Guidance for Practicing Primary Care

As primary care doctors, we diagnosis and treat many patients with osteoarthritis. In fact, according to World Health Organization statistics, approximately 528 million people around the world suffer from some form of this type of arthritis. With the aging of the population and the obesity epidemic, the rate of osteoarthritis has increased 113% since 1990 and is predicted to continue to rise.

While the knee is the most commonly affected joint, osteoarthritis also frequently affects the hands and hips. The American Academy of Orthopaedic Surgeons issued guidelines concerning the management of osteoarthritis of the hip. The clinical guidelines are aimed at orthopedists, but it is important for primary care doctors be aware of them as well since we are the physicians who usually diagnose the disease, manage it in its early stages, and follow the patients with and after the orthopedist has undertaken any procedures.

Castle Connolly

While the complete set of guidelines is 80 pages long, strong recommendations have been made that everyone should be aware of. The role of non-steroidal anti-inflammatory drugs has been reconfirmed as a modality to improve pain and function. A recommendation against using intra-articular hyaluronic acid in the hip was made as the evidence shows it did not improve pain or function better than placebo. Conversely, intra-articular corticosteroids were shown to improve pain and function in the short-term and many primary care doctors provide this treatment in their practice.

These guidelines do a great job covering the totality of management of osteoarthritis of the hip, from conservation management to surgical and post-surgical treatments. Patients often come to us with their questions so not only is it important to know the evidence for what we do in our practices, we need to know what our orthopedic colleagues are doing. We will be the ones asked to do the pre-operative evaluations on these patients, so we need to understand the procedure and its risks. We will also manage these patients post-operatively and need to be aware of what the evidence shows.

Opioid use is also covered in the guidelines: they recommend against the use of opioids to control pain in these patients. In the age of the opioid epidemic, it is a good reminder to be cautious with these meds. It is also a good time to stress smoking cessation with patients.

The guidelines discuss adverse outcomes in patients with diabetes and/or obesity. As primary care physicians, we need to be aware of those risks and be sure our patients are medically optimized before signing that pre-operative form.

A new feature of these guidelines is a discussion on social detriments to health. This is important for many diseases that we treat and we often don’t realize the impact they can have on a patient’s health and recovery. Even if we know a patient would benefit from physical therapy, it doesn’t help them if the patient has no way to get to the appointment. Some patients have copays for every physical therapy session and just can’t afford it. Knowing what the patient needs medically is not enough. We need to understand how they can access that care. Some patients have no one to help them after hip surgery and may avoid doing it for that reason. As primary care doctors, we should be helping our patients access the care they need.

We need to be able to say that a procedure needs to be delayed in the face of poorly controlled disease, such as diabetes. As the rates of osteoarthritis continue to rise, we need to understand that it is not an inevitable age-based occurrence in a patient’s life but rather an inflammatory disease that causes great pain and dysfunction. Utilizing these guidelines and working with our orthopedic colleagues can help patients decrease pain, improve functioning, and enjoy life again.
 

Dr. Girgis practices family medicine in South River, New Jersey, and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, New Jersey. She was paid by Pfizer as a consultant on Paxlovid, paid by GlaxoSmithKline as a consultant for the Shingrix vaccine, and is the editor in chief of Physician’s Weekly.

As primary care doctors, we diagnosis and treat many patients with osteoarthritis. In fact, according to World Health Organization statistics, approximately 528 million people around the world suffer from some form of this type of arthritis. With the aging of the population and the obesity epidemic, the rate of osteoarthritis has increased 113% since 1990 and is predicted to continue to rise.

While the knee is the most commonly affected joint, osteoarthritis also frequently affects the hands and hips. The American Academy of Orthopaedic Surgeons issued guidelines concerning the management of osteoarthritis of the hip. The clinical guidelines are aimed at orthopedists, but it is important for primary care doctors be aware of them as well since we are the physicians who usually diagnose the disease, manage it in its early stages, and follow the patients with and after the orthopedist has undertaken any procedures.

Castle Connolly

While the complete set of guidelines is 80 pages long, strong recommendations have been made that everyone should be aware of. The role of non-steroidal anti-inflammatory drugs has been reconfirmed as a modality to improve pain and function. A recommendation against using intra-articular hyaluronic acid in the hip was made as the evidence shows it did not improve pain or function better than placebo. Conversely, intra-articular corticosteroids were shown to improve pain and function in the short-term and many primary care doctors provide this treatment in their practice.

These guidelines do a great job covering the totality of management of osteoarthritis of the hip, from conservation management to surgical and post-surgical treatments. Patients often come to us with their questions so not only is it important to know the evidence for what we do in our practices, we need to know what our orthopedic colleagues are doing. We will be the ones asked to do the pre-operative evaluations on these patients, so we need to understand the procedure and its risks. We will also manage these patients post-operatively and need to be aware of what the evidence shows.

Opioid use is also covered in the guidelines: they recommend against the use of opioids to control pain in these patients. In the age of the opioid epidemic, it is a good reminder to be cautious with these meds. It is also a good time to stress smoking cessation with patients.

The guidelines discuss adverse outcomes in patients with diabetes and/or obesity. As primary care physicians, we need to be aware of those risks and be sure our patients are medically optimized before signing that pre-operative form.

A new feature of these guidelines is a discussion on social detriments to health. This is important for many diseases that we treat and we often don’t realize the impact they can have on a patient’s health and recovery. Even if we know a patient would benefit from physical therapy, it doesn’t help them if the patient has no way to get to the appointment. Some patients have copays for every physical therapy session and just can’t afford it. Knowing what the patient needs medically is not enough. We need to understand how they can access that care. Some patients have no one to help them after hip surgery and may avoid doing it for that reason. As primary care doctors, we should be helping our patients access the care they need.

We need to be able to say that a procedure needs to be delayed in the face of poorly controlled disease, such as diabetes. As the rates of osteoarthritis continue to rise, we need to understand that it is not an inevitable age-based occurrence in a patient’s life but rather an inflammatory disease that causes great pain and dysfunction. Utilizing these guidelines and working with our orthopedic colleagues can help patients decrease pain, improve functioning, and enjoy life again.
 

Dr. Girgis practices family medicine in South River, New Jersey, and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, New Jersey. She was paid by Pfizer as a consultant on Paxlovid, paid by GlaxoSmithKline as a consultant for the Shingrix vaccine, and is the editor in chief of Physician’s Weekly.

As primary care doctors, we diagnosis and treat many patients with osteoarthritis. In fact, according to World Health Organization statistics, approximately 528 million people around the world suffer from some form of this type of arthritis. With the aging of the population and the obesity epidemic, the rate of osteoarthritis has increased 113% since 1990 and is predicted to continue to rise.

While the knee is the most commonly affected joint, osteoarthritis also frequently affects the hands and hips. The American Academy of Orthopaedic Surgeons issued guidelines concerning the management of osteoarthritis of the hip. The clinical guidelines are aimed at orthopedists, but it is important for primary care doctors be aware of them as well since we are the physicians who usually diagnose the disease, manage it in its early stages, and follow the patients with and after the orthopedist has undertaken any procedures.

Castle Connolly

While the complete set of guidelines is 80 pages long, strong recommendations have been made that everyone should be aware of. The role of non-steroidal anti-inflammatory drugs has been reconfirmed as a modality to improve pain and function. A recommendation against using intra-articular hyaluronic acid in the hip was made as the evidence shows it did not improve pain or function better than placebo. Conversely, intra-articular corticosteroids were shown to improve pain and function in the short-term and many primary care doctors provide this treatment in their practice.

These guidelines do a great job covering the totality of management of osteoarthritis of the hip, from conservation management to surgical and post-surgical treatments. Patients often come to us with their questions so not only is it important to know the evidence for what we do in our practices, we need to know what our orthopedic colleagues are doing. We will be the ones asked to do the pre-operative evaluations on these patients, so we need to understand the procedure and its risks. We will also manage these patients post-operatively and need to be aware of what the evidence shows.

Opioid use is also covered in the guidelines: they recommend against the use of opioids to control pain in these patients. In the age of the opioid epidemic, it is a good reminder to be cautious with these meds. It is also a good time to stress smoking cessation with patients.

The guidelines discuss adverse outcomes in patients with diabetes and/or obesity. As primary care physicians, we need to be aware of those risks and be sure our patients are medically optimized before signing that pre-operative form.

A new feature of these guidelines is a discussion on social detriments to health. This is important for many diseases that we treat and we often don’t realize the impact they can have on a patient’s health and recovery. Even if we know a patient would benefit from physical therapy, it doesn’t help them if the patient has no way to get to the appointment. Some patients have copays for every physical therapy session and just can’t afford it. Knowing what the patient needs medically is not enough. We need to understand how they can access that care. Some patients have no one to help them after hip surgery and may avoid doing it for that reason. As primary care doctors, we should be helping our patients access the care they need.

We need to be able to say that a procedure needs to be delayed in the face of poorly controlled disease, such as diabetes. As the rates of osteoarthritis continue to rise, we need to understand that it is not an inevitable age-based occurrence in a patient’s life but rather an inflammatory disease that causes great pain and dysfunction. Utilizing these guidelines and working with our orthopedic colleagues can help patients decrease pain, improve functioning, and enjoy life again.
 

Dr. Girgis practices family medicine in South River, New Jersey, and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, New Jersey. She was paid by Pfizer as a consultant on Paxlovid, paid by GlaxoSmithKline as a consultant for the Shingrix vaccine, and is the editor in chief of Physician’s Weekly.

As primary care physicians, we are often the first ones patients see when they become infected with influenza. According to Centers for Disease Control and Prevention statistics, approximately 5%-20% of the US population will be infected with influenza every year. Additionally, more than 200,000 of these patients will be hospitalized because of complications related to influenza.

Earlier in September, the World Health Organization (WHO) issued its latest clinical practice guidelines for influenza for the 2024-2025 season. This is a 213-page document aimed at healthcare providers who treat patients infected with influenza. It includes treatment for those with severe and nonsevere influenza infections, those in both the outpatient and hospitalized setting, as well as medication prophylaxis for those exposed to the virus. Additionally, it defines risk estimates for those who are at risk of being hospitalized or dying. In contrast, previous updates focused on management of severe influenza or those at risk of severe influenza.

These guidelines cover recommendations regarding all the antiviral medications for treating influenza used around the world. For the purpose of this article, we will focus on those most commonly used in the United States.

A newer medication discussed was baloxavir. It is recommended to be used for patients with nonsevere influenza who are at high risk for progression to severe disease. The advice is to not use it for those with little risk of progression to severe disease. Oseltamivir is recommended for those with severe infection.

The guidelines recommend against using antibiotics for those who have a low likelihood of having a bacterial coinfection. As primary care doctors, we often prescribe medications to help with symptoms. These guidelines recommend against the use of corticosteroids and antibiotics but did advise that NSAIDs could be used for symptom relief.

One of the important parts of these guidelines is prevention in patients who have been exposed but are asymptomatic. They recommend baloxavir or oseltamivir but only for those patients who are at high risk of being hospitalized if they were to become infected. Any of the antivirals can be used for patients who are exposed to the novel influenza A, which is associated with a higher mortality rate. Caution when prescribing antivirals is recommended in immunocompromised patients because there is more drug resistance seen in these patients.

These updates also discuss the use of different influenza tests. In the outpatient setting, primary doctors don’t have time for test results that may take 2 days to come back. Only rapid tests make the sense in the primary care setting. Additionally, in the age of COVID, it is important to make an accurate diagnosis so we should be testing patients. There is resistance seen with the antivirals we prescribe for influenza so prescribing them empirically without a confirmed diagnosis of influenza may be doing more harm than good.

