Equitable access to care is a hallmark of ethical medical practice and the profession of patient navigation is a vanguard of this principle. Because navigators often work as part of an interdisciplinary team, our healthcare colleagues also have an important role in assisting us with ensuring each patient’s access to care, regardless of socioeconomic status, philanthropy history, or other “connections” to a healthcare facility.

Many patients have contacted our navigation office after being referred by someone, such as a benefactor or the friend of a friend of a friend of a staff member. We are unsure of the conversation that occurred before the call to us; however, we know that some patients feel confident that their connection to our facility will assure a flawless medical experience regardless of how they are connected. One of our tasks as navigators is to mitigate these expectations.

At our internationally-renowned cancer center, we encounter people who others may have labeled a VIP or assured of expedited care. When we initially learn of their expectations, which range from amusing (all-hours access to the doctors via e-mail and/or cell number), to challenging (a request for a private room when the hospital is full), to the near-impossible (a same-day or next-day appointment with a provider who is scheduled 6 months out).

Once in a while a request is so absurd that it astounds us. We recently navigated a patient we’ll call Mrs. X. She was referred to us by one of our major benefactors, a long-time friend. She needed a surgical consultation for a biopsy. According to her husband, Mrs. X. was always a person with very high anxiety, and this was further exacerbated by the possibility of a cancer diagnosis.

We first spoke with Mrs. X on a Wednesday. Following protocol, her imaging was sent to the surgical clinic director. He was at an out-of-state conference but kindly reviewed from afar. This was our first special accommodation. He determined it was appropriate to schedule her for a first clinic visit at the end of the following week. However, Mrs. X could not wait that long and requested an earlier appointment, which the practice manager identified (accommodation number 2).

When the benefactor heard of this ‘delay’, she called the navigator, asking, “Why should she have to wait a week?” The appointment was then moved up to see a different provider in 2 days, a third accommodation.

At that appointment, the patient learned she would need a surgical biopsy. The provider she saw in the clinic performs biopsies only 2 days a week, so Mrs. X was scheduled for 1 week later. However, the patient was anxious and asked the provider to be scheduled sooner, a fourth accommodation.

Nevertheless, Mrs. X. was not pleased with the late time. She later reported to the navigator that she asked the provider the following: “If I ask [Mrs. Benefactor] to give [your institution] a million dollars, could I have an earlier time?” She reported that the physician was kind, but informed her that other patients were scheduled, and he could not move her to an earlier time.

We spoke with the physician about the encounter. He recalled that he thought that the patient was making the statement in jest, but even if she was not, he would have replied in exactly the same way. He remembered telling Mrs. X that other patients have the same concerns and are also anxious. He further explained that he has a commitment to the other patients who had already been scheduled.

The provider also said that he thought that it was not appropriate for patients to exert pressure at the expense of another patient, especially because of a social connection or higher socioeconomic status. When he moved Mrs. X up to an earlier day, it was only his own busy schedule that was affected, not another patient. He added that there is a limit to what can be done to accommodate this type of request from a patient. Hearing this from a provider was reassuring to us as navigators that he is providing optimal care to all patients, the basis for ethical medical care.

This philosophy of our physician colleague keeps the focus on doing good for all as a duty and a moral standard and reminds us that all practitioners involved in healthcare gatekeeping have an obligation to provide equitable care, and that it can be done in a compassionate manner.

Other patients with whom we have interacted over the years have told us that they would be happy to make a financial gift to our cancer center at the same time that they are requesting our help with an appointment. Our protocol is to defer the financial discussion to our development office and also for a later date. We employ this tactic consistently to avoid entangling a person’s healthcare needs with a financial incentive for our institution. Patient navigation must be detached from philanthropic activities.

Many times during our effort to schedule with a person’s preferred provider or timeframe, we encounter constraints with a physician’s vacation or conference schedules or with a limited number of patients that can be accommodated on a particular day. One way around this is to look for options at another location within our health system, or an earlier appointment with another provider.

Routinely our patients have an expectation of a flawless and extraordinary healthcare experience, and they may ask us impossible questions. We can never promise or guarantee that a person’s expectation for a particular provider or next-day appointment can be met. Difficult questions demand our own million-dollar answer: We can only promise to try our best.

Angela Moore and Sandra Blackburn are patient navigators the Abramson Cancer Center at Penn Medicine.

Articles

Two nurse navigators report on the importance of equitable access to care, regardless of a patient's social connections, socioeconomic status, of philanthropy history.

