The rooms you can't see
It is 3 a.m. at a large medical center with a respected transplant program, and a family is sitting in the ICU waiting room with a paper cup of coffee that has gone cold. They have been here since the late afternoon. Their husband, their father, their brother is in an operating room down the hall. He has end-stage liver disease, his MELD score has climbed for months, and at four o’clock the day before, the call finally came that an organ had been allocated.
I sit down with them in the waiting room. I am the anesthesiologist. The surgeon will not be out for another hour, and there are questions the family did not know how to ask the surgical team during the consent conversation earlier. I translate. I draw a small picture on the back of a hospital form showing the new liver in place and the old liver out. I explain the meaning of the numbers on the monitor when the patient gets to the ICU. I tell them what the next twelve hours typically look like and which of those hours are the ones that worry the team most. Their questions slow down, and then they stop. The room is different than it was when I sat down.
Most readers will never sit in that room. They also will never sit in the operating room I just came from, where six clinicians worked through the night while their patient could not see them and his family could not enter. That OR is not the only room those readers cannot see.
There is the boardroom of a large non-profit health system, where the compensation committee approves the executive package against a market study the rest of the organization will never see. There is the executive office a floor below it, where workforce planning runs into the limits of how many nurses and physicians the country is actually graduating each year, and where the conversation either turns into a problem or turns into a plan. There is the credentialing committee, where the existing physicians on staff decide who joins them and where the names available to do the work get fewer every quarter. There is the peer review committee, where a physician’s clinical work is examined by their colleagues behind a closed door, and where the lessons of a hard case become the standard a department is held to. There is the conference room, where a payer and a health system negotiate the unit prices that will quietly determine, eighteen months later, how many nurses are at the bedside on a Tuesday night. There is the C-suite succession meeting where the question of who replaces the CEO when he retires gets decided long before the rest of the organization knows there is a question. There is the M&A meeting where a community hospital becomes a chain asset. There is the regulatory hearing room, where a federal agency writes a rule that will, twelve to eighteen months later, change which procedures can be done in which settings and who gets paid for them.
These rooms are not secret in any movie sense. The decisions made in them are not malicious or hidden. The rooms are simply not open to the people whose work and lives are most directly affected by what happens inside them.
I have spent more than two decades inside both kinds of rooms. The clinical ones, in the operating rooms and the ICU and the holding bay and the recovery unit. The administrative ones, in large health system leadership, and now in my role as Chief Clinical Officer at Essential Anesthesia Management. I am still in both. People sometimes ask why I would leave the bedside for the boardroom, a move some call “becoming a suit.” I have not left. The two are different kinds of work, and they are complementary. On a clinical day, the work is direct and immediate. It is the patient in front of me, the family in the waiting room, the team around the operating table. In the executive rooms, the work is a step removed: the conditions that determine what every team in the system can do at the bedside. I provide patient care a few shifts a month because there is nothing more grounding than an interaction with a patient and family on what is often one of the worst days of their lives. I sit in the executive rooms because the decisions made there determine how many of those interactions are possible, how well the people doing them are supported, and how long the system that makes them possible can keep operating.
This newsletter writes from those rooms.
It does not write about them in the gossip-column sense. It does not name and blame. It does not traffic in the kind of healthcare commentary that depends on outrage to hold a reader’s attention. It writes plainly and specifically about what happens in the rooms most readers do not enter, and why those things matter for the patients, clinicians, and families who live with the downstream effects.
The discipline of this writing is straightforward, and it is worth saying aloud at the start so the reader can hold me to it. I will credit by name the leaders, clinicians, and operators whose work I respect. I will not publicly name and critique colleagues or former employers; that work belongs in private conversation, not in a public forum. I will sit with complexity rather than pretend it does not exist. I will share the strongest counterargument to my position before answering it. If I change my mind on something I have argued for in print, I will say so, and I will explain why. I will not exaggerate for effect. I will not lean on absolute language to compensate for an argument I have not earned. Solid arguments do not need formatting to land well, and I will keep my hand off the bold key as much as I can.
A short preview of where the writing is going next.
I plan to write about the workforce cliff that healthcare is already starting to feel. The story most people hear is about a shortage of interest in clinical careers. The actual problem is closer to the opposite. In many of the relevant training programs, qualified applicants consistently outnumber seats, and the binding constraint is not interest or aptitude. The constraint is clinical training capacity, the number of teaching sites and clinical faculty the country can actually field, and the federal and state policy choices that determine how that capacity is funded and approved. That is a different problem than the one most leaders are solving for, and it has different solutions.
I plan to write about executive compensation in non-profit health systems. There are structural features of the non-profit construct, written into federal tax policy and overseen unevenly at the state level, that make it possible for a senior executive’s total compensation to run five or ten times that of the median nurse at the bedside in the same hospital, and to do so with less public visibility than equivalent compensation would receive in a for-profit setting. I am not arguing the non-profit construct is fundamentally broken. I am arguing the construct has features that allow executive compensation to scale faster than the mission’s reach into the communities the institution was built to serve, and that the same construct supports services for-profit systems will not provide. Both of those things are true. The conversation we are not having is about the features themselves.
I plan to write about leadership development as legacy work. One of the most important tasks of a senior healthcare leader is to develop the next generation of leaders to be better than we are, to think and plan and listen more carefully than we did, and to know we have done the work when those we are developing prove they are better positioned than we are to address the problems of the next decade. We are successful when those we are developing put us out of a job. The reason that line freezes the room is that most leaders are still measuring success by how long they hold their seat, not by who they have ready to take it.
The transplant case ended well. The patient was extubated a few hours after arriving in the ICU. His wife thanked the team while still holding the same paper cup of coffee, and every question she had walked in with had an answer. The room she had sat down in at midnight was a different room when she stood up to leave.
Most of healthcare’s rooms close before that kind of moment can happen in them. The work of this newsletter is to hold the door open long enough for the reader on the other side to see what happened inside, and to walk away understanding it.
The pieces that follow will trust the reader to hold complexity, decline the easy reach for outrage, and arrive at a regular rhythm whether the news cycle is hot or quiet. They will be uneven in topic and consistent in discipline.
If that is the kind of writing you want in your inbox, I am glad you are here.
A free post most weeks, on healthcare leadership, the systems we run, and the policy choices that quietly shape both. A paid post every other week, opening at Week 4, that goes deeper than the free posts can. The occasional argument I would not be able to make if I had not been in the rooms myself. Plain-spoken. Sharp on specifics. Constructive over corrosive.