There are two kinds of people who defend our absolutely trash and utterly inhumane medical system: those who basically never have to deal with it and those who personally benefit from its trash nature, and sometimes the latter are doctors.
The hell kind of health insurance do you have? No one I know has anything like these sorts of problems accessing healthcare. Like, a few months ago I was having some female issues, got an appointment with my doctor that week.
W hen she determined she needed more info, her office made an ultrasound appointment for me at the hospital. All I had to do was show up. My roommate had the same experience with a broken arm: urgent care took x-rays, determined surgery was required to properly set the break, and urgent care made a next-day appointment for her with an appropriate surgeon. We both have what I'd class as middle-of-the-road insurance, maybe slightly better than average? But certainly not rich person insurance.
We've definitely had issues--my roommate was once bit by a suspected rabid animal and told by police responding to the animal call to go to the ER, who charged $500 to squirt some saline in the wound and say they couldn't do anything else until the animal was tested. But aside from doctors being jackasses, that's really the only trouble we've had.
I am so sorry about the mishegas with your shoulder and with our terrible healthcare system. A few years ago, when I lived in Prague, I had cancer and appendicitis in one year. (It was a hell of a year.) I got all my treatments through the Czech healthcare system; the treatments were better (more days in the hospital, a better nurse-to-patient ratio, exceptional doctors who actually take time to talk with you, etc.), and they cost about 15-20 percent of what they would have in the US. The only thing I paid for was a private room (which was, I kid you not, $75 for a week—the cheapest hotel room in Prague!).
But what blew my mind—and counter to all the stereotypes about universal healthcare—is that I didn’t have to wait for appointments. The doctors are salaried rather than paid per procedure, so they don’t have an incentive to overtreat. The result is that they can spend more time with patients who actually need care. Once I was in the hospital, I just walked (or, in the case of appendicitis, was rolled) from office to office for scans, second opinions, and other procedures. If the doctor was with a patient, I waited on a bench outside the office door until s/he was ready for me. And needless to say there was no hassle with insurance. I just showed up and was treated.
The per capita GDP in the Czech Republic is about 50 percent of that of the US. It is insane to me that we have such a terrible system when poorer countries do so much better than us. I really hope you find a solution for your shoulder, Freddie. What a disgrace.
- There’s no such thing as too much posting. Some of us work boring desk jobs 40+ hours per week. Every email from Substack is like a lab rat getting a pellet (novelty = dopamine spike and desire for more pellets).
- On primary care, my spouse tells me the opposite is true in psychiatry. Primary care docs are overconfident and prescribe psych meds in combinations and doses that don’t make sense. I guess everyone thinks psych is easy.
- I’m not sure if we’re allowed to discuss the novel before it’s complete, but I caught up today and I’m hooked. I hope we’ll get a comment thread when it’s finished, so we can have Substack book club.
Go to your doctors office, tell them that you do not have an appointment but you are willing to wait until one is available to see you. I have only done it once, but I was seriously ill and they actually saw me in half an hour. This works better if you have a working relationship with your physician.
Keep pushing. I have a similar issue in my shoulder and never got it looked at. It isn’t the end of the world - I can still lift - but I have to be very careful with my left shoulder or it’ll give out. It’s been 20 years like this.
I don’t think the problem is your insurance. I think NYC has terrible healthcare, doctors per capita be damned. My 20 years there were filled with bad experiences (though I never had that “see your PCP first” bullshit insurance, thank god). Since we decamped for the burbs everything has been way better.
"I don’t know how people continue to justify our rotten system. I don’t."
That's rhetorical, right? Because surely you actually do know.
Well, OK, just in case: the system is justified by Republicans, who believe that health care is a marketable quantity that you should pay for, like any other good or service. If you can't pay for it (up front, in full), you must be a worthless slacker who doesn't deserve it. So as bad as the current system is, the vast majority of them would like to make it much much worse. (See the Obamacare repeal vote in 2017.)
If you don't agree with Republicans, I have a political strategy to suggest.
I'm sorry about your shoulder but I don't have that problem with insurance. On the other hand, I'm a teacher. For years, I wasn't a teacher, was self-employed, and had fake insurance that I paid for in case I got hit by a truck. I paid cash for everything: doctor visits, accupuncture, whatever.
