Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you wait on initiating biologic therapy for guttate psoriasis?
First, and foremost, it is important to identify the trigger for guttate psoriasis, which is often caused by step (which requires antibiotics). For most patients, a guttate flare will resolve on its own. When using biologics, we can help clear guttate psoriasis (note, this is largely based on anecd...
Do you check for EGFR and other mutations in patients with squamous cell lung cancer, including in adjuvant setting before considering immunotherapy?
Yes, I do. Our Cancer Institute performs NGS reflex testing for all patients with newly-diagnosed lung cancer, regardless of stage or histology. Although EGFR or other mutations are less common in squamous cell lung cancer, they do exist, and this also allows for testing for other mutations (MET exo...
When do you choose to switch to antidepressants vs augmentation in treatment-resistant depression?
When I approach depression that has been resistant to many antidepressant trials, I consider the following: First, I reassess the diagnosis. This includes considering comorbidities such as menopause symptoms, ED symptoms, exacerbation of chronic medical issues, and onset of MNCD. I ensure I have con...
What is your outpatient approach to monitoring paroxysmal atrial fibrillation (i.e. mobile cardiac telemetry, decision to anticoagulate if high likelihood of recurrence) in young adults with CHADsVASC score of 0, in light of potential remodeling and increased Afib burden as they age?
This is an important question, especially in light of the most recent data suggesting that early maintenance of sinus rhythm is beneficial in patients. If the patient truly has a CHADsVASC score of zero, they have lone atrial fibrillation, low stroke risk, and our major concern is prevention of remo...
Do you recommend starting anti-fungal prophylaxis for patients on systemic antibiotics who have a peritoneal dialysis catheter that is only currently being accessed for once weekly flushes?
This is a unique situation which is for me a strictly hypothetical one, as I've not encountered this situation in my 38-year PD career. Nor am I aware of data to guide a response. On reflection, however, I would answer in the affirmative. Fungal peritonitis is a very serious infection which invariab...
What is the best treatment option for a patient with bipolar disorder, who stopped her medication at the start of pregnancy and is now at the end of 2nd trimester?
This is a great question. Restarting medication would be a top priority, as we know that the risk of relapse for bipolar disorder mood episodes in women is at least as common during pregnancy as in the non-pregnant state, and that discontinuation of medications increases the risk of relapse during p...
For patients who do not have access to biologic therapies, what are some csDMARD combination pearls or tips that you have that have particular efficacy in different rheumatologic diseases?
I normally use MTX in RA. I initially aim for 15mg of MTX per week, then split the dose and maximize to 20-25mg/week. In some patients, I use SQ MTX if they have GI problems or are very obese. The addition of HCQ with MTX is better than MTX alone in some patients. I have rarely used SSZ+MTX+HCQ but ...
For patients over 90 years old, is there any foreseeable benefit to undergoing left atrial appendage occlusion over permanent cessation of anticoagulation, particularly for those at high risk for major bleeding?
I would have no qualms about referring a 90+ year-old patient with a-fib and high bleeding risk for an LAA occlusion device. However, this requires a shared decision-making process whereby the risks and benefits of the various treatment options are discussed with the patient and, when appropriate, t...
When would you consider initiating patients with CAD and aortic stenosis on PCSK9 inhibitors (as an adjunct to statin therapy), given favorable findings in the FOURIER trial?
There are limited data to support PCSK9 inhibitors in the treatment of aortic stenosis, and in fact, most is theoretical. Elevation of lipoprotein (a) levels independently increases the risk of in early-onset CAD and calcific aortic stenosis. Lp(a) levels are lowered by PCSK9 inhibitors by ~20-30%, ...
What is your approach to differentiating tender spots (as in fibromyalgia) and enthesitis (as in axSpA)?
The tender points in fibromyalgia are not limited to tendon insertion sites but are much more generalized, such as in the middle of the muscles of the neck, shoulders and back. Often tender points in fibromyalgia are found at the costochondral junction and at the lateral epicondyle or other tendons ...