DISCLAIMER: All definitions below reflect my current understanding based on experience and a bit of research. I cannot guarantee I am 100% correct on everything.

People generally recommended to see at least once a year:

1. Primary Care Physician (PCP) - your main doctor, responsible for taking care of your whole health rather than focusing on specific parts. They are generalists responsible for catching anything out of the ordinary and referring you to specialists as needed. They are able to diagnose and treat minor ailments such as a urinary tract infection (UTI) or unspecified leg pain, but if they find anything that they don't feel the best equipped to diagnose, they will refer you to a specialist to increase chances of an accurate diagnosis and a targeted treatment plan. Being the cheapest doctor you can see, they also often manage chronic diseases that require you to check in frequently, such as high blood pressure (hypertension) or diabetes.

Types of Primary Care (they all do the same thing; the different names indicate whether there is an age focus):

1. Pediatrics - kids, age 0-18 (depends on office whether there is a hard upper limit)

2. Internal Medicine - adults, age 18-65

3. Geriatrics - seniors, age 65+

4. Family Medicine - all ages

2. Dermatologist - skin doctor. While your PCP office can preliminarily identify suspicious skin abnormalities, dermatologists definitely have all the tools necessary to take biopsy samples to confirm/rule out cancerous tissue, and the skill to do so while minimizing chances of scarring.

3. Ophthalmologist - eye doctor. Deals with your eyeball health.

   1. Optometrist (not a doctor) - Deals with glasses and eyesight. DOES NOT check eyeball health.

4. Dentist - teeth doctor and first person to go to for any problems in your mouth. PCPs ARE NOT EQUIPPED to diagnose or treat any issues with the oral cavity (teeth, tongue, gums). Technically not medical doctors (MD); dentists go through a separate training and certification process. Dental care is excluded from medical health insurance, so requires separate dental insurance.

Specialists

1. Cardiologist - heart doctor. Important to have on care team if you have chronically high blood pressure, because that puts extra strain on your heart and puts you at higher risk for heart disease.

   1. Cardiovascular specialist - deals with potential blockages in your blood vessels.

2. Pulmonologist - lung doctor. Important to have on care team if you are a smoker, or have severe asthma or other breathing issues.

3. Otolaryngologist - Ears Neck Throat (ENT) doctor. Provides specific imaging of this facial area to diagnose problems and often surgical treatment if needed. Surgeries can usually be done in the doctor's office, rather than an operating room (OR).

4. Endocrinologist - hormone doctor. Specialize in abnormalities in the glands and organs that produce and regulate hormones, e.g. diabetes, thyroid disease, obesity.

5. Rheumatologist - autoimmune inflammation specialist. They are experts in conditions that result in chronic inflammation of the joints, bones, muscles, such as rheumatoid arthritis.

6. Orthopedist - musculoskeletal doctor. They specialize in treating mechanical problems of the musculoskeletal system, such as a fracture, dislocation, sports injury.

   1. Physiatrist - a doctor that does physical therapy, focusing on recovery and improving mobility and function.

   2. Physical Therapist (PT) (not a doctor) - helps identify and correct various body motions that are causing pain or stiffness, and helps you through exercises to restrengthen muscles that are weak.

   3. Occupational Therapist (OT) (not a doctor) - PT mostly for hands, as they focus on helping your fine motor movements to aid activities of daily living (ADL).

   4. Chiropractor (not a doctor) - helps realign skeletal imbalances that may be causing chronic pain, especially along the spine.

7. Pain Management Specialist - provides remedies that directly treat and manage pain itself, e.g. cortisone injections, but does not address or try to find the root cause of it.

8. Podiatrist - foot doctor. Often people with diabetes end up needing one because they lose feeling in their feet and find it harder to notice problems there.

9. Sleep Medicine Doctor - diagnoses and treats sleep disorders, usually through an overnight sleep study. They are the ones who prescribe CPAP machines.

10. Allergist - will really dive into finding what you may be allergic to so you know to avoid it.

11. Gastroenterologist (GI doctor) - gut doctor. Specializes in any issues in your digestive system, including your stomach and colon.

    1. Hepatologist - liver doctor. They are more specialized GI doctors who focus on diseases of the liver, gallbladder and pancreas.

