) with negative chest x-ray and no symptoms?
Prior to routine screening for latent TB for patients receiving or about to receive TNF inhibitor therapy, there were reports of miliary TB developing after initiation of TNF inhibitors. Therefore, one cannot say that a negative chest x-ray and no symptoms means the patient is not at risk for develo...
How do you counsel patients on peritoneal dialysis regarding the safety of engaging in aerobic and resistance exercises, considering the risk of developing abdominal wall complications?
The effect of exercise on intra-abdominal pressure (IAP) while on PD was examined decades ago by Twardowski et al., PMID 3774076. They found that walking, jogging, or using an exercycle resulted in only modest increases in IAP, while jumping or straining (e.g. weight- lifting) resulted in more marke...
Would you stop an ACE inhibitor/ARB or instead initiate a potassium binder to manage hyperkalemia in a patient with proteinuric CKD stage 5 who is on an ACEi/ARB?
This depends on where in CKD 5 the patient is, to some extent. Would also make sure to modify diet if possible and make sure on an appropriate dose of a loop diuretic. If very close to starting dialysis or getting a txp, I might reduce dose or stop, especially if a K-binder is expensive for the pati...
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...
What is your approach to patients with persistent low libido despite normal testosterone levels after use of exogenous testosterone replacement therapy?
The key point is understanding a man’s mental health and relationship status. I will always screen for depression and strongly encourage sex therapy. My unvalidated but effective screening question is asking when their last vacation was and how their libido and erections were. It’s surprising how ma...
What is your approach to patients with persistent low libido despite normal testosterone levels after use of exogenous testosterone replacement therapy?
The key point is understanding a man’s mental health and relationship status. I will always screen for depression and strongly encourage sex therapy. My unvalidated but effective screening question is asking when their last vacation was and how their libido and erections were. It’s surprising how ma...
What would you tell a trainee who is interested in pursuing a career in geriatric medicine but is concerned about the relatively low number of people who enter/match into the field?
A trainee who is interested in pursuing a career in geriatric medicine should consider the long-term potential of contributing meaningfully to the field and to the lives of their patients. Although there are concerns from trainees about the relatively low number of people who enter/match into the fi...
How do you approach treatment of hypersomnolence in dementia?
To state the obvious first that you will have had to exclude a hypoactive delirium. And then, considerations: 1. What stage of dementia is the person in? If severe or later stages, this could be normal and physiologic given the level of cerebral atrophy and damage. 2. What type of dementia? If you t...