In this first episode of the ESRD series, Dr. Montano and Bernstein discuss how to diagnose kidney failure while Drs. Hart and Aklilu wrestle with the fraught history of using race in the measurement of kidney function.

=== Outline ===

Chapter 1: A gradual progression

Chapter 2: A history of EGFR through the lens of race

Chapter 3: Involving the nephrologist

Chapter 4: Medication adjustments and monitoring

=== Learning Points ===

1. The symptoms underlying a progression from CKD to ESRD are often vague. A definitive diagnosis requires measuring kidney function.
2. The history of measuring kidney function includes the use of creatinine as a biomarker and the development of equations to calculate EGFR. Many of these equations have historically explicitly involved race, which has come under scrutiny and controversy.
3. Once a patient’s creatinine is consistently higher than 1.6, consider referral to a nephrologist for assistance with ongoing monitoring and considerations for transplantation.
4. A diagnosis of ESRD may require medication adjustments and careful monitoring for complications such as anemia, electrolyte changes, bone mineral disease, and swings in blood pressure.

=== Our Expert(s) ===

Dr. Paul Bernstein graduated from Union College in 1982, where he earned a BA in Biology. He then attended the Albert Einstein College of Medicine, where he was elected to AOA. In 1988, he joined the Yale Traditional Internal Medicine Residency, serving as Chief Resident from 1991-1992. From 1992-1995, he was a Yale nephrology fellow, and after that, he joined the faculty at the University of Rochester. From 1997-2000, he was an APD for the University of Rochester Primary Care Residency, and from 2000-2012, he was Program Director for the Internal Medicine Residency at Rochester General Hospital.

=== Further Reading ===

1. NIH National Institutes of Diabetes and Digestive and Kidney Diseases: Fast Facts on Kidney Disease https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease
2. Diao JA et al. National Projections for Clinical Implications of Race-Free Creatinine-Based GFR Estimating Equations. J Am Soc Nephrol. 2023 Feb 1;34(2):309-321. doi: 10.1681/ASN.2022070818. Epub 2022 Nov 11. PMID: 36368777; PMCID: PMC10103103.
3. St Peter WL et al; Written on behalf of the National Kidney Foundation Workgroup for Implementation of Race-Free eGFR-Based Medication-Related Decisions. Moving forward from Cockcroft-Gault creatinine clearance to race-free estimated glomerular filtration rate to improve medication-related decision-making in adults across healthcare settings: A consensus of the National Kidney Foundation Workgroup for Implementation of Race-Free eGFR-Based Medication-Related Decisions. Am J Health Syst Pharm. 2024 Nov 18:zxae317. doi: 10.1093/ajhp/zxae317. Epub ahead of print. PMID: 39552516.

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Host: Josh Onyango

Producers: Helen Cai, Josh Onyango

Logo and Name: Eva Zimmerman

Theme music and Editing: Helen Cai, Josh Onyango

Other background music: I Think I Can Help You, John Patitucci, Chris Haugen, DivKid, Asher Fulero, Jesse Gallagher, Saidbysed

Instagram: @pcpearls

Twitter: @PCarePearls

Listen on your favorite podcast platforms: linktr.ee/pcpearls

In our final episode of the Geriatric series, Dr. Xu and Drs. Ouellets discuss how to manage neurocognitive disorders in elderly patients. Daniel facilitates the conversation with a sweet couple navigating these challenges.

=== Outline ===

Chapter 1: An Unexpected Diagnosis

Chapter 2: Diagnosing Dementia

Chapter 3: Dementia Treatment and Specialist Care

Chapter 4: Supporting Caregivers

=== Learning Points ===

1. Dementia is characterized by both functional and cognitive impairment. While it’s important to consider a broad differential, it’s not strictly necessary to rule out all causes of impairment before proceeding with assessment for dementia.
2. Once a diagnosis of dementia has been made, there are certain components of long-term care to be addressed. This is where referral to a geriatrician can be helpful, as they can help to connect patients with resources and help to provide long-term counseling.
3. As dementia progresses, behavioral issues in patients may emerge. It’s important to gather as much information about the context of these issues as possible, in order to think about non-pharmacologic solutions and interventions.
4. Maintain a high index of suspicion for caregiver burnout, and try to determine what resources a caregiver needs and/or if they are willing to accept help.

