Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you always perform salivary gland biopsy to confirm the diagnosis In patients with suspected seronegative Sjogren's syndrome?
I often struggle with the decision of obtaining a biopsy in suspected Sjogren's in a person who is seronegative, when the main issue is dryness, and the main reason is that I wonder if it will make a difference in management. When I was a Rheumatology fellow, I was taught to give Hydroxychloroquine ...
Should tuberculosis screening be performed before beginning methotrexate for treatment of rheumatoid arthritis?
While it is not recommended or required to screen for latent TB (LTBI) prior to starting methotrexate, for many patients this may serve as a good opportunity to screen for LTBI, as many patients will go on to require biologic therapy due to incomplete response to methotrexate. There are many limitat...
What specific strategies have you found most effective in your academic program for inspiring internal medicine residents to consider nephrology as a career?
Probably the best tool we have is having residents rotate with us. Nephrology is a mandatory rotation at RUSH Internal Medicine, and frankly, we are excellent teachers, so that sparks interest that may not have happened if they did not rotate. I cannot believe that all IM programs do not require nep...
Do you offer semaglutide for weight loss management in patients with CKD?
I do, but mostly a different GLP-1, trizipitide. I think the side effect profile is cleaner and better tolerated in CKD and post-transplant patients, decreasing renal complications associated with the side effects.
How do you manage orthostatic symptoms from autonomic neuropathy due to diabetes?
Try conservative measures such as hydration, pressure stockings, abdominal binder, exercises, and precautions prior to positional change. Addition of midodrine or other medications like flourinef and adjustment of doses of their antihypertensive medications. There are other medications that can be u...
Do you ever consider tapering off steroid-sparing agents in patients with stable non-IPF ILD?
In short, the answer is YES—I always look for ways to reduce immunosuppression exposure over time and use the lowest effective dose required to keep a patient’s inflammatory ILD in check. I often remind myself that when these patients present with a mixture of fibrotic changes (e.g., traction bronch...
How do you decide when to recommend conservative kidney management over dialysis initiation in a frail older adult with stage 5 CKD?
This is definitely not a one-size-fits-all answer. Functional status and cognitive status, rather than age, are the most important considerations. The frailty syndrome itself is associated with poor outcomes for patients on dialysis. There is a clear association between kidney disease and frailty, w...
How do you decide when to recommend conservative kidney management over dialysis initiation in a frail older adult with stage 5 CKD?
This is definitely not a one-size-fits-all answer. Functional status and cognitive status, rather than age, are the most important considerations. The frailty syndrome itself is associated with poor outcomes for patients on dialysis. There is a clear association between kidney disease and frailty, w...
When discontinuing Denosumab after more than 2-3 years of therapy, when do you recommend giving the first dose of zoledronic acid?
My practice has been that after 2-3 years of denosumab, I wait 6 months and then start zoledronic acid.
What therapeutic approaches have you found effective for athletes with anorexia nervosa whose eating disorder symptoms are intertwined with sport-driven weight pressures?
The gold standard for treatment of anorexia nervosa and all eating disorders is a team-based approach, including the individual, psychiatrist, counselor, primary care or sports medicine physician, dietician, appropriate family members, and, in the case of elite athletes, sometimes their coaches. Rap...