But now I pay full dime for my insurance (about $12K/year) and it's fricking great. I went through the list and actually picked my own PCP (I agree, it's often out of date but I got lucky), one that seemed to have as secondary interests my issues (allergies, asthma), and I'm happy. But I use urgent care a lot because I don't like appointments. An urgent care physician tentatively diagnosed me with De Quervain's tendonitis but said I had to go to a hand doctor right away to confirm because it might be arthritis and referred me on the spot (it was, in fact, arthritis). If I email my doctor and describe issues, it's not uncommon to be referred without need for an appointment. I also go outside of network for my allergist and for sleep apnea, both to world class centers, and the insurance pays without hassle. Also pays for accupuncture out of network. Downside--lots of $500 deductibles if I have to have an MRI or xrays or things like that. But no serious complaints.
My own feeling of insurance is that it should be everyone pays for major medical and catastrophic coverage and then we pay for more out of pocket with a much lower number for deducting it from taxes ,but I know I'm alone in that.
From what I can tell, I don't have a particularly unique policy--others have it and whine about it. And I know my son pays a small fortune for insurance for his kids and has huge deductibles. I don't understand that at all. I wish parents could buy policies just for their kids.
I've heard a lot of horror stories about private insurance. I don't mean to boast, but I haven't experienced any of them. The reason is simple: I have Kaiser. My advice for virtually anyone who doesn't have significant mental health issues (so probably not including Freddie) on health insurance is this: move to a state (there are lots, but NY isn't one) that has Kaiser and get Kaiser. I recently moved within the SF Bay Area. I had a Kaiser doctor in my old location in north bay, but had never met him or her. When I got to my new place, I just picked a new doctor from a list of PCPs who were taking patients here in the east. I've still never met my doctor, but all I have to do is email him and he gets me the care I need.
For example: I have a notionally bad ankle that isn't actually problem during normal life. But I just went to Hawaii and it gave out on me twice while hiking (no serious injuries), so I decided I'd probably need an x-ray and some physical therapy. When I got back, I emailed and asked for those things, and my doctor emailed back with the number of the physical therapy department and that I could call them and schedule my care whenever, and literally just walk in to the nearest x-ray equipped facility any time during business hours and get x-rayed. If I need urgent care, I call the advice nurse and make an appointment (though that one did take some figuring) for just about any time of day or night. You can also order refills of prescriptions through the website. When I was in southern California, I had a serious skin issue on my back that required daily dressing changes by a nurse. I would walk in to the nurse clinic at the Kaiser office a block from my apartment every single day around lunch without an appointment and get it changed.
My brother (also just back from Hawaii) got an almost identical injury in Hawaii, but he has Sutter or some crap and has no idea how to do get care.
The caveat is mental health. Kaiser seems pretty skeptical about a lot of things, and psychiatry appears to be one of them. I haven't had this experience (having never sought mental health care), but it's apparently quite hard to get one-on-one mental health care through Kaiser. They tend to direct you to group classes and things. Unless this is a significant issue (and I imagine it probably is for a lot of people, so not trying undersell the gravity of the issue at all), I can't recommend Kaiser highly enough.
Probably the UK system is better or at least simpler but right now getting a face to face appointment is a nightmare. It’s a big talking point over here. And then the wait time for seeing the specialist can be pretty long. I suspect they manage things better in continental Europe.
Hi Freddie, as someone who is finishing medical school here in NYC, but planning on leaving for my residency, I understand your frustration with primary care doctors here in NYC. One problem is that the scope of practice for primary care docs is much more limited than in other places in this country, due mainly to the "availability" of specialists here with subsequent fear of litigation if they due treat something that would have been "better" handled by a specialist and something goes wrong, as well as the general atrophy of skills/knowledge that comes when you don't practice those skills. I would say it's exceedingly unlikely that your doc had no idea what was wrong with your shoulder, but due to the theoretical idea that you could see one of the hundreds of orthopods in the area, they could be held negligent if they didn't refer you out. Obviously, this is not an ideal situation, especially when combined with insurance companies which force you to see them first. This is also why there actually are very few family medicine trained docs (the true generalists) here in NYC, and most primary care docs are internally medicine boarded which has a different focus than true primary care for most of the training. One piece of advice (sorry if you already knew/tried this), for any musculoskeletal injuries in the future, check if any of the primary care docs you could see have done a fellowship in sports medicine which is an additional year of training for family medicine/internal medicine doctors in the non-surgical diagnosis and management of orthopedic injuries. I wish you luck and hope you feel better! I'm a long time reader since your original blog (I took very non-traditional route into medicine, with nearly a decade off in between college and medical school), but never commenter, so I'll also take this opportunity to thank you for all your writing which has brought me great meaning in my life.
