Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach the decision to initiate or continue bisphosphonate therapy in an older patient with significant esophageal disease or swallowing dysfunction?
Unless there are indications to turn first to non-bisphosphonate therapies, I would first consider whether the patient would be a candidate for IV bisphosphonate therapy. Many patients, even those without esophageal disease or dysphagia, find the convenience of an annual outpatient infusion appealin...
In what patient population(s) do you recommend RSV vaccination in adults 50-74 years old who would not meet the general age recommendation (>75 years old)?
For adults 50–74 years old who do not meet the routine age-based recommendation (>75 years), I would consider RSV vaccination for those at increased risk for severe RSV disease, consistent with guidance from the Advisory Committee on Immunization Practices (ACIP) of the CDC. In practice, this includ...
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 ...
What recommendations do you provide to patients on isotretinoin about timing of tattoos?
No specific recommendations due to the absence of robust data
What is your approach to the management of patients with recurrent nephrolithiasis who continue to have elevated stone risk parameters in the setting of dietary factors despite receiving education from a dedicated stone clinic dietician?
Diets are notoriously difficult to follow. Once it is apparent that the patient is not going to get satisfactory control of metabolic stone disease (an increase in stone number or size as opposed to the passage of pre-existing stones, unchanged in size or number), it is time to start preventative me...
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 ADT in patients with high-risk prostate cancer who have risk factors for VTE, such as Factor V Leiden?
My default recommendation for patients with localized, high-risk prostate cancer is to recommend the use of long-term ADT. This intervention seems to offer a relatively large, clinically significant OS benefit for patients in the modern era receiving dose-escalated ADT. This benefit has been observe...
How did the SPRINT MIND study influence your approach to blood pressure management in older patients at risk of dementia?
In general, results from SPRINT MIND as well as other studies of blood pressure management in older adults have changed my thinking from being conservative in blood pressure management to favoring more aggressive management in patients able to tolerate higher doses or additional medications for bloo...
How did the SPRINT MIND study influence your approach to blood pressure management in older patients at risk of dementia?
In general, results from SPRINT MIND as well as other studies of blood pressure management in older adults have changed my thinking from being conservative in blood pressure management to favoring more aggressive management in patients able to tolerate higher doses or additional medications for bloo...
Do you ever use POCUS to evaluate for fecal impaction or stool burden in a patient with abdominal pain?
I have used POCUS in the evaluation of abdominal pain suspected of being constipation. I generally find it easiest to assess this in the right upper quadrant near the gallbladder, where you can often get a decent view of the ascending/transverse colon. If there is significant stool in the colon at t...