Josh | ExpatsEverywhere (03:33.886)
Okay. Well, Sophia, I'm really glad to have you on the podcast so that we can talk more about the healthcare system. It's certainly something that I've grown interested in over the past few years since moving here. Obviously a lot gets said about what American healthcare is like and people wanting to leave the U S and other countries as well to get to Portugal and experience what is regarded as one of the best healthcare systems in the world.

but I would like to dive in, get a little deeper on what exactly that means, especially as people live here. So what's the biggest difference between the public and private healthcare systems?

Sofia (04:07.989)
Mm-hmm.

Sofia (04:14.076)
Oh, hello, Josh. Good morning. And thank you for having me. So I think that the main difference and the one that pops up immediately is the questions of who manage which system. So we have in Portugal, we have what we call the public health system. That's usually that we divided in public healthcare service and the private healthcare services. So, but who mainly manage the public?

is the Ministry of Health, in this case, what everything regardless from where the money, who finances it, who decides the rules, who provides the everything since from a hospital to a doctor to any material or any equipment that they use. And the private health care system is financed by insurance or the users itself, and it's managed by private groups.

the biggest groups that we have here in Portugal are Luz, Cuf and Luz Yedas are like the biggest groups. We also have a smaller group but it's mainly at the north but they're trying to come here that's called Trofa but those are like the major private groups. So in terms of when we discuss what's the main difference, one of the main differences is this one.

Josh | ExpatsEverywhere (05:21.335)
Okay.

Sofia (05:41.156)
There are other, other difference and that you can see once you start working, whether it's a public or the private, but mainly I would say if we have to put it in one, it's who manages, who manage which, which system one is a hundred percent managed by the, the ministry of health, the private healthcare system service is managed by the private companies. However, and this is where the catch comes because.

Josh | ExpatsEverywhere (05:53.609)
Okay.

Josh | ExpatsEverywhere (06:01.314)
Hmm.

Sofia (06:11.244)
And this is why we call it a healthcare system and with two services, because sometimes the public healthcare services will ask the private for some help, uh, providing certain types of, of treatments or certain types of, of procedures, especially when we come to testing or exams and so on that end, a client or a patient can go to the public.

Josh | ExpatsEverywhere (06:38.946)
Patient.

Sofia (06:41.04)
to the private, but being financially covered by the public health services. So this is where then it's like I subcontract, so to speak, to privates and ask them, okay, I need help with this particular thing. I will pay UX and you'll treat my patient or you do their blood tests or you do their exams so that I, because I don't have the capability.

to do that for myself. So this is why we then call a healthcare system, because at some points they will work very interline and very in together.

Josh | ExpatsEverywhere (07:23.502)
That's nice. That's really nice. So for someone that's first moving here, how do they know if a hospital or a clinic is public or private? Because I think whenever we first moved here, we were confused until we started to recognize the names like Koof, like Loosh. Yeah.

Sofia (07:24.538)
Mm-hmm.

Sofia (07:40.904)
Yeah, usually if you go to one of those private facilities, one of those, they're private. The public healthcare are usually the public, usually there's the big hospitals that you'll find. Usually there's, there always, a lot of them have names of saints. So every time you see

Josh | ExpatsEverywhere (07:58.85)
Okay.

Sofia (08:07.608)
So a lot of times, or if you see it with the name of the place where it is, Hospital de Faro, for example, or Hospital de Santarém, Hospital de Santarém, Distrital de Santarém, that means that usually it's a public facility, it's a public hospital. Those are usually the difference between them. And this is where, or you just, if you Google public hospital, you will have it.

Josh | ExpatsEverywhere (08:36.749)
Mm. Okay.

Sofia (08:37.4)
Because the thing is, in terms of the way that they are organized, it can be a little bit confusing. And just to give you an example, from whoever lives in Lisbon, there's, I'm going to say it in Portuguese, Centro Hospitalar de Lisboa Central. It's a hospital, it's a university center hospital, it's called Central Lisbon. And this is kind of like a group.

Josh | ExpatsEverywhere (08:42.83)
Sure.

Sofia (09:04.896)
of public hospitals that are managed by the same board, but they have four hospitals. So José, Santa Marta, Dona Estefânia, Curri Cabral, and the maternity ward. So there are like five different hospitals located in different parts of Lisbon. But every time you will Google and ask, they will send Centro Hospitalário Universitario de Lisboa Central. So it's like...

Josh | ExpatsEverywhere (09:06.711)
Hmm.

Sofia (09:33.604)
They're managed and the board is only one, but there's five different hospitals located in different facilities with different specialties within them, within the hospitals. So it's a bit confusing. Our public, the way that our public, it is, it is even for us. And we have lived here, I have lived here all my life. I worked in the public hospital.

Josh | ExpatsEverywhere (09:37.429)
Okay.

