Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is there a role for use of GLP-1/GIP receptor agonists in the management of substance use disorders, whether or not they meet other inclusion criteria for their use?
Currently, we lack the RCTs to understand the full impact of GLP-1s on SUD outcomes. Most evidence is pre-clinical, observational, suggesting potential reductions in cravings and alcohol use. A recent RCT, lab study of semaglutide in non-treatment-seeking adults with AUD showed decreased alcohol con...
What is your preferred workup for a patient who has a biopsy consistent with “dermal hypersensitivity reaction”?
When encountering a patient with a biopsy consistent with "dermal hypersensitivity reaction," it's crucial to acknowledge the inherent non-specificity of such a diagnosis. In my role as the Director of the Contact Dermatitis Clinic at Penn, I've found that clinical pathologic correlation becomes inv...
Do you use combination therapy for persistent MSSA bacteremia?
I don’t think I’ve ever come across a situation where the problem wasn’t source control…
In a patient with selective IgM deficiency who is completely asymptomatic in terms of infections, what is your typical laboratory work up?
B cell phenotyping, lymphocyte subsets, IgG to diphtheria, tetanus and S pneumonia. Evaluate the humoral function, as it is important to know and possibly follow with time, but with an asymptomatic treatment is not warranted.
How do you counsel patients who are concerned that discontinuation of certain chronic medications may actually perpetuate suffering at the end of life?
Great question, and it’s very nuanced. I’ll share how I typically approach this based on my experience. In the end-of-life care setting, when I review a medication list, I go through every single one and ask: “What is the purpose of this medication in this particular case?” For example, anticoagul...
How do you counsel patients who are concerned that discontinuation of certain chronic medications may actually perpetuate suffering at the end of life?
Great question, and it’s very nuanced. I’ll share how I typically approach this based on my experience. In the end-of-life care setting, when I review a medication list, I go through every single one and ask: “What is the purpose of this medication in this particular case?” For example, anticoagul...
In light of the challenges with non-adherence to oral therapies in breast cancer, how do you monitor patient adherence in your practice?
There are several strategies here. Much of this is around patient education and the clinic team of nurses, physicians, APPs and oncology pharmacists can all support our patients by ensuring there is good understanding of the dosing schedule, potential side effects and how we might manage those, impo...
Should patients starting cyclophosphamide be screened routinely for latent tuberculosis (TB)?
Yes, I think patients starting Cyclophosphamide should be screened routinely for latent TB since CYC is a strong immunosuppressant and increases the risk of TB reactivation. The issue is that CYC is often being considered for life or organ-threatening situations, for which it may not be ideal to wai...
In middle-aged adults with TSH 5–10 mIU/L and no symptoms, would you start levothyroxine or monitor, and does your threshold change with cardiovascular risk factors?
In a middle-aged patient with a TSH between 5-10 and no symptoms, I would initially monitor their thyroid levels. I would consider checking a TPO antibody titer; if positive, the rate of transition to overt hypothyroidism is greater. I would also screen for other medical issues that could be impacte...
Do you routinely monitor urine toxicology for primary care patients prescribed tramadol for chronic pain?
Yes, still an opioid and can be misused.