Answering Those "Million Dollar" Questions

Can I land my helicopter on top of the hospital? Can the doctor see my daughter before the clinic is open so she doesn’t miss too much work? Can you schedule my dog with a specialist at the veterinary school clinic? As navigators for the “special needs” population (aka VIP, or very important patients) at a top ten NCI-designated cancer center, these are actual questions from our patients, who most often are major benefactors to our institution. Though these may be atypical questions for healthcare navigators overall, we share common ground with all navigators: we recognize the specialized needs of our patients, and we engage in a trusting, helping relationship to facilitate optimal care.

Maybe you’re thinking that VIPs don’t visit your facility, but depending on how a VIP is defined, every healthcare facility can have VIP patients. Of course, famous people or public figures, such as professional athletes, rock stars and Hollywood actors are inherently considered VIPs, but 

 potentially could be designated as a VIP at a particular healthcare facility. Designated VIPs typically include benefactors, administrators, or donor prospects, but may also include the brother-in-law of the CEO or the cousin of a person connected with the facility, such as the dean or a top administrator.

When a person refers a patient to us and has labeled them a VIP, there may be an implicit or explicit message that this patient should receive “special care,” which is problematic in several ways. First, our providers, facilities, and health systems do wish to provide the same great care to everyone, regardless of status. Second, asking a healthcare professional to provide special care to a particular patient could imply that they are not providing great care to everyone, and the request could be received as an insult to their professionalism.

Of course as navigators, we’re not asking providers for different or better care, but sometimes notifying the staff of a person’s connection to our cancer center can be beneficial. For example, a physician may find it helpful to know that his patient is a local university president or a major benefactor who helped to fund the building we are working in.

As navigators, we use the term VIP judiciously when scheduling, as the term itself can be offensive to staff, especially because a goal of our facility is to reduce healthcare disparities. Many times providers and support staff have said to us that “everyone is a VIP” or, “I give the same care to everyone.” We would argue that some patients do need special considerations in deference to their position, status, or fame. For example, in this era of social media, a photo of a celebrity seated in the waiting area of a cancer center can be on the internet in a minute. Extending a small courtesy of arranging for a private waiting area can protect their privacy and identity, as well as their career.

Staff reaction to a VIP in the healthcare milieu can range from awe and admiration to resentment, which can affect the quality of care. If standard procedures are changed to accommodate the demands or expectations of a VIP, this can lead to predictable scenarios which have been organized into named syndromes in the medical literature. Psychiatrist Walter Weintraub wrote about 

 back in 1964; it’s initiated when standard care procedures are not adhered to, such as moving the location of care or switching providers. When rules are broken, it can contribute to care that is not better care, but actually worse than standard care.

Like all navigators working with specific populations, we’ve had to acquire a knowledge base of internal and external resources to help accommodate our VIP patients on a moment’s notice. Through in-person visits and frequent phone calls, we have developed relationships with colleagues in many departments at our facility. Transport will meet a patient at the front door at a specific time and Operations will help to ensure that the lab is ready for a patient. If we have a VIP who is an elected official or a public figure, we typically notify Security.

With our population we’ve become accustomed to receiving requests that are unrealistic. Patient expectations are high; they want their physicians’ cell phone numbers, e-mail addresses, and will often call them by their first name. Our patients are sometimes surprised that surgeons, for example, only see patients 1 day a week in clinic and therefore appointments are limited. Some may link their beneficence to the facility with expectations for same-day appointments for any malady or ‘front of the line’ expedited wait times in the Emergency Department.

As VIP patient navigators, we recognize that the financial resources at our patients’ disposal can move mountains. For example, one patient flew in from London for a single appointment and afterwards flew directly back. There are some VIP patients who we have never (or rarely) spoken to directly. Our relationship is often with their executive or personal assistants who have access to their schedules, habits, and preferences. For example one patient cannot be scheduled before noon on any date, due to his sleep schedule. Others are snowbirds and spend time here in the northeast and winter in Florida, so their medical appointments must be compressed into a brief window of time.

Patients call us miracle workers. Our success, at times, with setting up quick appointments with hard-to-get providers, can heighten their expectations for future encounters. We just try our best, every day. We are not successful every time, but we can appreciate these inspiring words of St. Francis of Assisi: “Start by doing what’s necessary; then do what’s possible; and suddenly you are doing the impossible.”

Sandra Blackburn has worked as a patient navigator, specifically with benefactors and other patients who are referred by Administration and Development, at the Abramson Cancer Center at Penn Medicine for nearly 15 years. Angela Moore joined the Abramson Cancer Center as a patient navigator in 2014 after a career at Health Partners, a Medical Assistance health plan, for 10 years as a case manager for the special needs and perinatal units.

Can I land my helicopter on top of the hospital? Can the doctor see my daughter before the clinic is open so she doesn’t miss too much work?

Angela Moore, BS

Articles

Answering Those "Million Dollar" Questions

Navigating "VIP" Patients With Cancer