12. Gynecologist - specializes in the female reproductive system.

    1. Obstetrician-Gynecologist (OBGYN) - deals with having babies.

    2. Urogynecologist - specialize in female pelvic floor disorders, can offer specialized physical therapy to alleviate urinary issues.

13. Urologist - specializes in the male reproductive system, and often surgical management of urinary tract, such as removal of kidney stones.

14. Nephrologist - kidney doctor. Specializes in non-surgical management of kidney function and diseases that may affect it, such as chronic kidney disease (CKD).

15. Neurologist - nerve and brain doctor. Specialize in physical abnormalities of the nervous system. They like MRIs.

16. Psychiatrist - mental health doctor. Responsible for diagnosing and prescribing medicine for mood and personality disorders, such as depression, anxiety, schizophrenia. They are NOT THERAPISTS; their primary tool is medicine, rather than talk therapy. This means they can have poor bedside manner but be excellent at prescribing effective medicine for your needs.

    1. Therapist (not a doctor, cannot prescribe medications) - provides talk therapy, where the treatment is guiding you to talk through your various issues and providing tools for better managing them. Most effective for long-term behavioral change.

    2. Psychologist - doctors who can both prescribe medicine and provide talk therapy, usually more expensive than a therapist.

17. Wound/Burn Doctor - specialize in large wounds on the surface of your body that require constant monitoring and sometimes specialized treatment, such as skin grafts.

18. Hematologist - blood doctor. Specialize in diagnosis, treatment and management of various blood disorders, such as anemia and blood cancers like leukemia, in which case they are usually also oncologists.

19. Oncologist - cancer doctor. The correct person to manage anybody with active cancer, in which case they SHOULD REPLACE YOUR PCP, as they become the point person for managing all of your medical care, including routine blood work.

20. Infectious Disease Doctor - deals with any contagious diseases with an external origin (meaning you were healthy and then you got sick), especially cases where it is difficult to diagnose the patient from the perspective of any other body system.

21. Surgeon - doctors who do the cutting, removing, restitching as necessary. Usually specialize in one of the specialties above, e.g. orthopedic surgeon. Those who don't specialize are "general surgeons."

22. Anesthesiologist - responsible for the drugs that control your consciousness and keep you alive during a surgery.

23. Radiologist - responsible for interpreting medical images (X-Ray, CT scan, MRI) for signs of disease, often not patient-facing.

24. Pathologist - responsible for processing biological samples, e.g. labs and biopsies, not patient-facing.

    1. Phlebotomist (not a doctor) - person who takes your blood and other biological samples (e.g. urine, stool).

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The rationale is that since physicals are by nature non-urgent, you should be able to wait that long. It also gives you time to collect any previous medical records you may have and transfer them to your new doctor's office. Everyone should have some medical records, with the bare minimum being a record of your childhood vaccinations. Otherwise, it is even more work for the first doctor you see to create your medical record from scratch.

My recommendation is that no matter how long the wait is, you should just schedule an appointment, because those wait times are not going to get any shorter.

Why do physicals require more work for PCPs?

Physicals are a comprehensive review of an individual's health, and there is a lot of ground to cover. The bare minimum a doctor has to do in a physical is:

1. Check status of preventative screening (pap, mammogram, colonoscopy, bone density) as appropriate. Amazingly, Epic does not have a way to easily see all this info at once - a provider has to search separately to find each last screening, then look into the corresponding note for the results of that screening and for follow up instructions.

2. Review your vitals taken during rooming, see if there is any cause for concern there.

3. Review status of any existing conditions.

4. Review all medications, refilling and making changes as necessary.

5. Give you a chance to bring up any new concerns, and begin to address them.

6. Review diet, exercise, sleep habits.

7. Update social history (smoking, drinking, etc).

8. Update family history.

9. Conduct the physical exam.

10. Review blood work, checking when labs were last done, what their results were, what you may be due for.

11. Review vaccination status, see if you are due for any.

Documentation is required for everything, even if there are no changes, and the Epic Electronic Health Record (EHR) requires a lot of clicking back and forth to document things in the right places. For example, placing any orders - a prescription, imaging, lab, vaccine, or referral - requires clicking through several screens and separate documentation in the "Assessment & Plan" part of the doctor's note.

