The Way To Level Up Your Healthcare May Not Be What You Think
(The three types of healthcare failure - And why fixing the wrong one keeps you stuck)
A busy executive - we’ll call him Michael – came to me after consultations with both a spine surgeon and a bariatric surgeon. Both were telling him he needed surgery (both surgeries). They both also told him the surgeries had low probabilities of success in meeting his goal.
His goal was better mobility. He wanted to stop needing a walker after a back injury 6 months ago. He wanted to be able to walk down Capital One Arena to his season seats at Caps games with his kids.
He had found expert doctors. He was doing his best to follow their advice. He was thoughtful, organized, and highly motivated.
He had done everything right.
And yet he was getting worse. And the only option presented to him –two major surgeries with low success probability– looked terrible.
He knew the problem he wanted to solve: improving his mobility. But he didn’t know the problem in the medical system that was getting in his way.
Healthcare fails because of a problem that may not be on your radar.
After years in medicine and many complex cases, I see healthcare failures fall into three distinct categories.
Two of the categories are relatively easy to solve. But most patients—and many physicians—aren’t even aware of the third. The third failure type is most often the reason intelligent, proactive people end up spending years, and a lot of energy and money, on solutions that don’t improve their health.
Here are the three types, and how to recognize which one you’re experiencing:
Failure Type 1: Access failure
(a logistical breakdown — frustrating, but usually straightforward to solve)
What it looks like
Long waits for appointments
Rushed 10–15 minute visits
Difficulty reaching your doctor between visits
What solves it
Very fast access, transactional care
Urgent care clinics
Direct-to-consumer medical websites such as Hims & Hers or Ro
Medical services that advertise response time as the product (same-day appointments, “get your prescription in 15 minutes”)
These models are optimized for speed and convenience.
If your condition is straightforward (cut-and-dry hair loss, erectile dysfunction, acne, needing antibiotics), this can be a much-needed breath of fresh air.
Improved access with continuity and time
Concierge medicine
Direct primary care
These models solve access differently: fewer patients per physician, longer visits, easier communication between appointments, and continuity over time.
If your primary problem is not being able to get enough time or attention from your doctor, this structure can dramatically improve your experience.
Failure Type 2: Expertise failure
(a knowledge gap — harder to identify where to go to correct)
What it looks like
Your doctor has little experience with your condition
You’re told, “This is rare” or “I don’t see this often”
Treatments you’re given don’t work and your team doesn’t know what to do about it
What’s actually broken
You are not seeing someone with sufficient domain expertise. They haven’t treated your specific issue - how could they manage it well?
What solves it
A specialist or center of excellence that regularly treats your condition.
This works when
The diagnosis is correct
The presentation is typical
The problem is largely confined to one organ system
Failure Type 3: Strategy failure
(a systems-level breakdown — complex, cross-disciplinary, and often mistaken for Types 1 or 2)
This is the most common failure among complex patients—and the least recognized.
What it looks like
You receive conflicting recommendations
You are acting as the coordinator, translator, and project manager of your own care, explaining Specialist #1’s plan to Specialist #3
You can see more doctors, but no one is “in charge” or taking responsibility for you getting better and the outcome you want.
No one seems to have looked carefully and thoughtfully at all the data and at your whole picture
What’s actually broken
Your problem requires coordination, challenging previous assumptions, and interdisciplinary problem-solving – something most primary care doctors and specialists have no incentive to do, and even concierge medicine lacks the needed infrastructure to do effectively. Isolated individuals who go above and beyond are out there, but it’s basically done off-hours and hinges on who they happen to know.
In modern healthcare, finding you the best specialists in the world for what you need, your doctors talking to them on your behalf, an expert researching the best practices for your unique symptom even if it is outside their area of expertise – that is, getting the strategy failure solved – often comes down to luck. You may get lucky once, but it’s not guaranteed to happen consistently like it should.
Why common solutions fail in these cases
Concierge medicine improves access, but usually does not have resources to do diligence on raw data or opinions given by outside specialists.
Seeing more specialists adds opinions without synthesis. The problem becomes worse, not better.
Patient advocates often lack the clinical authority to challenge diagnoses or treatment plans.
More access and more expertise cannot fix a coordination problem.
What changes when strategy finally happens
When patients with strategy failures finally get better, it’s because someone finally does the critical work no one was doing:
Reviewing the entire medical record, not just the latest diagnostic code
Identifying which specialists are actually needed and actually talking to each of them directly
Making sure everyone is working from the same model of the problem
Asking very basic questions again:
How do we know this diagnosis is true? What data is it based on?
Are we sure this case should be managed according to general guidelines?
The diagnoses that were “ruled out” – were they truly?
What else could be going on that we might have been missing?
Once the strategy is coherent, many decisions become obvious.
This is why patients often say, in hindsight, “I can’t believe this took so long.”
The information was there. It just wasn’t integrated.
Better access and expertise can be a mirage
Most patients think that having a concierge doctor or sought-after specialist is as good as it gets – and their care must be optimized once they get there.
They think to pay for:
If only I had more time with my doctor…
If only I could get into a better hospital…
So they escalate in the wrong direction.
For a while, it feels better. Appointments are longer. Offices are more luxurious. Doctors are warmer and more patient. The environment feels more elite.
But months later, nothing fundamental has changed.
How to tell which failure you’re experiencing
We’ve built a roadmap to help you figure out which of the three types of healthcare failure you’re experiencing.
What to do if you have a strategy failure
You don’t need more doctors.
You need someone equipped to deeply consider the whole case.
A Physician Advisor is a board-certified physician whose role is medical strategy: auditing diagnoses, pressure-testing treatment plans, coordinating specialists, and maintaining accountability for outcomes.
Not replacing your doctors.
Not selling procedures.
But ensuring that your care is coherent.
A good physician advisor is backed by a team of excellent specialists (Carte’s is over 80 strong across top institutions in the country), because no single doctor can re-evaluate all the breadth of medical diagnoses and treatment options.
You know you’re not getting strategy work if there is no budget built in for considering your plan without you there. If you’re only paying for the appointments when you’re face-to-face with your doctor, that’s likely the only work being done for you.
One final thought
Most healthcare failures are not caused by bad doctors or inattentive patients.
They’re caused by applying the wrong solution to the wrong problem.
If this framework helps you name what you’ve been experiencing, share it with someone else who needs it.
Sometimes clarity—not access—is the first real intervention.
If you’re already doing “everything right” and still getting worse, the answer is rarely more.
It’s different.