It doesn’t really matter what you are doing, it’s all about connections.  That’s fine when you are trying to get a job or score a deal, but it shouldn’t be a requirement for healthcare.  Especially if you are talking about cancer.

This story starts a long time ago, when I was a kid in preschool and was already so into cars that all I did was draw them.  Incidentally, they all had rockets on the back, making them more versatile than my current vehicles.  If only…

When I was in medical school, my mother enjoyed reminding me of my faded childhood fantasies, in which I didn’t much care where or how I lived, I just wanted a Ferrari.  No other material possessions were of much interest to me.  A table is a table, a bed a bed, a shower a shower.  But a Ferrari?  That’s magnifico.

Because I had no money to spend on cars, I buried these desires somewhere under my discarded ambition to be a fighter pilot, an impossibility with my 20:gazillion vision in a pre-LASIK world.  But then, on a fateful test drive with my brother-in-law up the side of Candler’s mountain in a Honda S2000, the motor screaming past any logical redline, I cracked.  Within 2 weeks I had traded my slush-box wagon on a manual shift Audi S4, and my descent into automotive depravity begin in earnest.

I have owned not one but three Ferraris.  They will always remain my absolute favorite cars.  And yet, like a girlfriend from a relationship that yielded experiences never to be divulged but was simply not going to work, I had to move on.  I had to move to something more compatible with my life.

Outside the world of the die-hard enthusiast, the Audi R8 is largely unknown.  People don’t know what it is, they don’t know the history, the significance, the intricacies.  I do. I know why it is called the R8.  I know the intent of its creators.  I know the ways in which it is oh so German, and the areas where they let some Italian flare color the page.  It has the sensibility (if any sports car can be said to be sensible), usability, and reliability that I require, but it checks the most important boxes that would need to be ticked if the order sheet were headed to Maranello (which, by the way, is where they make famous Italian cars).

Plus, they are half the price of a Ferrari.  Which is still way too much to spend on a car, but somehow that fact can be used as leverage to clamp down on the shouting voices of reason in your head that invariably tell you that this is a bad idea.  Pfffttt.  It’s a bargain!

I don’t know whether it was the fact that I was hanging out with a friend who seems to have an almost pathologic refusal to do stupid things, or the stark reality that I am to my core completely irresponsible with money, but the stage was set.  With the bulk of my sanity left mumbling and writhing furiously under a tarp in the corner of my brain, I only needed a nudge.  And the announcement that this was to be the end of the stick shift R8, that all future models would come with automated gearboxes? The response was predetermined.

The details of ordering the car, timing the purchase so that we could take delivery in Europe, choosing a color that I hoped would be both enduring and subtle (not), taking delivery of one of the last manual transmission R8s built, and driving it through 4 countries in 3 days, leaving it overnight in a crowded shed – with the keys – in the care of a teenage Italian girl; that is all chronicled in an issue of the magazine of Audi Club North America.  It was well and truly epic.

Which means it is kinda special to me.  So no, it is never, ever, going on a racetrack.  If some ill-fortune were to befall it, I would not have the means to pay the repair bills.  Plus, its replacement cannot be conjured from the pages of Autotrader. To me, it is one-of-a-kind.

And then Lisa said her mom wanted to go for a lap around VIR.  Dammit.

When we started the reimagination of our cancer center, our primary goal was to be able to bring comprehensive care to all of our patients, regardless of diagnosis or where they lived or who they were or what the issues.  One by one, each patient, everything and the kitchen sink.  Our prior Centra Health CEO, a cancer survivor, tasked us with devising a way to assure that all patients had the same opportunities afforded to him, opportunities that were not only instrumental in the success of his treatment, but came about at least in part by his deep understanding of the healthcare world.  In other words: remove the need for connections. 

And to do that, it means we have to make our own.

The system we are in the process of constructing is like no other system we have seen, anywhere.  It is based on connections: connections from patients to providers, connections between providers, connections to distant assets such as other hospitals.  By establishing these connections ourselves, we can remove the need for the patient to make their own.  But because no one else is doing this, it’s no easy task.