This is all just the mechanics - never mind the rapid diagnostic problem-solving the doctor does throughout everything they review and talk about with you and other members of their team. Layer on that a PCP may see 20 different patients a day, with more messaging them at any time regardless of urgency, so they have to at least look at everything to make sure there isn't an emergency. Layer on that a PCP may actually have a life of their own, with all the responsibility and unanticipated interruptions that entails.

Physicals require a doctor to evaluate your whole health in the context of your specific life circumstances, and a PCP's worst fear is that they miss something small that turns into something big. So it can be kind of exhausting in different ways.

This is why it is so important for you, as the patient, to understand what is and is not covered by your health insurance plan. Some plans cost more for a reason!

Here's the general overview, though as health insurance plans keep proliferating, the best way to know for sure is to double-check with your specific insurance carrier:

Medicaid (MassHealth in Massachusetts) - You better make your PCP your best friend, because ain't no way you are seeing a specialist unless your PCP refers you to one, which they can only do after seeing you in person.

HMO (Health Maintenance Organization) - You DO need a referral from your PCP in order to see a specialist.

PPO (Preferred Provider Organization) - You DO NOT need a referral from your PCP to see a specialist, as long as your specialist is in-network with your insurance. Find out by asking the specialist's office when you call to make your appointment.

Medicare - You DO NOT need a referral from your PCP to see a specialist. You can make an appointment directly with the specialist's office.

More often than not, claims are denied because of some mismatch of information between your health insurance plan and what your doctor’s office has in their system. Bringing your most up-to-date insurance card with you to every doctor’s appointment is one extremely easy way to minimize the chances of those denied insurance claims. It is part of your doctor’s office’s job to double-check that the information in their system matches your most up-to-date, active insurance plan. It is your job to bring your health insurance card with you to your appointment, and make sure that it is your most up-to-date one.

Most common rebuttals:

“But I’ve had the same health insurance for X years!”

“Don’t you have it in your system already?”

“Nothing has changed.”

It is likely that if you have kept the same health insurance plan for years, there are no impactful changes to your health insurance card. However, it is standard for every health insurance plan to renew after 1 year, meaning it is possible that your health insurance plan could have changed in some way. Maybe your office visit copay is different. Maybe the billing claim address is different. Maybe everything is exactly the same. Why not let the receptionists do their jobs and check for you?

The most important information they are checking for is:

• Health insurance company (BCBS, Harvard Pilgrim, Cigna, etc.)

• Spelling of your name (hyphenated vs non-hyphenated matters, believe it or not)

• Member ID number

• Office visit copay

• Phone numbers on the back (you want your doctor’s office have ready access to these numbers)

• Billing address

If you visit the same doctor’s office more than once a year, it’s less important, because health insurance plans renew after 1 year, usually in January. So if it’s really a hindrance for you to carry around a thin piece of plastic year-round, just make sure you bring your health insurance card to the first doctor’s visit you have in the calendar year. Important: this applies for every separate doctor’s office you go to. So for example, your orthopedic’s office is not going to have your health insurance card info that was collected at your PCP’s office, unless you are told otherwise.

Some health insurance companies are moving to electronic, rather than physical, insurance cards. That should be even easier to pull up! Just make sure you have that ready to show the receptionist when you check in.

A couple years ago, I decided to pursue my healthcare passion full time. I quit my engineering job to get a master's degree in healthcare management, with a focus on digital transformation in healthcare. Since theoretical learning drives me crazy, I also worked as a medical scribe to a primary care physician for 10 months, and then as a front desk receptionist for another family medicine practice for 6 months. In that time, through almost 10,000 patient interactions, I learned firsthand how a primary care clinic operates: what patients come in for, who everybody is and what their functions are, why providers do the things they do, and most importantly, where workflow pain points are and what an improved solution might look like.

Now, I have a lot of healthcare knowledge that I think everybody should know, because you deserve to know how your healthcare system works in order to take ownership of your own care. No one will advocate for you better than you can, so instead of assuming that your healthcare team will take care of things for you, here is the knowledge you need to navigate the system for yourself, as you are unfortunately expected to do. This is healthcare, explained.

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I'm going to start off with a few articles answering basic questions that I have not been able to easily find anywhere else. But after that, I am going to be counting on you, the readers, to ask questions to guide what I write about next. If at any point you're reading, or the next time you're interfacing with the healthcare system and you find yourself wondering WHY, please ask me!

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