Josh | ExpatsEverywhere (09:50.527)
Yeah.

Josh | ExpatsEverywhere (09:54.423)
Yeah.

Sofia (10:02.44)
And so I know that, but even for the regular citizen in Portugal, the regular person that does not work within the system, that does not deal with the system every day, has a difficulty sometimes in understanding exactly where are they supposed to go, who are they supposed to speak, how do they get there? So it's not, I think we got used to it.

Josh | ExpatsEverywhere (10:23.659)
Yeah.

Sofia (10:31.704)
But it's interesting seeing that every time, this is like when something, someone new comes and tells us, oh, you should be doing this differently. Why don't you do, you know, every time someone new comes in our job and all of a sudden brings up this wonderful new idea. And I think it's the same with us. At some point we got, oh, they're right. It's so confusing. How does someone get this? So it's confusing to understand

Josh | ExpatsEverywhere (10:42.932)
Yeah.

Josh | ExpatsEverywhere (10:48.142)
Sure.

Sofia (11:01.572)
the little perks and particularities of the system. Again, because it's supposed to be, and this is what our constitution says, it's supposed to be universal, free, and accessible for everyone. So when we have this in our constitution, the right for healthcare, there is the right of healthcare, the same that there is the right to have a house, a home.

Josh | ExpatsEverywhere (11:18.912)
Okay.

Josh | ExpatsEverywhere (11:23.348)
Mm.

Okay.

Josh | ExpatsEverywhere (11:32.107)
Okay.

Sofia (11:33.796)
So, and I think this is the best way that I have to understand this and this main difference between the public and the private is that because this is a part of the constitution, there is always going to be a responsibility for the Ministry of Health, in this case, and the government to assure that there are healthcare available in Portugal for the citizens or residents

Josh | ExpatsEverywhere (12:00.446)
Mm-hmm. I see.

Sofia (12:01.304)
charge. With that said, a lot of times comes the problem of how to access that service itself, and that can be a little bit more tricky.

Josh | ExpatsEverywhere (12:17.406)
Yeah. Well, okay. So there's a lot of different ways we can go here. I'm going to keep it general at first and I'm going to ask you, um, when should someone use the public system? When should someone use the private system? Because many foreigners move here and we're required, uh, at least initially to have a private coverage up into a certain point of time, uh, which many people end up keeping their private coverage. I think certainly Americans do just cause we're so used to paying

Sofia (12:22.22)
Okay.

Josh | ExpatsEverywhere (12:46.754)
private healthcare anyways, and it's so much less than what we would pay in the states. Most people just go ahead and keep their private, but they could go fully public. So my question is when should someone use the public system? When should someone use private?

Sofia (12:48.473)
Mm-hmm.

Sofia (13:01.964)
I think mainly here has to do a lot with what issues you bring or what's your medical situation. And for example, what we always do and our recommendations, whether it's going to the public or to the private, depends always on the assessments that we do of the medical situation of the person, the diagnosis that we do for their needs.

Josh | ExpatsEverywhere (13:28.855)
Okay.

Sofia (13:30.16)
because there are specific situations that even prior for someone coming, we would say, no, we will need to go public. So this would always go through the public. I can give you one or two examples of things that we deal in our service on a daily basis, for example, HIV patients. The HIV medication is only available through the public service.

Josh | ExpatsEverywhere (13:46.946)
Please.

Sofia (13:56.716)
So we would always have to refer someone to the public. Another example is multiple sclerosis, for example, or some gastrointestinal conditions like Crohn's disease or that usually, or some rheumatologist conditions where people use specific types of drugs and specific types of medication, they're only available in the public. And so there we cannot go around. We would always have to end up there.

Josh | ExpatsEverywhere (14:09.206)
Hmm.

Sofia (14:27.472)
For other medical issues, and to tell you the truth, we always recommend and advise our clients to purchase and keep their health insurance if this is something that they can afford within their budget, of course, because for a lot of other conditions and sometimes to have access to other physicians and other possibilities, having private insurance is the best way and it's the easiest way and the fastest way.

Josh | ExpatsEverywhere (14:41.922)
Mm-hmm.

Sofia (14:57.704)
Again, when we work with the public and with all the financial need and the need to give healthcare to 10 million people, we always have a gatekeeper. There will always be a gatekeeper. And so I know that the cons, probably you in the US with the type of insurance you have, I think you also have a gatekeeper for the...

to access specialists here, it happens in the public. You will have a gatekeeper to be able to assess and give you access to further specialists, to another specialist, to surgery, to specific types of medication. Again, so I think another difference is that is when you're dealing with a private system, you don't have that gatekeeper. You go to whatever specialist you want.

Josh | ExpatsEverywhere (15:42.259)
Right.

Josh | ExpatsEverywhere (15:52.775)
Okay.

