Let's Be Honest About Health Equity

THE PALLIATIVE LENS

By Andrew Esch

There’s a moment most of us don’t talk about in healthcare because we know we can’t, at least not honestly.

• It’s not on rounds.

• It’s not in a QI meeting.

• It’s not in the social media posts we write about equity, access, or “transforming care.”

It’s the moment something happens to someone you love.

And suddenly, you’re not navigating the system like everyone else.

You’re calling someone.

• A colleague

• A specialist you trained with

• A medical director

• A friend who “knows how things really work”

You text. You DM. You bypass.

You don’t wait in the queue you tell your patients is “just how the system works.”

“I Would Never”…Yes You Would

I’ve seen this play out in real time over 26 years in palliative care.

• Executives and physicians getting care in systems other than their own

• Hospital leaders calling after hours to move something along in the system they oversee

• A steady stream of calls—3 to 5 a month—from family, colleagues and friends asking for help, a nudge, a name, a way through

This isn’t unique to me.

It’s the culture.

We’ve Even Operationalized It

Many health systems have internal pathways for “executive” or expedited referrals

In hospice, we didn’t even pretend, some patients were labeled “VIPs.” Clinicians called them “Friends of Bill.” Everyone knew what that meant.

Some hospitals have VIP wings:

• The Pavilion @ Mass General

• Phillips House @ Brigham and Women's

• 11 west @Mt. Sinai

• Mckeen Pavillion@ NY Presbyterian

All hospitals have VIP behavior.

This isn’t accidental.

It’s designed.

Let’s Stop Pretending

We say we want a better, more equitable, system.

• We post about it

• We speak on panels about it

• Our national organizations release statements about it

And then, when it’s personal, we opt out.

We use whatever access, influence, or proximity we have to get something different:

• faster care

• better communication

• a name attached to the chart

We don’t call the main number.

We call our number.

If the System Worked, You Wouldn’t Do That

This is the part that should bother us more than it does.

We don’t do this because we’re bad people.

We do it because we don’t trust the standard path.

• We know delays are real

• We know communication breaks

• We know that if no one is watching, things fall through

More specifically, we trust individual clinicians.

We don’t trust the system around them.

So we step in. We intervene.

We fix it for the people we care about.

And then we go back to work and accept that same unreliable path for everyone else.

Understandable?

Yes.

Acceptable?

No.

You Are Not Outside the System

We like to talk about “the system” as if it’s something done to us.

It’s not. We are it.

Every time we:

• Accept a leadership decision we know will make care worse

• Stay quiet when access erodes

• Normalize delays, fragmentation, and understaffing

• Adjust our expectations downward and call it “realistic”

We’re not surviving the system.

We’re maintaining it.

The Quiet Hypocrisy

Here’s the part we rarely say out loud:

We do not offer our patients the same system we secure for our own families and friends.

We can dress it up however we want:

• professional courtesy

• networking

• “helping navigate”

But the reality is simple:

When it matters most, we don’t trust the standard path.

And instead of fixing that path, we route around it.

Where This Doesn’t Happen

And here’s what makes that harder to defend, because we’ve all seen a version of care that looks different.

My wife runs an anesthesia practice that operates entirely in the cash-pay world, alongside surgeons and offices that have opted out of this system.

Everyone gets the same care.

There aren’t multiple layers of administrative filtering between the clinician and the patient. There’s no maze disguised as coordination.

When she needs to talk to a surgeon, she calls, and they pick up.

When a patient needs to talk to her, or the surgeon, they call, and the doctors pick up.

It’s doctor to doctor. It's patient to doctor.

• No gatekeepers

• No automated phone tree

• No message telling someone to hang up and call 911

Just two clinicians, responsible for the same patient, actually talking to each other, and more importantly, to patients.

Now, let’s be honest about this too:

That model works in part because it’s smaller, simpler, and not trying to absorb the full burden of the healthcare system.

It doesn’t scale easily.

But that’s the point.

We’ve built a system so complex that basic, direct, accountable care now feels like a luxury feature instead of the standard.

Meanwhile, the Next Generation Is Watching

Residents are organizing.

They’re unionizing.

They’re saying no to conditions we accepted as the cost of doing the work.

And many of us, who talk endlessly about burnout, moral injury, and broken systems, are still sitting on the sidelines.

We tell ourselves it is professionalism.

Mostly, it’s compliance.

This Isn’t About Outrage

It’s easy to be outraged.

It’s harder to be honest.

If we actually believe in equity, access, and quality,

then the goal can’t be to preserve a workaround system for the connected.

The goal has to be a system that works without workarounds.

For everyone.

So What Would It Look Like to Mean It?

It would look like:

• Saying no to decisions that predictably degrade care

• Walking away from roles that require you to defend them

• Refusing to normalize delays and fragmentation as inevitable

• Using your voice internally the same way you use it publicly

• Not deluding yourself into believing that access to a community health worker somehow = equity

And yes, sometimes it looks like leaving.

Not performatively.

But because staying quietly is a form of endorsement.

The Question We Avoid

The real question isn’t whether the system is broken.

We all know it is.

The real question is why it stays that way.

Because we allow it to.

Because there is no real consequence for not fixing it.

Because workarounds are easier than reform.

And because, when it matters most, we know how to get something better.

Just not for everyone.

One More Thing

You’ve done it.

I have too.

That’s the point.

This isn’t about calling out “them.”

Those hospitals mentioned earlier, the ones with VIP wings, produced over 50 papers on health equity in the last 5 years, and that is purposely underestimated.

That's nice, but maybe we should be publishing the truth.

Maybe we can start being honest about us.

And the decide whether we’re going to keep building a two-tiered system, one for those who know someone, and one for everyone else,

or finally do the harder work of making it better for all.