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2025-2026 COVID Vaccine: What Patients and Providers Should Know

On By Dr. Scott RennieIn Infectious DiseaseLeave a comment

I’m already fielding questions about the newly approved 2025-2026 COVID-19 vaccine. The FDA has authorized the updated version. That’s step one. Step two usually comes from the Advisory Committee on Immunization Practices, ACIP, which sets the vaccine schedule for the CDC. ACIP has not yet issued its formal recommendations for this updated vaccine.

Here’s why that matters. Pharmacists’ authority to independently order and administer vaccines is tied directly to ACIP recommendations. Without those recommendations in place, pharmacists may not be able to give the shot without a prescription from a physician, nurse practitioner, or physician assistant.

So if you’re a patient hoping to get your vaccine at the pharmacy, you may be told you need a prescription first. Some pharmacies may decide to keep requiring prescriptions even after ACIP issues its guidance, especially since the FDA’s approval for those under 65 comes with labeling restrictions that pharmacists may interpret conservatively.

For prescribers, the FDA’s labeling does not stop us from prescribing the vaccine to patients we feel will benefit. Even with some limitations around pharmacy authority, the clinical judgment of a licensed provider still stands.

In practice, this means you might see more prescription requests come across your desk in the next few weeks. Patients may call after being turned away at the pharmacy. Prepare for it. Have a clear plan for how you’ll respond.

Avoiding unnecessary delays in vaccination is the goal. DC Health has said it is working to minimize the paperwork and make access smoother for patients. In my own practice these calls tend to start around September, and patients most often ask about Walmart or Costco, both of which are efficient most of the time. As more updates come from ACIP, and as pharmacies adjust their policies, the process should get easier.

For patients, the takeaway is simple. If you’re under 65 and planning to get the updated vaccine at a pharmacy, check ahead to see if they’ll require a prescription. If they do, call your provider’s office first so you don’t make an extra trip.

For colleagues, expect to step in more actively during this transition period. We’ve been through similar rollouts before. The logistics are frustrating. Florida in particular tends to be conservative when it comes to vaccines, in my experience. Patients still need timely protection, and that’s what matters most.

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Sources:

U.S. Food and Drug Administration (FDA). COVID-19 Vaccines. www.fda.gov

Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization Practices (ACIP). www.cdc.gov

Shifting to Telemedicine: Reflections for Fellow Physicians

On By Dr. Scott RennieIn Healthcare System & TechnologyLeave a comment

Not long ago, two of my medical school classmates reached out to me. One is an emergency room physician. The other is a dermatologist. Both wanted to talk about telemedicine and whether they should make the transition. Their questions reminded me of my own when I started, and it got me thinking about how different this kind of work really is compared to in-person care.

Telemedicine has real upsides. The flexibility is genuine: you can work from anywhere with a reliable internet connection, from home while helping with your kids, or on the road while staying productive. The lack of a commute alone changes your day. No traffic, no wasted time. Hours flex more easily when family emergencies or illnesses come up. Exposure to infectious disease drops significantly too, a lesson plenty of us learned the hard way during COVID. On top of that, paperwork drops. Charts are streamlined and forms are lighter, which frees up the time you’d otherwise spend on documentation to actually talk with patients; if you’re efficient, the pay is good, and seeing more patients per day brings a sense of making a difference on a large scale. You can meet people from all over the country, provided you are licensed in multiple states. For many providers, this is one of the best work-life balance opportunities in medicine.

Some patients treat telemedicine like a transaction, logging on expecting a specific medication and pushing back when your judgment doesn’t match what they came for. That’s one of the real downsides. You lose the camaraderie of the clinic or hospital, the in-person interaction with colleagues that a lot of physicians miss. Hands-on procedures disappear entirely. Loved draining an abscess, suturing a laceration, placing a central line? You won’t get that satisfaction here. Some days it feels like you’re redirecting more patients than you’re treating, sending people in for care you’d rather deliver yourself; and the liability is identical to an in-person visit, just with fewer tools to manage it.

The monotony can creep in too. During winter, you may see upper respiratory complaints on repeat. You have to be skilled at quickly identifying the patient who sounds much sicker than they realize. That judgment call, who can be safely treated virtually and who needs in-person evaluation, has to be made fast and accurately. Get it wrong and the consequences can be serious.

Guidelines from telemedicine companies like Teladoc, MDLive, and Amwell are conservative for a reason: they steer providers toward in-person evaluation whenever there’s doubt. It keeps patients safe. It protects the practice of telemedicine itself, too. You have to be comfortable following those guidelines, even if it feels restrictive at times.

I have had both frustrating and rewarding cases.