Sofia (15:55.78)
and whatever needs you have. When we're dealing only or singly with the public service, you will have a gatekeeper. In this case, the gatekeeper is the primary care physician, the family doctor. And so here is one of also the, and sometimes we can go past the family doctor when we have ways and they also predict some ways where we don't have to go specifically to the primary doctor at the public and we can do it.

Josh | ExpatsEverywhere (16:09.634)
Okay.

Sofia (16:25.464)
We usually do it, but it's still a gatekeeper and it's still a process that needs to be done and respected in order to access public healthcare.

Josh | ExpatsEverywhere (16:39.07)
How did people find this public doctor? Their GP or like, how does that happen? Are you assigned it or?

Sofia (16:49.929)
This is kind of like looking for... I remember there was a game when we were looking for the... There was when you go looking for something online and it's the same thing, looking for the pot of gold. We now have... Exactly, exactly, worse volume, something like that.

Josh | ExpatsEverywhere (17:05.374)
Okay, like where's Waldo? Or British, where's Wally? Yeah. Yeah, okay. Yeah, yeah.

Sofia (17:13.396)
And I think it's very important because sometimes I know that the expectations of our public health services is very high. And in fact, the quality of the service, the quality of the professionals, of the equipment, it's the same as any other country or is. And sometimes I think even better. But we have almost two million people in Portugal. So we're 10 million, two million.

without a family doctor. So they do not have a family doctor assigned. This is worse in certain areas of the country, of course. Strangely enough, the area of Lisbon, we call Lisboa e Val do Tejo, it's very difficult. And just to give you an idea, the news yesterday was that they just opened several

Josh | ExpatsEverywhere (17:48.331)
Okay.

Sofia (18:12.568)
availabilities for the speciality of family doctor. And for certain somewhat like 300 and something openings, a hundred were not filled. So that means that not only they do not have the doctors, but young doctors, they're starting their specialties, do not want to go and be family doctors. So having in consideration that most of our family doctors are...

Josh | ExpatsEverywhere (18:26.434)
There's a...

Josh | ExpatsEverywhere (18:36.599)
Hmm.

Sofia (18:42.556)
Mainly the high of the population of family doctors are around 50 something. So we will, this will be a, a decrease in increase problem with the upcoming years. Um, and some of them, a lot of them do not want even to work anymore with a private public service. So they just work in the public up to a few years ago. And I have to tell you, I worked for 12 years in a public hospital.

Josh | ExpatsEverywhere (18:47.771)
Mm-hmm.

Sofia (19:12.732)
And since when I began working in up to 10 years, more or less, it was very common for nurses and doctors to work both in the private and the public. It was normal. It was very normal for you to both work in both locations. Being your primary job would always be a public hospital or a public health center. It was kind of like.

Josh | ExpatsEverywhere (19:36.895)
Okay.

Sofia (19:38.772)
Almost mandatory. If you want to learn something, if you want to become a good doctor or a good nurse, first you go to the public and then you can work in a private facility. Since I would say around five years or something from now, the mentality, it changed a lot. The private hospitals grew a lot. They have very big hospitals. They have school hospitals also. They have.

Josh | ExpatsEverywhere (19:45.038)
Mm-hmm.

Josh | ExpatsEverywhere (19:55.638)
Hmm.

Sofia (20:04.372)
access to a lot of money and a lot of equipment and the possibility of being always doing new things. So I think that they'll be giving more money than we can get in the public. So at some point it became better in terms of career for certain people to just work in the private and not in the public. So being a family doctor, yes, that is a problem. Having a family doctor.

Josh | ExpatsEverywhere (20:24.501)
Mm-hmm.

Sofia (20:32.748)
So again, that gatekeeper process becomes even more hard because if you do not have a family doctor assigned, you always have to go to that loop of going to the public health center in your community. Ask when can I have an appointment with some doctor that can see me? And the other way to get in that I never advise, but I'm going to tell you anyway, but I never advise.

Josh | ExpatsEverywhere (20:52.322)
Mm-hmm.

Josh | ExpatsEverywhere (20:59.959)
haha

Sofia (21:01.388)
Because you see it on the news and after you've been in Portugal for a while, you will see that on the news is if you go to an emergency room at the public hospital. I never advise it, I it's the because it's not it's not a good thing. It's not. But a lot of Portuguese people, and I tell you this because this is a very common thing and a lot of Portuguese people end up doing that. They've waited for.

Josh | ExpatsEverywhere (21:09.326)
I thought you were gonna say this. Yeah, yeah.

Josh | ExpatsEverywhere (21:15.031)
Yeah.

Sure.

Sofia (21:27.708)
months and months and months at a certain point, they're like, okay, I'm just going to go there, sit there for 12 hours. Something will happen. Not sure what. Yeah.

