Photo source: Wikimedia Commons

Going to the gym in the morning is one of those things I do because it’s good for me and I feel better afterward. That doesn’t change my lack of enthusiasm. I get up early, put on my work-out clothes and then start writing, delaying my gym visit as long as possible.

One morning, my trip to the gym was over icy sidewalks, so I walked carefully on the strip of grass between the sidewalk and the street, which was a little less slippery. I calculated that I had just enough time to get to the gym, get my heart rate up for 30 minutes, and get back to my next call.

A block from my house, I saw a young woman kneeling on the sidewalk. Two policemen hovered nearby as if to protect her. She wore a red coat, her red hat upside down about two feet away from her. As I got closer, I noticed blood on the sidewalk.

A teaspoon of blood looks like a quart, and this was more than a teaspoon. The young woman covered her face with bloodied hands.

Is there anything I can do?

Once I finally head to the gym, I am reluctant to stop for anything—that’s my way to get it over with. I grappled for a moment with the temptation to just keep going and get the miserable half-hour out of the way, but I finally did what my medical training compels me to do. I stopped.

Is there anything I can do?” I asked, identifying myself as a doctor.

I’ve called an ambulance,” the officer told me.

The woman started talking through her blood-covered hand, eyes red and damp. I sat next to her, eye-to-eye, and put my hand on her shoulder. My one-cotton-layer-covered butt settled on the sidewalk ice.

What happened?

I fell and broke my tooth.”

May I take a look? I used to work in an emergency department in a ski resort.”

Thinking like a doctor, coach and policy wonk

I asked her to open her mouth and she dropped her hand. She looked like a horror movie escapee. Blood was everywhere—head and lip wounds bled profusely—and her right front incisor was about half gone. She might need sutures, depending upon what happened behind her lower lip. Later, she’ll need a dentist to determine what to do about the injured tooth.

You might also enjoy: My Doctor Diagnosed Me With Thin White Female Syndrome

My linear-thinking, differential-diagnosis, medical-school-trained, quick-assessment self-knew she was mostly just scared. She didn’t really need an ambulance. My coach trained self-listened to her story. My health-policy-trained self-wondered about her insurance.

I was torn between annoyance and ecstasy at having my workout cut short. What a great excuse to avoid the gym.

Is there anyone you can call?

I’ll call my boss,” she said. “She’ll come to the hospital for me.”

An ambulance was called

Fortunately, she was covered by her parents’ insurance policy, which was with a reputable company. Her insurance would most likely cover the emergency department visit, but it might not cover an ambulance ride. If the insurance company decides later, when they get the bill, that the ambulance wasn’t necessary, it could deny the claim—it doesn’t matter that the police called the ambulance and put her in it. That’s most likely a hit of a $1,000 or more.

She didn’t have to take the service just because the police suggested it. She could take a cab or call a friend. For that matter, she could say, “No, thanks,” and walk away, if she felt up to it.

Two taxis passed us on the street.

Do you have Uber?” I asked.

She didn’t.

Had the policemen not been there, I would have encouraged her to just call her boss to take her to the ER. She would have been fine. But she seemed pretty shaky and the EMT unit had already been called. I decided not to push the issue.

The nearest fire station, with the EMT units, was only about five minutes away. When it comes to hospitals, you never know which one they’ll take you to. A few years back, a DC ambulance driver was at the end of her shift when she picked up an unconscious man. She assumed he was just drunk and dropped him at a hospital close to her house, instead of the nearest one. It turned out that he had been whacked over the head in a mugging during an after-dinner walk. He died from the head injury.

The case only made the news because the man happened to be a prominent journalist – a sad commentary on our system.

Cost & care

This woman wasn’t going to die, but what hospital she would end up at was a crapshoot. It had nothing to do with what her insurance would cover. Even if the hospital was on her health plan, the emergency room physician might not be.