One that stands out was a patient who logged on for hives. Her husband was telling the story while she was in the background, but when she finally spoke, her voice was high-pitched and strained. I realized she was in anaphylaxis. She had access to her child’s epinephrine auto-injector, used two doses, and her breathing improved almost immediately. EMS was called. She got the care she needed. That visit was one of my first telemedicine visits. I was still working 1099, part time, treating telemedicine as something on the side. Walking away from that call believing I might have just saved someone’s life is what changed my mind, and I went looking for a full-time W2 telemedicine role not long after.

Rashes and Telemedicine: A Special Challenge

One of the trickiest areas of telemedicine is dermatology. Rashes seem like they should be simple. A patient shows you a patch of red skin or bumps, you identify it, and you prescribe a cream. The reality is that it is rarely that easy.

The biggest issue is image quality. Patients often upload photos that are poorly lit, out of focus, or taken from too far away; sometimes they only capture a tiny area of skin without showing the bigger picture; diagnosing a rash accurately takes more than a photo: distribution, texture, timing, and whether there are associated systemic symptoms all factor in; and without good photos and without the ability to do a full physical exam, we are often working with incomplete information.

I ask for photos for telemedicine rashes rather than relying on video alone. Video is generally not as good quality as a high-resolution image. The challenge is getting a patient to take that photo well: right distance, multiple angles, not blurry. I like a distance shot and a macro shot up close if I can get one.

History-taking matters just as much: was the rash itchy or painful, did it spread quickly, was there a recent medication change, a new detergent, an insect bite, or outdoor exposure? Even careful questioning doesn’t always yield the full story. Some rashes are harmless. Others can be signs of serious systemic illness. Sorting out which is which over video can be challenging and sometimes unsafe. One diagnostic call that turns entirely on photo quality: angular cheilitis. It can be hard to distinguish from perioral dermatitis without a close-up image. A good macro shot of the corners of the mouth and the two conditions look different. A blurry photo taken from three feet away, and you are guessing between them.

That is why tele-dermatology has emerged as a subspecialty. Some telemedicine companies, including Teladoc, now offer patients access to board-certified dermatologists who can focus exclusively on skin issues; having a dermatologist review high-resolution photos, sometimes with dermatoscopic images, makes accurate diagnosis and treatment more reliable. Even so, patients need to understand that when the photo quality is poor or the history is incomplete, a referral for in-person evaluation may still be necessary.

Would I tell my classmates to make the switch? Yes, eyes open. Real flexibility and real reach, but you give up procedures, in-person camaraderie, and full control over what you can safely rule out on a screen. Know the limits, tell patients the truth about them, and telemedicine works, for them and for you.

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Why Some Conditions Need an In-Person Visit, Not Virtual Care

On By Dr. Scott RennieIn Healthcare System & TechnologyLeave a comment

Telemedicine has become part of everyday care, and for good reason; it allows patients to connect with a physician from home, from work, or while traveling; and many problems can be managed safely and effectively through video visits. But not everything belongs in a virtual setting.

I follow guidelines, like the ones Teladoc, MDLive, and Amwell use, that help decide what’s safe to manage online and what has to be seen in person. Those rules aren’t arbitrary. They’re built around safety, the limits of a video encounter, and the risk of missing something serious.

What Actually Keeps a Visit Off Camera

Some diagnoses depend on a tool or a test that doesn’t exist on a video call. An ear infection needs a direct look at the eardrum through an otoscope. Ear pain alone could just as easily mean wax buildup, dental pain, or referred throat irritation, and without visualizing the drum, the real cause gets missed (swimmer’s ear is the exception, along with cases where a family can upload a high-quality otoscope photo). A suspected blood clot in the leg, deep vein thrombosis, has exactly one way to confirm or rule out: an ultrasound, which no video visit can provide. Pneumonia works the same way. A cough that persists, worsens, or comes with fever and shortness of breath needs a chest x-ray and sometimes labs. Neither of which exists on a screen. Pediatric urinary tract infections need a urine sample tested before treatment. And abnormal uterine bleeding, which can signal serious gynecologic issues, usually needs labs or imaging to sort out.

Other conditions need hands-on assessment. Looking is not enough. Post-operative pain that’s worsening rather than expected can mean infection, bleeding, or a wound problem, and a physical exam is needed to check for swelling, drainage, or fever. Post-op patients are safest going back to their surgeon. Mastitis is similar. Breast pain and redness in a breastfeeding patient could be simple mastitis or could be an abscess that needs drainage. And a virtual exam cannot reliably tell the difference. Any laceration or wound that needs stitches has to be assessed and repaired in person; so do animal bites, dog, cat, or human, because of the infection risk and sometimes rabies exposure; and wound care, tetanus updates, and rabies prophylaxis all have to happen in the room.