One gap in these recommendations is vaccination. This topic was not covered at all. It would be helpful to have a strategy in place to prevent infection in populations rather than focusing just on exposed individuals. A discussion of when and who and to vaccinate would be helpful. Research into the effectiveness of vaccines is key and more accurate development of a season’s influenza vaccine would be beneficial. Currently, there is much vaccine misinformation being spread around. Education and information regarding influenza vaccines, especially coming from WHO, is crucial.

Another failure of these recommendations is that the guidelines apply only to those who present within a few days of becoming symptomatic. As family doctors, we know many of our patients self-treat or consult Google. They often don’t come for medical care until they’ve been sick for a week or longer. There are no guidelines for these patients.

In general, these guidelines are comprehensive and do a great job discussing the current medications available. However, more is needed to increase vaccination rates. Patients need to know that if they may be sick with influenza, they need to seek medical care as soon as possible. We, as family doctors, need to do a better job of risk-stratifying our patients and prescribing prophylactic medication when suitable. Every infection we prevent aids in the health of our community and the global population at large.

Dr. Girgis practices family medicine in South River, New Jersey, and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, New Jersey. She has no relevant conflicts of interest.

As primary care physicians, we are often the first ones patients see when they become infected with influenza. According to Centers for Disease Control and Prevention statistics, approximately 5%-20% of the US population will be infected with influenza every year. Additionally, more than 200,000 of these patients will be hospitalized because of complications related to influenza.

Earlier in September, the World Health Organization (WHO) issued its latest clinical practice guidelines for influenza for the 2024-2025 season. This is a 213-page document aimed at healthcare providers who treat patients infected with influenza. It includes treatment for those with severe and nonsevere influenza infections, those in both the outpatient and hospitalized setting, as well as medication prophylaxis for those exposed to the virus. Additionally, it defines risk estimates for those who are at risk of being hospitalized or dying. In contrast, previous updates focused on management of severe influenza or those at risk of severe influenza.

These guidelines cover recommendations regarding all the antiviral medications for treating influenza used around the world. For the purpose of this article, we will focus on those most commonly used in the United States.

A newer medication discussed was baloxavir. It is recommended to be used for patients with nonsevere influenza who are at high risk for progression to severe disease. The advice is to not use it for those with little risk of progression to severe disease. Oseltamivir is recommended for those with severe infection.

The guidelines recommend against using antibiotics for those who have a low likelihood of having a bacterial coinfection. As primary care doctors, we often prescribe medications to help with symptoms. These guidelines recommend against the use of corticosteroids and antibiotics but did advise that NSAIDs could be used for symptom relief.

One of the important parts of these guidelines is prevention in patients who have been exposed but are asymptomatic. They recommend baloxavir or oseltamivir but only for those patients who are at high risk of being hospitalized if they were to become infected. Any of the antivirals can be used for patients who are exposed to the novel influenza A, which is associated with a higher mortality rate. Caution when prescribing antivirals is recommended in immunocompromised patients because there is more drug resistance seen in these patients.

These updates also discuss the use of different influenza tests. In the outpatient setting, primary doctors don’t have time for test results that may take 2 days to come back. Only rapid tests make the sense in the primary care setting. Additionally, in the age of COVID, it is important to make an accurate diagnosis so we should be testing patients. There is resistance seen with the antivirals we prescribe for influenza so prescribing them empirically without a confirmed diagnosis of influenza may be doing more harm than good.

One gap in these recommendations is vaccination. This topic was not covered at all. It would be helpful to have a strategy in place to prevent infection in populations rather than focusing just on exposed individuals. A discussion of when and who and to vaccinate would be helpful. Research into the effectiveness of vaccines is key and more accurate development of a season’s influenza vaccine would be beneficial. Currently, there is much vaccine misinformation being spread around. Education and information regarding influenza vaccines, especially coming from WHO, is crucial.

Another failure of these recommendations is that the guidelines apply only to those who present within a few days of becoming symptomatic. As family doctors, we know many of our patients self-treat or consult Google. They often don’t come for medical care until they’ve been sick for a week or longer. There are no guidelines for these patients.

In general, these guidelines are comprehensive and do a great job discussing the current medications available. However, more is needed to increase vaccination rates. Patients need to know that if they may be sick with influenza, they need to seek medical care as soon as possible. We, as family doctors, need to do a better job of risk-stratifying our patients and prescribing prophylactic medication when suitable. Every infection we prevent aids in the health of our community and the global population at large.

Dr. Girgis practices family medicine in South River, New Jersey, and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, New Jersey. She has no relevant conflicts of interest.

As primary care physicians, we are often the first ones patients see when they become infected with influenza. According to Centers for Disease Control and Prevention statistics, approximately 5%-20% of the US population will be infected with influenza every year. Additionally, more than 200,000 of these patients will be hospitalized because of complications related to influenza.

Earlier in September, the World Health Organization (WHO) issued its latest clinical practice guidelines for influenza for the 2024-2025 season. This is a 213-page document aimed at healthcare providers who treat patients infected with influenza. It includes treatment for those with severe and nonsevere influenza infections, those in both the outpatient and hospitalized setting, as well as medication prophylaxis for those exposed to the virus. Additionally, it defines risk estimates for those who are at risk of being hospitalized or dying. In contrast, previous updates focused on management of severe influenza or those at risk of severe influenza.

These guidelines cover recommendations regarding all the antiviral medications for treating influenza used around the world. For the purpose of this article, we will focus on those most commonly used in the United States.

A newer medication discussed was baloxavir. It is recommended to be used for patients with nonsevere influenza who are at high risk for progression to severe disease. The advice is to not use it for those with little risk of progression to severe disease. Oseltamivir is recommended for those with severe infection.

The guidelines recommend against using antibiotics for those who have a low likelihood of having a bacterial coinfection. As primary care doctors, we often prescribe medications to help with symptoms. These guidelines recommend against the use of corticosteroids and antibiotics but did advise that NSAIDs could be used for symptom relief.

One of the important parts of these guidelines is prevention in patients who have been exposed but are asymptomatic. They recommend baloxavir or oseltamivir but only for those patients who are at high risk of being hospitalized if they were to become infected. Any of the antivirals can be used for patients who are exposed to the novel influenza A, which is associated with a higher mortality rate. Caution when prescribing antivirals is recommended in immunocompromised patients because there is more drug resistance seen in these patients.

These updates also discuss the use of different influenza tests. In the outpatient setting, primary doctors don’t have time for test results that may take 2 days to come back. Only rapid tests make the sense in the primary care setting. Additionally, in the age of COVID, it is important to make an accurate diagnosis so we should be testing patients. There is resistance seen with the antivirals we prescribe for influenza so prescribing them empirically without a confirmed diagnosis of influenza may be doing more harm than good.

One gap in these recommendations is vaccination. This topic was not covered at all. It would be helpful to have a strategy in place to prevent infection in populations rather than focusing just on exposed individuals. A discussion of when and who and to vaccinate would be helpful. Research into the effectiveness of vaccines is key and more accurate development of a season’s influenza vaccine would be beneficial. Currently, there is much vaccine misinformation being spread around. Education and information regarding influenza vaccines, especially coming from WHO, is crucial.

Another failure of these recommendations is that the guidelines apply only to those who present within a few days of becoming symptomatic. As family doctors, we know many of our patients self-treat or consult Google. They often don’t come for medical care until they’ve been sick for a week or longer. There are no guidelines for these patients.

In general, these guidelines are comprehensive and do a great job discussing the current medications available. However, more is needed to increase vaccination rates. Patients need to know that if they may be sick with influenza, they need to seek medical care as soon as possible. We, as family doctors, need to do a better job of risk-stratifying our patients and prescribing prophylactic medication when suitable. Every infection we prevent aids in the health of our community and the global population at large.

Dr. Girgis practices family medicine in South River, New Jersey, and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, New Jersey. She has no relevant conflicts of interest.

Primary care physicians know the complexities of treating older patients, from increased complications from medications and procedures to comorbidities stemming from having multiple medical conditions. The Beers Criteria were established by the American Geriatrics Society as a guide for physicians about medications that may possess more risks than benefits in older patients, specifically those aged 65 years and older.

There are approximately 100 medications on the list. Criteria used to establish the list include medications to avoid over the age of 65 in an outpatient setting, medications to avoid in certain medical conditions, medications to avoid that may interact with other medications, medications to avoid with renal impairment, and medications to avoid where harmful side effects outweigh the possible benefits. The American Geriatrics Society updates the list as new published evidence becomes available.

The latest updates to the Beers Criteria include several medications commonly used in primary care. Regarding anticoagulation, warfarin should be avoided as initial therapy and apixaban should be used in patients with reduced renal function. These guidelines looked particularly at antithrombotic medications because of new evidence arising in nonvalvular atrial fibrillation and venous thromboembolism. In addition to the previous recommendations, the use of aspirin is no longer recommended in older adults.

The latest guidelines also make recommendations regarding certain diabetic medications as well as combinations to avoid. The Beers Criteria now place all sulfonylureas in the class to avoid, and not just the long-acting formulations as was recommended in the previous guidelines. If a sulfonylurea is necessary, use of a short-acting one is advised. Several other classes of medications were addressed and doctors practicing primary care medicine should be aware of these guidelines, especially as the population continues to age.

Overall, these guidelines are a great resource for treating patients aged 65 and older. It is important to keep in mind that they look at a whole population of patients and it is not patient specific. As primary care doctors, we know many of our patients don’t fit into the textbook box. While these guidelines consider the dangers of a certain medication, sometimes the benefits do outweigh the risks at the patient-specific level.

As doctors, we are trained to weigh the risks and benefits when prescribing any medication to our patients. These guidelines shouldn’t be approached as a do or don’t list but should be considered in the overall plan when prescribing for our patients. Sometimes, these medications can be used with careful observation by the prescribing physician. When they are utilized, we need to make the patient aware of specific side effects and what to watch out for. We need to make these decisions together with our patients and their caregivers.

For example, we all know how agonizing taking care of an older dementia patient can be, and sometimes there is nothing left to try except one of the medications on the list.

An additional practical point not considered in the guidelines is real-world use. Often, certain medications are not covered by a patient’s insurance company. The cost can be prohibitive to use the recommended agent. We are left in the middle to go off script with a medication that the patient may be able to access easily or keep pushing for the most appropriate medication for the patient. Unfortunately, in our current healthcare climate, prior authorizations can sometimes take weeks to obtain (or to be denied). For most of the conditions we treat in our older patients, it is not safe to leave them without any medication while we fight this prior authorizations war.

Our older patients often have multiple specialists as well. Each of these specialists may be prescribing different medications. It is imperative that we know all the medications a patient is taking so that we may look for potentially dangerous drug interactions. Many patients don’t remember the names of all their medications, nor do they realize that many classes of medications are “little white pills.” Asking them to bring their pill bottles to every visit can be a great help in searching out interactions.

That being said, the Beers Criteria do an excellent job reviewing the latest evidence and developing guidelines. As primary care physicians, we have never been busier and having someone do the research and set it forth so clearly is a great tool. We should be aware of the Beers Criteria and the medications and interactions listed there.

Dr. Girgis practices family medicine in South River, New Jersey, and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, New Jersey. She has no conflicts of interest.

Primary care physicians know the complexities of treating older patients, from increased complications from medications and procedures to comorbidities stemming from having multiple medical conditions. The Beers Criteria were established by the American Geriatrics Society as a guide for physicians about medications that may possess more risks than benefits in older patients, specifically those aged 65 years and older.

There are approximately 100 medications on the list. Criteria used to establish the list include medications to avoid over the age of 65 in an outpatient setting, medications to avoid in certain medical conditions, medications to avoid that may interact with other medications, medications to avoid with renal impairment, and medications to avoid where harmful side effects outweigh the possible benefits. The American Geriatrics Society updates the list as new published evidence becomes available.

