Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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.
Do you ever recommend the use of a Creatine Monohydrate supplementation to your patients looking to improve physical fitness?
Yes. I do recommend Creatine Monohydrate for patients/athletes hoping to gain strength and muscle mass. The current data is favorable for short bursts of strength or speed, but there is some growing evidence that there may be some benefit for higher rep/longer exertion and possibly for cognitive hea...
Do you routinely order karius in evaluation of culture negative prosthetic valve endocarditis?
Don’t “routinely” order Karius test. Rarely, in culture-negative suspected endocarditis, especially if a prosthetic valve is present. Once for suspected culture-negative aortic graft infection. 3x for culture-negative meningitis. Likely to become more frequent but adoption very dependent on cost an...
What are your preferred non-benzodiazepine therapies for the hyperactive/agitated phase of methamphetamine withdrawal, both in the hospital and in the office?
In our outpatient substance use disorder practice, we tend to use lisdexamphetamine (Vyvanse) at fairly high doses off-label for patients with meth withdrawal. We establish a buddy system preferably with someone who lives with them, provide Suicide hotline phone number, describe reasons to transport...
What strategies do you recommend for discussing the use of OCP in women with a history of migraines with or without aura?
In light of the recent publication from 2025 publication by Ihara et al. in Cephalagia, modern low-dose combined hormonal contraceptives (CHCs) do not appear to add vascular risk in otherwise healthy young women with migraine. Migraine with aura remains an important marker of vascular risk regardles...
Do you routinely treat patients with neurosyphilis with IM penicillin for 1-3 weeks after completing a full treatment course of IV penicillin?
The same question was asked almost exactly two years ago. Repeating the same reply with minor edits: This has been a topic of a debate among syphilis experts for decades. There are no data at all on whether there is benefit (e.g. in preventing later relapse) in adding low-dose but long-acting penici...
What studies do you find helpful to determine if an axial spondyloarthritis patient presenting late in the disease course with significant irreversible joint damage may benefit from immunosuppression?
I think this is a very clinically relevant question. While I do not know of any study that specifically examines this question, studies suggest that tumor necrosis factor inhibitors may inhibit long-term radiographic progression and improve functional status. Long-term extension of secukinumab trial...
How do you approach the concept of spondyloarthritis disease activity "burning out" and no longer requiring immunosuppression?
This is a difficult question to discuss academically, as we will have to accept a definition for “burning out,” which may or may not be synonymous with remission or a state that will support drug-free remission. That being stated, the possibility of spondyloarthritis going into remission (no “inflam...