Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would a history of definitive chemoRT for anal SCC change the workup for an ASCUS/HPV negative PAP smear in a patient who has never had an abnormal PAP smear in the past?
Interesting question. We do know that radiation changes can lead to atypia which can interfere with cytological analysis. I would counsel the patient that her current ASCUS/HPV negative pap smear results may have some relation to her prior radiation, but ultimately I would still follow ASCCP guideli...
How do you counsel male-to-female transgender patients on the VTE risk of hormonal therapy?
Overall, there are minimal data in pediatric populations, but the data from adult populations suggests that in the vast majority of cases, it is safe from a VTE standpoint to administer estrogen therapy in male-to-female transgender patients. The current formulations of estrogen that are recommende...
How do you approach patients with overlapping features of PMR and seronegative RA?
To me, this is the same as saying how to treat large and small joint rheumatoid arthritis in the same patient. For me, the difference is largely in the use of steroids. I have used much less steroids in my patients who I believe to have small joint seronegative rheumatoid arthritis, initiating a DMA...
Are you recommending the mRNA COVID-19 vaccines to your patients with immune mediated inflammatory diseases?
This is THE question at the moment for providers of patients with immune mediated inflammatory diseases. For now, we are merely extrapolating as patients with active IMIDS were censored from trials (Pfizer & Moderna). Organizations like the American College of Rheumatology are moving quickly to clos...
How soon after a VTE would you feel comfortable with a patient undergoing an elective surgery?
Here is my approach: Many factors play a role in decision making such as type of venous thromboembolic event, clot burden, provoked versus unprovoked nature of the event, patient's bleeding and clotting phenotype, associated risk factor such as cancer, etc, type of anticipated surgery, and risk for ...
What is your strategy for having COVID positive patients resume infusions after they have recovered from the infection?
If they are asymptomatic and doing well, we may resume systemic therapy as clinically indicated. I have used either chemotherapy or IO, depending on the case. We follow institutional guidelines but retesting for Covid19 is not required at our center if the patient has recovered and has been asymptom...
Is a comprehensive physical exam with vital signs warranted for routine follow-up visits in well-controlled uncomplicated RA patients?
This is an important question for which we don't have an evidence-based answer yet, but it is likely that our practice will change with these new guidelines, and with the expansion of telemedicine. I think we cannot have a one size fits all recommendation. Many factors may influence the need for a f...
Do you recommend long term anticoagulation for all patients with first time unprovoked VTE?
I consider long term anticoagulation after a first unprovoked proximal DVT or PE in patients with low bleeding risk, especially if they are male. Risk/benefit discussion is employed for patients who have a higher bleeding risk after a first unprovoked VTE event.
What type of surveillance would you recommend following resection of primary mucinous carcinoma of the skin?
A full skin examination every 6 to 12 months. Reminding the patient to call the clinic immediately for any symptoms that are unusual, or for a new skin lesion and perform a symptoms directed work-up.
Do you switch to certolizumab in RA patients who are doing well on other TNFis and planning to become pregnant?
I have not “switched” any patients who are stable and doing well on an anti-TNF agent when the issue of pregnancy arises. The risk of flare remains a concern in this situation. There is enough data-base derived information (such as the OTIS registry) to suggest safety to continue an established anti...