A third group can turn dangerous fast and needs hospital-level resources. A fever over 103°F, or any systemic illness, can point to sepsis, meningitis, pneumonia, or another serious infection needing immediate labs, imaging, or IV treatment. Suspected meningitis, headache with fever and a stiff neck, needs immediate hospital evaluation with spinal fluid testing and IV antibiotics. It cannot be managed on a screen. Croup in a child, the barking cough and stridor, can worsen quickly enough that treatments like racemic epinephrine or oxygen have to happen in person and urgently. A skin abscess on the face, or periorbital cellulitis, can spread to deeper tissue including the brain and needs urgent evaluation, often with IV antibiotics. Suspected sepsis or a bloodstream infection has to be treated urgently in a hospital, full stop. Unexplained abdominal pain could be appendicitis, gallbladder disease, a bowel obstruction, or another emergency. And usually needs imaging and labs to sort out. Chest pain gets taken most seriously of all. It can represent a heart attack, a pulmonary embolism, or another life-threatening problem, and it gets an urgent in-person evaluation every time. The same logic covers a headache described as the worst of someone’s life, which can mean bleeding in the brain or meningitis; a concussion or closed head injury, which needs a neurologic exam and sometimes imaging; and eye problems like a foreign body, a chemical burn, sudden vision loss, or trauma, all of which need immediate in-person evaluation.

A last group has nothing to do with how sick someone looks and everything to do with what has to happen in a room. Controlled substances, stimulants, opioids, benzodiazepines, carry real risk of misuse and dependence. So regulations require in-person visits for initiation and refills. Some STD treatments need an in-office procedure; genital warts are the clearest example. And anything tied to a work-related claim, FMLA paperwork, workers’ comp, a disability determination, usually needs physical documentation and an in-person exam to be valid.

What About Rashes?

Rashes are a gray zone in telemedicine. Sometimes they are straightforward, like ringworm or athlete’s foot, and can be treated virtually with antifungal creams. Other times they are difficult to interpret. Safely treating a rash through telemedicine depends heavily on two things. The quality of the photo the patient uploads and a detailed medical history.

If the picture is blurry, poorly lit, or taken at the wrong angle, it may be impossible to tell the difference between something benign and something serious. Something like shingles or cellulitis. Even with good photos, asking the right questions, when it started, whether it itches, spreads, or comes with fever, can take time to sort out.

Diagnosing rashes virtually can sometimes be challenging, which is exactly why tele-dermatology has become its own field. Companies such as Teladoc now offer access to board-certified dermatologists who specialize in skin conditions. Patients can upload high-quality images and receive expert input, which improves accuracy and treatment options.

Conditions That Can Often Be Managed Virtually

Plenty of complaints are safe to handle over video: viral upper respiratory infections, sinus infections, uncomplicated urinary tract infections, mild to moderate asthma exacerbations, vaginal yeast infections, bronchitis without red-flag symptoms, most pink eye, cold sores, sprains and strains, seasonal allergies, skin conditions like eczema, ringworm, and jock itch, uncomplicated headaches or low back pain, and early or uncomplicated dental infections.

When a “Simple” Complaint Turns Out Not to Be

Patients don’t always see the warnings that some conditions can’t be managed online, and even when they do, some push back because getting to a clinic in person is inconvenient or expensive. Sometimes what looks straightforward at first turns into something else once the clarifying questions start: a “sinus infection” complaint that turns out to be severe facial swelling, a “back pain” complaint that turns out to come with fever and urinary incontinence. In my own practice, abdominal pain is the one that converts to an in-person visit almost every time, because it needs a hands-on exam. Boils and abscesses, febrile urinary tract infections, and rashes I can’t visualize well enough on a photo make up most of the rest.

Where These Guidelines Come From

Companies such as Teladoc, MDLive, and Amwell built their red-flag lists after years of clinical review. The goal is to prevent missed diagnoses and keep telemedicine a safe, effective model of care. These rules protect both patients and providers.

Telemedicine is powerful. It expands access and provides convenience. But it has boundaries. When I recommend that a patient be seen in person, it’s because safe, thorough care sometimes needs tools and testing. A video screen simply can’t provide them. When a patient pushes back, I tell them plainly that an in-person evaluation is needed for their own safety. If they keep insisting on staying virtual, I decline and explain that telemedicine has its own standards of care, similar to an in-person visit, built around guidelines that protect patients. Most understand. Not all of them agree.

