r/FamilyMedicine

Curious how others have handled this. I am a male PA. I had a patient recently that was changed to my schedule last minute as I was light on patients and helping a colleague out. Chief complaint was a groin rash for which he was seen at an urgent care one week earlier.

I walk in and he immediately said, “You’re not Dr. Female. I specifically asked for a female provider.” I said, “I see. Okay. So what’s your concern? Why do you need a female provider.” After a lot of grumbling and moaning and him repeating that he only sees females and that should “be all over my chart,” I said “okay, why don’t we take a moment. I’ll be back.”

There was a recent incident at our clinic a few weeks ago where a different patient asked to only see a female and was a total creep, borderline assaulting her/unwanted touching. I went back in the room and said look, here are your options: see me today, go back to the urgent care you already went to a week ago (where incidentally, yes, he was seen by a male provider), or reschedule a few weeks out from today. I counted the seconds of silence and him huffing and puffing (18 seconds), and he said “I’m all set,” and proceeded to stand up from his wheel chair and push it out the door. He did not reschedule with anyone.

Frankly, I just don’t see a reason why a male would require a female provider, especially when there is going to be an examination of his genitals. Yes, if he was assaulted by a male himself and has PTSD, I do understand that in retrospect, but my intuition was telling me that was not the situation. I told my manager we should have a protocol in place for front desk staff when patients ask for this.

I could have handled this better and offered a chaperone, but I feel like my gut was saying this patient has gross intentions.

How do you guys handle this? Has anyone had something like this happen, particularly a male asking for only female providers?

Hello Everyone, I have started working as a new job out of residency and have been reading about billing. Wanted to ask if you guys bill following codes:

1. For well child visit: 96110, 96161, 96127.
2. Tobacco: 99406, 99407.
3. Alcohol: G0442, G0443.
4. CVD/Obesity: G0446, G0447.
5. INR Testing: 93793, G0250.

An independent imaging center will essentially always be cheaper than a hospital due to no facility fee.

From what I've seen they're roughly 1/3 the price.

Strictly speaking from the financial side. I'd like to avoid any "if you love what you do" type answers.

I mean, compared to other medical residencies, FM pays less but you do finish training sooner. Now, I'm wondering if a salary around $200k-320k is actually enough once you factor everything in. Like, student loans >300k, taxes and cost of living especially in coastal cities, etc.

For those in FM, is that enough to live comfortably, pay off loans, and save? Or does it only really work in lower cost of living areas? How are you now compared to your peers?

27-year-old male with no significant PMHx presented with a very reproducible episode of left lower-extremity numbness and motor weakness that occurs specifically with running.
He initially feels completely normal, but at approximately the 20-minute mark, he develops numbness in the left leg below the knee, followed by progressive motor weakness. At its worst, he describes it as essentially complete paralysis of the lower leg and says it feels like his “knee is slipping.”
The symptoms resolve with rest, with sensation and motor function returning to baseline after approximately 5–7 minutes.

A few additional details:
No pain associated with the episodes
No symptoms at rest
No similar symptoms in the right leg
No other neurologic symptoms
No significant PMHx
Denies current smoking; previously vaped for approximately 1 year
Rare alcohol use
Denies recreational drug use
The reproducibility with exertion and relatively rapid resolution with rest caught my attention.

What would be on your differential? Would you approach this primarily as a vascular, neurologic, or musculoskeletal/compartment-related issue?

CURB-65.
It's beautifully simple.
Five letters. Five criteria.

In a career full of dumb, convoluted acronyms and funny-sounding drugs, CURB-65 is a breath of fresh air. It’s the guideline, AND its letters spell out its criteria. 

Confusion
Urea >7 
Resp Rate > 30
Blood Pressure <90/65 mmHg
Age > 65

It’s oh, so simple. But it hasn’t always been…

The year is 2002. But to your respiratory consultant, it is 1 BC. Before CURB. 

Patients with pneumonia were arriving in A&E every day with the same question hanging over them. How bad is this infection anyway? 

In the years before CURB, we had two main tools to use. 

1. The Pneumonia Severity Index(PSI): A thorough scoring criterion… but it had 20 different variables to plug into to get an answer. Calculating it felt like filling in your tax return before prescribing antibiotics.
2. The modified British Thoracic Society rule (mBTS): It had just 4 criteria. Confusion, Resp rate, Diastolic BP, Urea > 7. But it was too black and white. Score >2 = severe, Score <2 = not severe. A very blunt instrument.