The latest updates to the Beers Criteria include several medications commonly used in primary care. Regarding anticoagulation, warfarin should be avoided as initial therapy and apixaban should be used in patients with reduced renal function. These guidelines looked particularly at antithrombotic medications because of new evidence arising in nonvalvular atrial fibrillation and venous thromboembolism. In addition to the previous recommendations, the use of aspirin is no longer recommended in older adults.

The latest guidelines also make recommendations regarding certain diabetic medications as well as combinations to avoid. The Beers Criteria now place all sulfonylureas in the class to avoid, and not just the long-acting formulations as was recommended in the previous guidelines. If a sulfonylurea is necessary, use of a short-acting one is advised. Several other classes of medications were addressed and doctors practicing primary care medicine should be aware of these guidelines, especially as the population continues to age.

Overall, these guidelines are a great resource for treating patients aged 65 and older. It is important to keep in mind that they look at a whole population of patients and it is not patient specific. As primary care doctors, we know many of our patients don’t fit into the textbook box. While these guidelines consider the dangers of a certain medication, sometimes the benefits do outweigh the risks at the patient-specific level.

As doctors, we are trained to weigh the risks and benefits when prescribing any medication to our patients. These guidelines shouldn’t be approached as a do or don’t list but should be considered in the overall plan when prescribing for our patients. Sometimes, these medications can be used with careful observation by the prescribing physician. When they are utilized, we need to make the patient aware of specific side effects and what to watch out for. We need to make these decisions together with our patients and their caregivers.

For example, we all know how agonizing taking care of an older dementia patient can be, and sometimes there is nothing left to try except one of the medications on the list.

An additional practical point not considered in the guidelines is real-world use. Often, certain medications are not covered by a patient’s insurance company. The cost can be prohibitive to use the recommended agent. We are left in the middle to go off script with a medication that the patient may be able to access easily or keep pushing for the most appropriate medication for the patient. Unfortunately, in our current healthcare climate, prior authorizations can sometimes take weeks to obtain (or to be denied). For most of the conditions we treat in our older patients, it is not safe to leave them without any medication while we fight this prior authorizations war.

Our older patients often have multiple specialists as well. Each of these specialists may be prescribing different medications. It is imperative that we know all the medications a patient is taking so that we may look for potentially dangerous drug interactions. Many patients don’t remember the names of all their medications, nor do they realize that many classes of medications are “little white pills.” Asking them to bring their pill bottles to every visit can be a great help in searching out interactions.

That being said, the Beers Criteria do an excellent job reviewing the latest evidence and developing guidelines. As primary care physicians, we have never been busier and having someone do the research and set it forth so clearly is a great tool. We should be aware of the Beers Criteria and the medications and interactions listed there.

Dr. Girgis practices family medicine in South River, New Jersey, and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, New Jersey. She has no conflicts of interest.

Primary care physicians know the complexities of treating older patients, from increased complications from medications and procedures to comorbidities stemming from having multiple medical conditions. The Beers Criteria were established by the American Geriatrics Society as a guide for physicians about medications that may possess more risks than benefits in older patients, specifically those aged 65 years and older.

There are approximately 100 medications on the list. Criteria used to establish the list include medications to avoid over the age of 65 in an outpatient setting, medications to avoid in certain medical conditions, medications to avoid that may interact with other medications, medications to avoid with renal impairment, and medications to avoid where harmful side effects outweigh the possible benefits. The American Geriatrics Society updates the list as new published evidence becomes available.

The latest updates to the Beers Criteria include several medications commonly used in primary care. Regarding anticoagulation, warfarin should be avoided as initial therapy and apixaban should be used in patients with reduced renal function. These guidelines looked particularly at antithrombotic medications because of new evidence arising in nonvalvular atrial fibrillation and venous thromboembolism. In addition to the previous recommendations, the use of aspirin is no longer recommended in older adults.

The latest guidelines also make recommendations regarding certain diabetic medications as well as combinations to avoid. The Beers Criteria now place all sulfonylureas in the class to avoid, and not just the long-acting formulations as was recommended in the previous guidelines. If a sulfonylurea is necessary, use of a short-acting one is advised. Several other classes of medications were addressed and doctors practicing primary care medicine should be aware of these guidelines, especially as the population continues to age.

Overall, these guidelines are a great resource for treating patients aged 65 and older. It is important to keep in mind that they look at a whole population of patients and it is not patient specific. As primary care doctors, we know many of our patients don’t fit into the textbook box. While these guidelines consider the dangers of a certain medication, sometimes the benefits do outweigh the risks at the patient-specific level.

As doctors, we are trained to weigh the risks and benefits when prescribing any medication to our patients. These guidelines shouldn’t be approached as a do or don’t list but should be considered in the overall plan when prescribing for our patients. Sometimes, these medications can be used with careful observation by the prescribing physician. When they are utilized, we need to make the patient aware of specific side effects and what to watch out for. We need to make these decisions together with our patients and their caregivers.

For example, we all know how agonizing taking care of an older dementia patient can be, and sometimes there is nothing left to try except one of the medications on the list.

An additional practical point not considered in the guidelines is real-world use. Often, certain medications are not covered by a patient’s insurance company. The cost can be prohibitive to use the recommended agent. We are left in the middle to go off script with a medication that the patient may be able to access easily or keep pushing for the most appropriate medication for the patient. Unfortunately, in our current healthcare climate, prior authorizations can sometimes take weeks to obtain (or to be denied). For most of the conditions we treat in our older patients, it is not safe to leave them without any medication while we fight this prior authorizations war.

Our older patients often have multiple specialists as well. Each of these specialists may be prescribing different medications. It is imperative that we know all the medications a patient is taking so that we may look for potentially dangerous drug interactions. Many patients don’t remember the names of all their medications, nor do they realize that many classes of medications are “little white pills.” Asking them to bring their pill bottles to every visit can be a great help in searching out interactions.

That being said, the Beers Criteria do an excellent job reviewing the latest evidence and developing guidelines. As primary care physicians, we have never been busier and having someone do the research and set it forth so clearly is a great tool. We should be aware of the Beers Criteria and the medications and interactions listed there.

Dr. Girgis practices family medicine in South River, New Jersey, and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, New Jersey. She has no conflicts of interest.

On February 11, 2024, the American Academy of Ophthalmology (AAO) issued new guidelines regarding dry eye syndrome or keratoconjunctivitis sicca. According to the National Eye Institute, dry eye affects approximately 16 million Americans. Dry eye is a multifactorial disease with causes including excessive screen time and refractive surgery. While it may seem that dry eye is a nuisance disease, it can actually damage the cornea if not treated appropriately.

The guidelines state that dry eye can affect the quality of life as well as the outcomes of ocular surgeries such as cataract surgery. It is imperative that we discuss this potential complication before our patients undergo these procedures. As primary care physicians, we have seen that patients may not be well educated on their health conditions by other doctors. We may not be the one performing the surgery but it is likely the patient will seek our advice if any complication arises.

The guidelines say that clinical examination is the gold standard for diagnosing this disease. We need to be proficient at doing eye exams and refer to a specialist when appropriate. The treatment can likely be undertaken in the primary care office unless there are other symptoms such as loss of visual acuity. The guidelines suggest several diagnostic tests, such as the Schirmer test and tear osmolarity test, which may be outside the scope of the primary care setting. Often, clinical history will guide the diagnosis.

Treatments include several Food and Drug Administration–approved eye drops. We need to know what they are and when to prescribe them. We know they will not cure the disease but can keep it under control and improve the patient’s quality of life.

Dry eye may seem a trivial complaint in the sea of diseases we treat on a daily basis. However, it is not trivial to the patient. It can affect their vision and make their life miserable. We need to pay attention when our patients bring this to our attention. We are not just making them comfortable but protecting their corneas. This can be done in conjunction with routine ophthalmologic visits.

According to the authors of these guidelines, approximately 10% of patients with significantly dry eyes and mouth will have Sjögren’s syndrome. Autoimmune testing should be undertaken in these patients.

These guidelines also suggest a classification for dry eye including mild, moderate, and severe. Since the treatment varies depending on classification, we need to learn this classification system. They also stress follow-up visits. It is not enough just to diagnose the disease and start treatment, we need to see the patients back for follow-up.

Currently, most people work and play on electronic devices. Dry eye syndrome can make this more difficult and vice versa. While it is typically not a vision-threatening disease, it can be a life-altering one. Ocular symptoms are something we see frequently in our practices, from allergic conjunctivitis to glaucoma. Often, the patient starts seeking help in our office.

Yes, our patients may have more life-threatening diseases. Our job is not just to save lives but to help our patients live healthy lives. If their lives are being affected by any disease, we must step in and do something. Dry eye is not just an inconvenience but something that causes great suffering. Eventually we may end up referring the patient to the ophthalmologist, but if we can do something to ease their discomfort while they are waiting, we would be changing their lives. We must educate ourselves on this disease and appropriate treatments to be prescribed depending on the classification of disease.

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, NJ. She has no conflicts of interest.

On February 11, 2024, the American Academy of Ophthalmology (AAO) issued new guidelines regarding dry eye syndrome or keratoconjunctivitis sicca. According to the National Eye Institute, dry eye affects approximately 16 million Americans. Dry eye is a multifactorial disease with causes including excessive screen time and refractive surgery. While it may seem that dry eye is a nuisance disease, it can actually damage the cornea if not treated appropriately.

The guidelines state that dry eye can affect the quality of life as well as the outcomes of ocular surgeries such as cataract surgery. It is imperative that we discuss this potential complication before our patients undergo these procedures. As primary care physicians, we have seen that patients may not be well educated on their health conditions by other doctors. We may not be the one performing the surgery but it is likely the patient will seek our advice if any complication arises.

The guidelines say that clinical examination is the gold standard for diagnosing this disease. We need to be proficient at doing eye exams and refer to a specialist when appropriate. The treatment can likely be undertaken in the primary care office unless there are other symptoms such as loss of visual acuity. The guidelines suggest several diagnostic tests, such as the Schirmer test and tear osmolarity test, which may be outside the scope of the primary care setting. Often, clinical history will guide the diagnosis.

Treatments include several Food and Drug Administration–approved eye drops. We need to know what they are and when to prescribe them. We know they will not cure the disease but can keep it under control and improve the patient’s quality of life.

Dry eye may seem a trivial complaint in the sea of diseases we treat on a daily basis. However, it is not trivial to the patient. It can affect their vision and make their life miserable. We need to pay attention when our patients bring this to our attention. We are not just making them comfortable but protecting their corneas. This can be done in conjunction with routine ophthalmologic visits.

According to the authors of these guidelines, approximately 10% of patients with significantly dry eyes and mouth will have Sjögren’s syndrome. Autoimmune testing should be undertaken in these patients.

These guidelines also suggest a classification for dry eye including mild, moderate, and severe. Since the treatment varies depending on classification, we need to learn this classification system. They also stress follow-up visits. It is not enough just to diagnose the disease and start treatment, we need to see the patients back for follow-up.

Currently, most people work and play on electronic devices. Dry eye syndrome can make this more difficult and vice versa. While it is typically not a vision-threatening disease, it can be a life-altering one. Ocular symptoms are something we see frequently in our practices, from allergic conjunctivitis to glaucoma. Often, the patient starts seeking help in our office.

Yes, our patients may have more life-threatening diseases. Our job is not just to save lives but to help our patients live healthy lives. If their lives are being affected by any disease, we must step in and do something. Dry eye is not just an inconvenience but something that causes great suffering. Eventually we may end up referring the patient to the ophthalmologist, but if we can do something to ease their discomfort while they are waiting, we would be changing their lives. We must educate ourselves on this disease and appropriate treatments to be prescribed depending on the classification of disease.

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, NJ. She has no conflicts of interest.