=== Our Expert(s) ===

Dr. Gregory Ouellet graduated from Brown University in Providence, RI with a Bachelor of Science in biology and then attended medical school at the University of Rochester. Dr. Jennifer Ouellet is a geriatrician who specializes in the care of older adults with multiple chronic illnesses. They completed their clinical training in Internal Medicine and Geriatrics at Yale and are currently full time faculty in the Section of Geriatrics.

=== References ===

1. Albrecht T, Schroeder M, LeCaire T, Endicott S, Marschall K, Felten K, Sayavedra N, Russmann S, Kern V, Blazek MC, Kales HC, Carlsson CM, Mahoney J, Walaszek A. Training dementia care professionals to help caregivers improve the management of behavioral and psychological symptoms of dementia using the DICE Approach: A pilot study. Geriatr Nurs. 2022 Nov-Dec;48:74-79. doi: 10.1016/j.gerinurse.2022.08.016. Epub 2022 Sep 22. PMID: 36155312; PMCID: PMC11881159.
2. Mehrani I, Sachdev PS. The role of Memory Clinics in the assessment and management of dementia, now and into the future. Curr Opin Psychiatry. 2022 Mar 1;35(2):118-122. doi: 10.1097/YCO.0000000000000777. PMID: 35026801.
3. Reuben DB, Romero T, Evertson LC, Jennings LA. Overwhelmed: a Dementia Caregiver Vital Sign. J Gen Intern Med. 2022 Aug;37(10):2469-2474. doi: 10.1007/s11606-021-07054-3. Epub 2021 Aug 13. PMID: 34389938; PMCID: PMC9360256.
4. van Dyck CH, Swanson CJ, Aisen P, Bateman RJ, Chen C, Gee M, Kanekiyo M, Li D, Reyderman L, Cohen S, Froelich L, Katayama S, Sabbagh M, Vellas B, Watson D, Dhadda S, Irizarry M, Kramer LD, Iwatsubo T. Lecanemab in Early Alzheimer's Disease. N Engl J Med. 2023 Jan 5;388(1):9-21. doi: 10.1056/NEJMoa2212948. Epub 2022 Nov 29. PMID: 36449413.

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Hosts: Helen Cai

Producers: Helen Cai, Josh Onyango, Daniel Wang

Logo and Name: Eva Zimmerman

Theme music and Editing: Helen Cai, Josh Onyango

Other background music: True Cuckoo, Asher Fulero, Dan Bodan, Ammil, Dan Bodan

Instagram: @pcpearls

Twitter: @PCarePearls

Listen on your favorite podcast platforms: linktr.ee/pcpearls

In our first episode of the Geriatric series, Dr. Xu and Drs. Ouellets discuss how to have difficult topics with patients involving death and loss of function. Darius facilitates the conversation with a beautiful couple facing these existential questions.

=== Outline ===

Chapter 1: Introduction to Advance Care Planning

Chapter 2: Discussing Difficult Topics

Chapter 3: Who’s in the room? Stakeholders

Chapter 4: Key Elemaents of an Advance Care Plan

=== Learning Points ===

1. We can define advance care planning in 1 of 2 ways: as a form of legal document or contract, or as an ongoing conversation about a patient’s values that will be revisited over the course of a patient’s lifetime.
2. Another way of approaching the topic of ACP is in framing it as building a team who will be able to best support the patient through a difficult time: this could include family members, home health aides, financial planners, and so on. The most important member of this team to identify is the healthcare proxy: this person is designated to assist in making decisions should the patient be unable to.
3. Discussing ACP is applicable in any care setting: on the floors, in the ICU, and in the clinic. In the clinic, we have the benefit of time and a longitudinal relationship to keep on revising this topic--since a patient’s goals and priorities may shift over time, and the interventions they may desire will also shift accordingly.