Josh | ExpatsEverywhere (21:36.586)
That's crazy. So in the ER, they'll show up with something that's not an emergency, and then they just get triaged and set aside for 12 hours, or that's how long it takes to get to emergencies.

Sofia (21:48.027)
Yes.

12 hours because you are not an emergency. You're listed with like a green or a blue bracelet. That means that you're not an urgent case. This is not something that it's urgent. This is something that can be dealt with within the family care and the public health center. So you will wait and wait and wait and wait until.

Josh | ExpatsEverywhere (21:53.642)
An emergency. Got it.

Josh | ExpatsEverywhere (22:02.326)
Yep.

Sofia (22:20.116)
At some point it will happen because every time anyone that's urgent and that's, we use the Manchester triage, so it's red for red and red, orange and yellow. Those are like, those are the ones that exactly orange and then yellow. So that means if it's critical and if it comes by, you go directly to the emergency.

Josh | ExpatsEverywhere (22:36.426)
Okay. Red's the most critical. Yeah, yep. Yep.

Sofia (22:47.74)
And the emergency room, you don't pass through anything. There's a direct way. And then the time can take longer or less time, depending on the color. If you're green or blue, that means that it's something that it's not urgent. So when you have 5,000 people waiting.

Josh | ExpatsEverywhere (23:06.418)
Oh, that is a, that that's, that's bleak. Okay. So with the public system, how does someone get into the public system? What are things that they need to do to, to enter the system, get registered? Yeah.

Sofia (23:22.932)
Okay, so once you become a resident in Portugal, an authorized resident in Portugal, that is the mark. Of course, that if for any reason, and this is valid for people that are coming and still waiting for their appointments and getting their cards, or for just people that are coming to visit or tourists, at no point, no one will ever deny care at the public facility.

Josh | ExpatsEverywhere (23:32.853)
Okay.

Sofia (23:51.724)
So if at some point there is some need for an emergency situation or no one will be put outside or said we're not going to treat you because you're not a full resident here, this is not this doesn't happen. So.

Josh | ExpatsEverywhere (23:52.087)
Yeah.

Josh | ExpatsEverywhere (24:03.23)
Okay. Can I ask a question? So like let's say someone's a tourist here in Porto and they're walking down the street on Santa Catarina, the famous pedestrian street, yet there are a few sections of Santa Catarina where cars go by. We notice this all the time. Oh my goodness. If you come to Porto, please be careful on Santa Catarina because people will start walking.

Sofia (24:22.554)
question.

Josh | ExpatsEverywhere (24:32.802)
and they will not have the green light to walk. And cars maybe are not paying attention to the fact that people are walking when they shouldn't be walking and there could be an accident. So a tourist comes, they get hit, they end up in the emergency room, they don't have travel insurance. Would they have to pay in the public system or is that also kind of free access?

Sofia (24:58.961)
Okay, no, they will have to ideally and the system is designed to guarantee access and guarantee treatment, but the financial responsibility does not belong to the public service. So they will look for who is paying this. Usually because of this policy of treat first, pay after, which makes sense. And I still believe that it makes sense. And I know that.

Josh | ExpatsEverywhere (25:10.466)
Got it.

Josh | ExpatsEverywhere (25:23.254)
Totally agree.

Sofia (25:25.036)
I say this against myself because I pay taxes for a long time now, but I always, I think we treat first and then we ask because this is again, a right and non-constitution, a basic right and it's the human way to do it, the responsible human and community way to do it. So if someone is hit by a car, for example, in that situation, the responsibility, if it's from the driver, the driver will have to pay for the...

Josh | ExpatsEverywhere (25:41.102)
Sure.

Sofia (25:53.64)
everything related to that person. It's very common, for example, here in Lisbon, one of the main emergency rooms, because it's very close to where the ships come, the cruise ships. So usually, a lot of times it happens. People get off the cruise, they go around their life again, walking in our...

Josh | ExpatsEverywhere (26:09.218)
Uh-huh.

Sofia (26:19.204)
or sidewalks, it's not easy, slip, it's raining, you slip, you broke your hip, you're seven, you're 80 years old, you broke your hip, there you go to the hospital. This is very common, very common situation, so they treat it and then usually those, those person always have an insurance that have a travel insurance, it's charged to the travel insurance and, but they're always treated within the public care. I have, I will...

Josh | ExpatsEverywhere (26:21.614)
Sure.

Josh | ExpatsEverywhere (26:29.389)
Hmm.

Josh | ExpatsEverywhere (26:44.462)
Okay.

Sofia (26:46.06)
give you an example that was something that happened not so long ago, I had exactly that situation. Canadian couple was coming to Portugal first time, very happy, put their luggage in the hotel in town the streets. Avenida do Liberdade, they were very happy to see in the city. One of them slip, boom, fell, broke his knee. And so all of their time here was spent in the hotel.

