Healthcare operates with back doors for some.
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Everyone in healthcare knows what it means to “make the call.”
A family member cannot get an appointment with a specialist for months. A friend has been denied a medication that every physician involved agrees is appropriate. A colleague is caught in an endless cycle of prior authorizations, referrals, and appeals. Rather than trusting the process, someone reaches for their phone. A text is sent to a department chair, a hospital CEO, an insurance executive, or an old residency classmate. Suddenly, what seemed impossible becomes routine. The appointment appears. The authorization is approved. The problem dissolves.
We tend to view these moments as examples of generosity, professional courtesy, or simply people helping people. In one sense, they are. But they are also something else: evidence that the system itself cannot be trusted to reliably produce the right outcome.
The existence of medicine’s back door tells us something important about the front door.
I have used that back door myself. Like many physicians and healthcare leaders, I have called colleagues to help family members and close friends navigate a healthcare system that I know all too well. When a family member encountered administrative barriers to obtaining an important medication, I was fortunate enough to know the executive responsible for the organization involved. One conversation resolved a problem that had persisted through the normal channels.
Nothing about her clinical condition changed. Nothing about the medical evidence changed. The only thing that changed was our proximity to someone with the authority to fix the problem.
I was grateful the call worked. But I was left wondering why it had been necessary at all.
That experience forced me to confront an uncomfortable truth: many of us who lead healthcare organizations do not actually trust the systems we oversee when the stakes become personal. If our spouse became ill tonight, would we simply wait in the same queue as everyone else? Would we calmly accept a four-month delay for an appointment or spend hours navigating automated phone trees and fragmented referral systems? Or would we immediately begin calling people we know?
For most healthcare leaders, the honest answer is obvious.
We would make the call.
That is not because we are entitled or unwilling to wait our turn. It is because we understand, often better than anyone else, where the system breaks down. We know which departments are overwhelmed, which authorization processes routinely fail, which clinics are impossible to access, and which bureaucratic obstacles can be overcome only through personal intervention.
Ironically, the people with the greatest knowledge of the healthcare system are often the least willing to rely on it without leveraging personal relationships.
This should concern us.
Healthcare has quietly developed two parallel systems of access. The first is the one every patient sees. It is governed by scheduling algorithms, referral pathways, insurance requirements, and administrative processes. The second is largely invisible. It operates through relationships, reputation, institutional influence, and professional networks. It is available to physicians, executives, board members, donors, and anyone fortunate enough to know someone with enough authority to move a problem to the top of the pile.
Most of us who participate in this informal system do so with the best of intentions. We are not asking for unnecessary care or preferential treatment. More often, we are trying to secure the care that should have been available in the first place. We tell ourselves we are correcting an isolated failure rather than seeking special privileges.
Yet from the patient’s perspective, the distinction hardly matters.
If one person’s access depends on who they know while another person’s depends solely on their ability to navigate a dysfunctional bureaucracy, then the system is distributing opportunity unevenly even when clinical need is identical.
Healthcare organizations often celebrate stories of extraordinary employees who solve seemingly impossible problems. The nurse who personally tracks down a specialist. The medical director who intervenes to overturn a denial. The executive who helps a patient obtain an urgent appointment. These stories are inspiring because they showcase remarkable commitment.
But they should also make us uncomfortable.
Every time an organization requires extraordinary effort to deliver ordinary care, it is revealing a design flaw rather than demonstrating excellence. Heroic employees often become substitutes for reliable systems. Over time, organizations begin celebrating the heroism instead of eliminating the conditions that made it necessary.
Healthcare leaders are especially vulnerable to missing this distinction because leadership itself creates distance. Senior executives rarely experience healthcare the way ordinary patients do. They know department chairs. They have direct access to specialists. Their assistants schedule appointments. Their physicians return text messages. Even when they receive care within the organizations they lead, they experience a fundamentally different version of the healthcare system.
None of this reflects bad intentions. In fact, many healthcare leaders entered medicine because they wanted to improve people’s lives. The problem is not a lack of compassion. The problem is a gradual separation from the lived experience of the people our organizations exist to serve.
Over time, that separation changes what feels normal.
Waiting three months for a specialist becomes a statistic rather than an experience. Prior authorization becomes an operational metric rather than a source of anxiety. Call center wait times become dashboard measurements instead of moments of frustration. The system becomes something we manage rather than something we personally endure.
Perhaps that is why I have come to believe that one of the most revealing questions any healthcare executive can ask is remarkably simple: “If someone I loved needed care today, would I trust the front door, or would I immediately look for the back door?”
The answer tells us far more about our organizations than almost any quality metric we publish.
None of this is an argument that physicians or executives should stop helping the people they love. If my mother became seriously ill tomorrow, I would make every phone call available to me. Most readers would do the same. Family loyalty is not the problem.
The problem is that we have quietly accepted the existence of two different systems of access and have mistaken our ability to navigate around dysfunction for evidence that the dysfunction is manageable.
It is not.
Every executive intervention, every physician favor, every expedited appointment obtained through personal relationships should be treated as valuable organizational data. Each one identifies a point where the formal system failed to deliver what patients reasonably expected. Rather than simply celebrating the successful rescue, we should ask what process needs to change so that no rescue is required next time.
That, ultimately, is the difference between management and leadership.
Managers solve today’s exception. Leaders eliminate tomorrow’s exception.
The goal should never be to close medicine’s back door. Compassion, relationships, and professional generosity will always have a place in healthcare. The goal is far more ambitious: to build a front door so dependable, so humane, and so responsive that no one feels compelled to search for another entrance.
When that day arrives, the most powerful person in the healthcare system will no longer be the executive with everyone’s cell phone number. It will be the patient who can trust that the ordinary path is good enough.