You might also enjoy: How One Student Struggles to Become a Good Doctor

The plastic surgeon, the ER would likely call, might or might not be a preferred provider with the insurance company’s negotiated rate. I doubted that she had the provider list in her pocket. Also, the ER would probably just contact whoever was on call. Was she supposed to ask them to look up her company’s provider list? Decline the care? I could only hope that she would have the presence of mind to ask the right questions before she ran up a bill that would bankrupt her.

Too many people end up like that woman, getting random treatment because they either can’t speak for themselves or don’t ask the right questions.

There’s so much to think about when you’re injured, in pain, and distressed. What if you’re comatose? In another city? Don’t have anyone to run interference, as I tried to do? Any passer-by can step in, can be present, for an injured person. However, once the authorities arrive, that opportunity is gone. The police only let me help because my MD degree gave me credibility and confidence.

By the time an ambulance showed up about 20 minutes later, I knew I could feel entirely justified in skipping the gym. I shared what I knew with the paramedics, who guided the injured woman into the back of the ambulance. They would clean up the blood and assess the injury. I suggested the closest hospital, which I was pretty sure her policy covered.

Replaying the story

I pushed the lazy demon off my shoulder and hauled myself to the gym, anyway. As I shuffled the day’s schedule to accommodate an abbreviated workout, I told the desk attendant the whole story.

On the elliptical, my brain had replayed that woman’s morning. There were so many moving pieces. Everyone followed the rules. The police called professional help, and the in-the-moment handoff to the kind EMT went smoothly. I tried to provide comfort by sitting down to talk to her and touching her to help her feel less alone. I hope that helped. Still, the whole experience bothered me.

Everyone did their job that morning. But that woman may just be starting a long battle with her insurance company. The desk attendant who heard me out just shook his head, baffled, as I unloaded my frustration on him.

I’m from Germany,” he said. “We don’t have these problems.”


Love our content?  Want more information on Cost & Care, Health Insurance, and Health Policy?  Signup for our Weekly Newsletter here.

This story was first published on February 18, 2015. It has reviewed and updated for republication.


  1. As others have pointed out, that was beautifully written.

    Living in Japan, I’m tempted to repeat the desk attendant’s comment. But it’s not just Germany and Japan; the US is unique in its insanity. The term “preexisting conditions” plays no role in any other industrialized country’s medical system, a simple factoid that demonstrates conclusively that we’re being completely ridiculous. Sigh. Other countries have their problems, of course. And medicine itself has problems (if a doctor looks at a patient and some rare unlikely disease pops into her head, if she doesn’t follow that up, she’s on the hook for malpractice, but if she does, the patient is on the hook for unnecessary tests, which are not harm-free (exploratory surgery, biopsies)).

    Anyway, a doctor’s job is hard enough as it is, and she shouldn’t have to worry that a medically justified decision will bankrupt the patient.

  2. Excellent read. I’m making the decision on whether to help pretty often as well. I could completely relate to that component of your story.

    The line “I’m from Germany, … We don’t have these problems.” reminded me of my own recent experience with US insurance and “retail” medicine.

    I was reviewing a web site that described a patient with an exercise-related soft-tissue complaint. It could have been a pharma site, or a payer or provider site, or simply ad-driven revenue information resource. The bottom line was that it steered the patient to seeing an orthopedic sports physician who was in network, or cost efficient, or part of the well-branded local healthcare conglomerate. It offered an estimated cost of $200 and offered to schedule the appointment within any provided zip code.

    My reaction, (I am like you, with practice experience, board certification, and compassion) was, “I’m apparently from another country as well, how about rest, ice, ibuprofen, or even just pharmacy-based minute-clinic at less than a quarter of the predicted cost of an orthopedist ?

    Getting a good, unbiased diagnostic opinion is still too hard and unpredictable in every country I’m familiar with, although for different reasons and contexts.

    Thanks again for writing this terrific piece.


Please enter your comment!
Please enter your name here

This site uses Akismet to reduce spam. Learn how your comment data is processed.