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Gabapentin and Dementia Risk: What Patients and Colleagues Should Know

On By Dr. Scott RennieIn NeurologyLeave a comment

Gabapentin is one of the most commonly prescribed drugs in the U.S., used for nerve pain, seizure disorders, and sometimes off-label for sleep or anxiety. I don’t prescribe it myself. It’s generally not a medication that gets started over telemedicine, but many of the patients I see are already on it, sometimes for years, by the time it comes up in our visit. Dizziness, fatigue, and the risk of misuse are the usual concerns. Now there’s new research raising concern about a possible link to dementia.

A study published in July 2025 in Regional Anesthesia & Pain Medicine looked at prescription records and medical outcomes for thousands of adults. This was a retrospective cohort study. In other words, the researchers didn’t assign patients to groups or give some people placebo pills. They looked back at existing data and compared outcomes between people who had taken gabapentin and those who had not (Lin et al., 2025).

That design matters. The gold standard in medical research is a randomized, double-blind, placebo-controlled trial, where patients are randomly assigned to receive either the medication or a placebo and neither patients nor researchers know who is in which group until the study ends. This approach minimizes bias and helps establish cause and effect. An observational study like this one, by contrast, can only show association. It tells us that patients on gabapentin had higher rates of dementia, but it can’t prove gabapentin caused it. Other factors, such as the underlying conditions that led to prescribing gabapentin, may have influenced the outcome.

Even with that limitation, the findings are striking. Adults aged 35 to 49 who filled six or more prescriptions were more than twice as likely to develop dementia and more than three times as likely to develop mild cognitive impairment compared to non-users. Adults aged 50 to 64 had a 29 percent higher risk of dementia and an 85 percent higher risk of mild cognitive impairment.

I tell patients not to stop gabapentin suddenly. For someone with a seizure disorder or severe neuropathic pain, stopping without a plan can be unsafe. But it may be time to review why a patient is on it and whether the benefit is still there. The pattern I run into is people staying on it. It gets started for something like restless legs, it helps at first, and then it just stays on the list long after symptoms have settled, because nobody goes back and revisits the prescription. Now there’s another reason to ask whether it still belongs there.

For families, this means paying attention too. If a parent or older relative is taking gabapentin, bring it up at their next appointment. Long-term prescriptions sometimes get renewed automatically. I don’t taper gabapentin myself. When it comes up in a visit, I tell the patient to bring it to their primary care provider, or whoever prescribes it for them, and talk through together whether it still makes sense.

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Sources:

Lin S, et al. “Gabapentin exposure and risk of cognitive decline and dementia.” Regional Anesthesia & Pain Medicine. July 2025.

Fisher Center for Alzheimer’s Research Foundation. “Pain Reliever Tied to Higher Dementia Risk.” alzinfo.org.

2025 COVID-19 Vaccine: Eligibility, Prescriptions, and Debate

On By Dr. Scott RennieIn Infectious DiseaseLeave a comment

Patients have been asking me the same question all week: is the new COVID-19 vaccine out yet? As of late August 2025, updated shots targeting the LP.8.1 subvariant have FDA clearance and are expected to ship this fall. Not everyone will be able to get one.

The FDA has cleared vaccines from Pfizer, Moderna, and Novavax, but eligibility is narrower than it was. You need to be 65 or older, or have a qualifying condition such as asthma, obesity, diabetes, immunosuppression, or a smoking history. Moderna’s shot is cleared for children six months and up with underlying conditions, Novavax from age 12. Healthy younger adults, healthy children, and pregnant women are no longer routinely included (AP News, The Cut).

The shift followed HHS Secretary Robert F. Kennedy Jr. removing vaccine recommendation language for healthy children and pregnant women, in favor of what he described as shared clinical decision making, meaning healthy people need to discuss vaccination with a physician rather than walk into a pharmacy. He has framed the change around science, safety, and common sense (The Cut). Professional organizations saw it differently.

The American Academy of Pediatrics, American Academy of Family Physicians, and American College of Osteopathic Family Physicians all pushed back. The AAP called the guidance deeply troubling and warned that pulling the shots from routine schedules leaves children exposed. AAFP and ACOFP argued for broader access with winter respiratory season approaching (AP News).

Pharmacies are handling this inconsistently. CVS now requires a valid prescription to vaccinate adults in some states, which means eligibility alone may not get you a shot. Coverage is unsettled too. Doses may run $140 to $150 if insurance does not pick them up. Medicare will cover eligible seniors, while adults and children outside the eligible groups may be paying out of pocket (Times of India, The Cut).