=== Our Expert(s) ===

Dr. Gregory Ouellet graduated from Brown University in Providence, RI with a Bachelor of Science in biology and then attended medical school at the University of Rochester. He completed his clinical training in Internal Medicine and Geriatrics at Yale. He concomitantly completed a postdoctoral fellowship in Geriatric Epidemiology and Aging-Related Research and a Master in Health Science degree in 2018. Dr. Ouellet subsequently joined the full time faculty in the Section of Geriatrics.

Dr. Jennifer Ouellet is a geriatrician who specializes in the care of older adults with multiple chronic illnesses.

=== References ===

1. Sudore RL, Fried TR. Redefining the "planning" in advance care planning: preparing for end-of-life decision making. Ann Intern Med. 2010 Aug 17;153(4):256-61. doi: 10.7326/0003-4819-153-4-201008170-00008. PMID: 20713793; PMCID: PMC2935810.
2. Sudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, Matlock DD, Rietjens JAC, Korfage IJ, Ritchie CS, Kutner JS, Teno JM, Thomas J, McMahan RD, Heyland DK. Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. J Pain Symptom Manage. 2017 May;53(5):821-832.e1. doi: 10.1016/j.jpainsymman.2016.12.331. Epub 2017 Jan 3. PMID: 28062339; PMCID: PMC5728651.
3. Fried TR, Bradley EH. What matters to seriously ill older persons making end-of-life treatment decisions?: A qualitative study. J Palliat Med. 2003 Apr;6(2):237-44. doi: 10.1089/109662103764978489. PMID: 12854940.

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Hosts: Helen Cai

Producers: Helen Cai, Josh Onyango

Logo and Name: Eva Zimmerman

Theme music and Editing: Helen Cai, Josh Onyango

Other background music: Noir Et Blanc Vie, Asher Fulero, Astron, The Tides

Instagram: @pcpearls

Twitter: @PCarePearls

Listen on your favorite podcast platforms: linktr.ee/pcpearls

In this episode, Dr. Barenboim and Dr. Holt discuss the important role that medications and mutual support groups play in helping James maintain sobriety from alcohol.

Share your reactions and questions with us at Speak Pipe . We might feature you on a future episode!

=== Outline ===

Chapter 1: Managing Alcohol Withdrawal in the Outpatient Setting

Chapter 2: Medications for AUD

Chapter 3: Recovery Group/Social Support

=== Learning Points ===

1. Although our training has historically focused on the inpatient setting, managing alcohol withdrawal in the outpatient setting is also possible. A sample regimen for this may be 10mg diazepam every 6 hours on the first day, then every 8 hours on the second day, every 12 hours on the third day, and then once on day 4.
2. Medications approved by the FDA in the treatment of alcohol use disorder include: naltrexone, acamprosate, and disulfiram. Disulfiram is considered a first-line medication.
3. Successful treatment of AUD often requires trying lots of combinations of interventions, which can include medications and non-pharmacologic interventions such as mutual support groups or therapy. The diversity of support groups is growing, making them more accessible to patients; but patients may need to trial many different groups before finding one that “works” for them.

=== Our Expert(s) ===

Dr. Stephen Holt attended Columbia University’s College of Physicians & Surgeons and subsequently completed his residency training and Chief Residency at Yale's Primary Care Internal Medicine Residency Program before joining the program as an Assistant Professor. He currently serves as the Associate Program Director for Ambulatory Education in the Primary Care Program. His areas of interest include addiction medicine, medical education, and the art and science of physical diagnosis.

=== References ===

1. Tiglao SM, Meisenheimer ES, Oh RC. Alcohol Withdrawal Syndrome: Outpatient Management. Am Fam Physician. 2021 Sep 1;104(3):253-262. PMID: 34523874.
2. McPheeters M, O'Connor EA, Riley S, Kennedy SM, Voisin C, Kuznacic K, Coffey CP, Edlund MD, Bobashev G, Jonas DE. Pharmacotherapy for Alcohol Use Disorder: A Systematic Review and Meta-Analysis. JAMA. 2023 Nov 7;330(17):1653-1665. doi: 10.1001/jama.2023.19761. Erratum in: JAMA. 2024 Oct 2. doi: 10.1001/jama.2024.11331. PMID: 37934220; PMCID: PMC10630900.
3. Garbutt JC, Kranzler HR, O'Malley SS, et al. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. JAMA 2005; 293:1617.
4. Skinner MD, Lahmek P, Pham H, Aubin HJ. Disulfiram efficacy in the treatment of alcohol dependence: a meta-analysis. PLoS One 2014; 9:e87366.

