Everyone knows the game. You can’t get into the specialist. Insurance says no to the drug you definitely need. Your colleague is stuck in referral purgatory for the third month running. So they call. A text to the department chair. A ring to a residency classmate who’s now an exec. The problem vanishes. It feels like help. Generosity, we say. Courtesy.
It’s actually evidence that the front door is broken.
The back door exists because we don’t trust the main entrance.
I’ve done it. Called in a marker for a family member trapped in administrative red tape. One conversation fixed a mess that normal channels had let rot for weeks. Did the medicine change? No. Did the science change? Nope. Just our proximity to power. I felt lucky. Then I felt guilty. Then I wondered why luck was even on the table.
Here is the ugly truth about healthcare leadership: if your spouse woke up sick tonight, you wouldn’t wait your turn. You wouldn’t accept the four-month waitlist. You wouldn’t brave the automated phone trees. You’d pick up the phone. You know which systems choke. You know where the bottlenecks live. You know that bureaucracy yields to pressure if you have the right contact.
We aren’t doing this because we are snobs. We’re doing it because we know the house of cards.
Healthcare actually runs on two parallel tracks. The visible one has algorithms, referral pathways, and insurance prior auths. This is what patients see. The invisible track runs on reputation, influence, and who you know. It’s available to the doctor. The board member. The donor. The lucky person whose cousin works at the hospital.
We tell ourselves it’s just fixing errors. Just ensuring care should have been delivered isn’t being blocked. From our seat it looks like rescue.
Does it look that way from the patient’s seat?
Not really. When one person’s outcome depends on their Rolodex and another’s depends on their patience with dysfunction, that isn’t efficiency. It’s inequality dressed up as helpfulness.
Celebrating the Wrong Hero
Organizations love a savior story. The nurse who hunted down a specialist. The director who overturned the denial. We cheer these moments. They show commitment. Heart.
They should make you sweat instead.
Requiring a superhero to deliver standard care is a design failure, not a success story. When employees have to be extraordinary just to make things work, you have a broken process. And over time you start rewarding the hero while ignoring the fire that required one.
Execs are blind to this because we live in a bubble. We have direct lines. Our assistants schedule. Our docs reply to texts. We never wait three months. That wait time is a metric on my dashboard. To the patient it’s panic. That distance between the manager and the managed warps reality. Metrics feel safe. The anxiety feels someone else’s problem.
Ask yourself this.
If you loved someone needed help today would you trust the system or look for a bypass.
That answer tells you everything. It tells you more than your quality scores ever could.
Stop pretending we should just stop helping our families. If my mom got sick I’d pull every string. That’s love. The issue is thinking that pulling strings is a feature. It’s not. It’s proof the standard path is unreliable. We’ve mistaken our ability to hack the system for the system working fine.
Every favor should be data. A signal that the formal process failed. Don’t just high-five the rescuer. Ask how to build the bridge so the rescue is unnecessary.
Managers put out fires. Leaders install sprinklers.
The goal isn’t to ban the back door. Relationships matter. Compassion isn’t bureaucratic. The goal is a front door so solid, so fast, so humane that nobody needs to look for a way around it. Until then the most powerful person in medicine isn’t the doctor. It’s whoever has the phone number that works.