So where does that leave you? Doses should reach clinics and pharmacies by mid-to-late fall, roughly on flu season timing. If you are eligible under the FDA criteria, you probably do not need a prescription. If you fall outside them, expect to need a visit, a written order, and your own money.

A few situations that have come up with my own patients recently.

A healthy parent of young children called to ask whether they could simply walk into CVS once the vaccine arrived. They were told prescriptions only, and they did not qualify under the current rules anyway.

A patient in her seventies with COPD wanted to know when it would be available. I told her early fall was likely and that she should not wait once her pharmacy had it.

A pregnant nurse called wondering whether she could get one. I explained the CDC no longer recommends it in healthy pregnancy, and that we would revisit if she developed asthma or another risk factor.

CDC definitions of high-risk individuals under 65

For patients below the routine age cutoff, the CDC still defines groups at high risk of severe illness and hospitalization, and these patients may qualify under the current FDA authorization:

  • People with chronic lung disease including moderate-to-severe asthma, COPD, pulmonary fibrosis, or cystic fibrosis.
  • People with heart disease, including heart failure, coronary artery disease, or congenital heart disease.
  • People with diabetes, type 1 or type 2.
  • People who are overweight (BMI 25 or above), obese (BMI 30 or above), or severely obese (BMI 40 or above).
  • People with weakened immune systems, whether from cancer treatment, transplant, HIV, or immunosuppressive medication.
  • People with chronic kidney or liver disease.
  • Current and former smokers.
  • Pregnant patients with co-existing conditions that raise their risk.

What clinicians and patients can do now

Make sure patients know their own risk category. Those over 65, immunocompromised, pregnant with risk factors, or managing chronic illness still qualify, and in many cases without a prescription.

Offer a telehealth visit to anyone who thinks they need a physician’s order. I do not yet know whether Teladoc, MDLive, or Amwell will handle vaccine prescriptions this season; I would expect that to be under discussion internally at all three.

Tell patients to call their pharmacy early in the fall and ask what they stock and what their rules are. The rules are not uniform.

Warn patients that coverage may hinge on new CDC guidance. If they are healthy and not recommended for the shot, they should plan on paying for it.

Keep pushing masking, distancing, and flu vaccination. A seasonal bump alongside influenza and RSV is plausible, and fewer vaccinated people means more pressure downstream (AP News).

The frustration is fair. This is no longer one recommendation that covers everybody, and the layering of political change on top of clinical guidance has made it genuinely confusing. What it is not is an abandonment of science. Federal agencies narrowed eligibility, medical societies objected, pharmacies adjusted, and patients now have to go through a physician more than they used to. Timing still points to this fall, and we will know more as orders and shipments start moving.

That is where things stand. Questions are welcome.

Scott Rennie, D.O.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Why Are Some U.S. Physicians Moving to Canada to Practice?

On By Dr. Scott RennieIn Healthcare System & TechnologyLeave a comment

I have had several conversations recently with colleagues who are seriously considering leaving the U.S. to practice in Canada. This is not happening quietly. Interest from U.S.-trained physicians in moving north has jumped sharply over the past year, and the reasons run deeper than any single administration or policy.

American physicians looked at Canada as an option well before the current political moment. What changed is the volume. CanAm Physician Recruiting reported a 65 percent increase in inquiries between January and April, with some days bringing calls from as many as 15 U.S. doctors asking about moving immediately.

The licensing numbers tell the same story. According to the Medical Council of Canada, U.S. physicians creating accounts on physiciansapply.ca, typically the first step toward licensure, rose from 71 to 615 over seven months. That is a 765 percent increase. Ontario registered 116 U.S.-trained doctors in the first quarter of 2025, at least 50 percent more than the prior two quarters. British Columbia licensed 28 U.S.-trained physicians in the fiscal year ending February 2025, roughly triple the year before.

KFF Health News reported on one emergency physician, identified only as Michael, who moved his family to Canada this year. He described the work of a physician as “being kind to people who are in their weakest place,” and said he no longer saw that reflected in the country he was practicing in. KFF and NPR granted him anonymity because he feared reprisal if he returned to the U.S.

Canada’s publicly funded system is part of the draw. Physicians cite fewer administrative obstacles and more stability. Licensing rules have also loosened to help fill shortages, which lowers the barrier for U.S. doctors considerably.

Canada has its own problems, and they are not small. The country needs roughly 23,000 more family physicians to meet current demand. Surgical wait times and crowded emergency departments are real. For a lot of American physicians the trade is still worth making.

