Comment by johannbok | Hacker News Reader

Comment by johannbok | Hacker News Reader

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This is partly true. In no small part because they tend to control the bulk (or all) of our patient supply. In part because people have gotten the idea that insurance equals care, and vice versa - so people tend not to think about high-impact moments where it pays to go cash.

For instance, I specialize in neuromodulation for highly-treatment-resistance psychiatry. I'm very good at what I do; my mentor is (IMO) better, and one of the absolute best in the country. A single consultation session with him is around $200 if he happens not to take your insurance. If you have a highly-treatment resistant condition, and are about to embark on a course of neuromodulation, it absolutely behooves you to go to him for a single session consultation to plan out your intervention before going to some local mediocre whatever to actually slap the equipment on your head and carry out the intervention.

For instance, people have incredibly debilitating autoimmune conditions. Rheumatic conditions are notable for their polymorphic presentations. It absolutely behooves you to go to an absolute top rheumatologist for one to three visits to confirm your diagnosis before going on a lifelong adventure of immune modulating drugs.

But folks hear "this guy doesn't take my insurance" and treat it as equivalent to "I can't get care there," even when they can afford it. I have a chronic condition, it's terrible, and my absolute world-famous specialist costs me about $250/yr - a small fraction of my monthly insurance premium. Less than my monthly prescription costs. Yet people will go to whatever specialist happens to be near them, while bearing all those other costs, and not investing in the linchpin.

Who is the top rheumatologist? Who would you recommend? My mother is in constant pain and has gone to a dozen different specialists. We are near Chicago, but I am happy to take her anywhere in the country.

Robert Spiera, currently director of vasculitis at the hospital for special surgery, still maintains a private practice in Manhattan. He's worth every second of the wait time, and every penny of his consultation fee. He is ridiculously good.

Many people do not realize how cheap it can be to do direct-consultations; and it can't hurt to ask.

Even a doctor pulling down $1m a year is only about $500 an hour, and that could be entirely worth it to get their time and dedicated.

And if you call to ask, the front desk secretary will have absolutely no clue how to route an out-of-the-ordinary request. If the doc you're calling doesn't already do the type of service you're looking for (e.g., a phone consultation), be absolutely firm about wanting to speak with the office manager.

The office manager may not be able to accommodate you, but if it can be done, they're the ones with the authority and autonomy to make it happen.

How do you find these top people?

Generally, you have to ask doctors already in the know. You find the top academic medical center in your area, and you ask the relevant specialist there who the absolute top person in their field is for a second opinion.

It's not always a guaranteed correct answer - I know for a fact of some people at absolutely top ranked institutions, with top pedigrees, who clearly got there by academic skills and are absolute shit as clinicians - but for the most part, it'll get you where you need to go. Generally the only way you'll end up with one of those shiny pieces of shit is if referred to them strictly by reputation; no one that's worked with them would make that referral.

It's also an answer likely to overlook excellent clinicians - many (many!, maybe most) very good clinicians aren't academics, and this won't route you to them. But you're okay with overlooking excellent docs, as long as you end up at a top doc.

Finding excellent doctors without shiny pedigrees is not something a layman can do. It's just something that local docs eventually come to know about other docs in their social-professional network, and by no means is it an unbiased assessment.

If all you have available is people's online CVs, look strongly at people with mediocre or shitty medical schools and highly prestigious residencies and fellowships. Those are people who had networking and social signaling working actively against them, and managed to positively impress everyone they worked with. E.g., a buddy of mine got into a shit medical school, and got one of the country's most prestigious subspecialties in a prestigious institution. He had to impress every single person he worked with, had to do surpass everyone on his standardized exams, and otherwise be top-of-the-top in every way. He's a ridiculously top-notch doc.

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