Josh | ExpatsEverywhere (27:09.833)
Hmm.

Sofia (27:15.8)
with treatments. Of course, the hospital will do this. They treated, they did the surgery and they say, okay, you're fit to go. Goodbye. Nice meeting you. Have a safe flight back. But again, they didn't feel comfortable, a lot of pain, still managing things. So we end up doing all of that part of the post-op and maintaining a physical therapy and all of that because they will not, of course, the public will not assure that they will not assure like, oh,

Josh | ExpatsEverywhere (27:43.054)
Sure.

Sofia (27:44.38)
Do you have a place to go? No, it's, we did our job. You're fit for us. For us, you're okay to, I don't see any inconvenience. If you go get it to catching a flight back to Canada, good luck. Here is the documents. Have a safe flight back. Don't forget to take your stitches seven days after your surgery. So, um, and all of that then was arranged with us and the family, uh, because this is then the way you will find probably the gap.

Josh | ExpatsEverywhere (27:48.289)
Right.

Sofia (28:14.524)
is not, yeah, there's a gap and there's a gap and that gap is, I think it's consistent with everything because it's, we're very good acting in an emergency situation. You'll have the top of the top of, yes, well equipped, the top of the top of doctors, of cardiac, if it's a cardiac event or a topedic or something, you have the top of the top people working on you, making sure you're alive and making sure everything's well. The problem is, okay.

Josh | ExpatsEverywhere (28:15.078)
Yeah, I was going to use that word. There's a gap. Mm hmm.

Josh | ExpatsEverywhere (28:27.49)
Mm-hmm. Well equipped.

Sofia (28:43.672)
what happens after, what next, and how do I do this next? So, you know.

Josh | ExpatsEverywhere (28:44.414)
next. Yeah. Okay, so I'm going to use a key term that I need you to help me out with the audience so that they know what it means. Uten. What is a new tent? And how do you get a new tent?

Sofia (28:58.113)
Yes.

Sofia (29:02.544)
Okay, utente is a user of the system. It's not a patient, não é paciente, nem doente, because it's not someone, it's the generic term, okay? It's not someone that's sick, so it's not doente, doente means sick. We don't like to use the word paciente, don't ask me why.

Josh | ExpatsEverywhere (29:17.834)
Mm.

Josh | ExpatsEverywhere (29:22.786)
Yeah, sick.

Sofia (29:28.432)
It's not a term that we use, so we use the term utent. Uttent means the user, the user of the system. And so that's why you use, you listen to that, the utent number, because it's the number, it's the registration that says this person is a user of the system or is eligible and everything is okay and he can use the system. So the utent number is that. We have...

Josh | ExpatsEverywhere (29:28.916)
Okay.

Josh | ExpatsEverywhere (29:34.954)
Okay.

Josh | ExpatsEverywhere (29:41.975)
Mm-hmm.

Josh | ExpatsEverywhere (29:54.882)
Okay.

Sofia (29:58.188)
Again, another expression in Portuguese, something that's called Registo Nacional de Utentes, National Registration of Utentes. That is where it's a platform and it's a registration that it's managed by the public health service, so the Ministry of Health. And it has everyone that is, has ever come in contact with the public health service.

Josh | ExpatsEverywhere (30:05.038)
Okay.

Sofia (30:27.204)
Whether they are residents and authorized residents with financial responsibility of the system or whether they were just a temporary use of the system because you are a tourist and at some point you failed and you had to use the system. Or it was, this was created during COVID because we needed to vaccinate a lot of people that were not residents, authorized residents, but we need to keep a record of them.

and what was made and give them access to the information that they were vaccinated. So they created this temporary or a utent number. The main difference between the two is who has the financial responsibility, who is financially responsible for the care of that person within the public health service. And so to be...

Josh | ExpatsEverywhere (31:00.81)
Hmm.

Josh | ExpatsEverywhere (31:11.84)
Okay.

Sofia (31:22.248)
a, you tend to have your intent number and be registered and have the financial responsibility of the system the same way as any citizen, you have to be an authorized resident. So that means to have your residency card in your hand.

Josh | ExpatsEverywhere (31:36.2)
And once you.

Josh | ExpatsEverywhere (31:41.094)
Okay. And once you go and have your residency appointment, are you just given that number or do you have to like tick a box or something? Do you have to request it? If you have to request it, where do you request it?

Sofia (31:54.76)
I know that you are here a year, and so some of the people are here longer, other less, there's one thing that we in Portugal love, and it's called bureaucracy. No, you go to your appointment, now it's not called CEF, it's something else, but we're going to say CEF just for the, because it's easier.

Josh | ExpatsEverywhere (32:05.056)
Mm-hmm.

