Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you use oral cefixime as an alternative treatment for early syphilis in cases of benzathine penicillin G shortages?
Based on in vitro activity against T. pallidum and the study you cite, cefixime 400 mg BID for 14 days likely is effective for treatment of early syphilis (Klementová et al., PMID 40795115). However, I see no advantage over the recommended option of doxycycline (100 mg BID for 14 days) when BPG isn'...
How do you counsel patients on the risks vs benefits of naltrexone for alcohol use disorder with persistently elevated liver enzymes?
Before answering this question, it is first important to point out that obtaining baseline liver function tests (LFTs) is not necessary before starting a patient on any formulation of naltrexone (oral or long-acting injectable XR). However, it is essential to consider if the patient has an underly...
How are you incorporating the newer RCT data suggesting no mortality benefit to indefinite beta-blocker therapy for patients who are several years out from an MI with preserved LVEF and no angina or arrhythmia?
I have been de-prescribing after counseling once the patient is a couple of years out. This reduces symptoms, pill burden, drug interactions, etc., so I see an active benefit even if the patient seems to be tolerating medication. Obviously, they would have no other indication for BB, mainly arrhythm...
How would you approach hormone replacement therapy for perimenopause in a patient with increased risk factors for VTE?
Like many medical choices, this decision involves weighing trade-offs—specifically, the risk of venous thromboembolism (VTE) versus the burden of severe menopausal symptoms. If we focus only on VTE risk (and set aside the trade-offs related to menopausal symptoms and the controversial issue of breas...
How would you approach hormone replacement therapy for perimenopause in a patient with increased risk factors for VTE?
Like many medical choices, this decision involves weighing trade-offs—specifically, the risk of venous thromboembolism (VTE) versus the burden of severe menopausal symptoms. If we focus only on VTE risk (and set aside the trade-offs related to menopausal symptoms and the controversial issue of breas...
How do you counsel cancer patients when they ask if they should avoid sugar?
“We don’t have evidence to support any specific diet that can either worsen or improve outcomes. I encourage a healthy, well-balanced diet with my top priority being you maintaining your weight during treatment.” Particularly for my head and neck patients, getting in sufficient calories is of the ut...
Do you typically include exercise restrictions and/or alcohol intake restrictions in routine counseling for patients with atrial fibrillation?
I counsel on adopting a heart-healthy diet, exercising regularly, limiting alcohol (reasonable amounts of caffeine likely not a big deal), quitting smoking, managing stress, and ensuring quality sleep, especially treating sleep apnea. No exercise restrictions (unless they do extreme exercise; data m...
How do you approach a treatment relationship with a patient who is non-adherent to recommendations and also is not interested in transfer to another practitioner?
This situation superficially forces a provider to sit with frustration and perhaps resentment versus skirt the issue of abandonment. Some would (or would wish to) choose the latter and be ethically content to follow rules about providing referral information and a "buffer" period of continued care w...
How would you work-up an older male patient with elevated testosterone-level-for-age?
To rule out CAH, testosterone-producing tumors, and a spurious rise due to elevated SHBG.
Should presence of coronary artery calcifications on CT/CTA be considered as presence of vascular disease on CHA2DS2-VASc score?
This is a great question, not only for this aspect but also even defining as what counts as secondary prevention vs primary prevention, etc. The short answer is that it is not clarified in CHADSVASC, but at that time, they were more using the definition of "clinical CAD," so I generally do not count...