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Hosts: Dylan Balter

Producers: Helen Cai, Josh Onyango

Logo and Name: Eva Zimmerman

Theme music and Editing: Helen Cai, Josh Onyango

Other background music: Asher Fulero, Dan Bodan, Penguin Music, Nathan Moore, Chris Haugen

Instagram: @pcpearls

Twitter: @PCarePearls

Listen on your favorite podcast platforms: linktr.ee/pcpearls

In this episode, Dr. Barenboim and Dr. Holt explore a couple's journey through a changing relationship to alcohol and when it became an alcohol use disorder.

Share your reactions and questions with us at Speak Pipe . We might feature you on a future episode!

=== Outline ===

Chapter 1: Early Development of a Relationship with Alcohol

Chapter 2: Diagnosing AUD

Chapter 3: Approaching the Conversation

Chapter 4: Motivational Interviewing

=== Learning Points ===

1. Someone’s relationship with alcohol is shaped by many factors. Learning more about these elements--such as upbringing, social circles, and if alcohol is used to cope with stressors--will provide a comprehensive biopsychosocial understanding about the role that alcohol plays in a patient’s life.
2. Be familiar with and use screening tools for excessive alcohol use. These might include the AUDIT-C or the NIAAA Single Alcohol Screening Question.
3. Motivational interviewing not only allows us to understand more about someone’s relationship with alcohol, but provides the guiding framework to explore what they are willing to take on in terms of change and intervention. A key aspect of motivational interviewing in this context is eliciting the patient’s perspectives on what is beneficial and detrimental about their alcohol use, and pointing out the discrepancies in alcohol’s impact on their life.

=== Our Expert(s) ===

Dr. Stephen Holt attended Columbia University’s College of Physicians & Surgeons and subsequently completed his residency training and Chief Residency at Yale's Primary Care Internal Medicine Residency Program before joining the program as an Assistant Professor. He currently serves as the Associate Program Director for Ambulatory Education in the Primary Care Program. His areas of interest include addiction medicine, medical education, and the art and science of physical diagnosis.

=== References ===

1. What is a standard drink? https://www.niaaa.nih.gov/alcohols-effects-health/what-standard-drink
2. Highlights for the 2022 National Survey on Drug Use and Health: https://www.samhsa.gov/data/sites/default/files/reports/rpt42731/2022-nsduh-main-highlights.pdf
3. Facts About U.S. Deaths from Excessive Alcohol Use: https://www.cdc.gov/alcohol/facts-stats/index.html
4. AUDIT-C: https://www.mirecc.va.gov/cih-visn2/Documents/Provider_Education_Handouts/AUDIT-C_Version_3.pdf
5. AUDIT: https://auditscreen.org/

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Hosts: Dylan Balter

Producers: Helen Cai, Josh Onyango

Logo and Name: Eva Zimmerman

Theme music and Editing: Helen Cai, Josh Onyango

Other background music: Puddle of Infinity, Adam MacDougall, Density & Time, Jesse Gallagher, Asher Fulero, Astron, Lauren Duski,

Instagram: @pcpearls

Twitter: @PCarePearls

Listen on your favorite podcast platforms: linktr.ee/pcpearls

Please complete this brief 3 minute survey to provide us Feedback on Season 1 so we can continue to improve the podcast for all our listeners!

In this episode, Dr. Vasudevan and Dr. Moreno explore the ever-expanding treatment options for Obeisty, and our patient tells us about his experience with some of these interventions.

Share your reactions and questions with us at Speak Pipe . We might feature you on a future episode!