Sofia (32:15.7)
Um, you have your, your self appointment, the person that's seeing sees all of your documents, perfect, you are now an authorized resident, we will send you your card in two months or up to two or three months. I don't know. Once you receive your card, you, it only has saying that you're an authorized resident. Then the other process of getting the UTENT number starts. Then, okay. Now with this, yes, you can go and ask for your UTENT number.

and have it be assigned to it. The laws have changed a little bit. This is something that I think internally they had the need to clarify a little bit more and to turn it a little bit more clear, even for the services that were receiving this. So there is some legislation now that says exactly what the documents are that you need.

But then you're always dealing with people. And again, at some places, and we have experienced that with a lot of our clients, the changing of the rules between COVID and now, a lot of things are much more difficult now. Because during COVID, for example, they would accept your proof that you have your self-appointment.

Josh | ExpatsEverywhere (33:31.188)
Uh-huh.

Josh | ExpatsEverywhere (33:43.475)
Mm-hmm.

Sofia (33:44.04)
Now they do not accept any of that. You have to be an authorized resident. So all of after that process, only after that, you have to be, um, approved of residency, the, that, and most of the service now requests that you go there in person with all of that documents. And they confirm it and only then they will give it to you.

Josh | ExpatsEverywhere (33:46.889)
Right.

Josh | ExpatsEverywhere (34:07.622)
Yeah. And I mean, this is another reason why it's really important for people to have that private insurance coverage, uh, so that they can at least get to the point where they can register them with the public system, get the attendance number and be able to access, uh, both the public and the private system. Yeah. Is that accurate?

Sofia (34:25.152)
Yeah, I've lost you for a little bit. I lost you for a little bit. I didn't hear the last part.

Josh | ExpatsEverywhere (34:32.938)
It's just, it's accurate to say that people need to be able to have their private insurance when they first arrive so that they can have coverage, some coverage up until they get the utens number and get registered into the system. So they, they after that will have public and private. Okay.

Sofia (34:50.932)
Yes, yes, that is correct. A lot of times this is a process that can take you a while. And again, this is why they ask, and this is why they want you to have a private insurance, because they know that you, we are not going to be financially responsible for you until you are an authorized residence of this country, until we see that you comply with everything and only after that, okay, this is something that you can go.

Josh | ExpatsEverywhere (35:05.255)
Mm-hmm. Yeah, exactly.

Josh | ExpatsEverywhere (35:13.794)
Yeah.

Sofia (35:20.456)
A lot of times people are very, even for example, the question of the medication, the difference and they think that they can only have, for example, their medication prescribed or with a discount or the co-payments from the state once only if it's prescribed by the family doctor in the public health center and this is not true. So once you have your utent number, even if you go to your private doctor because you have a private family doctor.

Josh | ExpatsEverywhere (35:42.158)
Mm.

Sofia (35:50.108)
The prescriptions of the medications are a part of the system and this is something that you will always have a co-payment.

Josh | ExpatsEverywhere (35:58.878)
Okay. Um, I wanted to touch on something that we spoke a little bit about earlier. Um, just to dive a little more into kind of some, something socio-cultural, and we were talking about the age of, uh, GPs or family doctors and the fact that there weren't very many, uh, younger people that were graduating, wanting to move into this, you know, specific field.

What's happening right now in Portugal when it comes to doctors and nurses, are they overworked? Is there a shortage? Are there other issues? Where are the doctors and nurses going if they're not here in Portugal practicing medicine?

Sofia (36:38.68)
Okay, so again, this is one thing that we could keep, we could talk about this for weeks and weeks, because again, whenever we talk about the public system, we always talk about also, I think we cannot disconnect that from policy. And so what type of policies do we have and what type of government do we have and what's the general feeling? When I think...

Josh | ExpatsEverywhere (36:47.539)
I know.

Sofia (37:08.4)
is not as much a problem if they are overworked in the public service. I think in the public, we have a huge problem. That's a problem of managing. We have really bad people managing the system. But this is my personal opinion again, as a nurse working in the public. And the thing is, and I will explain you why we see an increase.

Josh | ExpatsEverywhere (37:26.558)
Okay.

Sofia (37:36.1)
From the last, even before coming of COVID, I would say from 2019, 18 up, we have seen an increase of, for example, the budget for health has been increasing every time. So the budget for healthcare comes from the general budget of the country. So there's a general budget and they say, we're going to give, I don't know how many billions to the public health care service.

And it has been increasing, always increasing. So the amount of money that we as a country put into healthcare service has been increasing. But that has not been translated into better care of the population, into best access, into better response from the system.

There has not been a lot of investments. A lot of public hospital are unfortunately old or in needing of renovations. And so I think most of all, and the biggest issues for nurses and doctors and other providers are, is this, is that the lack of, well, they don't feel supported in terms of who manages them, in terms of...

Josh | ExpatsEverywhere (38:40.987)
Mm-hmm.