On February 11, 2024, the American Academy of Ophthalmology (AAO) issued new guidelines regarding dry eye syndrome or keratoconjunctivitis sicca. According to the National Eye Institute, dry eye affects approximately 16 million Americans. Dry eye is a multifactorial disease with causes including excessive screen time and refractive surgery. While it may seem that dry eye is a nuisance disease, it can actually damage the cornea if not treated appropriately.

The guidelines state that dry eye can affect the quality of life as well as the outcomes of ocular surgeries such as cataract surgery. It is imperative that we discuss this potential complication before our patients undergo these procedures. As primary care physicians, we have seen that patients may not be well educated on their health conditions by other doctors. We may not be the one performing the surgery but it is likely the patient will seek our advice if any complication arises.

The guidelines say that clinical examination is the gold standard for diagnosing this disease. We need to be proficient at doing eye exams and refer to a specialist when appropriate. The treatment can likely be undertaken in the primary care office unless there are other symptoms such as loss of visual acuity. The guidelines suggest several diagnostic tests, such as the Schirmer test and tear osmolarity test, which may be outside the scope of the primary care setting. Often, clinical history will guide the diagnosis.

Treatments include several Food and Drug Administration–approved eye drops. We need to know what they are and when to prescribe them. We know they will not cure the disease but can keep it under control and improve the patient’s quality of life.

Dry eye may seem a trivial complaint in the sea of diseases we treat on a daily basis. However, it is not trivial to the patient. It can affect their vision and make their life miserable. We need to pay attention when our patients bring this to our attention. We are not just making them comfortable but protecting their corneas. This can be done in conjunction with routine ophthalmologic visits.

According to the authors of these guidelines, approximately 10% of patients with significantly dry eyes and mouth will have Sjögren’s syndrome. Autoimmune testing should be undertaken in these patients.

These guidelines also suggest a classification for dry eye including mild, moderate, and severe. Since the treatment varies depending on classification, we need to learn this classification system. They also stress follow-up visits. It is not enough just to diagnose the disease and start treatment, we need to see the patients back for follow-up.

Currently, most people work and play on electronic devices. Dry eye syndrome can make this more difficult and vice versa. While it is typically not a vision-threatening disease, it can be a life-altering one. Ocular symptoms are something we see frequently in our practices, from allergic conjunctivitis to glaucoma. Often, the patient starts seeking help in our office.

Yes, our patients may have more life-threatening diseases. Our job is not just to save lives but to help our patients live healthy lives. If their lives are being affected by any disease, we must step in and do something. Dry eye is not just an inconvenience but something that causes great suffering. Eventually we may end up referring the patient to the ophthalmologist, but if we can do something to ease their discomfort while they are waiting, we would be changing their lives. We must educate ourselves on this disease and appropriate treatments to be prescribed depending on the classification of disease.

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, NJ. She has no conflicts of interest.

In January 2024, the American Academy of Dermatology released updated clinical guidelines for the treatment of acne. These guidelines include 18 evidence-based recommendations.

As primary care physicians, we commonly encounter acne vulgaris in our practices. While it may not be a life-threatening condition, it deeply affects the quality of life for many who suffer from it. It can be accompanied by stigmatization and bullying and can affect a person’s self-esteem; it can lead to suicidal ideation. It is important to treat it and know when to refer to a dermatologist.

According to the AAD, acne is the most common skin condition, affecting 50 million Americans annually. It can occur at any stage in life, often starting during puberty. It is so common that at least 85% of people between the ages of 12 and 24 experience at least mild acne.

The guidelines stress using multimodal therapies combining multiple mechanisms of action. For example, they show strong evidence for using topical retinoids with topical benzoyl peroxide or topical retinoids with topical antibiotics. They recommend against using oral antibiotics, except in severe cases, to prevent antibiotic resistance. The strongest evidence regarding antibiotics shows doxycycline or minocycline to be the most effective for treating acne and these can be combined with topical medications.

These guidelines also include isotretinoin to be used for severe acne patients, who are defined as “patients with psychosocial burden or scarring.” They recommend monitoring liver function and lipids as good practice and mandatory pregnancy prevention. These guidelines find no conclusive evidence for physical modalities such as lesion extraction, chemical peels, use of laser and light-based devices, microneedling, use of radiofrequency devices, and photodynamic therapy.

A conditional recommendation is given for the use of combined oral contraception pills and spironolactone. The AAD advises considering the risks of these agents along with other conditions present that they may be useful for.

In primary care, we see many complicated patients and often acne is not considered a serious condition. However, it can be as life-altering to the patient as other chronic diseases such as rheumatoid arthritis. We need to know the appropriate management of acne and start following the evidence-based guidelines. Acne needs follow-up as close as for other chronic diseases. We need to be able to assess the severity of disease and the effectiveness of treatments we have prescribed.

Some patients may be embarrassed to start the discussion about acne. If the patient doesn’t initiate the discussion, we should in an empathetic way. Acne is one of those diseases that doesn’t need any diagnostic tests to discover as it is readily apparent right in front of us.

Some patients may not be bothered by it, but for others, it may be ruining their lives, and they just don’t feel comfortable starting the conversation. Offering them a treatment will alleviate their disease but may also change their lives for the better.

Acne is also one of those conditions that has a host of misinformation and myths surrounding it. These myths range from dietary recommendations to hygiene and many others. As physicians, we need to educate ourselves about these myths and misconceptions. Patients will have questions regarding them and we need to be able to give them answers to their questions. We also shouldn’t give out misinformation ourselves. The evidence around acne treatment is readily available.

Given the availability of multiple acne therapies, shared-decision making is important. We need to discuss options with the patients and devise the best treatment regimen for them. If our therapies are not getting the results we would like, we need to consider referring the patient to a dermatologist.

We need to remember that acne is not just a cosmetic disease. It affects the lives of those suffering from it and we need to address it like any other chronic disease.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J.

In January 2024, the American Academy of Dermatology released updated clinical guidelines for the treatment of acne. These guidelines include 18 evidence-based recommendations.

As primary care physicians, we commonly encounter acne vulgaris in our practices. While it may not be a life-threatening condition, it deeply affects the quality of life for many who suffer from it. It can be accompanied by stigmatization and bullying and can affect a person’s self-esteem; it can lead to suicidal ideation. It is important to treat it and know when to refer to a dermatologist.

According to the AAD, acne is the most common skin condition, affecting 50 million Americans annually. It can occur at any stage in life, often starting during puberty. It is so common that at least 85% of people between the ages of 12 and 24 experience at least mild acne.

The guidelines stress using multimodal therapies combining multiple mechanisms of action. For example, they show strong evidence for using topical retinoids with topical benzoyl peroxide or topical retinoids with topical antibiotics. They recommend against using oral antibiotics, except in severe cases, to prevent antibiotic resistance. The strongest evidence regarding antibiotics shows doxycycline or minocycline to be the most effective for treating acne and these can be combined with topical medications.

These guidelines also include isotretinoin to be used for severe acne patients, who are defined as “patients with psychosocial burden or scarring.” They recommend monitoring liver function and lipids as good practice and mandatory pregnancy prevention. These guidelines find no conclusive evidence for physical modalities such as lesion extraction, chemical peels, use of laser and light-based devices, microneedling, use of radiofrequency devices, and photodynamic therapy.

A conditional recommendation is given for the use of combined oral contraception pills and spironolactone. The AAD advises considering the risks of these agents along with other conditions present that they may be useful for.

In primary care, we see many complicated patients and often acne is not considered a serious condition. However, it can be as life-altering to the patient as other chronic diseases such as rheumatoid arthritis. We need to know the appropriate management of acne and start following the evidence-based guidelines. Acne needs follow-up as close as for other chronic diseases. We need to be able to assess the severity of disease and the effectiveness of treatments we have prescribed.

Some patients may be embarrassed to start the discussion about acne. If the patient doesn’t initiate the discussion, we should in an empathetic way. Acne is one of those diseases that doesn’t need any diagnostic tests to discover as it is readily apparent right in front of us.

Some patients may not be bothered by it, but for others, it may be ruining their lives, and they just don’t feel comfortable starting the conversation. Offering them a treatment will alleviate their disease but may also change their lives for the better.

Acne is also one of those conditions that has a host of misinformation and myths surrounding it. These myths range from dietary recommendations to hygiene and many others. As physicians, we need to educate ourselves about these myths and misconceptions. Patients will have questions regarding them and we need to be able to give them answers to their questions. We also shouldn’t give out misinformation ourselves. The evidence around acne treatment is readily available.

Given the availability of multiple acne therapies, shared-decision making is important. We need to discuss options with the patients and devise the best treatment regimen for them. If our therapies are not getting the results we would like, we need to consider referring the patient to a dermatologist.

We need to remember that acne is not just a cosmetic disease. It affects the lives of those suffering from it and we need to address it like any other chronic disease.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J.

In January 2024, the American Academy of Dermatology released updated clinical guidelines for the treatment of acne. These guidelines include 18 evidence-based recommendations.

As primary care physicians, we commonly encounter acne vulgaris in our practices. While it may not be a life-threatening condition, it deeply affects the quality of life for many who suffer from it. It can be accompanied by stigmatization and bullying and can affect a person’s self-esteem; it can lead to suicidal ideation. It is important to treat it and know when to refer to a dermatologist.

According to the AAD, acne is the most common skin condition, affecting 50 million Americans annually. It can occur at any stage in life, often starting during puberty. It is so common that at least 85% of people between the ages of 12 and 24 experience at least mild acne.

The guidelines stress using multimodal therapies combining multiple mechanisms of action. For example, they show strong evidence for using topical retinoids with topical benzoyl peroxide or topical retinoids with topical antibiotics. They recommend against using oral antibiotics, except in severe cases, to prevent antibiotic resistance. The strongest evidence regarding antibiotics shows doxycycline or minocycline to be the most effective for treating acne and these can be combined with topical medications.

These guidelines also include isotretinoin to be used for severe acne patients, who are defined as “patients with psychosocial burden or scarring.” They recommend monitoring liver function and lipids as good practice and mandatory pregnancy prevention. These guidelines find no conclusive evidence for physical modalities such as lesion extraction, chemical peels, use of laser and light-based devices, microneedling, use of radiofrequency devices, and photodynamic therapy.

A conditional recommendation is given for the use of combined oral contraception pills and spironolactone. The AAD advises considering the risks of these agents along with other conditions present that they may be useful for.

In primary care, we see many complicated patients and often acne is not considered a serious condition. However, it can be as life-altering to the patient as other chronic diseases such as rheumatoid arthritis. We need to know the appropriate management of acne and start following the evidence-based guidelines. Acne needs follow-up as close as for other chronic diseases. We need to be able to assess the severity of disease and the effectiveness of treatments we have prescribed.

Some patients may be embarrassed to start the discussion about acne. If the patient doesn’t initiate the discussion, we should in an empathetic way. Acne is one of those diseases that doesn’t need any diagnostic tests to discover as it is readily apparent right in front of us.

Some patients may not be bothered by it, but for others, it may be ruining their lives, and they just don’t feel comfortable starting the conversation. Offering them a treatment will alleviate their disease but may also change their lives for the better.

Acne is also one of those conditions that has a host of misinformation and myths surrounding it. These myths range from dietary recommendations to hygiene and many others. As physicians, we need to educate ourselves about these myths and misconceptions. Patients will have questions regarding them and we need to be able to give them answers to their questions. We also shouldn’t give out misinformation ourselves. The evidence around acne treatment is readily available.

Given the availability of multiple acne therapies, shared-decision making is important. We need to discuss options with the patients and devise the best treatment regimen for them. If our therapies are not getting the results we would like, we need to consider referring the patient to a dermatologist.

We need to remember that acne is not just a cosmetic disease. It affects the lives of those suffering from it and we need to address it like any other chronic disease.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J.