Universal coverage carries weight of its own. When every patient is covered, the work shifts back toward care and away from arguing about whether a medication or a scan will be approved. I think about my family in Isokyrö, Finland, where this is simply how it works. They do not worry about losing insurance when they change jobs. They do not put off care because of what it will cost. It is treated as a basic obligation of a society, and it feeds the trust people have in their physicians.

Recent shifts in U.S. health policy are pushing more doctors to look north. The American Academy of Family Physicians, American Academy of Pediatrics, and American College of Osteopathic Family Physicians have all criticized changes to federal vaccine guidance, including the removal of COVID-19 vaccine recommendations for healthy children and pregnant women, decisions made outside the CDC’s Advisory Committee on Immunization Practices, and appointments of individuals with a documented history of vaccine skepticism. These groups have filed suit and issued public statements about the erosion of evidence-based policy.

None of this is hypothetical. I know a family physician who left a chaotic Texas clinic for a small town in Ontario. She gave up income and proximity to family. What she got back was the ability to practice the way she was trained to, without political interference.

Leaving is hard. Licenses, families, and routines hold people where they are. But when physicians feel their core values are under threat, a move like this stops looking dramatic and starts looking reasonable. That is the part worth paying attention to. This is not really a trend. It is a symptom.

If you are curious about Canadian licensing or how this shift might affect your own career, I am glad to talk it through. We all went into medicine to take care of people, and a fair number of our colleagues are going where they believe they can still do it.

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Sources:

Perimenopause and Menopause Symptoms and How to Manage Them

On By Dr. Scott RennieIn Menopause & Women's HealthLeave a comment

Menopause comes up on my schedule most weeks, and patients still arrive unsure what to expect from it. So it helps to start with definitions. Perimenopause is the transition before menopause. Hormone levels fluctuate, cycles become irregular, and the phase can run several years. Menopause itself is twelve straight months without a period. The average age in North America is around 51.

Symptoms vary more than most patients expect. During perimenopause, bleeding may be heavier some months and absent others. Hot flashes and night sweats are common. Some women notice mood changes or brain fog. Others raise vaginal dryness or discomfort with intercourse, usually only after I ask directly. Sleep problems come up constantly, and they are often just night sweats wearing a different hat. In full menopause those symptoms can continue, though bleeding stops for good. Skin and hair changes, weight shifts, and urinary urgency show up here too.

One patient in her late forties came to me worried she had a thyroid problem. She felt “off,” with fatigue, poor sleep, and irregular cycles. Her lab work came back normal, but her story fit perimenopause cleanly. That visit turned into the conversation she had actually needed, about what was happening in her body and what we could do about it.

Treatment follows the symptom pattern and the patient’s health profile. For hot flashes, hormone replacement therapy is the most effective option we have, though it is not right for everyone. Non-hormonal options including SSRIs and gabapentin also reduce vasomotor symptoms. Vaginal estrogen, as cream or tablets, works well for dryness and discomfort. Lifestyle changes carry real weight: a cool bedroom, less alcohol, regular exercise, stress management. Cutting caffeine after mid-afternoon sometimes does more than patients expect.

Preventive care deserves attention in this phase. Bone health matters more once estrogen declines, so I bring up calcium, vitamin D, and weight-bearing exercise. DEXA scans depend on age and risk factors. Cardiovascular risk climbs after menopause, which makes cholesterol, blood pressure, and diabetes screening worth staying current on. Breast and cervical cancer screening continue as appropriate. Colon cancer screening tends to land right in this age range as well, and over video I have to ask about it directly, because nobody volunteers that they are overdue.

Menopause is a normal stage of life that still manages to catch people off guard. Family physicians are well placed to normalize the conversation, take the symptoms seriously, and point patients toward both relief and prevention. Medication is not always part of that. Listening and practical support always are.

Scott Rennie, D.O.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

What Is an Obesity Medicine Board Certified Doctor?

On By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

More family physicians, myself included, are choosing to become certified through the American Board of Obesity Medicine. The credential looks small on paper. What sits behind it is a real change in how we handle obesity and the conditions that travel with it.

ABOM certification is open to physicians who can show advanced knowledge in preventing, evaluating, and treating obesity. There are two routes. One is 60 hours of continuing medical education credits in obesity-related topics, half of which must specifically address obesity treatment. The other is an accredited obesity medicine fellowship. Either way, candidates then sit for a 4-hour exam covering the physiology and pathophysiology of obesity, nutrition and behavioral treatment, medications, surgery, and bias in care.

Why go through all that? We are the ones patients come to first. About 40% of U.S. adults have obesity, and it is tied to diabetes, heart disease, infertility, arthritis, and worse outcomes with infections. Yet most of us had very little structured training on obesity in medical school or residency. I certainly didn’t. ABOM fills that gap with something more useful than repeating “eat less, move more.”

