Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...
What techniques do you find most helpful to optimize image acquisition for cardiac POCUS in patients with poor acoustic windows?
For the parasternal windows, your enemies are ribs and lungs. Regarding ribs: Whenever an image gets dark, people tend to try and crank up the gain knob to compensate. In many cases, however, it's usually because one of the edges of the probe is abutting a rib. Try and slide the probe a few millimet...
In outpatient primary care settings, would you recommend routinely checking Cystatin-C as a marker of renal function in older adults?
I probably would not recommend routine Cystatin-C testing for all older adults, but would consider it in certain scenarios where eGFR may be inaccurate or misleading. In geriatrics, sarcopenia and low muscle mass often make serum creatinine a less reliable marker of true kidney function. Cystatin-C ...
When would you phlebotomize patients with secondary hemochromatosis, such as due to NAFLD/cirrhosis?
My simple answer is “rarely, if ever” (but it can get much more complicated). Related to hepcidin changes, patients with chronic liver disease frequently have elevated serum ferritin and transferrin saturation, more so with alcoholic liver disease and non-alcoholic fatty liver disease. It is far fro...
How do you counsel patients with depression about the role exercise may play in alleviating depressive symptoms?
I’m a big fan of exercise for all of my patients, to the point where I have my 5th-degree black belt diploma on the wall of my office next to my undergrad, PhD, and MD diplomas. I tell patients, “That’s up there to say to try and fit in exercise as realistically as your schedule allows, in a way you...
When an older adult with multiple comorbidities develops a new, significant functional decline after a hospitalization, how do you decide whether to pursue further diagnostic workup versus accept it as post-hospitalization deconditioning and focus on rehabilitation?
I try to characterize the nature of the functional decline in a descriptive sense - what has become difficult and why, what are the patient and caregivers experiencing? I think through a differential diagnosis for that, and then I look at the totality of diagnosed problems from the hospitalization a...
When an older adult with multiple comorbidities develops a new, significant functional decline after a hospitalization, how do you decide whether to pursue further diagnostic workup versus accept it as post-hospitalization deconditioning and focus on rehabilitation?
I try to characterize the nature of the functional decline in a descriptive sense - what has become difficult and why, what are the patient and caregivers experiencing? I think through a differential diagnosis for that, and then I look at the totality of diagnosed problems from the hospitalization a...
How do you decide on switching to a different preventative anti-CGRP treatment in migraine patients who are experiencing reduced effectiveness with their current treatment?
The CGRP antibodies and gepants are my preventive treatments of choice. In fact, I hardly ever prescribe anything else anymore preventively, including botulinum toxin. Tolerability issues I hardly ever encounter with the antibodies, but sometimes I do with the gepants, in particular fat...
How do you counsel patients on wearable heart monitor devices when they ask about specific products and diagnostic accuracy of these devices available on the market?
It depends on the device. If a patient is experiencing palpitations infrequently, or there is an ongoing need to identify the cause of palpitations, I typically recommend a consumer-facing ambulatory ECG device that is FDA-cleared. They are quite accurate for detecting AFib and ectopic beats such as...
How do you treat disruptive mood dysregulation disorder?
DMDD is quite an enigma. The whole concept of irritability, which transcends many diagnoses, is also interesting. DMDD was meant to avoid overdiagnosis of moody disruptive behavior as bipolar. Since many of those kids are not suffering from bipolar disorder, I thought it was a great move. Unfortunat...