I think your problem is that it's your shoulder and they don't think shoulders are an emergency if you can move your arm. I had rotator cuff surgery and they treated it like that. Surgery was just an option along with do nothing and here's some exercises to strengthen the muscles holding your shoulder together. If I were you I'd ask for a referral to PT. Those guys see shoulder injuries all day long and can tell you what's wrong just by feeling around. MRIs don't work on soft tissue injury. A good PT or ortho will know by manipulating it and asking a few questions.
Just a thought - did you ask for a telehealth visit with your PCP? You can usually get one with your PCP or their nurse practitioner same day. Or just email your PCP with the details and they can often just submit the referral. And if you’re right that you’re going to need imaging then you might also do Telehealth with the orthopedist.
Hi Freddie. Primary care doctor here. Sorry you're having so much trouble getting in to see someone. HMO systems can be really rough and finding a good primary care doctor to navigate these systems is essential. Once you have someone responsive who you like and trust, getting referrals can be easier by emailing your doc or via telehealth as BronxZooCobra suggests. The problem is finding someone good who is taking new patients and then getting an initial visit- which can sometimes take months. For now: change your PCP to whomever can get you in immediately (which it sounds like your girlfriend managed), get your referral to ortho AND to physical therapy. You may or may not need an MRI but ortho should decide this. Once you get your referral and your shoulder is taken care of, if you like your new doc- great. If not, do the work to find someone you do like now and change your provider so that if you need something in the future, you're not stuck in this bind. Maybe your psychiatrist can recommend someone in your network and help you get in for an appt? I'm closed to new patients precisely so that I can be responsive and see people when they need to be seen, but I make exceptions if another doctor reaches out to me and asks me to take a patient.
There are two kinds of people who defend our absolutely trash and utterly inhumane medical system: those who basically never have to deal with it and those who personally benefit from its trash nature, and sometimes the latter are doctors.
We do have bad problems with medical service, but your insurance sucks.
The hell kind of health insurance do you have? No one I know has anything like these sorts of problems accessing healthcare. Like, a few months ago I was having some female issues, got an appointment with my doctor that week.
W hen she determined she needed more info, her office made an ultrasound appointment for me at the hospital. All I had to do was show up. My roommate had the same experience with a broken arm: urgent care took x-rays, determined surgery was required to properly set the break, and urgent care made a next-day appointment for her with an appropriate surgeon. We both have what I'd class as middle-of-the-road insurance, maybe slightly better than average? But certainly not rich person insurance.
We've definitely had issues--my roommate was once bit by a suspected rabid animal and told by police responding to the animal call to go to the ER, who charged $500 to squirt some saline in the wound and say they couldn't do anything else until the animal was tested. But aside from doctors being jackasses, that's really the only trouble we've had.
I am so sorry about the mishegas with your shoulder and with our terrible healthcare system. A few years ago, when I lived in Prague, I had cancer and appendicitis in one year. (It was a hell of a year.) I got all my treatments through the Czech healthcare system; the treatments were better (more days in the hospital, a better nurse-to-patient ratio, exceptional doctors who actually take time to talk with you, etc.), and they cost about 15-20 percent of what they would have in the US. The only thing I paid for was a private room (which was, I kid you not, $75 for a week—the cheapest hotel room in Prague!).
But what blew my mind—and counter to all the stereotypes about universal healthcare—is that I didn’t have to wait for appointments. The doctors are salaried rather than paid per procedure, so they don’t have an incentive to overtreat. The result is that they can spend more time with patients who actually need care. Once I was in the hospital, I just walked (or, in the case of appendicitis, was rolled) from office to office for scans, second opinions, and other procedures. If the doctor was with a patient, I waited on a bench outside the office door until s/he was ready for me. And needless to say there was no hassle with insurance. I just showed up and was treated.
The per capita GDP in the Czech Republic is about 50 percent of that of the US. It is insane to me that we have such a terrible system when poorer countries do so much better than us. I really hope you find a solution for your shoulder, Freddie. What a disgrace.
- There’s no such thing as too much posting. Some of us work boring desk jobs 40+ hours per week. Every email from Substack is like a lab rat getting a pellet (novelty = dopamine spike and desire for more pellets).
- On primary care, my spouse tells me the opposite is true in psychiatry. Primary care docs are overconfident and prescribe psych meds in combinations and doses that don’t make sense. I guess everyone thinks psych is easy.