So, an opportunity emerged.
Hope for the Goldilocks score.
Granular enough to guide the full range of decisions (home, ward or ICU). But without an onboarding process longer than opening a new bank account.

In 2003, the landmark study was published in Thorax, A BMJ journal 

https://preview.redd.it/gejegq8lcith1.png?width=1780&format=png&auto=webp&s=bb9e1578fc28f9cb6d5d4bd59a7953608a050bc1

The primary aim was simple: Develop a better severity score. Make it practical. Make it sort patients based on mortality risk. Make it work both in hospital and, if possible, community settings. 

The hunt for the Goldiocks score begins…

The researchers combined data from three prospective CAP studies in the UK, New Zealand and the Netherlands. Rounding up to a total of 1,068 patients.

Things get a little complex here.
To come up with the Goldilocks score, they first needed to find the relevant criteria. Now comes the detective work.

The researchers threw dozens of variables into a mathematical model and did some statistical wizardry to find out: Which of them actually predicted death?

It just so happens the letters that make up CURB were the biggest needle movers in regards to mortality.

• They excluded variables like serum albumin – whilst independently associated with mortality, it’s not readily available at the time of initial assessment. So they binned it.
• They later on included age, as it was just so damn easy to get a hold of.

With that, CURB-65 was born. `
It was made in such a way that each factor was equally weighted. It didn’t matter which letter was ticked. As you went from 0 => 1 => 2 => 3 and beyond, your risk of death increased a proportional amount. 

So the acronym sounds good, n’ all, but does it accurately predict severity?

That's where the validation step comes in. Of the 1,086 patients included in the study:

• 80% were used to build CURB-65 (derivation group)
• 20% were used to test if CURB-65 actually worked (validation group)

https://preview.redd.it/919l1p8lcith1.png?width=1946&format=png&auto=webp&s=ccdc2555ab6abd8a18b6d1a54d480bb75a3244c0

The validation group supported the trend seen in the derivation group. Mortality rose as CURB-65 increased. 

• Score 0: 0 deaths out of 55 patients.
• Score 1: 5 deaths out of 86 patients, about 5.8%.
• Score 2: 8 deaths out of 46 patients, about 17.4%.
• Score 3: 6 deaths out of 23 patients, about 26%.
• Score 4: 1 death out of 4 patients, about 25%.
• Score 5: 1 death out of 3 patients, about 33.3%

Now, compared to the old tools:

• CURB vs PSI: A systematic review found no significant difference in overall mortality prediction between PSI and CURB-65.
• CURB vs mBTS: Roughly a coin flip in raw accuracy; sensitivity and specificity were near identical between the two in the analysis. But CURB wins as it splits results into more buckets and tells you what to do about it. Home, ward or ICU.

Shortly afterwards, CURB-65 spread.
Through guidelines. To hospitals around the UK. Then around the world. 

And now, more than 20 years later, it’s still one of the first scores doctors learn and one of the few scores that actually sticks.  

What’s that like? (And how do you legally discharge them from your practice without getting hit with patient abandonment or retaliation?)

I’m realizing I’m in the final stretch of residency and want to take advantage of any resident/student/medical professional discounts before I graduate and suddenly have to pay full price for a lot of things **😂**

What are the things you’d recommend signing up for/buying while I still qualify?
I’m thinking beyond the obvious stuff like Amazon Prime/student discounts. I’m looking for the **“**I’m so glad someone told me about this before I graduated**”** type of stuff.
Could be anything:
Fitness/gym memberships
Travel programs, airline/hotel memberships or discounts
Software/subscriptions
Medical resources/board prep/CE
Professional memberships\* (plan to do hospital med and rural ED)
Credit cards/banking perks
Home/life services
Clothes, scrubs, shoes, etc.
Wellness/fitness apps
Museums, attractions, entertainment
Additional subscription services
💰Anything that gives you a better price specifically because you’re a resident/physician
**Bonus points for things that stay discounted after graduations once you sign up, or things that are significantly more expensive once you become an attending.**

60 y/o male with these findings, H/o HTN, DM.

I understand the workup I have to do in this case, but what is the disposition of this patient?

Is it a ED referral or outpatient management?

Is it correct that new possible HF is ED referral, but already diagnosed HF with mild exacerbation is probably an outpatient followup?