Sofia (39:01.337)
what's the gold line here and we need this and this. And so I think during COVID, a lot of people were overworked, but I think this was worldwide because it was a lot of people with no vacations, a lot of people with not access, even getting able to be home. So I think the main problem here with doctors of nurses, it's not, they end up being overworked because there is no good management. So you end up getting,

Josh | ExpatsEverywhere (39:11.188)
Mm.

Sofia (39:28.768)
frustrated with a lot of things that you're not supposed to do as a doctor, as a nurse, and then you end up having to do them because it's just the system is not well managed. So that's where I see the overworked. I will give you a very, very quick example. We now use internet systems and operating systems everywhere at every hospital.

For me, and I'm not a manager, the most expensive research in a hospital is the doctor or the surgeon because they cost a lot of money. So we should have him do whatever he has to do for the eight hours that he's working. If he's a doctor, he has to do appointments. I have to have them there doing only that and not worrying that every time the system fails, there I go trying to write to the doctor. So we end up seeing the doctors.

spending a lot of their times with this administrative issues, with little things that they're not supposed to be doing because we need this. They're very expensive, so we need them to be doing this. And we nurses end up doing a lot of this also and not doing what, for example, it's a very simple case, nurse case manager. There are nurse case managers in Portugal, except from us at Serenity.

Josh | ExpatsEverywhere (40:35.463)
Mm-hmm.

Sofia (40:55.612)
at the public hospital, you don't have that or you, and so the doctor has to have 10 appointments every time the patient has a question or anything. And so I think, and this is only a matter of managing and who managed the system, but again, it's such a huge system. It's such a...

you get policy involved, you give to government, and you have the prime minister, and you have everyone and the ministry of health and finance minister that says, hmm, don't spend as much money. So when we have all of that and all of those conflicting things, you have people that are in fact overworked, disappointed with the system, tired of working in the system, yes.

Josh | ExpatsEverywhere (41:19.523)
Sure.

Sofia (41:44.052)
In terms of shortness, we had a lot of nurses going away and working in other countries. At this point, for example, the UK, I think they have all the nurses there. They just import them directly from Portugal to the UK and they just come. And we have nurses all around and even doctors now, we're seeing that. And this is something different. But I think that this is also a worldwide thing.

Josh | ExpatsEverywhere (41:53.168)
Hmm.

Josh | ExpatsEverywhere (42:02.162)
Ha ha ha.

Sofia (42:11.896)
All of a sudden people understood that they could work somewhere else. They can go to another country also. And so we have a lot of doctors that are also deciding, I want to go and work in Germany or I want to work in Spain or I want to work in the UK. So yes, I think we will have, we do not have in terms of, but this is not a very, it's the all CDA numbers per capita.

Josh | ExpatsEverywhere (42:18.99)
Sure.

Josh | ExpatsEverywhere (42:29.387)
Yeah.

Sofia (42:41.624)
We do not have a certain a sure test of doctors. The problem is not all doctors are in the active duty in doing what they're supposed to do. So, but if you see the numbers, the official numbers from all CDA and whatever, we are not like the country that doesn't have doctors. We have more doctors per capita than others. But the question is we have doctors probably doing stuff that they're not supposed to do instead of being doctors.

Josh | ExpatsEverywhere (42:45.517)
Okay.

Josh | ExpatsEverywhere (42:50.254)
I see. Okay.

Josh | ExpatsEverywhere (42:56.744)
Yeah.

Josh | ExpatsEverywhere (43:04.515)
Mm-hmm.

Josh | ExpatsEverywhere (43:10.006)
Mm-hmm. I see. Okay. Well, we recently had a listener ask us about pain clinics. So I wanted to take this time to get this question over to you. What are pain clinics and do they exist in Portugal?

Sofia (43:17.712)
Thank you.

Sofia (43:25.2)
Okay, so the pain clinics usually, and I think in the US you have more, we have some here are clinics or departments that specialize in pain management. When I started working in the last year that I was at school, I worked in a pain management clinic in a public hospital and there are several within public or private hospitals. And basically...

It started a lot with chronic pain for cancer patients. So this is the evolution of chronic pain. So we started recognizing that pain has a problem with cancer patients, and then you start being more active and proactive of that. I experienced in what we do, a lot of our clients that have a chronic pain associated to

muscular, skeletal issues or associated with a car accident or with an event that they would have. We have some pain clinics here, but in the private facilities, they also usually have departments. For example, we at Serenity, we have a doctor that's our pain management doctor, because usually doctors, this is not a specialty. This is like a subspecialty.

So you would find doctors with different backgrounds. It could be from oncology, from anesthesiologists, to physicians or orthopedic doctors. So from several other, they will come with different backgrounds and then they do these subspecialties. They have a more intense interest in this area. So they start exploring pain management and medication and all of that.

