Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What techniques do you use in the lab to reduce the amount of contrast that needs to be used in patients with CKD?
Avoid LV angiogram. Use ECHO instead to assess LV function.
How would you treat a patient with osteoarthritis of just one joint of the hand?
People do this in various ways - some people treat the joint with a large margin, others may treat the whole hand.I originally started by treating the affected joint, but pretty soon I after I switched and started treating the whole hand - pain is subjective and though it may appear localized, there...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
Would you consider sotalol to be a suitable non-selective beta blocker for primary prevention of variceal bleeding in a patient who requires sotalol for treatment of arrhythmia in the setting of Fontan-associated liver disease and clinically significant portal hypertension?
The answer to this question will need to be case-by-case, unfortunately.The short answer:The priority in this patient's case for using sotalol is likely the underlying heart disease and its associated arrhythmia, and this cardiac benefit would not be achieved by carvedilol and other NSBBs. Thus, it ...
How do you approach the management of patients who require nutritional restoration in the setting of a presumed functional GI disorder recalcitrant to behavioral medicine and pharmacologic therapies?
It certainly is a very good question if indeed the patient has functional disease; then, for sure, they need more than just my help. They probably need the help of a nutritionist, but even more so, they need perhaps psychiatric medication and the treatment of a behavioral therapist or psychological ...
How would you manage persistent Norovirus diarrheal infections in a kidney transplant patient that are not responding to a decrease in the patient’s maintenance immunosuppressive regimen?
This is a difficult situation and does not have a strong evidence based response. First, I would really make sure they are not on mycophenolate as this is really the main problem with chronic Norovirus for most patients. Next, I would see if there are any available clinical trials that the patient m...
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...
What criteria do you use to decide when to perform a BAL in hypersensitivity pneumonitis?
Short answer: When the vibes are right. I know that's a flippant answer, but that's an honest-to-God real answer. Long answer: This is really complicated and personally, I'm frustrated by our guidelines and the level of evidence we have for diagnosing HP. To answer the question, it's worth delineati...
Do you regularly recommend an immunological workup for patients with suspected immunodeficiency or defer to immunology?
I defer after a very preliminary work-up based on the type of immunodeficiency expected. I try to direct the consult to a provider most likely to have expertise in the problem I suspect. Often, I suggest consulting with a provider at NIH.