Patients are also asking harder questions than they used to. GLP-1 medications like semaglutide and tirzepatide changed the conversation. People have worked out that weight regulation is physiology, not character. They want to know whether medication makes sense for them, what the risks are, and what else they should be doing. Certification puts you in a better position to answer that honestly and to build a plan that lasts longer than a few months.

For me, the certification built confidence. I know how to adjust anti-obesity medications, screen for related conditions like PCOS or fatty liver, and talk about weight without stigma. Patients notice. They feel taken seriously when obesity gets treated as the chronic medical condition it is.

One case stays with me. A patient in her fifties came to me with obesity and prediabetes, worn down after years of failed diets. Using what I’d learned, I recognized she was a candidate for pharmacotherapy. We started semaglutide, and we built a plan around meal structure, activity, and sleep. Within months her A1c had come back into the normal range and her energy had returned.

Colleagues are seeing benefits too. A physician I know in rural Missouri became ABOM-certified and quickly became a regional referral point. Practices in nearby towns began sending her patients rather than having them drive hours to an urban obesity clinic. In an underserved area, that is the difference between getting treated and not.

For doctors considering it, the field is growing quickly. More than 11,500 physicians in the United States and Canada now hold the certification, up from roughly 9,800 a year earlier. Insurers are beginning to recognize obesity medicine, which means more treatments get covered when a certified physician is guiding them. You also end up connected to a national group of people working on one of the largest drivers of chronic disease we have.

So the certification is a line on a CV. It is also the reason I practice differently than I did before I sat the exam, and that is the part that reaches patients.

Scott Rennie, D.O.

Sources:

American Board of Obesity Medicine: https://www.abom.org

Johnson-Rabbett B, et al. An Update on the American Board of Obesity Medicine (ABOM): 2017-2024. Obesity. 2025. doi:10.1002/oby.70013

CDC/NCHS. Obesity and Severe Obesity Prevalence in Adults: United States, August 2021-August 2023. NCHS Data Brief No. 508: https://www.cdc.gov/nchs/products/databriefs/db508.htm

Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in Obesity Among Adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284-2291.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Mosquitoes Are More Than a Nuisance to Your Health

On By Dr. Scott RennieIn Infectious DiseaseLeave a comment

For a long time, malaria, dengue, and Zika were filed under “somewhere else.” In the U.S. and Europe most people encountered them in a textbook or a travel clinic and nowhere else. That is changing.

Climate shifts, international travel, and the sheer resilience of mosquitoes like Aedes aegypti have pushed these infections north. They are turning up in the southern U.S. and in parts of Europe now. Calling them tropical diseases is starting to be inaccurate.

Sanjay Gupta and Timothy Winegard made the scale of it plain in a CNN interview: mosquitoes kill more people than any other animal, and more than 700,000 people die each year from what they carry. That number is difficult to sit with.

The viral illnesses get most of the attention. Dengue, Zika, chikungunya, and West Nile are the familiar names. Dengue was once almost entirely tropical and now appears in Florida and Europe. Zika made headlines for the birth defects it caused. Chikungunya is remembered by anyone who has had it for the joint pain. West Nile is simply established across much of the U.S. at this point.

Malaria is a different animal, caused by protozoa rather than a virus. Most people still think of it as an African disease. Yet there have been locally acquired cases in the U.S. recently. Warm temperatures and standing water are all the transmission cycle really needs.

Parasitic worms belong in the conversation too. Lymphatic filariasis is still overwhelmingly tropical, but the movement of people and goods makes expansion more plausible than it used to be.

Prevention is unglamorous and effective. Emptying standing water around a house does more than people expect. Repellent, intact window screens, and long sleeves cut exposure. For travelers, treated bed nets and the right vaccines, yellow fever among them, still carry the load.

Clinicians need to reframe how we think about these illnesses. They are not filed under travel medicine anymore. With malaria reappearing in Florida and Texas, recognizing early symptoms and pushing prevention falls to us. I have had patients look genuinely surprised when I brought up insect repellent on a video visit for something unrelated. It struck them as beside the point. That reaction is the thing that has to change.

Mosquitoes are not slowing down, and the illnesses they carry keep moving closer to where our patients actually live. The questions are coming. We should have answers ready.

Scott Rennie, D.O.

References

Gupta S, Winegard T. CNN interview on mosquito-borne disease, 2023.

Centers for Disease Control and Prevention. Malaria in the United States, 2023.

World Health Organization. Mosquito-borne diseases fact sheet, 2023.