=== Outline ===
1. Introduction
2. Chapter 1: Lifestyle Changes (Diet/Exercies)
3. Chapter 2: Weight Loss Medications
4. Chapter 3: Bariatric Surgery
5. Chapter 4: Advise to Young Clinicians and Fellow Patients
6. Conclusion

=== Learning Points ===

1. Lifestyle modifications need to be tailored to the patient. This often involves starting with a careful dietary and activity history and helping the patient incorporate small, healthy changes that are congruent with their cultural background
2. There are multiple medications available for weight loss and selecting the right one requires knowledge of a patient's comorbid health conditions, as well as taking into account their personal preference. Side-effects tolerance cost, and or insurance coverage
3. Recognize how to counsel patients on when it may be appropriate to pursue bariatric surgery and what they can expect following the procedure.
4. The most important step in helping patients manage obesity is by starting the conversation and letting patients know that you are there to support them along every step of the way.
5. 
   

=== Our Expert(s) ===

Dr. Jorge O. Moreno is an Assistant Professor of Medicine at Yale School of Medicine.

Dr. Moreno is originally from Mexico and is also fluent in Spanish. He grew up in New Rochelle, NY and completed his undergraduate degree at Columbia University in 2006. In 2011, he obtained his medical degree from the University of Rochester School of Medicine and Dentistry. He completed his internal medical residency at the Yale University’s Primary Care Residency Program Yale New Haven in 2014.

=== References ===

1. Heymsfield SB, Wadden TA. Mechanisms, Pathophysiology, and Management of Obesity. N Engl J Med. 2017 Jan 19;376(3):254-266. doi: 10.1056/NEJMra1514009. PMID: 28099824. https://www.nejm.org/doi/full/10.1056/nejmra1514009
2. Wilding, J. P. H., et al. (2021). "Once-Weekly Semaglutide in Adults with Overweight or Obesity." New England journal of medicine 384(11): 989-1002.

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Hosts: Maisie Orsillo
Producers: Helen Cai, JW Allen, August Allocco
Logo and Name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Other background music: Corbyn Kites, Quincas Moreira, Jesse Gallagher, Patrick Patrikios

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on your favorite podcast platforms: linktr.ee/pcpearls

In this episode, Dr. Vasudevan and Dr. Moreno unpack our patient's experience with weight and how it's impacted his life.

Share your reactions and questions with us at Speak Pipe . We might feature you on a future episode!

=== Outline ===
1. Introduction
2. Chapter 1: Personal Relationship to Weight
3. Chapter 2: Impact of Weight on Mental Health
4. Chapter 3: Relationship with PCP
5. Conclusion

=== Learning Points ===

1. Commonly used measures of obesity include BMI and waist circumference. These measures are imperfect, since they are attempting to quantify adiposity.
2. Patients often undergo an emotional journey that is related to their weight. Many patients prefer to move towards tangible end goals such as increased mobility, lowered risk for future adverse health events, or other factors rather than a specific weight, BMI, or waist circumference.
3. Screening and treatment of mental health conditions such as anxiety and depression can be instrumental in the care of patients who have elevated BMI.
4. Be sure to ask permission to discuss the patient’s weight before jumping in. Set SMART goals with your patients and set expectations early.

=== Our Expert(s) ===

Dr. Jorge O. Moreno is an Assistant Professor of Medicine at Yale School of Medicine.

Dr. Moreno is originally from Mexico and is also fluent in Spanish. He grew up in New Rochelle, NY and completed his undergraduate degree at Columbia University in 2006. In 2011, he obtained his medical degree from the University of Rochester School of Medicine and Dentistry. He completed his internal medical residency at the Yale University’s Primary Care Residency Program Yale New Haven in 2014.

=== References ===

1. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity and severe obesity among adults: United States, 2017–2018. NCHS Data Brief, no 360. Hyattsville, MD: National Center for Health Statistics. 2020. Retrieved from: https://www.cdc.gov/nchs/products/databriefs/db360.html
2. https://www.cdc.gov/obesity/data/adult.html

*For additional resources discussed in the episode, check out our transcript!

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Hosts: Nate Wood
Producers: Helen Cai, JW, August Allocco
Logo and name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Other background music: Emily A. Sprague, Unicorn Heads, Godmode, Corbyn Kites, Ammil, Coma

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on most podcast platforms: linktr.ee/pcpearls