The idea of the use of probiotics has a history going back more than a century when Russian scientist, Elie Metchnikoff, theorized that lactic acid bacteria may offer health benefits as well as promote longevity. In the early 1900s, intestinal disorders were frequently treated with nonpathogenic bacteria to replace gut microbes.

Today, the market is flooded with products from foods to prescription medications containing probiotics that extol their health benefits. It has been estimated that the global market for probiotics is more than $32 billion dollars annually and is expected to increase 8% per year.

As family doctors, patients come to us with many questions about the use of probiotics. Look online or on store shelves — there are so many types, doses, and brands of probiotics it is hard to decipher which are worth using. We older doctors never received much education about them.

Earlier this year, the World Gastroenterology Organization (WGO) developed recommendations around the use of probiotics and defined them as “live microbes that have been shown in controlled human studies to impart a health benefit.” Their recommendation is to use the strains that have been shown to be beneficial for the condition they claim to help and have been shown to do so in controlled studies. The dosage advised should be that shown to be useful in studies.

While this is an easy statement to make, it is much less so in clinical practice. The guidelines do a good job breaking down the conditions they help and the strains that have shown to be beneficial for specific conditions.

There have been claims that probiotics have been shown to be beneficial in colorectal cancer. While there have been some studies to show that they can improve markers associated with colorectal cancer, there are no data that probiotics actually do much in terms of prevention. Eating a healthy diet is more helpful here.

One area where probiotics have been shown to be beneficial is in the prevention of antibiotic-associated diarrhea. This makes sense since we know that antibiotics can kill the “good bacteria” lining the gut wall and probiotics work to replace them. Other conditions where these agents have been shown to be beneficial include radiation-induced diarrhea, acute diarrhea, irritable bowel syndrome, and colic in breast-fed infants.

The guideline contains good evidence of where and which types of probiotics are useful and it is good to look at the charts in the paper to see the specific strains recommended. It also contains an extensive reference section, and as primary care physicians, it is imperative that we educate ourselves on these agents.

While probiotics are typically sold as supplements, we should not dismiss them summarily. It is easy to do that when supplemental products are marketed and sold unethically with no clinical evidence of benefit. We need to remember that just because something is a supplement doesn’t necessarily mean that it was not studied.

Family physicians need to be able to educate their patients and answer their questions. When we don’t have the answers, we need to find them. Any time our patient doesn’t get good information from us, they will probably go to the Internet and get bad advice from someone else.

There is much ongoing research about the gut microbiome and the bacteria that can be found in the gut. Researchers are looking into the “gut-brain” axis but there is not much good evidence of this link yet. There is no evidence that probiotics can cure Alzheimer’s disease or Parkinsonism. The future may reveal different stories, but for now, we need to follow the evidence we have available.

There are many outlandish claims about what the gut microbiome is responsible for and can do for health. It is easy to have a knee-jerk reaction when anyone brings it up in conversation. We need to arm ourselves with the evidence. We are stewards of the health and safety of our patients.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. She was paid by Pfizer as a consultant on Paxlovid and is the editor in chief of Physician’s Weekly.

The idea of the use of probiotics has a history going back more than a century when Russian scientist, Elie Metchnikoff, theorized that lactic acid bacteria may offer health benefits as well as promote longevity. In the early 1900s, intestinal disorders were frequently treated with nonpathogenic bacteria to replace gut microbes.

Today, the market is flooded with products from foods to prescription medications containing probiotics that extol their health benefits. It has been estimated that the global market for probiotics is more than $32 billion dollars annually and is expected to increase 8% per year.

As family doctors, patients come to us with many questions about the use of probiotics. Look online or on store shelves — there are so many types, doses, and brands of probiotics it is hard to decipher which are worth using. We older doctors never received much education about them.

Earlier this year, the World Gastroenterology Organization (WGO) developed recommendations around the use of probiotics and defined them as “live microbes that have been shown in controlled human studies to impart a health benefit.” Their recommendation is to use the strains that have been shown to be beneficial for the condition they claim to help and have been shown to do so in controlled studies. The dosage advised should be that shown to be useful in studies.

While this is an easy statement to make, it is much less so in clinical practice. The guidelines do a good job breaking down the conditions they help and the strains that have shown to be beneficial for specific conditions.

There have been claims that probiotics have been shown to be beneficial in colorectal cancer. While there have been some studies to show that they can improve markers associated with colorectal cancer, there are no data that probiotics actually do much in terms of prevention. Eating a healthy diet is more helpful here.

One area where probiotics have been shown to be beneficial is in the prevention of antibiotic-associated diarrhea. This makes sense since we know that antibiotics can kill the “good bacteria” lining the gut wall and probiotics work to replace them. Other conditions where these agents have been shown to be beneficial include radiation-induced diarrhea, acute diarrhea, irritable bowel syndrome, and colic in breast-fed infants.

The guideline contains good evidence of where and which types of probiotics are useful and it is good to look at the charts in the paper to see the specific strains recommended. It also contains an extensive reference section, and as primary care physicians, it is imperative that we educate ourselves on these agents.

While probiotics are typically sold as supplements, we should not dismiss them summarily. It is easy to do that when supplemental products are marketed and sold unethically with no clinical evidence of benefit. We need to remember that just because something is a supplement doesn’t necessarily mean that it was not studied.

Family physicians need to be able to educate their patients and answer their questions. When we don’t have the answers, we need to find them. Any time our patient doesn’t get good information from us, they will probably go to the Internet and get bad advice from someone else.

There is much ongoing research about the gut microbiome and the bacteria that can be found in the gut. Researchers are looking into the “gut-brain” axis but there is not much good evidence of this link yet. There is no evidence that probiotics can cure Alzheimer’s disease or Parkinsonism. The future may reveal different stories, but for now, we need to follow the evidence we have available.

There are many outlandish claims about what the gut microbiome is responsible for and can do for health. It is easy to have a knee-jerk reaction when anyone brings it up in conversation. We need to arm ourselves with the evidence. We are stewards of the health and safety of our patients.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. She was paid by Pfizer as a consultant on Paxlovid and is the editor in chief of Physician’s Weekly.

The idea of the use of probiotics has a history going back more than a century when Russian scientist, Elie Metchnikoff, theorized that lactic acid bacteria may offer health benefits as well as promote longevity. In the early 1900s, intestinal disorders were frequently treated with nonpathogenic bacteria to replace gut microbes.

Today, the market is flooded with products from foods to prescription medications containing probiotics that extol their health benefits. It has been estimated that the global market for probiotics is more than $32 billion dollars annually and is expected to increase 8% per year.

As family doctors, patients come to us with many questions about the use of probiotics. Look online or on store shelves — there are so many types, doses, and brands of probiotics it is hard to decipher which are worth using. We older doctors never received much education about them.

Earlier this year, the World Gastroenterology Organization (WGO) developed recommendations around the use of probiotics and defined them as “live microbes that have been shown in controlled human studies to impart a health benefit.” Their recommendation is to use the strains that have been shown to be beneficial for the condition they claim to help and have been shown to do so in controlled studies. The dosage advised should be that shown to be useful in studies.

While this is an easy statement to make, it is much less so in clinical practice. The guidelines do a good job breaking down the conditions they help and the strains that have shown to be beneficial for specific conditions.

There have been claims that probiotics have been shown to be beneficial in colorectal cancer. While there have been some studies to show that they can improve markers associated with colorectal cancer, there are no data that probiotics actually do much in terms of prevention. Eating a healthy diet is more helpful here.

One area where probiotics have been shown to be beneficial is in the prevention of antibiotic-associated diarrhea. This makes sense since we know that antibiotics can kill the “good bacteria” lining the gut wall and probiotics work to replace them. Other conditions where these agents have been shown to be beneficial include radiation-induced diarrhea, acute diarrhea, irritable bowel syndrome, and colic in breast-fed infants.

The guideline contains good evidence of where and which types of probiotics are useful and it is good to look at the charts in the paper to see the specific strains recommended. It also contains an extensive reference section, and as primary care physicians, it is imperative that we educate ourselves on these agents.

While probiotics are typically sold as supplements, we should not dismiss them summarily. It is easy to do that when supplemental products are marketed and sold unethically with no clinical evidence of benefit. We need to remember that just because something is a supplement doesn’t necessarily mean that it was not studied.

Family physicians need to be able to educate their patients and answer their questions. When we don’t have the answers, we need to find them. Any time our patient doesn’t get good information from us, they will probably go to the Internet and get bad advice from someone else.

There is much ongoing research about the gut microbiome and the bacteria that can be found in the gut. Researchers are looking into the “gut-brain” axis but there is not much good evidence of this link yet. There is no evidence that probiotics can cure Alzheimer’s disease or Parkinsonism. The future may reveal different stories, but for now, we need to follow the evidence we have available.

There are many outlandish claims about what the gut microbiome is responsible for and can do for health. It is easy to have a knee-jerk reaction when anyone brings it up in conversation. We need to arm ourselves with the evidence. We are stewards of the health and safety of our patients.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. She was paid by Pfizer as a consultant on Paxlovid and is the editor in chief of Physician’s Weekly.

Patients often come to us with questions about vitamin and mineral supplements. Sometimes they come to us with bags full of the things they are taking. The Internet is full of the wonders these nutritional supplements can do, from turmeric curing cancer to vitamin D curing COVID. It is hard to keep up with medicine itself without learning a whole new field of nutritional supplements.

However, for cardiovascular disease (CVD) and cancer prevention, the answer is pretty easy according to USPSTF (United States Preventative Services Task Force) guidelines. They evaluated 17,459 unique citations as well as 379 full-text articles that included randomized clinical trials and observational cohort studies. The conclusions of their research showed that there was little to no benefit in taking vitamin or mineral supplements to prevent CVD, cancer, or death. In fact, beta-carotene supplementation was associated with increased risk of lung cancer and other adverse outcomes in patients at increased risk of lung cancer.

Although they are often marketed like drugs, nutritional supplements are regulated as foods, with less stringent standards.* Our current medical culture pushes us to practice evidence-based medicine. Without evidence, we simply cannot counsel patients about supplements because there is little evidence to support their use.

Additionally, many patients assume that they are safe. While this may be true for many of them, some of them can be harmful in several ways. They can interact with medications the patient may be taking for medical conditions. Some of them have been shown to cause liver and other organ damage. When they are used to replace traditional medicine, they can also lead to harm by delaying appropriate medical care. For example, a patient who believes a supplement can treat cancer when it does nothing is delaying care that might save their life. By the time they realize it is not working, the cancer may have advanced too far to be treatable.

While there may be a few studies that do show some efficacy for vitamins and minerals in certain diseases, these guidelines are looking only at use in terms of preventing cancer and CVD. As primary care physicians, we all know the screening guidelines for cancer prevention. We are better off recommending screening mammograms and colon cancer screening tests. And we all know the risk factors for CVD and how to mitigate these risks.

What can we do when patients come to us with false claims regarding supplements?

• Hear what they are saying. They don’t know who to trust. We will never become their trusted source of medical information if we don’t listen to their concerns.
• Answer their questions, no matter how ridiculous they may seem to us. Many people who sell supplements sound convincing. That is how they sell their products. Our advice may seem just as ridiculous to them. We need to explain the facts clearly and be sure the patient understands.
• Give the patient resources. Know what websites to direct them to so that they can get accurate information.
• Know what’s out there. I was once surprised when a patient told me she was going to try turmeric as a treatment for uterine cancer. We cannot combat misinformation when we don’t know what’s being said.
• Become a voice for medical information. There is so much misinformation being spread. We need more doctors to speak up about the right medical information.