- I’m not sure if we’re allowed to discuss the novel before it’s complete, but I caught up today and I’m hooked. I hope we’ll get a comment thread when it’s finished, so we can have Substack book club.
Go to your doctors office, tell them that you do not have an appointment but you are willing to wait until one is available to see you. I have only done it once, but I was seriously ill and they actually saw me in half an hour. This works better if you have a working relationship with your physician.
Keep pushing. I have a similar issue in my shoulder and never got it looked at. It isn’t the end of the world - I can still lift - but I have to be very careful with my left shoulder or it’ll give out. It’s been 20 years like this.
I don’t think the problem is your insurance. I think NYC has terrible healthcare, doctors per capita be damned. My 20 years there were filled with bad experiences (though I never had that “see your PCP first” bullshit insurance, thank god). Since we decamped for the burbs everything has been way better.
"I don’t know how people continue to justify our rotten system. I don’t."
That's rhetorical, right? Because surely you actually do know.
Well, OK, just in case: the system is justified by Republicans, who believe that health care is a marketable quantity that you should pay for, like any other good or service. If you can't pay for it (up front, in full), you must be a worthless slacker who doesn't deserve it. So as bad as the current system is, the vast majority of them would like to make it much much worse. (See the Obamacare repeal vote in 2017.)
If you don't agree with Republicans, I have a political strategy to suggest.
I'm sorry about your shoulder but I don't have that problem with insurance. On the other hand, I'm a teacher. For years, I wasn't a teacher, was self-employed, and had fake insurance that I paid for in case I got hit by a truck. I paid cash for everything: doctor visits, accupuncture, whatever.
But now I pay full dime for my insurance (about $12K/year) and it's fricking great. I went through the list and actually picked my own PCP (I agree, it's often out of date but I got lucky), one that seemed to have as secondary interests my issues (allergies, asthma), and I'm happy. But I use urgent care a lot because I don't like appointments. An urgent care physician tentatively diagnosed me with De Quervain's tendonitis but said I had to go to a hand doctor right away to confirm because it might be arthritis and referred me on the spot (it was, in fact, arthritis). If I email my doctor and describe issues, it's not uncommon to be referred without need for an appointment. I also go outside of network for my allergist and for sleep apnea, both to world class centers, and the insurance pays without hassle. Also pays for accupuncture out of network. Downside--lots of $500 deductibles if I have to have an MRI or xrays or things like that. But no serious complaints.
My own feeling of insurance is that it should be everyone pays for major medical and catastrophic coverage and then we pay for more out of pocket with a much lower number for deducting it from taxes ,but I know I'm alone in that.
From what I can tell, I don't have a particularly unique policy--others have it and whine about it. And I know my son pays a small fortune for insurance for his kids and has huge deductibles. I don't understand that at all. I wish parents could buy policies just for their kids.
I've heard a lot of horror stories about private insurance. I don't mean to boast, but I haven't experienced any of them. The reason is simple: I have Kaiser. My advice for virtually anyone who doesn't have significant mental health issues (so probably not including Freddie) on health insurance is this: move to a state (there are lots, but NY isn't one) that has Kaiser and get Kaiser. I recently moved within the SF Bay Area. I had a Kaiser doctor in my old location in north bay, but had never met him or her. When I got to my new place, I just picked a new doctor from a list of PCPs who were taking patients here in the east. I've still never met my doctor, but all I have to do is email him and he gets me the care I need.
For example: I have a notionally bad ankle that isn't actually problem during normal life. But I just went to Hawaii and it gave out on me twice while hiking (no serious injuries), so I decided I'd probably need an x-ray and some physical therapy. When I got back, I emailed and asked for those things, and my doctor emailed back with the number of the physical therapy department and that I could call them and schedule my care whenever, and literally just walk in to the nearest x-ray equipped facility any time during business hours and get x-rayed. If I need urgent care, I call the advice nurse and make an appointment (though that one did take some figuring) for just about any time of day or night. You can also order refills of prescriptions through the website. When I was in southern California, I had a serious skin issue on my back that required daily dressing changes by a nurse. I would walk in to the nurse clinic at the Kaiser office a block from my apartment every single day around lunch without an appointment and get it changed.
My brother (also just back from Hawaii) got an almost identical injury in Hawaii, but he has Sutter or some crap and has no idea how to do get care.
