Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the single best piece of advice you received when starting out as a hospitalist for the first time?
Billing is just a part of routine practice. While everyone is scared of overbilling, underbilling is also a big problem. During my training, I had very little exposure to billing and coding. During my hospitalist onboarding, we had a couple of sessions on billing, but I was anxious when I submitted ...
What is your approach to a newly diagnosed LBBB in individuals >70 years old who are free of any signs or symptoms of heart disease and without other significant ASCVD risk factors besides age?
The presence of BBB; whether IVCD or RBBB or LBBB, signifies infranodal conduction delay from a myopathy. That myopathy may be hypertensive (LVH) or ischemic (LAD disease) or something less common (inflammatory etc). The ideal test would evaluate anterior septal LV thickness and vascular flow; it’s ...
How do you make the decision to empirically treat for GCA when a patient is referred but cannot be immediately seen in clinic?
This is an important question because referrals for possible GCA are common scenarios when a rheumatologist may be asked to recommend a treatment before seeing the patient which are often challenging scenarior. The factors I typically rely on to rate the probability of GCA include: - Specific sympto...
In patients with sicca symptoms and positive SSA/SSB how often do you perform other diagnostic testing such as salivary gland ultrasound, biopsy, Shirmers, ocular staining, stimulated salivary flow, etc?
In patients with sicca symptoms and positive SSA antibodies, I always try to confirm that they have objective evidence of dryness/gland involvement. This is because patients can say they have dry eye and/or dry mouth yet not have this bear out on objective testing (Bezzina et al., PMID 27992710, Rip...
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...
How do you approach managing patients with diabetic kidney disease and proteinuria who develop hypoglycemia after initiation of a SGLT2 inhibitor?
I would first determine if there are other medications the patient is on that reduce the blood glucose. Hypoglycemia with SGLT-2 inhibitors is usually due to something else. Another medication is most likely. Could be very poor dietary intake. Could lower the dose if not on the lowest available dose...
Is there any benefit in maintaining statin or aspirin therapy in patients >75 years old with stable, multivessel ischemic heart disease in light of challenges encountered with polypharmacy?
This is a great geriatric cardiology question because it acknowledges that guidelines may not apply in an older patient with multiple medical problems and a complex medication regimen. The question further implies that treatment should be individualized and patient-centered. I agree with the questio...
Is there any benefit in maintaining statin or aspirin therapy in patients >75 years old with stable, multivessel ischemic heart disease in light of challenges encountered with polypharmacy?
This is a great geriatric cardiology question because it acknowledges that guidelines may not apply in an older patient with multiple medical problems and a complex medication regimen. The question further implies that treatment should be individualized and patient-centered. I agree with the questio...
What role do you feel there is for antibiotics in the management of severe perianal Crohn's disease?
Without access to biologics you still should have access to a thiopurine. That has some efficacy and was all we had prior to biologics along with chronic antibiotics.
Do you routinely recommend diagnostic endoscopy for patients with persistent enterococcus bacteremia despite receiving adequate antimicrobial therapy and no clear nidus?
It depends. Did you do an echocardiogram to rule out endocarditis? Urine cultures were negative? Gallbladder ultrasound was negative? CT of the abdomen and pelvis with contrast was negative?Any other symptomatology that accompanied the recurrent episodes of enterococcus bacteremia that could help us...