Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In patients on long-term proton pump inhibitors for GERD with stable symptoms, do you routinely attempt discontinuation or continue indefinitely given relapse risk?
This is a good question, as we see many patients who were placed on PPIs and continued indefinitely for GERD. As this question implies, this may not be necessary, and long-term PPI use comes with risks that include C. diff. There are additional studies that suggest fractures, CKD, and nutrient defic...
When considering deprescribing antihypertensives in older patients, how do you approach prioritization of which antihypertensives to target first?
When deprescribing antihypertensives in older adults, my approach is individualized, goal-concordant, and iterative with close monitoring after each step. Every patient is a little different, so there isn't one class of antihypertensives I always deprescribe first. My general rule of thumb is that w...
What resources do you find helpful for patients with MSK concerns who may not have access to physical therapy or who cannot afford it?
This is an excellent question and important because every MSK concern needs some form of exercise intervention for maximum benefit/recovery. In some (most?) EMR systems, general, basic home exercise programs (HEP) are available for patients. This is a convenient way to get patients started. Rarely, ...
What resources do you find helpful for patients with MSK concerns who may not have access to physical therapy or who cannot afford it?
This is an excellent question and important because every MSK concern needs some form of exercise intervention for maximum benefit/recovery. In some (most?) EMR systems, general, basic home exercise programs (HEP) are available for patients. This is a convenient way to get patients started. Rarely, ...
What is the next best osteoporosis treatment option for patients who completed 2 years of teriparatide, but has contraindication to bisphosphosnate therapy (e.g. history of atypical femur fracture)?
I have successfully treated several patients with bisphosphonate-induced subtrochanteric femoral fractures with Forteo. However, before initiating another antiresorptive therapy, I first want to be sure that the Forteo at the desired effect on bone remodeling by increasing both bone formation and bo...
Do you have any concerns about lower extremity compression (e.g., compression stockings, intermittent pneumatic compression, etc.) worsening ascites in a patient with portal hypertension?
This is an interesting question, and I have to admit, not one I've thought about regularly. When I think of lower extremity compression and the contraindications, portal hypertension and ascites are not contraindications that immediately come to mind. I do understand the reasoning behind the questio...
Do you have any concerns about lower extremity compression (e.g., compression stockings, intermittent pneumatic compression, etc.) worsening ascites in a patient with portal hypertension?
This is an interesting question, and I have to admit, not one I've thought about regularly. When I think of lower extremity compression and the contraindications, portal hypertension and ascites are not contraindications that immediately come to mind. I do understand the reasoning behind the questio...
What are the best techniques to reduce POCUS artifact and increase the diagnostic accuracy of lung ultrasound?
It is important to first clarify that essentially all of lung ultrasound is artifact, and this is a great illustration of how artifact can actually help us to make a diagnosis rather than obscuring it. When we see B-lines, for example, that is an artifact that does not represent a similarly appearin...
How do you approach the management of newly discovered prediabetes in adults over the age of 65?
We know that even at the same given HgA1c, a 90-year-old patient and a 30-year-old patient have different patterns in their day-to-day sugars. The 90-year-old patient will have a wider amplitude of sugars above and below a given average sugar level. Therefore, while a given HgA1c gives us an idea of...
What additional screening/management, if any, would you recommend to a patient whose annual mammogram showed heterogeneously or extremely dense breast tissue?
As of now, the USPSTF has stated that there is insufficient evidence to support adjunct screening modalities in women with dense breast tissue (category C or D). The other issue to consider is that some insurance does not cover adjunct screening since it is not considered "screening" per se. That sa...