The caveat is mental health. Kaiser seems pretty skeptical about a lot of things, and psychiatry appears to be one of them. I haven't had this experience (having never sought mental health care), but it's apparently quite hard to get one-on-one mental health care through Kaiser. They tend to direct you to group classes and things. Unless this is a significant issue (and I imagine it probably is for a lot of people, so not trying undersell the gravity of the issue at all), I can't recommend Kaiser highly enough.
Hi Freddie, you should write as much as you want. Your subscribers can choose whether to read the posts......
And yes, Free Black Thought is great. The post on origins of CRT is an eye-opener and clear.
https://freeblackthought.substack.com/p/why-did-critical-race-theory-emerge?token=eyJ1c2VyX2lkIjo5MjE3NTgsInBvc3RfaWQiOjQwMDY2MjU1LCJfIjoiNG0vcVkiLCJpYXQiOjE2MzAyMTYzMzgsImV4cCI6MTYzMDIxOTkzOCwiaXNzIjoicHViLTQxNDIxMCIsInN1YiI6InBvc3QtcmVhY3Rpb24ifQ.ltgFnPbd5QBTTBHjGYdeEWtm10oMjY9--rE713USgqI
Probably the UK system is better or at least simpler but right now getting a face to face appointment is a nightmare. It’s a big talking point over here. And then the wait time for seeing the specialist can be pretty long. I suspect they manage things better in continental Europe.
Hi Freddie, as someone who is finishing medical school here in NYC, but planning on leaving for my residency, I understand your frustration with primary care doctors here in NYC. One problem is that the scope of practice for primary care docs is much more limited than in other places in this country, due mainly to the "availability" of specialists here with subsequent fear of litigation if they due treat something that would have been "better" handled by a specialist and something goes wrong, as well as the general atrophy of skills/knowledge that comes when you don't practice those skills. I would say it's exceedingly unlikely that your doc had no idea what was wrong with your shoulder, but due to the theoretical idea that you could see one of the hundreds of orthopods in the area, they could be held negligent if they didn't refer you out. Obviously, this is not an ideal situation, especially when combined with insurance companies which force you to see them first. This is also why there actually are very few family medicine trained docs (the true generalists) here in NYC, and most primary care docs are internally medicine boarded which has a different focus than true primary care for most of the training. One piece of advice (sorry if you already knew/tried this), for any musculoskeletal injuries in the future, check if any of the primary care docs you could see have done a fellowship in sports medicine which is an additional year of training for family medicine/internal medicine doctors in the non-surgical diagnosis and management of orthopedic injuries. I wish you luck and hope you feel better! I'm a long time reader since your original blog (I took very non-traditional route into medicine, with nearly a decade off in between college and medical school), but never commenter, so I'll also take this opportunity to thank you for all your writing which has brought me great meaning in my life.
I think your problem is that it's your shoulder and they don't think shoulders are an emergency if you can move your arm. I had rotator cuff surgery and they treated it like that. Surgery was just an option along with do nothing and here's some exercises to strengthen the muscles holding your shoulder together. If I were you I'd ask for a referral to PT. Those guys see shoulder injuries all day long and can tell you what's wrong just by feeling around. MRIs don't work on soft tissue injury. A good PT or ortho will know by manipulating it and asking a few questions.
Just a thought - did you ask for a telehealth visit with your PCP? You can usually get one with your PCP or their nurse practitioner same day. Or just email your PCP with the details and they can often just submit the referral. And if you’re right that you’re going to need imaging then you might also do Telehealth with the orthopedist.
Hi Freddie. Primary care doctor here. Sorry you're having so much trouble getting in to see someone. HMO systems can be really rough and finding a good primary care doctor to navigate these systems is essential. Once you have someone responsive who you like and trust, getting referrals can be easier by emailing your doc or via telehealth as BronxZooCobra suggests. The problem is finding someone good who is taking new patients and then getting an initial visit- which can sometimes take months. For now: change your PCP to whomever can get you in immediately (which it sounds like your girlfriend managed), get your referral to ortho AND to physical therapy. You may or may not need an MRI but ortho should decide this. Once you get your referral and your shoulder is taken care of, if you like your new doc- great. If not, do the work to find someone you do like now and change your provider so that if you need something in the future, you're not stuck in this bind. Maybe your psychiatrist can recommend someone in your network and help you get in for an appt? I'm closed to new patients precisely so that I can be responsive and see people when they need to be seen, but I make exceptions if another doctor reaches out to me and asks me to take a patient.