Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you approach counseling an older patient with significant hearing loss and nonadherence to use of hearing aids?
Using my own grandmother as an example, hearing aides were an affront to her vanity, and she perceived them as a sign of weakness in aging…and she probably felt as if they were thrust upon her by the family—so, in the end, she was stuck in silence within her own world—which was a sad and lonely and ...
How do you counsel patients on pelvic floor physical therapy who are initially very hesitant to try it?
I typically will inform patients that I can understand the hesitation of pursuing pelvic floor physical therapy, as it involves exercising muscles in a sensitive area of the body. However, patients who have completed pelvic floor PT have a significant improvement in their symptoms, with some studies...
Do you scale up 2nd generation anti-histamines to 4x daily in acute urticaria in the pediatric population as you do in adults?
Severe urticaria is certainly a therapeutic challenge. Updosing 2nd generation antihistamines in children has been studied, more trials need to be done. For refractory urticaria in children, I will often recommend 2X the recommended dose of a 2nd generation antihistamine in the morning and maximize ...
How do you decide the right time to transition to hospice?
Talking about hospice is one of the hardest jobs we have. It's hard because we don't like doing it, because we often don't know how to do it well, and because we angst about doing it too early or too late. It's an important thing to think about. I actually think perhaps the most important factor in ...
What is your preferred screening tool for colon cancer in an average-risk patient?
For their first time screening, I universally recommend a colonoscopy (in the absence of contraindications or social barriers) to evaluate for polyps, followed in 5-10 years by a yearly FIT or Cologuard every three years (unless the patient has a strong preference for a repeat colonoscopy). Repeat c...
Based on most current research regarding the more widespread use of class IC antiarrhythmic drugs, what are your prescribing practices in patients with coronary artery disease?
Fair question, as we know the definition of "structural heart disease" is unknown. In the trial, it was likely ischemia driving the poor outcomes, so I will get stress with imaging on everyone >50 years old (CAD risk). Given the common finding of "questionable" stent placement in the community, I wi...
In what situations would you recommend metformin in addition to aggressive lifestyle interventions for patients with prediabetes and obesity?
So based on studies such as the Diabetes Prevention Program and newer meta-analyses such as Comparison of the Efficacy of Metformin and Lifestyle Modification for the Primary Prevention of Type 2 Diabetes: A Meta-Analysis of Randomized Controlled Trials (Vajje et al., PMID 38021728). Lifestyle modif...
What is the minimum duration of weeks on anticoagulation in which you would consider performing a DCCV without the need for TEE, provided the patient is an excellent historian and otherwise reliable?
If this were a board question, I agree with the guideline-listed answers here - it's 3 weeks. The most recent 2023 ACC AHA hours Atrial Fibrillation Guidelines by Joglar et al., PMID 38033089 are consistent: In patients with AF duration of ≥48 hours, a 3-week duration of uninterrupted therapeutic an...
How long do you continue IVIG for myositis patients in remission on that therapy?
Typical total duration of IVIG is about 1-2 years. If someone is in remission, I will decrease IVIG to 1 gm/kg monthly dose. If still in remission for 3 months, I decrease to 1 gm/kg every other month for 2 more cycles. If still in remission, you could either stop or do 1-2 doses every 3 months befo...
When would you consider checking JC virus prior to initiating biologic therapy?
JC is a ubiquitous virus with sero-prevalence in the adult population of 60-70% in most studies. The concern is that in those who harbor latent JC are vulnerable to reactivation and ultimately the development of Progressive Multifocal Leukoencephalopathy (PML). The drug natalizumab used to treat MS ...