Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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 decision-making around initiation of osteoporosis therapy in patients with advanced dementia?
Great question, there are many things that I consider. First, I limit consideration of osteoporosis therapy to patients who have a life expectancy of 1 year or more. This is because the time to benefit from a bisphosphonate is estimated to be about 12 months (Deardorff et al., PMID 34807231). Assumi...
What practical next steps would you recommend once identifying loneliness in an older adult patient?
First, normalize and validate the experience, emphasizing that it is common and appreciating that the patient is willing to discuss this with you. Explaining that they can and deserve to feel better may help set the stage for the conversation. Listen with genuine attention. Clarify the type of lonel...
What practical next steps would you recommend once identifying loneliness in an older adult patient?
First, normalize and validate the experience, emphasizing that it is common and appreciating that the patient is willing to discuss this with you. Explaining that they can and deserve to feel better may help set the stage for the conversation. Listen with genuine attention. Clarify the type of lonel...
Do you routinely recommend a lumbar puncture for patients with suspected ocular or otic syphilis in the absence of additional CNS symptoms?
No, this isn’t necessary, assuming no other evidence of non-ocular/otic neurosyphilis. I recommend management as advised by CDC in the 2021 treatment guidelines (https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf, p. 40). An especially careful neurological exam is advised, includin...
What surveillance do you recommend for a patient with locally advanced rectal adenocarcinoma who had a complete clinical response to total neoadjuvant therapy and declines to undergo surgery?
It is important to watch these patients closely since ~15-20% will have local regrowth/recurrence that are salvageable (Dossa et al Lancet 2017). The OPRA trial, recently presented at ASCO 2020, included 324 patients treated with TNT regimens and WW if complete response. Organ preservation rates wer...
How do you decide whether to place an NGT or PEG tube in patients with dysphagia precluding adequate PO nutritional intake?
There are several factors that go into the decision of PEG tube vs continued nutrition via a nasogastric feeding tube(NGT). Anticipated time to recovery of oral pharyngial function (especially in the most common underlying illness, which is stroke). NGT can stay in place for up to 2 months without...
Do you recommend routinely monitoring pancreatic markers such as amylase and lipase while receiving GLP1 R agonist or dual agonist therapies to determine their risk of pancreatitis?
Absolutely not. We know that changes in amylase and lipase levels on these drugs are very common. For example, if you look at the supplementary data across the SUSTAIN series of phase 3 trials with subcutaneous semaglutide, the average person had about a 15-30% rise in their amylase/lipase. Further,...
Do you continue to check tryptase levels in your patients with idiopathic anaphylaxis despite normal levels >5 on repeated checks?
Baseline serum tryptase levels have been reported to be quite stable in the vast majority of patients, but can vary more in people with HaT or mastocytosis. With a bST <8 ng/ml, there is no obvious reason to continue to check it. However, even with normal bST, the Practice Parameters recommend furth...
How do you counsel non-diabetic patients who wish to start metformin to reduce the risk of developing dementia?
There have been some interesting observational studies evaluating the reduction of cognitive decline in patients with type 2 DM. First, they are all in patients WITH diabetes, so not yet generalizable to patients without DM. Second, they are observational trials, which means that they cannot adjust ...