Navigating the Medical System- Tips From a Nurse

Me deciding on a degree in Nursing was not a big shock to anyone. My Mother, Uncle, Aunt, and Grandmother were all Nurses. (Originality is not a big concept in our family.) When I was growing up, I would walk across the street after school and wait for my Mom to finish her shift at the hospital. I would sit at the nurses' station, do my homework (pre-HIPAA), and listen to all the chatter. It only made sense that I also became a nurse. 

I went into cardiac nursing, and I really enjoyed a lot of aspects of it. I LOVED constant learning, critical thinking, and problem-solving. I found the connections with patients and families to be so fulfilling and rewarding. I learned that living isn't always best and dying isn't always worst, that there is always a silver lining and that what is best for the patient is not always what is best for the family. I learned a lot about life, love, and loss. I quickly found out that what you are taught in school is barely scratching the surface of what you need to know to be a good nurse.   

For me, the most rewarding thing was helping patients. Over the years, the drain of administration and management pinching pennies, making everything about money, and not placing the patient care first and foremost got old. Having more patients, sicker patients, less help from nurses, assistants, and techs, and more pushing for faster discharges and admissions wore on me. Patient satisfaction scores became more important than telling patients the hard truths they needed to hear, and money was always the underlying driver in decision-making by upper management. I was fortunate to be in a position to follow my passion, so I left the medical field, and I continued my education in health and fitness while I became a Mother and cared for my babies. I was able to transition into a career doing what I loved when my kids attended school, and here I am now! 

I'd like to share some of what I've learned about navigating the medical system from the perspective of a former nurse and as a patient. Knowing how to advocate for yourself is invaluable, and there are some tips that will go a long way in helping you do this.

*This is written with the US Medical system in mind. I know various countries have different ways of doing this, so some of this will not apply to those with other types of insurance. This is not being given as medical advice and does not replace the advice of your medical providers. Every insurance plan is different, and these are generalized descriptions.*

1. Understanding Your Insurance

I know there are more entertaining things to read through than your insurance pamphlets, but there are some key areas that you should understand about your policy. The following are important things to know and understand:

*What is in-network, and what is out of network?

Most policies cover larger percentages of costs when you see in-network providers. You can access a database of providers on most insurance websites and can check to see which providers and specialists are in-network. 

*What is your deductible?

Most insurance companies will not pay any coverage until you meet your deductible. These numbers will vary greatly from one plan to another. Know what this amount is.

*What is your out-of-pocket maximum?

This is the maximum amount you will pay out of pocket for the policy year. If you need a big surgery or are hospitalized, give birth, etc., you may hit your out-of-pocket maximum. 

*Understand what your copays are and what coverage you have for services you regularly use.

Read through your coverage guidelines. Sometimes you may be surprised at what things may be covered. Some policies may cover chiropractic, acupuncture, gym memberships, etc. So read all the fine print.

*Use the number on your insurance card when you aren't clear about your coverage.

Many websites have a lot of resources and even dashboards that track your coverage, claims, deductibles, copays, etc. Some companies have apps that can do this as well.

2. Bring Notes to the Doctor. 

Your primary care physician is busy. They see many patients a day and have a short amount of time scheduled for each interaction. This isn't their fault- it usually comes from management trying to process as many patients as possible in a day. Hopefully, they are still being attentive and making you feel like you care! There are some things you can do to help the situation, knowing that this is generally the case. 

*Show up on time.

Be as patient as possible if you have to wait—plan to wait. Bring something to do in the waiting room, so you aren't wasting your time.

*Bring notes.

Make a list of the things you wish to discuss with your Doctor. Put the most important things at the top of the list. Keep these things short and concise. A bullet-point style list is best. Bring a pen and a paper or a laptop to take notes as the Doctor responds to your questions. Alternatively, bring someone with you to help you listen or to take notes for you so you can focus on what the Doctor is saying. Ask them to write down anything they do not know how to spell. You can also ask them if you can record the conversation so that you can listen to it later, but many physicians may be apprehensive about allowing that to protect themselves legally. If you make this request, let them know that you only want to do this so that you can listen later because the medical terminology can be confusing, and it can be a lot to remember. 

*Be honest with them.

If there is something that is on your list that is of high importance and they shrug it off as "not an issue," "normal for your age," etc., but it is really having an impact on your quality of life, tell them that. Tell them how important it is to you and how much it impacts your life. Skip the small talk and be transparent about your needs. 

*If there are specific labs you are requesting, make a list with a very short 2-3 word description of why you want each lab checked. 

*Do your homework before your visit.

