Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Which patient characteristics or scenarios drive you to choose tezepelumab over dupilumab for asthma?
I typically put adult patients with T2 high, and allergic phenotype on dupilumab whereas those that are T2 high only or T2 low are on tezepelumab. Additionally, if the patient has nasal polyps or AD, then I would prefer dupilumab over tezepelumab. I always have a discussion with the patient regardin...
How do you manage persistent insomnia despite ASV titration in patients with complex sleep apnea?
It is an excellent question, and I am not sure if I have a perfect answer. The first question I would have is if the insomnia pre-dated the treatment-emergent central sleep apnea. It is assumed if they are on adaptive servo-ventilation (ASV) that they already tried CPAP, had treatment-emergent centr...
How do you approach the management of patients with mildly elevated mPAP (21-24 mmHg) and PVR (2-3 WU) who may be at risk of progression, given the recent changes in the hemodynamic definition of pulmonary hypertension?
The "new" definition of PH with a cutoff of 20 mmHg is a very sensible change, based on the study by Kovacs et al., PMID 19324955, which showed that a mean PAP of 20 mmHg is already two standard deviations above the mean PAP in normals. Thus, the cut off of 20 mmHg makes more sense than 25 mmHg.To a...
Is there a role for the use of transient elastography (FibroScan) to monitor liver fibrosis in patients on long term methotrexate?
Liver elastography is a useful tool to use when assessing the potential hepatotoxicity of various drug therapies. Traditionally, methotrexate accounted for nearly all the hepatotoxicity issues that we faced; however, we can add many other drugs to that list. Virtually, every immune suppressive drug ...
How do you sequence pharmacologic treatments for primary insomnia?
First, be sure you have already addressed deficiencies in sleep hygiene: Room at 65 degrees F Wearing earplugs Complete darkness (no visible hand in front of face) No clock Golden hour before bed ETOH, nicotine, and caffeine reduction with cessation of 4 hours before bed Writing a list of worries B...
How do you counsel patients who want to use vaping to quit smoking cigarettes?
My patient population is largely persons with severe opioid use disorder. Most use tobacco/ nicotine in some form - typically cigarettes and/or vaping. I have seen people minimize their use of cigarettes with vaping and feel very happy with their results. I don't see, however, a lot of patients stop...
What strategies do you recommend to address the negative self-talk/internalized bias that patients carry about their own weight?
I always discuss the "five fingers" of health (and hold up my hand). Eat good food most of the time. Exercise on a regular basis, especially strength training. Get good sleep. Manage your stress. Self-care. When you do those five things, pat yourself on the back, and weight loss is the side effec...
How would you manage symptomatic, bilateral subsegmental PE developed after long air travel?
I generally consider air travel to be a relatively weak provoking factor. Although the 2020 ASH guidelines do not address this, the ASH Guidelines from 2018 on management of VTE cite a 2.8-fold increased risk for VTE associated with air travel, which is roughly similar to the increased risk associat...
How do you identify patients with false positive AcHR antibodies?
First of all, of course, one should look for the clinical correlation. Even a weakly positive AchR binding antibody is likely to be "real" (true positive) if accompanied by unequivocal clinical signs of MG, e.g., fatigable ptosis with positive ice pack test, or fatigable bulbar/limb weakness. Ideall...
Do you recommend self-breast exams to your patients with history of breast cancer in addition to imaging surveillance?
This is a somewhat controversial question. I cannot find any data on the risks or benefits of counseling on self-exams in breast cancer survivors. I will simply say this. Among survivors, there are differences between patients that I think the physician must understand and meet the patients where th...