Tag: primary care

Unlabeled blister pack of six white oval antibiotic tablets beside a plain paper pharmacy bag on a kitchen table

I hear it almost every day now. “I think I just need a Z-Pak.”

On By Dr. Scott RennieIn Infectious DiseaseLeave a comment

Sometimes it’s phrased as a question. Sometimes it isn’t. In telemedicine especially, many patients request azithromycin by name within the first minute of the visit. The symptoms are familiar. Runny nose. Congestion. Post-nasal drip. Scratchy throat. Maybe a cough that started yesterday. No fever. No shortness of breath. No focal findings anyone could reasonably point to as bacterial.

But they’re convinced the Z-Pak will help them get better faster. They’ve taken it before. It worked last time. Or at least they felt better a few days later and connected the dots.

This didn’t happen by accident.

Azithromycin earned its place in outpatient medicine because it was easier to tolerate than older antibiotics like erythromycin, had fewer drug interactions than clarithromycin, and came packaged in a way that felt efficient. Six pills. Five days. Done. The Z-Pak became a symbol of modern medicine that didn’t slow you down.

Over time, it also became the antibiotic people expected.

In telemedicine, that expectation is even stronger. There’s no exam table. No stethoscope. No labs. No chest X-ray down the hall. The visit is brief by design. When a patient feels sick and wants something tangible, the Z-Pak becomes the path of least resistance. Prescribing it can shorten the encounter. It avoids a long explanation. It reduces the risk of a bad review. It keeps patient satisfaction scores high. It keeps supervisors and clinic managers happy. Everyone moves on to the next visit.

I understand why this happens. I’ve seen it from the inside.

But convenience doesn’t make a treatment safe or appropriate.

Azithromycin does not treat viral infections. It does not help the common cold. It does not clear post-nasal drip. It does not shorten the course of uncomplicated upper respiratory infections. When patients feel better after taking it, they almost always would have improved anyway.

What it does do is expose people to real risk.

Azithromycin can prolong the QT interval. That matters. QT prolongation can predispose patients to dangerous heart rhythms, including torsades de pointes and sudden cardiac death. This risk is higher in people with underlying heart disease, electrolyte abnormalities, or those taking other QT-prolonging medications, but it is not zero in otherwise healthy adults. Large observational studies have shown an increased risk of cardiovascular death during azithromycin treatment compared with other antibiotics or no antibiotics at all.

That risk is invisible to patients. They don’t feel their QT interval getting longer. They just know they want something to help them feel better.

Antibiotics also carry more familiar side effects. Nausea. Diarrhea. Abdominal cramping. Yeast infections. Rashes. Allergic reactions. These are not rare, and they are not trivial when the medication wasn’t needed in the first place.

Then there’s resistance. Every unnecessary antibiotic course applies selective pressure. Azithromycin resistance is already a growing problem in common respiratory pathogens. When we reach for it reflexively, we make it less useful for the patients who actually need it.

The harder part of these visits is the explaining.

It takes longer to walk someone through why their symptoms are viral. Why time, fluids, nasal saline, antihistamines, or intranasal steroids actually help. Why rest matters. Why antibiotics won’t fix inflammation or mucus production. Why feeling miserable does not automatically mean something dangerous is happening.

It’s much faster to send a prescription.

But faster is not better medicine.

I get patients asking for Z-Paks every day that I work in telemedicine. It’s so common that it happens at least once a day, if not three or four times a day. One example sticks with me. A patient requested a Z-Pak for congestion and sinus pressure that had been present for two days. No fever. No facial pain. No worsening course. When I explained why antibiotics wouldn’t help, they were frustrated at first. We talked through what sinus infections actually look like and when antibiotics are appropriate. We discussed symptom control instead. Two days later, they messaged to say they felt better and were glad they didn’t take an antibiotic they didn’t need.

That outcome required time. It required education. It required saying no.

Not every visit goes that smoothly. Some patients remain disappointed. Some leave poor reviews. That pressure is real, especially in high-volume telemedicine environments.

But prescribing antibiotics to keep the peace comes at a cost. It shifts risk onto the patient. It shifts harm into the future. And it reinforces the idea that medicine should always offer a pill, even when the best treatment is patience and support.

Azithromycin became dominant because it was easy. That same ease is why we need to be more careful with it now.

Scott Rennie, D.O.

Sources:

Ray WA, Murray KT, Hall K, Arbogast PG, Stein CM. Azithromycin and the risk of cardiovascular death. New England Journal of Medicine. 2012;366:1881-1890.

Sax PE. How the Z-Pak Took Over Outpatient Medicine. Substack lecture notes and essay.

Svanstrom H et al. Use of azithromycin and death from cardiovascular causes. New England Journal of Medicine. 2013;368:1704-1712.