You can ask when you schedule your appointment what things will be checked at the appointment. If it is a routine physical, you can ask ahead of time what labs will be part of the routine check.

3. Choose Your PCP Wisely (Primary Care Physician)

Think of your PCP as the team coach. They oversee your health care team. You will build a relationship with them. They can send you to specialists, give you referrals, order necessary tests, and work with you on your long-term health goals. When you are hospitalized, different physicians will typically care for you, and then when you are discharged from the hospital, you will go back to your PCP and any specialists to continue your care outside of the acute hospital setting. 

*You wouldn't hire a nanny without doing an interview, checking references, running a background check, meeting in person, etc.

Hiring a PCP should be no different. Look them up, read about them, call and ask questions before meeting them, or request a meet and greet before choosing them as your PCP.

*Find a PCP who matches your style.

Are you more holistic? Do you prefer more natural forms of healing when possible? Do you have very specific beliefs, cultural, or religious practices that impact your healthcare? Find someone who aligns with those things. If you believe in a functional medicine approach, find someone who practices that way. If you want someone who prescribes medication, quickly ask for that person. If preventative medicine and a holistic, nutrition-based approach are important, look for that. If you have complex medical issues, look for a PCP who is well-versed in dealing with those or who is willing to learn with you. 

*Remember that you can change your PCP.

If they are not meeting your needs, if you feel that they aren't listening to your words, aren't honoring your feelings, or are brushing off your valid concerns, find someone better. 

4. Ask Questions + Get Second Opinions.

Don't understand the medical lingo? Ask them to rephrase it for you. Are you a visual learner? Ask if they can show you a picture of what they are describing. Are they testing you for something? Ask about a differential diagnosis. (That basically means what else could it be if it is not the thing they are testing for). Ask what you can do to improve your health outcomes.

Did you receive a new diagnosis that you do not understand or feel confident about? Do you question the recommended procedure, surgery, or course of treatment? Get a second opinion. There's absolutely NOTHING wrong with doing this. When surgery was recommended to me, I spoke with five (!) different urogynecologists prior to selecting one to do my surgery. There were a few options for my surgery, as is sometimes the case, so the opinions of various professionals were important in helping me decide which route to choose. When it comes to an emergency, this is unlikely to be an option. But for chronic conditions and non-emergent procedures, you can seek second opinions. You do not have to say anything more than "I'd like to get a second opinion." Go to your second opinion with any lab results, imaging, or testing results so they can review them all. You can typically submit those electronically prior to your visit.

If your physician is irritated with your questions, dismissive, or unwilling to educate you, find a new one. Again, keep in mind that they are very busy and have limited time, so you MUST be concise. If you know you have a lot to discuss then book a longer appointment time when you schedule. You can do this by explaining to the receptionist that you have a lot of questions and that you want extra time to go through them.

5. Take Ownership

It's your body and your responsibility. The Doctor and medical team are there to care for you when you are sick, but ultimately your health is your responsibility. No matter how great a Doctor is, they can't undo years and decades of poor health decisions on your part. Genetics play a role, of course, but your lifestyle choices play a HUGE role in your health. Don't wait for the Doctor to tell you to be healthier. Don't wait for the high blood pressure or diabetes diagnosis. Start making choices today that will help you avoid those things. If you are already at that point and struggling to make health changes, find good guides. The reality is that, unfortunately, your PCP is unlikely to have the time or resources to teach you how to grocery shop, prepare healthy meals, or how to exercise. Seek out that knowledge and put it to use.

6. Consider Private-Pay if it is an Option to You

I understand that this is not an option for everyone, and this is not necessary. But if you have the ability for private pay options you may want to consider it. Some insurance plans will cover these costs as out-of-network visits if you submit them, some will not. This is an individual decision and you will need to weigh the cost of your co-pays, how often you see the Doctor, the cost of private pay options, and your goals to know if it is the best option for you. 

We use a service called SteadyMD and we see Dr. Dani Urcuyo. He practices functional medicine, he’s a crossfitter, and he understands our goals and priorities. We are able to text him anytime, we see him over video chat on the computer or phone from anywhere. He’s able to order labs that we use our insurance for, he can write prescriptions when needed, and most importantly he has time to spend with us to go over our healthcare. Because it is not dependent on insurance they have more time to spend with their patients. This service matches you with a Doctor based on your priorities and I’d say they nailed it for us with Dr. Dani. 

You should be a bit better equipped to advocate for yourself now. As always, feel free to respond with feedback! Was this helpful? Was any of this new information? Would another blog diving into more specific situations such as in-patient (hospital stays) or physical therapy/chiropractic visits be helpful to you?

If you have friends or family navigating medical care, consider forwarding this to them!