Lisa has worked with me for many years, and she has worked in the medical world for even more.  She has connections.

The first report was that her mother had a stroke.  But then the story got murky, involving suspicious imaging studies, and quickly leading to neurosurgery removing a lesion from her brain.  By the time we had figured out that this was metastatic lung cancer, her mother was in a limbo-like place in our system: she was, in many ways, invisible.

Virtually all cancer programs function in silos.  There is a breast cancer program, a colon cancer program, a lung cancer program, and so on.  Most neurosurgery patients are – fortunately – not cancer patients, so their silo can be poorly connected to ours.  A year ago, a patient with metastatic lung cancer diagnosed outside our lung cancer silo may or may not find their way.  They may not make the connection.  Today, things are different.  And because Lisa had a bit of a home-track advantage, I asked her for a favor: would she help us develop our process by giving us feedback?  What works?  What is helpful?  What is missing?  Both she and her mother weren’t just willing, they were eager.

Understand, this is not so much about the actual treatment.  In Lynchburg, we have that part down.  Yes, there are things that for a variety of reasons we can’t do, but we also have the connections to get patients whatever treatment modality is most appropriate.  But there is much, much more to caring for patients than just knives and drugs and photons. And it is these things that we have the greatest potential for improvement.  In their case, it turned out to be questions.

With her past experience, Lisa is as about as knowledgeable as any layperson.  But medicine has become so complex, so specialized, that even doctors are fish out of water when they dive into areas outside their own field.  And what happens when two doctors – two good doctors – have different opinions?  These complex scenarios where a variety of disease specifics and treatment options and patient desires churn together represent the choppy waters that nurse navigators are expert at steering patients through.  It’s not the answers themselves, but translating the information between the patient and their family members and caregivers and providers that helps keep everyone on the same page, speaking the same language.

But if you don’t have a navigator, you are left swimming alone.  Having unanswered questions is disconcerting.  Having unanswered questions relating to the fight of your life?  It’s a bit more than that.

So the simple solution: connect every patient with a nurse navigator.  And yet, it is not actually simple at all.  But that’s precisely what we have figured out.  And if you want to know if it is working, I know a couple of people you can ask.

And when you do, be sure to ask about our trip to VIR, because you know I couldn’t turn down her request.  Yes, the car is important to me, but it’s still just a car.  So be sure to ask about hitting 160 in an R8.  But even more entertaining, ask about following a certain ex-pro in a German boat.  A real ex-pro. One whose mischievous grin as he loaded 2 teenage granddaughters into his wife’s E63 AMG Mercedes luxorocket should have been my clue that there would be no quarter taken on the race track, and none given.

I wasn’t sure Lisa’s mom realized the super-sedan we were following up the climbing essess at triple digits carried her granddaughters, plumes of black smoke puffing out of the rear brakes as the undefeatable onboard computers tried in vain to bring some of the laws of physics to bear on Victor’s heavy right foot.

And then, while fixated on their bumper, she yelled, “I know they are in there.  You gotta pass that car!”


You have to be a track junkie to understand the point-by.  The point-by is a somewhat reasonable attempt at calming the insanity of recreational speed-freaks as they play together on race tracks.  It’s a technique where the driver of leading car reaches out the window, acknowledges a passing car, and points them by to the side they want them to go when they pass.  It’s so everyone knows what is going on.

As we rounded the slowest turn on the track and started down the longest straight, Victor kindly – and sarcastically – gave me a point by.

And then matted the gas.

Whereupon the 4000 pound Mercedes appeared to literally shudder from the otherworldly forces that heaved it down the asphalt like a giant stone in a catapult, no doubt straining the chassis to the limit, the front of the car frantically demanding that any and all air in their path get the hell out of the way.  If we could have seen its face, I know it would have looked like it needed to poop.

And Victor left his hand out of the car, pointing, all the way down the straight.

Somehow, someway, he and I were sharing a …connection… Dammit!


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