Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Should metformin be used in women with PCOS for weight loss?
I would not use metformin with the goal of weight loss in PCOS. Its effects on weight loss are modest (probably a few kg at most) and inconsistent. I agree with the Endocrine Society 2013 guidelines and that recommend metformin should not be used for the treatment of PCOS unless there is coexisting ...
How do you decide whether average-risk patients should undergo annual or biennial breast cancer screening?
It's gotten really tricky in the last few years! The ACS and ACR (of course) recommend annual screening, and the USPSTF, as well as other societies, recommend biennial screening. ACS guidelines recommend annual screening from age 45-54, since it seems to make a difference in premenopausal women (bot...
How would you approach pursuing a kidney biopsy in a patient with suspected lupus nephritis who is on warfarin for antiphospholipid antibody syndrome?
This is a decision to be made carefully involving multiple specialists. Personally have had a bad experience with resuming anticoagulation after kidney biopsy. I have seen patients bleed even one week after doing the kidney biopsy when resuming anticoagulation. Can switch to a heparin drip before th...
Is there a BMI cutoff for which you would refer a patient needing a native kidney biopsy to interventional radiology?
I refer all my patients who require a kidney biopsy irrespective of BMI to our in-hospital Interventional Nephrology service. They evaluate the depth of the kidney from the skin surface with ultrasound and decide whether they will be able to obtain adequate renal tissue for diagnosis. If the kidney ...
What is your treatment approach to prevent progression of phymatous rosacea?
Isotretinoin has definitely been the gold standard at our office to shrink/slow the growth of the sebaceous glands. However, Monopolar RF (i.e. Agnes RF) can also selectively target and ablate sebaceous glands while minimizing epidermal damage if the goal is sebaceous control rather than dermaplanin...
How do you screen alopecia patients to determine whether they are appropriate candidates for JAK inhibitors?
Factors that have to be taken into account when considering a JAK inhibitor include but are not limited to age, past medical history (particularly smoking, cardiac risk factors, cancer, thrombosis), and the emotional toll of the alopecia on the patient. I have an informational handout on the use of ...
How do you counsel patients who ask if they should take a daily multivitamin?
Here is what I typically recommend to patients in my primary care practice: Most healthy adults who eat a balanced diet, including lots of produce/plants, do not need to take a daily multivitamin. They are expensive, and whole foods are a better form of micronutrients than manufactured vitamins. Th...
How would you counsel a patient on the risk/benefit profile of preventive management such as statin initiation if they have an elevated lipoprotein (a) level, markedly elevated LDL > 200 but a CAC score of 0 without other CV risk factors?
Assuming this patient is over 45 years, and has tried dietary approaches to reduce cholesterol first, I would recommend a initiation of a moderate intensity statin to lower the risk of ASCVD events as the risk equation does not take into account the CAC score.
What is your preferred method of surveillance after mastectomy?
The answer depends on clinical circumstances. For all the details, I refer you to NCCN guidelines where this is discussed specifically. However, let me summarize a few key points. Patients are usually seen several times a year for 5 years, less often thereafter. A history and physical exam is always...
Does your treatment strategy differ when managing patients with recurrent calcium oxalate monohydrate versus calcium oxalate dihydrate stones?
I manage calcium oxalate monohydrate and calcium oxalate dihydrate stones the same way. Based on my laboratory studies of calcium oxalate crystallization, the differentiating feature between these two stone types is likely related to differing inhibitor properties of urinary proteins; forming the di...