FDA Drug Safety Communication. Azithromycin and risk of potentially fatal heart rhythms. US Food and Drug Administration. 2013.

CDC. Antibiotic use in the United States: Progress and opportunities. Centers for Disease Control and Prevention.

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 Menopause Care Is Missing From Women’s Checkups

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

I hear some version of the same question most weeks on video visits, patients trying to figure out whether what they’re feeling is actually menopause.

Women often come to me with vague but frustrating symptoms. Trouble sleeping. Brain fog. New anxiety. Irregular or heavy periods. Weight creeping up despite no major changes. Sometimes joint pain, palpitations, or new migraines. Many times, we both suspect something hormonal. The connection to menopause doesn’t always click right away.

Most of us were never taught to see the menopause transition as its own physiologic phase with real preventive implications, not because we don’t care. Medical training gives menopause a brief mention inside reproductive aging, with the emphasis staying on fertility, not on what happens once it ends. Patients ask me about hormone therapy, sleep, mood, or sexual changes, and more often than I’d like, I don’t feel equipped in the moment to explain what’s happening or lay out the options.

The average woman in the United States reaches menopause at about age 51, according to the Mayo Clinic (2024). The years leading up to that point, called perimenopause, can last four to eight years. Hormone levels fluctuate widely during this time. These shifts affect body temperature regulation, brain chemistry, metabolism, and cardiovascular function. Symptoms can begin well before the final menstrual period. A woman in her mid-forties may show up with new anxiety, fatigue, or night sweats. That’s an easy substitution to make instead of perimenopause, and it’s one I watch for now specifically because of how often it happens.

There are several reasons why menopause-related concerns get missed. Many women are still menstruating irregularly and do not yet think of themselves as menopausal; primary care visits are short and filled with competing priorities. The confusion that followed older studies on hormone therapy still lingers. I’d rather be direct about where I land: the newer safety data is solid, and hesitation still rooted in the old fear is outdated. Newer research from The Menopause Society and the National Institutes of Health shows clear safety and benefit for most healthy women under 60 or within 10 years of menopause onset (The Menopause Society, 2023; NIH, Office on Women’s Health, 2024).

I ask every woman in her forties about menstrual changes, hot flashes, sleep, mood, libido, and vaginal or urinary symptoms, because awareness starts with the question, not the answer. Simple questions open the door. If a patient raises the issue herself, I’d rather start the conversation than defer it to a specialist on the spot.

I lean on The Menopause Society’s practical resources and CME, and I’m working through their Menopause Society Certified Practitioner (MSCP) program myself. Reading Menopause Practice: A Clinician’s Guide or reviewing their treatment algorithms has strengthened my own confidence here. Other organizations such as the NIH, AAFP, and Cleveland Clinic also offer free CME courses and case examples.

Treatment doesn’t always mean prescribing systemic hormone therapy right away. I explain the range of choices and personalize them: for some patients that means hormone therapy, for others it’s non-hormonal medications, localized vaginal treatment, or lifestyle interventions. For a symptomatic perimenopausal patient who still needs contraception, I favor continuous combined hormonal contraceptives, since standard menopausal hormone therapy can produce breakthrough bleeding in that setting; a typical low-dose choice is ethinyl estradiol 20 mcg plus levonorgestrel 100 mcg orally once daily, often continuously. If contraception isn’t a factor, my usual starting menopausal regimen is transdermal 17-beta-estradiol 0.025 to 0.05 mg/day plus micronized progesterone 100 mg nightly, continuously, if the uterus is present. Weight-bearing exercise, protein intake, and good sleep remain foundational regardless of what else we add. My job is to know the options well enough to guide that discussion, and to know when a referral actually helps more than I can.

When menopause management becomes part of preventive care, patients feel seen and supported. It becomes a normal part of the health conversation, the same as colon screening or cholesterol management; I try to keep these discussions inside the relationship I already have with a patient, rather than routing her to someone new for something I can manage myself.

Menopause represents a turning point for cardiovascular, metabolic, and bone health, and recognizing it early is a real opportunity to prevent disease later. My honest read on where primary care gets this wrong: it’s decades-old caution about hormone therapy that the newer data no longer supports, not a lack of caring. Women deserve clinicians who treat that caution as outdated and prescribe with the confidence the evidence now allows.

Scott Rennie, D.O.

References:

Cleveland Clinic. Menopause and Preventive Care: What Every Woman Should Know. 2023.

The Menopause Society. Menopause Practice: A Clinician’s Guide, 6th Edition. 2023.

Mayo Clinic. Menopause: Symptoms and Causes. Updated 2024.

NIH Office on Women’s Health. Menopause and Heart Health. 2024.

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.

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.