Currently, patients often look for medical information online. We do them a disservice when we brush aside their questions regarding supplements, no matter how trivial they seem. We need to take a firm stand and tell them the evidence regarding these supplements: They are neither FDA approved nor studied for safety and efficacy. Anyone can sell a supplement and make any claim regarding it that they want. It is much better to eat a healthy, balanced diet to get the vitamins and minerals that you need. Not only do we need to show them the evidence, we need to convince them that it is true.

*Correction, 12/4: An earlier version of this article misstated the regulatory requirements for nutritional supplements.

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. She was paid by Pfizer as a consultant on Paxlovid and is the editor in chief of Physician’s Weekly.

Patients often come to us with questions about vitamin and mineral supplements. Sometimes they come to us with bags full of the things they are taking. The Internet is full of the wonders these nutritional supplements can do, from turmeric curing cancer to vitamin D curing COVID. It is hard to keep up with medicine itself without learning a whole new field of nutritional supplements.

However, for cardiovascular disease (CVD) and cancer prevention, the answer is pretty easy according to USPSTF (United States Preventative Services Task Force) guidelines. They evaluated 17,459 unique citations as well as 379 full-text articles that included randomized clinical trials and observational cohort studies. The conclusions of their research showed that there was little to no benefit in taking vitamin or mineral supplements to prevent CVD, cancer, or death. In fact, beta-carotene supplementation was associated with increased risk of lung cancer and other adverse outcomes in patients at increased risk of lung cancer.

Although they are often marketed like drugs, nutritional supplements are regulated as foods, with less stringent standards.* Our current medical culture pushes us to practice evidence-based medicine. Without evidence, we simply cannot counsel patients about supplements because there is little evidence to support their use.

Additionally, many patients assume that they are safe. While this may be true for many of them, some of them can be harmful in several ways. They can interact with medications the patient may be taking for medical conditions. Some of them have been shown to cause liver and other organ damage. When they are used to replace traditional medicine, they can also lead to harm by delaying appropriate medical care. For example, a patient who believes a supplement can treat cancer when it does nothing is delaying care that might save their life. By the time they realize it is not working, the cancer may have advanced too far to be treatable.

While there may be a few studies that do show some efficacy for vitamins and minerals in certain diseases, these guidelines are looking only at use in terms of preventing cancer and CVD. As primary care physicians, we all know the screening guidelines for cancer prevention. We are better off recommending screening mammograms and colon cancer screening tests. And we all know the risk factors for CVD and how to mitigate these risks.

What can we do when patients come to us with false claims regarding supplements?

• Hear what they are saying. They don’t know who to trust. We will never become their trusted source of medical information if we don’t listen to their concerns.
• Answer their questions, no matter how ridiculous they may seem to us. Many people who sell supplements sound convincing. That is how they sell their products. Our advice may seem just as ridiculous to them. We need to explain the facts clearly and be sure the patient understands.
• Give the patient resources. Know what websites to direct them to so that they can get accurate information.
• Know what’s out there. I was once surprised when a patient told me she was going to try turmeric as a treatment for uterine cancer. We cannot combat misinformation when we don’t know what’s being said.
• Become a voice for medical information. There is so much misinformation being spread. We need more doctors to speak up about the right medical information.

Currently, patients often look for medical information online. We do them a disservice when we brush aside their questions regarding supplements, no matter how trivial they seem. We need to take a firm stand and tell them the evidence regarding these supplements: They are neither FDA approved nor studied for safety and efficacy. Anyone can sell a supplement and make any claim regarding it that they want. It is much better to eat a healthy, balanced diet to get the vitamins and minerals that you need. Not only do we need to show them the evidence, we need to convince them that it is true.

*Correction, 12/4: An earlier version of this article misstated the regulatory requirements for nutritional supplements.

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. She was paid by Pfizer as a consultant on Paxlovid and is the editor in chief of Physician’s Weekly.

Patients often come to us with questions about vitamin and mineral supplements. Sometimes they come to us with bags full of the things they are taking. The Internet is full of the wonders these nutritional supplements can do, from turmeric curing cancer to vitamin D curing COVID. It is hard to keep up with medicine itself without learning a whole new field of nutritional supplements.

However, for cardiovascular disease (CVD) and cancer prevention, the answer is pretty easy according to USPSTF (United States Preventative Services Task Force) guidelines. They evaluated 17,459 unique citations as well as 379 full-text articles that included randomized clinical trials and observational cohort studies. The conclusions of their research showed that there was little to no benefit in taking vitamin or mineral supplements to prevent CVD, cancer, or death. In fact, beta-carotene supplementation was associated with increased risk of lung cancer and other adverse outcomes in patients at increased risk of lung cancer.

Although they are often marketed like drugs, nutritional supplements are regulated as foods, with less stringent standards.* Our current medical culture pushes us to practice evidence-based medicine. Without evidence, we simply cannot counsel patients about supplements because there is little evidence to support their use.

Additionally, many patients assume that they are safe. While this may be true for many of them, some of them can be harmful in several ways. They can interact with medications the patient may be taking for medical conditions. Some of them have been shown to cause liver and other organ damage. When they are used to replace traditional medicine, they can also lead to harm by delaying appropriate medical care. For example, a patient who believes a supplement can treat cancer when it does nothing is delaying care that might save their life. By the time they realize it is not working, the cancer may have advanced too far to be treatable.

While there may be a few studies that do show some efficacy for vitamins and minerals in certain diseases, these guidelines are looking only at use in terms of preventing cancer and CVD. As primary care physicians, we all know the screening guidelines for cancer prevention. We are better off recommending screening mammograms and colon cancer screening tests. And we all know the risk factors for CVD and how to mitigate these risks.

What can we do when patients come to us with false claims regarding supplements?

• Hear what they are saying. They don’t know who to trust. We will never become their trusted source of medical information if we don’t listen to their concerns.
• Answer their questions, no matter how ridiculous they may seem to us. Many people who sell supplements sound convincing. That is how they sell their products. Our advice may seem just as ridiculous to them. We need to explain the facts clearly and be sure the patient understands.
• Give the patient resources. Know what websites to direct them to so that they can get accurate information.
• Know what’s out there. I was once surprised when a patient told me she was going to try turmeric as a treatment for uterine cancer. We cannot combat misinformation when we don’t know what’s being said.
• Become a voice for medical information. There is so much misinformation being spread. We need more doctors to speak up about the right medical information.

Currently, patients often look for medical information online. We do them a disservice when we brush aside their questions regarding supplements, no matter how trivial they seem. We need to take a firm stand and tell them the evidence regarding these supplements: They are neither FDA approved nor studied for safety and efficacy. Anyone can sell a supplement and make any claim regarding it that they want. It is much better to eat a healthy, balanced diet to get the vitamins and minerals that you need. Not only do we need to show them the evidence, we need to convince them that it is true.

*Correction, 12/4: An earlier version of this article misstated the regulatory requirements for nutritional supplements.

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. She was paid by Pfizer as a consultant on Paxlovid and is the editor in chief of Physician’s Weekly.

Obesity is a major factor affecting the health of many Americans. It is estimated by the Centers for Disease Control and Prevention that 41% of adults and 19.7% of children in our country now meet the criteria for being obese. Obesity costs the United States approximately $147 billion annually in health care costs. While these numbers are staggering, they continue to rise.

The recent craze over medications such as Ozempic, Wegovy, and Mounjaro shows how eager people are to lose weight. Yet, many of them face bias, not just in their daily lives, but from health care professionals who should do better. No one should feel stigmatized when they come for medical help. This just drives away patients who need us and who may then suffer more severe consequences of obesity-related illnesses.

Earlier this year, the American Association of Clinical Endocrinology issued a consensus statement on the role stigma and weight bias play in the management of obesity. They proposed a staging system to address the severity of obesity and suggested stigma and bias should be assessed in all patients.

While we are good at diagnosing obesity, many of us fail at addressing it empathetically with patients. I’ve seen many patients cry about past encounters they’ve had in the health care system. We need to address the emotional effect that obesity has as well as the physical complications.

Obesity is a major contributor to many diseases such as diabetes and heart disease, but we are finding it also plays a role in other diseases such as certain cancers. Treating obesity is imperative to prevent these diseases as well as to promote better treatment outcomes. We’ve all seen the diabetic patient lose weight and have their blood glucose levels come under control.

Many patients have tried hard to lose weight yet health care providers talk to them as if they haven’t made any efforts. This is very frustrating for patients. Simply telling a patient to diet and lose weight is a setup for failure. We need to address their past efforts and see what has worked and what hasn’t. Redoing the same thing over and over again is not a recipe for success.

Additionally, the focus on “diet and exercise” fails to account for emotional factors that may be contributing to a person’s obesity. Some people eat when they are stressed or depressed. It can become a habit or even an addiction. If this contributor to obesity isn’t fixed, nothing will work.

However, no medication will work well without the basic building blocks of diet and exercise. Routinely prescribing weight-loss medications without discussing diet and exercise will not result in much weight loss. Some patients simply don’t know how to eat healthfully or what they should do for exercise. A little education can go a long way. Ancillary staff, such as nutritionists or diabetic counselors, can help and free up the doctor’s time. In small practices, we can’t afford to provide those services in house but we should learn where patients can go for these services.

The AACE guidelines do a great job staging obesity. The guidelines make it easier to measure progress and decide on treatment plans. With this system, it is no longer necessary to use terms such as “excess weight” or “morbid obesity.” Patients already know they are overweight. What they need to know are clear steps so that they can reach goals. These guidelines greatly assist with providing those steps.

Most of us can do better when treating patients with obesity, We are probably not even aware of the times we have been guilty of stigmatization or weight bias. When we start treating obesity as a serious medical problem rather than something that’s the fault of the patient, it becomes much easier. When we remind ourselves what can happen to our patients when we fail to treat their obesity, we can become more serious about trying to help them reverse this critical medical problem. Bring an end to throwing out a “lose weight” or “eat healthier” suggestion to our already stressed patients. In order to address the obesity crisis that is here, we need to look inside ourselves and ask how we are going to contribute to the solution.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant of medicine at Robert Wood Johnson Medical School, New Brunswick, N.J.

Obesity is a major factor affecting the health of many Americans. It is estimated by the Centers for Disease Control and Prevention that 41% of adults and 19.7% of children in our country now meet the criteria for being obese. Obesity costs the United States approximately $147 billion annually in health care costs. While these numbers are staggering, they continue to rise.

The recent craze over medications such as Ozempic, Wegovy, and Mounjaro shows how eager people are to lose weight. Yet, many of them face bias, not just in their daily lives, but from health care professionals who should do better. No one should feel stigmatized when they come for medical help. This just drives away patients who need us and who may then suffer more severe consequences of obesity-related illnesses.

Earlier this year, the American Association of Clinical Endocrinology issued a consensus statement on the role stigma and weight bias play in the management of obesity. They proposed a staging system to address the severity of obesity and suggested stigma and bias should be assessed in all patients.

While we are good at diagnosing obesity, many of us fail at addressing it empathetically with patients. I’ve seen many patients cry about past encounters they’ve had in the health care system. We need to address the emotional effect that obesity has as well as the physical complications.

Obesity is a major contributor to many diseases such as diabetes and heart disease, but we are finding it also plays a role in other diseases such as certain cancers. Treating obesity is imperative to prevent these diseases as well as to promote better treatment outcomes. We’ve all seen the diabetic patient lose weight and have their blood glucose levels come under control.

Many patients have tried hard to lose weight yet health care providers talk to them as if they haven’t made any efforts. This is very frustrating for patients. Simply telling a patient to diet and lose weight is a setup for failure. We need to address their past efforts and see what has worked and what hasn’t. Redoing the same thing over and over again is not a recipe for success.

Additionally, the focus on “diet and exercise” fails to account for emotional factors that may be contributing to a person’s obesity. Some people eat when they are stressed or depressed. It can become a habit or even an addiction. If this contributor to obesity isn’t fixed, nothing will work.