It's an ongoing process for us here. I think when it comes to very specific medical conditions, this is very well managed and very well carried. Something that most of the doctors already have in their consideration, seeing pain not only has a, because acute pain is a good thing. Acute pain, when we have acute pain, is a good thing because it's a warning sign.

Josh | ExpatsEverywhere (45:47.413)
Okay.

Sofia (45:47.456)
It's our body telling us, it's kind of like the alarm when you have a fire. So acute pain is an alarm. So that's important. It's an, if it's an acute, what the difference is when this pain is no longer a sign of something and a good thing, and it becomes a condition or a disease for itself. So this is where you come into the field of a chronic pain. And those are two very different things with two very...

Josh | ExpatsEverywhere (45:54.224)
Mm-hmm.

Josh | ExpatsEverywhere (46:09.463)
Hmm.

Sofia (46:15.404)
very different dimensions and treat it in very different issues. So I think there exists, there are pain clinics here in Portugal, there is doctors within the public and the private that will be able to help. Again, the way that they work is the same way. If you are in the public, you have to be a gatekeeper, you have to pass your gatekeeper and get until there. If you aren't in the private system,

It's easier, we can find the perfect person to help with that. Again, it depends a lot on the situation of the client, the diagnose, and what we can do to help with that. Some of the medication that you use a lot in the US is not as common here in Portugal to use, in my personal opinion, and very well.

Josh | ExpatsEverywhere (47:10.176)
Mm-hmm.

Sofia (47:14.124)
because a lot of the easy access to very, very strong and specific painkillers when you have an acute pain can be a problem itself, not a cure. So if you give, if I would put everyone doing a specific medication for a chronic pain,

Josh | ExpatsEverywhere (47:30.674)
Uh huh. Sure.

Sofia (47:42.884)
to every time I just fell, I hurt my knee. So now I have to ice it and put some ibuprofen instead of that here. Take 10 milligrams of morphine. Is it balance? Is it a good care? Am I doing, remember the first principle of every medical profession is do no harm. So I don't think that here we deny people medication just because we like to see them suffer. I think that there are...

Josh | ExpatsEverywhere (47:53.206)
Yeah.

Josh | ExpatsEverywhere (48:03.394)
Hmm.

Sofia (48:13.272)
The first thing is do no harm. So make sure first of all, that you're doing the best thing you have to write diagnosed and a lot of times, and I, we have several clients that are treated for pain, chronic pain with our doctors. And a lot of times is yes, we'll continue this treatment, but let's work on the cause let's do continuous work. And sometimes.

Maybe in two or three or five or six or one year from now, you're not going to need this medication anymore because we have treated this and this and this, and now we are at the root cause of the problem and now we are treating the cause and there's other situations. We really need chronicle medication. Our doctor, for example, is one of the first advocates and the person that's

started more working with medicinal cannabis, for example, that it's something that's still starting here. And not everyone is willing to prescribe it, for example. And so it's sometimes the matter of finding the right doctor that will be able to assess and is comfortable with this type of medication. And being medicinal cannabis, one of them, it's very restricted the use of the

Josh | ExpatsEverywhere (49:25.897)
Right.

Sofia (49:32.844)
It's restricted to seven diagnoses. Only with seven possible diagnoses, you can prescribe it. And so not everyone is comfortable managing it and treating the person with the chronic pain. So pain has always been an issue and I think it's always a dilemma for the team of doctors and nurses that's working with that person, for the person itself.

And I think it's always finding the best between the two of the things.

Josh | ExpatsEverywhere (50:06.118)
Okay. Well, Sophia, if we have other listeners that, uh, really enjoy this episode, if we have a lot of listeners that enjoy this episode and they want us to bring you back on, would you come back on talk more about the healthcare in Portugal?

Sofia (50:17.444)
Sure, sure, of course. There's one thing that I like to do is to talk. So yes, of course, of course. I know that we didn't, I don't know if we get into everything that we wanted to, but at least I think the main topics we were able to get and I know that sometimes giving these answers brings more questions after.

Josh | ExpatsEverywhere (50:25.299)
Awesome.

Josh | ExpatsEverywhere (50:36.606)
Exactly.

Josh | ExpatsEverywhere (50:41.802)
That's right. Yep.

Sofia (50:43.877)
And this is why it's important to discuss this and have, when you want to have a deep understanding of where the country is and all of, and also accepting. There's certain things that we just have to accept. It is what it is.

Josh | ExpatsEverywhere (50:57.534)
Yeah, that's right. Well, we're definitely learning those things the longer we live here. So if listeners want to ask more questions as they want to learn more about this, we will have you back on. Sound good?

Sofia (51:16.416)
Yes, yes, of course. Thank you. Thank you. Take care. Thank you.

Josh | ExpatsEverywhere (51:18.966)
Thanks, Sophia. Take care. Bye.

Okay.