Watch: Dr. Sanjay Gupta & Timothy Winegard discuss how to avoid mosquito bites and the diseases they carry.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Is Obesity a Brain Problem? How the Body Controls Weight

On By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

Patients ask me some version of this constantly: “Why can’t I just eat less and lose the weight?” On the surface it sounds like a fair question. Obesity is a chronic disease with a great deal of biology behind it, and the brain sits at the center of that biology. Treatment that ignores this tends to fail, and the patient usually gets blamed for the failure.

Research from Dr. Sabrina Diano at Columbia University lays out how the brain regulates weight and why it matters clinically.

The central nervous system runs energy balance through two systems. The hypothalamus handles hunger and fullness, the homeostatic side. The hedonic pathway, running on dopamine, responds to reward. That second system is why cravings and emotional eating feel as forceful as they do (Lenoir et al., 2007; Samaha et al., 2020).

Within the hypothalamus, the arcuate nucleus holds two opposing groups of neurons. NPY/AgRP neurons drive eating when energy runs low. POMC/α-MSH neurons suppress appetite when energy is adequate. Both communicate with the PVN, VMH, and LH, and the result is a negotiated balance between intake and expenditure (Diano, 2024; Gropp et al., 2005).

The body feeds signals into that system constantly. Fat tissue releases leptin, which should reduce appetite, except that many patients with obesity develop leptin resistance and the signal lands blunted (Zhang et al., 1994). Adiponectin helps regulate insulin and fat metabolism, and levels fall in obesity (Mahmoud, 2022). After meals, insulin, GLP-1, PYY, and amylin generate satiety. Ghrelin, made in the stomach, climbs before meals and drives hunger. In Prader-Willi syndrome it runs abnormally high (Drucker & Holst, 2023).

Diet interferes with the signaling directly. High-fat, high-sugar foods provoke inflammation in the hypothalamus that disrupts how these neurons talk to each other, through oxidative stress and breakdown of melanocortin pathways (Kim et al., 2019; Diano, 2023). Obesity also generates low-grade inflammation throughout the body, visceral fat especially, which worsens insulin resistance (Mukherjee et al., 2023).

Genetics complicates it further. A few single-gene mutations cause obesity outright, but most cases involve many genes each nudging risk slightly. Epigenetics matters too: maternal obesity during pregnancy can alter gene expression in the child and raise their risk decades later (Farooqi et al., 2003; Mahmoud, 2022; Catalano & Shankar, 2017).

The gut microbiome is another piece, with lower microbial diversity and more gut inflammation both tracking with obesity (Vezza et al., 2020). Environmental chemicals including BPA and phthalates can disrupt hormone signaling and tilt the body toward storing fat (Heindel et al., 2015).

All of this explains the part patients find most demoralizing, which is why weight loss is so hard to hold onto. The body defends a set point. Weight comes down, metabolism slows, hunger hormones rise, and regain becomes the likely outcome (Diano, 2024).

Consider what that looks like in practice. Someone loses 20 pounds through real effort, and then finds themselves hungrier than they have ever been while burning fewer calories at rest. Nothing about their discipline changed. Their body is defending the weight it had before.

Recognizing obesity as a biologically regulated condition changes the approach. Treatment has to work on several fronts at once: nutrition, behavioral strategy, medication, and sometimes surgery. GLP-1 receptor agonists like liraglutide and semaglutide, and dual agonists like tirzepatide, act on these pathways directly, which is a large part of why they work as well as they do.

Obesity is physiology, environment, and genetics interacting. Personal choice is in there somewhere, well downstream of the rest. Understanding that gives us better tools and considerably more patience.

Scott Rennie, D.O.

References

Diano, S. Physiology and Pathophysiology of Obesity, Columbia University, 2024.

Zhang Y, et al. Nature, 1994;372(6505):425-32.

Gropp E, et al. Nature Neuroscience, 2005;8(10):1289-91.

Farooqi IS, et al. NEJM, 2003;349(6):570-8.

Drucker DJ, Holst JJ. Diabetologia, 2023;66(4):651-64.

Kim DW, et al. Cell Metabolism, 2019;30(1):110-122.

Mukherjee R, et al. Front Endocrinol, 2023;14:1154067.

Heindel JJ, et al. Nat Rev Endocrinol, 2015;11(11):653-61.

Mahmoud AM. Int J Mol Sci, 2022;23(3):1225.

Catalano PM, Shankar K. BMJ, 2017;356:j1.

Vezza T, et al. Antioxidants, 2020;9(7):578.

Lenoir M, et al. PLoS One, 2007;2(8):e698.

Samaha AN, et al. Neurosci Biobehav Rev, 2020;113:198-213.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.