However, no medication will work well without the basic building blocks of diet and exercise. Routinely prescribing weight-loss medications without discussing diet and exercise will not result in much weight loss. Some patients simply don’t know how to eat healthfully or what they should do for exercise. A little education can go a long way. Ancillary staff, such as nutritionists or diabetic counselors, can help and free up the doctor’s time. In small practices, we can’t afford to provide those services in house but we should learn where patients can go for these services.

The AACE guidelines do a great job staging obesity. The guidelines make it easier to measure progress and decide on treatment plans. With this system, it is no longer necessary to use terms such as “excess weight” or “morbid obesity.” Patients already know they are overweight. What they need to know are clear steps so that they can reach goals. These guidelines greatly assist with providing those steps.

Most of us can do better when treating patients with obesity, We are probably not even aware of the times we have been guilty of stigmatization or weight bias. When we start treating obesity as a serious medical problem rather than something that’s the fault of the patient, it becomes much easier. When we remind ourselves what can happen to our patients when we fail to treat their obesity, we can become more serious about trying to help them reverse this critical medical problem. Bring an end to throwing out a “lose weight” or “eat healthier” suggestion to our already stressed patients. In order to address the obesity crisis that is here, we need to look inside ourselves and ask how we are going to contribute to the solution.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant of medicine at Robert Wood Johnson Medical School, New Brunswick, N.J.

Obesity is a major factor affecting the health of many Americans. It is estimated by the Centers for Disease Control and Prevention that 41% of adults and 19.7% of children in our country now meet the criteria for being obese. Obesity costs the United States approximately $147 billion annually in health care costs. While these numbers are staggering, they continue to rise.

The recent craze over medications such as Ozempic, Wegovy, and Mounjaro shows how eager people are to lose weight. Yet, many of them face bias, not just in their daily lives, but from health care professionals who should do better. No one should feel stigmatized when they come for medical help. This just drives away patients who need us and who may then suffer more severe consequences of obesity-related illnesses.

Earlier this year, the American Association of Clinical Endocrinology issued a consensus statement on the role stigma and weight bias play in the management of obesity. They proposed a staging system to address the severity of obesity and suggested stigma and bias should be assessed in all patients.

While we are good at diagnosing obesity, many of us fail at addressing it empathetically with patients. I’ve seen many patients cry about past encounters they’ve had in the health care system. We need to address the emotional effect that obesity has as well as the physical complications.

Obesity is a major contributor to many diseases such as diabetes and heart disease, but we are finding it also plays a role in other diseases such as certain cancers. Treating obesity is imperative to prevent these diseases as well as to promote better treatment outcomes. We’ve all seen the diabetic patient lose weight and have their blood glucose levels come under control.

Many patients have tried hard to lose weight yet health care providers talk to them as if they haven’t made any efforts. This is very frustrating for patients. Simply telling a patient to diet and lose weight is a setup for failure. We need to address their past efforts and see what has worked and what hasn’t. Redoing the same thing over and over again is not a recipe for success.

Additionally, the focus on “diet and exercise” fails to account for emotional factors that may be contributing to a person’s obesity. Some people eat when they are stressed or depressed. It can become a habit or even an addiction. If this contributor to obesity isn’t fixed, nothing will work.

However, no medication will work well without the basic building blocks of diet and exercise. Routinely prescribing weight-loss medications without discussing diet and exercise will not result in much weight loss. Some patients simply don’t know how to eat healthfully or what they should do for exercise. A little education can go a long way. Ancillary staff, such as nutritionists or diabetic counselors, can help and free up the doctor’s time. In small practices, we can’t afford to provide those services in house but we should learn where patients can go for these services.

The AACE guidelines do a great job staging obesity. The guidelines make it easier to measure progress and decide on treatment plans. With this system, it is no longer necessary to use terms such as “excess weight” or “morbid obesity.” Patients already know they are overweight. What they need to know are clear steps so that they can reach goals. These guidelines greatly assist with providing those steps.

Most of us can do better when treating patients with obesity, We are probably not even aware of the times we have been guilty of stigmatization or weight bias. When we start treating obesity as a serious medical problem rather than something that’s the fault of the patient, it becomes much easier. When we remind ourselves what can happen to our patients when we fail to treat their obesity, we can become more serious about trying to help them reverse this critical medical problem. Bring an end to throwing out a “lose weight” or “eat healthier” suggestion to our already stressed patients. In order to address the obesity crisis that is here, we need to look inside ourselves and ask how we are going to contribute to the solution.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant of medicine at Robert Wood Johnson Medical School, New Brunswick, N.J.

In the United States this year, approximately 288,300 men will be newly diagnosed with prostate cancer and about 34,700 men will die from this disease. It is the second leading cause of cancer in men, and one out of every eight men will be diagnosed with this cancer at some point in their lives.

As primary care physicians, a large part of our role is to prevent or detect cancers early. Patients look to us for this guidance. However, prostate cancer screening has long been a controversial issue. Earlier this year, the American Urological Association along with the Society of Urologic Oncology published updated guidelines.

Clear recommendations that come from this set of guidelines that are relevant to primary care physicians include:

• using PSA as the screening test of choice.
• repeating PSA in patients with newly elevated results before moving on to other test.
• offering PSA screening every 2-4 years in patients aged 50-69 years.
• offering baseline screening in those between 45-50 years of age.

In high-risk patients, screening can be initiated at 40-45 years of age. All of these recommendations come with the caveat that we give the patient all the pros and cons and leave it up to their “values and preferences.”

The guidelines make recommendations regarding PSA screening and biopsy standards. These guidelines are very specific in their recommendations; however, the question about whether to do PSA screening in the first place is left open to debate. While shared decision-making is important with any testing, it is more difficult with prostate cancer screening. Patients need to understand that there are possible adverse events that can result because of an elevated PSA, such as unneeded biopsies that may come with complications.

The authors of this set of guidelines suggest that physicians talk to patients more often about the benefits of the screening than they do about the negative consequences. This assumes that a negative biopsy result is an unnecessary test, which is not a fair assessment. Negative test results can provide useful clinical information. While a PSA result may lead to a biopsy that could have possibly been avoided, we don’t have any better screening tests available. Missing a prostate cancer that could have been detected by PSA screening is also very harmful. Deciding whether to do PSA screening for any given patient then becomes a difficult question.

More research into biomarkers to detect prostate cancer is needed, as suggested by the guideline authors. As primary care doctors, we’re the first ones to order these tests and make decisions regarding the results. While we may not be the ones to do the biopsies, we do need to know when to refer the patients to specialists or when we can just repeat the test.

Population health is often the benchmark used when looking at screening guidelines. But in the primary care setting, we are responsible for individual patients. Applying guidelines that take whole populations into consideration often doesn’t translate well to single patients. We do need to make them responsible for their own health care decisions but, at the same time, we need to offer them some guidance. If the guidelines are clear, this is easy. When they suggest giving patients all the pros and cons and letting them make their own decision, this is hard. Some of them want us to tell them what to do.

Additionally, patients in the primary care setting develop close relationships with their physicians. They are not an elevated PSA test or a negative biopsy result. They have concerns and fears. When they are high risk, the advice is easy. Keeping in mind that prostate cancer is the second leading cause of cancer in men in the United States, we should have clear screening guidelines, such as we do with mammograms in women. Yes, shared decision-making is important, but we also need to know the answer when our patients ask us whether or not they should have a PSA test done.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J.

In the United States this year, approximately 288,300 men will be newly diagnosed with prostate cancer and about 34,700 men will die from this disease. It is the second leading cause of cancer in men, and one out of every eight men will be diagnosed with this cancer at some point in their lives.

As primary care physicians, a large part of our role is to prevent or detect cancers early. Patients look to us for this guidance. However, prostate cancer screening has long been a controversial issue. Earlier this year, the American Urological Association along with the Society of Urologic Oncology published updated guidelines.

Clear recommendations that come from this set of guidelines that are relevant to primary care physicians include:

• using PSA as the screening test of choice.
• repeating PSA in patients with newly elevated results before moving on to other test.
• offering PSA screening every 2-4 years in patients aged 50-69 years.
• offering baseline screening in those between 45-50 years of age.

In high-risk patients, screening can be initiated at 40-45 years of age. All of these recommendations come with the caveat that we give the patient all the pros and cons and leave it up to their “values and preferences.”

The guidelines make recommendations regarding PSA screening and biopsy standards. These guidelines are very specific in their recommendations; however, the question about whether to do PSA screening in the first place is left open to debate. While shared decision-making is important with any testing, it is more difficult with prostate cancer screening. Patients need to understand that there are possible adverse events that can result because of an elevated PSA, such as unneeded biopsies that may come with complications.

The authors of this set of guidelines suggest that physicians talk to patients more often about the benefits of the screening than they do about the negative consequences. This assumes that a negative biopsy result is an unnecessary test, which is not a fair assessment. Negative test results can provide useful clinical information. While a PSA result may lead to a biopsy that could have possibly been avoided, we don’t have any better screening tests available. Missing a prostate cancer that could have been detected by PSA screening is also very harmful. Deciding whether to do PSA screening for any given patient then becomes a difficult question.

More research into biomarkers to detect prostate cancer is needed, as suggested by the guideline authors. As primary care doctors, we’re the first ones to order these tests and make decisions regarding the results. While we may not be the ones to do the biopsies, we do need to know when to refer the patients to specialists or when we can just repeat the test.

Population health is often the benchmark used when looking at screening guidelines. But in the primary care setting, we are responsible for individual patients. Applying guidelines that take whole populations into consideration often doesn’t translate well to single patients. We do need to make them responsible for their own health care decisions but, at the same time, we need to offer them some guidance. If the guidelines are clear, this is easy. When they suggest giving patients all the pros and cons and letting them make their own decision, this is hard. Some of them want us to tell them what to do.

Additionally, patients in the primary care setting develop close relationships with their physicians. They are not an elevated PSA test or a negative biopsy result. They have concerns and fears. When they are high risk, the advice is easy. Keeping in mind that prostate cancer is the second leading cause of cancer in men in the United States, we should have clear screening guidelines, such as we do with mammograms in women. Yes, shared decision-making is important, but we also need to know the answer when our patients ask us whether or not they should have a PSA test done.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J.

In the United States this year, approximately 288,300 men will be newly diagnosed with prostate cancer and about 34,700 men will die from this disease. It is the second leading cause of cancer in men, and one out of every eight men will be diagnosed with this cancer at some point in their lives.

As primary care physicians, a large part of our role is to prevent or detect cancers early. Patients look to us for this guidance. However, prostate cancer screening has long been a controversial issue. Earlier this year, the American Urological Association along with the Society of Urologic Oncology published updated guidelines.

Clear recommendations that come from this set of guidelines that are relevant to primary care physicians include:

• using PSA as the screening test of choice.
• repeating PSA in patients with newly elevated results before moving on to other test.
• offering PSA screening every 2-4 years in patients aged 50-69 years.
• offering baseline screening in those between 45-50 years of age.

In high-risk patients, screening can be initiated at 40-45 years of age. All of these recommendations come with the caveat that we give the patient all the pros and cons and leave it up to their “values and preferences.”

The guidelines make recommendations regarding PSA screening and biopsy standards. These guidelines are very specific in their recommendations; however, the question about whether to do PSA screening in the first place is left open to debate. While shared decision-making is important with any testing, it is more difficult with prostate cancer screening. Patients need to understand that there are possible adverse events that can result because of an elevated PSA, such as unneeded biopsies that may come with complications.

