Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach when a female patient does not want a male MA/scribe present in the exam room but other staff are unavailable?
I think we need to respect a patient’s request for same sex providers. Some patients are shy. For some, it is religion-based. I would ask the scribe to stand behind the curtain while I am seeing the patient. Regarding the MA, I would ask the MA to leave the room during my full-body skin exam. If I n...
How do you counsel patients who express concerns about receiving multiple vaccinations at once versus spacing them out over time?
The evidence shows it’s fine to give several vaccinations at once, but if you prefer to space them out, that’s fine as well. Just don’t forget to get all the recommended ones.
Is addition of SLIT likely to provide additional benefit for isolated dust mite allergy that is not completely treated with SCIT?
I offer both and have patient decide.
How should we approach the recommendation of intermittent fasting for weight loss in patients with pre-existing cardiovascular conditions, given the observed association of increased CV mortality with eating durations of less than 8 hrs?
I will admit my prejudice on this topic. I don’t understand the biologic plausibility of shortening the time during which meals are consumed to 8 consecutive hours a day with no snacking for 16 hours a day (but without calorie restriction) in order to lose weight. This would be like saying “have bru...
What is your approach when counseling patients interested in bio-identical hormones for management of menopause versus traditional hormone replacement therapy?
The term bioidentical hormones commonly refers to custom-compounded hormone drugs. Before an oral capsule of micronized progesterone was commercially available, it was always prescribed custom-compounded. The problem with custom-compounded hormones is that they have not gone through the rigorous tes...
How would you treat an asymptomatic patient with a positive Blastomyces antibody, evidence of prior granulomatous lung disease on imaging, and who may require immunosuppression in the future?
We practice in an area with a good bit of blastomycosis and rarely see a positive Blastomyces antibody, even in patients with culture-proven blastomycosis. The newer EIA antibody that MiraVista lab is doing may be more reliable. If the prior granulomatous lung disease has been worked up with negativ...
How would you approach management of a patient who develops squamous cell skin cancer while on abatacept?
I would discontinue abatacept. Several studies now have reported an increased risk of squamous cell cancer/non-melanoma skin cancers in patients on abatacept (Wadstrom et al., PMID 28975211, Simon et al., PMID 37932010) and in someone who actually develops this malignancy on the drug, I would hesita...
What varying approaches do you take in suicide risk assessments?
I agree with the following from Dr. @Dr. First Last: "Ultimately, no scale or method is going to be perfect. We are unfortunately bad at predicting which individuals with suicidal ideation progress to an attempt. The most we can do is gather as much information as possible about how someone is feeli...
What is your approach to patients with biopsy proven giant cell arteritis that continue to have symptoms after initiation of high dose glucocorticoid therapy?
First, let's define and discuss “high-dose” steroids. Oral therapy is typically 60-100 mg of prednisone daily, and IV is 500-1000 mg of methylprednisolone daily for three days, followed by oral prednisone. There has been no difference in long-term outcomes for vision loss or diplopia. The complicati...
How do you determine the severity of restrictive lung disease?
My interpretation of the latest ATS/ERS guidelines is that FEV1 should be used for "any spirometric abnormality" including restriction or mixed disorders, which is unchanged from the 2005 ERS Guidelines.That said, I tend to use FVC when grading pure restrictive disorders, habituated as a result of F...