Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to young teenagers with acne who have extremely sensitive skin, cannot tolerate typical acne regimens, cannot tolerate oral antibiotics, and refuse Accutane?
The formulation of benzoyl peroxide encapsulated in silica shells is extremely well tolerated by sensitive-skinned individuals. I was involved in pre-approval studies and found it remarkably well tolerated in such patients.
How soon after a fracture would it be safe to start anti-resorptive therapy?
This is an important question. There is no definitive answer, and there have been no clinical or preclinical studies that demonstrate delayed healing in the presence of bisphosphonates. Personally, I favor waiting a few weeks before we start. That also gives us time to do a proper metabolic workup. ...
How would you treat a patient with osteoarthritis of just one joint of the hand?
People do this in various ways - some people treat the joint with a large margin, others may treat the whole hand.I originally started by treating the affected joint, but pretty soon I after I switched and started treating the whole hand - pain is subjective and though it may appear localized, there...
What is your treatment paradigm for rectal cancer in the setting of COVID-19?
We haven't changed our standard recommendation: short course radiation -> 3-4 months of FOLFOX. In a very timely manner, the RAPIDO ASCO abstract was released here in May. It showed that the patients who received short course radiation -> FOLFOX had improved pCR, less disease related treatment failu...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
Should asymptomatic esophageal candidiasis identified incidentally on endoscopy be treated?
Yes, in our practice, we do treat asymptomatic esophageal candidiasis when found incidentally on endoscopy. A few things to consider: 1) While patients may be asymptomatic at the time of the endoscopy, untreated disease can lead to the future development of complications/symptoms, such as odynophagi...
Would you consider sotalol to be a suitable non-selective beta blocker for primary prevention of variceal bleeding in a patient who requires sotalol for treatment of arrhythmia in the setting of Fontan-associated liver disease and clinically significant portal hypertension?
The answer to this question will need to be case-by-case, unfortunately.The short answer:The priority in this patient's case for using sotalol is likely the underlying heart disease and its associated arrhythmia, and this cardiac benefit would not be achieved by carvedilol and other NSBBs. Thus, it ...
What is your approach to a situation where DILI is suspected secondary to an important medication (e.g., anticoagulation, antibiotics, etc.), but the diagnosis is uncertain and the liver injury is relatively mild?
If the drug suspected to induce liver injury causes symptoms and ALT is >3 times the upper limit of normal (ULN), I would stop the drug and find an alternative. Even if no symptoms are present, I would stop if ALT is >5 times ULN. Any level increase of ALT below the above parameters would still requ...
What is your approach to a situation where DILI is suspected secondary to an important medication (e.g., anticoagulation, antibiotics, etc.), but the diagnosis is uncertain and the liver injury is relatively mild?
If the drug suspected to induce liver injury causes symptoms and ALT is >3 times the upper limit of normal (ULN), I would stop the drug and find an alternative. Even if no symptoms are present, I would stop if ALT is >5 times ULN. Any level increase of ALT below the above parameters would still requ...
How do you approach the management of patients who require nutritional restoration in the setting of a presumed functional GI disorder recalcitrant to behavioral medicine and pharmacologic therapies?
It certainly is a very good question if indeed the patient has functional disease; then, for sure, they need more than just my help. They probably need the help of a nutritionist, but even more so, they need perhaps psychiatric medication and the treatment of a behavioral therapist or psychological ...