The authors of this set of guidelines suggest that physicians talk to patients more often about the benefits of the screening than they do about the negative consequences. This assumes that a negative biopsy result is an unnecessary test, which is not a fair assessment. Negative test results can provide useful clinical information. While a PSA result may lead to a biopsy that could have possibly been avoided, we don’t have any better screening tests available. Missing a prostate cancer that could have been detected by PSA screening is also very harmful. Deciding whether to do PSA screening for any given patient then becomes a difficult question.

More research into biomarkers to detect prostate cancer is needed, as suggested by the guideline authors. As primary care doctors, we’re the first ones to order these tests and make decisions regarding the results. While we may not be the ones to do the biopsies, we do need to know when to refer the patients to specialists or when we can just repeat the test.

Population health is often the benchmark used when looking at screening guidelines. But in the primary care setting, we are responsible for individual patients. Applying guidelines that take whole populations into consideration often doesn’t translate well to single patients. We do need to make them responsible for their own health care decisions but, at the same time, we need to offer them some guidance. If the guidelines are clear, this is easy. When they suggest giving patients all the pros and cons and letting them make their own decision, this is hard. Some of them want us to tell them what to do.

Additionally, patients in the primary care setting develop close relationships with their physicians. They are not an elevated PSA test or a negative biopsy result. They have concerns and fears. When they are high risk, the advice is easy. Keeping in mind that prostate cancer is the second leading cause of cancer in men in the United States, we should have clear screening guidelines, such as we do with mammograms in women. Yes, shared decision-making is important, but we also need to know the answer when our patients ask us whether or not they should have a PSA test done.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J.

According to the World Health Organization (WHO), approximately 5% of adults (or 280 million people) suffer from depression globally. Although depression is more common in women, it can affect anyone. It is seen in all socioeconomic classes, ages, and races. In response, the WHO developed the Mental Health Gap Action Programme to bring mental health care services to those in need.

Depression can lead to severe consequences, such as loss of employment, relationships difficulties, and suicide. In fact, suicide is the 10th leading cause of death in the United States.

The U.S. Preventive Services Task Force (USPSTF), in past years, concluded that there was insufficient evidence to screen adolescents and adults for depression, However, new guidelines were issued this year in which the task force concluded there was a moderate benefit to screening adults for depression but insufficient evidence to screen for suicide risk. The agency now recommends screening for depression in all adults, even in the absence of risk factors, by using brief screening instruments such as the PHQ (Patient Health Questionnaire).

As family doctors, we have witnessed the burden of depression in our practices. The previous recommendations neglected the fact that mental health disorders were often purposely hidden because of stigma. Many patients do not readily come for treatment for mental illness and sometimes do not even accept these diagnoses. It is good that screening is now recommended, but we need to do more to tear down the stigma attached to mental illness.

These new guidelines do not address the effect that the lack of available mental health services has on treatment. It can take months to get an appointment for a patient with a mental health disorder, even if that person is potentially suicidal. Primary care physicians are often left treating these disorders; sometimes we are treating mental illness whether we feel comfortable doing so or not. Patients may not receive the best care but it is better than no care at all.

Although treating anxiety and depression is common for primary care doctors, specialists should be contacted when cases get more complicated. Even a call to crisis intervention can lead to an emergency department visit with discharge back to the family doctor because there is nowhere else to send the patient. The burden falls on us when we are already burdened by many other things, such as the rising rates of obesity with the resultant consequences of diabetes and heart disease. We simply do not have the time or expertise to treat complicated mental illness.

Creating guidelines to diagnose more undetected cases of depression without increasing the infrastructure to handle it is only going to lead to more pressure on family doctors. Many of us are already burnt out and at our limits. Yes, we want to diagnose every case of depression we can and to treat these patients for these disorders, but we need help.

Another problem with the guidelines is the recommendation to screen for depression and not suicide risk. As family doctors, we ask all patients who are depressed if they have thoughts of hurting themselves or others. Also, some people who commit suicide are not clinically depressed. These questions are simple to ask on an intake form.

Screening for depression is a pretty simple process. A patient can complete a screening tool or the clinician can directly ask the questions. It is a quick, noninvasive process. The Diagnostic and Statistical Manual of Mental Disorders criteria for diagnosing depression are pretty rigid and straightforward so misdiagnoses are not likely to be common.

The new guidelines do not make recommendations for treatment. In the real world, we often see patients unable to get the medications we prescribe because their insurance won’t cover it. Having guidelines supporting medication use would be very helpful.

In the area where I practice, it is difficult to refer a patient for counseling despite there being a plethora of counselors, therapists, and psychologists. These mental health providers often take only cash-paying patients, which eliminates access for many patients.

If we truly want to address the ever-increasing rates of depression in our country, we need to do much more than create new screening guidelines (screening that many family doctors were already doing). We must remove stigma, especially in the health care setting, fund mental health services, make them more readily available, and provide care that is affordable and covered by insurance. Until then, we are just going to add to the load of family doctors until we either break or leave our profession. Patients deserve better.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. She was paid by Pfizer as a consultant on Paxlovid and is the editor in chief of Physician’s Weekly.

According to the World Health Organization (WHO), approximately 5% of adults (or 280 million people) suffer from depression globally. Although depression is more common in women, it can affect anyone. It is seen in all socioeconomic classes, ages, and races. In response, the WHO developed the Mental Health Gap Action Programme to bring mental health care services to those in need.

Depression can lead to severe consequences, such as loss of employment, relationships difficulties, and suicide. In fact, suicide is the 10th leading cause of death in the United States.

The U.S. Preventive Services Task Force (USPSTF), in past years, concluded that there was insufficient evidence to screen adolescents and adults for depression, However, new guidelines were issued this year in which the task force concluded there was a moderate benefit to screening adults for depression but insufficient evidence to screen for suicide risk. The agency now recommends screening for depression in all adults, even in the absence of risk factors, by using brief screening instruments such as the PHQ (Patient Health Questionnaire).

As family doctors, we have witnessed the burden of depression in our practices. The previous recommendations neglected the fact that mental health disorders were often purposely hidden because of stigma. Many patients do not readily come for treatment for mental illness and sometimes do not even accept these diagnoses. It is good that screening is now recommended, but we need to do more to tear down the stigma attached to mental illness.

These new guidelines do not address the effect that the lack of available mental health services has on treatment. It can take months to get an appointment for a patient with a mental health disorder, even if that person is potentially suicidal. Primary care physicians are often left treating these disorders; sometimes we are treating mental illness whether we feel comfortable doing so or not. Patients may not receive the best care but it is better than no care at all.

Although treating anxiety and depression is common for primary care doctors, specialists should be contacted when cases get more complicated. Even a call to crisis intervention can lead to an emergency department visit with discharge back to the family doctor because there is nowhere else to send the patient. The burden falls on us when we are already burdened by many other things, such as the rising rates of obesity with the resultant consequences of diabetes and heart disease. We simply do not have the time or expertise to treat complicated mental illness.

Creating guidelines to diagnose more undetected cases of depression without increasing the infrastructure to handle it is only going to lead to more pressure on family doctors. Many of us are already burnt out and at our limits. Yes, we want to diagnose every case of depression we can and to treat these patients for these disorders, but we need help.

Another problem with the guidelines is the recommendation to screen for depression and not suicide risk. As family doctors, we ask all patients who are depressed if they have thoughts of hurting themselves or others. Also, some people who commit suicide are not clinically depressed. These questions are simple to ask on an intake form.

Screening for depression is a pretty simple process. A patient can complete a screening tool or the clinician can directly ask the questions. It is a quick, noninvasive process. The Diagnostic and Statistical Manual of Mental Disorders criteria for diagnosing depression are pretty rigid and straightforward so misdiagnoses are not likely to be common.

The new guidelines do not make recommendations for treatment. In the real world, we often see patients unable to get the medications we prescribe because their insurance won’t cover it. Having guidelines supporting medication use would be very helpful.

In the area where I practice, it is difficult to refer a patient for counseling despite there being a plethora of counselors, therapists, and psychologists. These mental health providers often take only cash-paying patients, which eliminates access for many patients.

If we truly want to address the ever-increasing rates of depression in our country, we need to do much more than create new screening guidelines (screening that many family doctors were already doing). We must remove stigma, especially in the health care setting, fund mental health services, make them more readily available, and provide care that is affordable and covered by insurance. Until then, we are just going to add to the load of family doctors until we either break or leave our profession. Patients deserve better.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. She was paid by Pfizer as a consultant on Paxlovid and is the editor in chief of Physician’s Weekly.

According to the World Health Organization (WHO), approximately 5% of adults (or 280 million people) suffer from depression globally. Although depression is more common in women, it can affect anyone. It is seen in all socioeconomic classes, ages, and races. In response, the WHO developed the Mental Health Gap Action Programme to bring mental health care services to those in need.

Depression can lead to severe consequences, such as loss of employment, relationships difficulties, and suicide. In fact, suicide is the 10th leading cause of death in the United States.

The U.S. Preventive Services Task Force (USPSTF), in past years, concluded that there was insufficient evidence to screen adolescents and adults for depression, However, new guidelines were issued this year in which the task force concluded there was a moderate benefit to screening adults for depression but insufficient evidence to screen for suicide risk. The agency now recommends screening for depression in all adults, even in the absence of risk factors, by using brief screening instruments such as the PHQ (Patient Health Questionnaire).

As family doctors, we have witnessed the burden of depression in our practices. The previous recommendations neglected the fact that mental health disorders were often purposely hidden because of stigma. Many patients do not readily come for treatment for mental illness and sometimes do not even accept these diagnoses. It is good that screening is now recommended, but we need to do more to tear down the stigma attached to mental illness.

These new guidelines do not address the effect that the lack of available mental health services has on treatment. It can take months to get an appointment for a patient with a mental health disorder, even if that person is potentially suicidal. Primary care physicians are often left treating these disorders; sometimes we are treating mental illness whether we feel comfortable doing so or not. Patients may not receive the best care but it is better than no care at all.

Although treating anxiety and depression is common for primary care doctors, specialists should be contacted when cases get more complicated. Even a call to crisis intervention can lead to an emergency department visit with discharge back to the family doctor because there is nowhere else to send the patient. The burden falls on us when we are already burdened by many other things, such as the rising rates of obesity with the resultant consequences of diabetes and heart disease. We simply do not have the time or expertise to treat complicated mental illness.

Creating guidelines to diagnose more undetected cases of depression without increasing the infrastructure to handle it is only going to lead to more pressure on family doctors. Many of us are already burnt out and at our limits. Yes, we want to diagnose every case of depression we can and to treat these patients for these disorders, but we need help.

Another problem with the guidelines is the recommendation to screen for depression and not suicide risk. As family doctors, we ask all patients who are depressed if they have thoughts of hurting themselves or others. Also, some people who commit suicide are not clinically depressed. These questions are simple to ask on an intake form.

Screening for depression is a pretty simple process. A patient can complete a screening tool or the clinician can directly ask the questions. It is a quick, noninvasive process. The Diagnostic and Statistical Manual of Mental Disorders criteria for diagnosing depression are pretty rigid and straightforward so misdiagnoses are not likely to be common.

The new guidelines do not make recommendations for treatment. In the real world, we often see patients unable to get the medications we prescribe because their insurance won’t cover it. Having guidelines supporting medication use would be very helpful.

In the area where I practice, it is difficult to refer a patient for counseling despite there being a plethora of counselors, therapists, and psychologists. These mental health providers often take only cash-paying patients, which eliminates access for many patients.

If we truly want to address the ever-increasing rates of depression in our country, we need to do much more than create new screening guidelines (screening that many family doctors were already doing). We must remove stigma, especially in the health care setting, fund mental health services, make them more readily available, and provide care that is affordable and covered by insurance. Until then, we are just going to add to the load of family doctors until we either break or leave our profession. Patients deserve better.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. She was paid by Pfizer as a consultant on Paxlovid and is the editor in chief of Physician’s Weekly.