If you want to learn about the complexities of the modern healthcare delivery system, there's no better person to ask than a physician. Their familiarity with the bureaucracy and tough patient choices associated with medical care is driving many out of clinical practice. And now it's causing some to look into a developing industry that has emerged.

The concept of medical navigation was originally born out of oncology to help cancer patients understand their options and reach tough decisions. As patients now face more choices and assume more financial responsibility for their care than ever before, the navigator concept is emerging as a mainstream industry that is spreading across almost every medical discipline.

It's not only gaining attention from patient advocacy proponents, but also from physicians and other clinicians who view medical navigation as a post-retirement opportunity. They're able to put their medical knowledge to use while having the type of relationship with patients they wanted to have in their clinical lives.

"Over the years I have had a lot of calls from doctors asking me if it makes sense for them to do this after retirement," said Elisabeth Russell, founder and president of Patient Navigator, a navigation service provider in the D.C. area.

"One common theme I hear from folks is, 'I have been inside this system and have seen all its failings, and now I want to take what I know and work outside the system to help people get better care.'"

Medical navigator trailblazers agree that physicians, nurses and others with a clinical background can bring a lot to the table when it comes to helping patients understand their options. But those considering making the move should be aware that there is a clear line between advocacy and clinical care. And that line can easily become blurred by those who are used to providing care, Russell said.

The definition of healthcare advocacy excludes direct, hands-on care, said Joanna Smith, who founded the National Association of Healthcare Advocacy Consultants in 2009. NAHAC developed the code of ethics that navigators are bound to follow, which establishes a clear distinction between advocacy and patient diagnosis and treatment. NAHAC is now working to develop a credentialing program for navigators.

"What I think gets tempting for some physicians is for them to just want to tell people what to do, which is not really how patient advocates work," said Smith, who also services as CEO of Healthcare Liason.

Dr. Alan Weder, a retired internist from the University of Michigan Health System, said turning off his physician instincts was one of the hardest things for him to get used to when he started his medical navigator business, My Friend the Doctor, in Ann Arbor, Mich.

"It's really easy for me to say, 'you really should just do this,' because I generally know what the right thing to do is — and it’s hard not to do that," Weder said. "And it took me a while to figure out how not to do that."

Weder's strategy is to present three options and to give the pros and cons of all three. He will then help the patients develop lists of questions to ask their physicians that will help them reach a decision. He also has clients sign a contract that says they understand he will not provide medical advice.

These boundaries are what allow him to do his work without the treating physicians feeling like he is stepping on their toes or competing in some way.

Different types of navigation

The navigator industry is growing at such a rapid rate that the term "navigator" is being used in a variety of ways to mean different things. The Affordable Care Act, for example, created a subset of navigators meant solely to walk people through the process of buying health insurance.

And, as more provider compensation is tied to patient satisfaction, coordination of care and improved outcomes, several healthcare organizations are employing medical navigators — also known as patient navigators, case managers, advocates, patient consultants, care coordinators, etc. — to assist physicians with managing their patient panels.

Jordan Hall, director of public health management and medical home care coordination at the UCLA Medical Center, said care coordinators at UCLA are performing tasks that primary care physicians were performing themselves.

"We target patients with high utilization of emergency department services and who have been admitted into the hospital multiple times and present high risk factors for future visits and admissions," Hall said. "Our goal is to provide care coordination services to these fragile patients in varying acuity levels with the goal of helping them transition to healthy care plans. This includes making regular contact with patients and becoming a consistent resource in their care team."

Hospital-based navigators provide a valuable service, Russell said, "but what they do is completely different from what I do."

The biggest difference is a hospital-based navigator's role is to ensure a good experience with that health system. They are paid by the hospital system. An independent navigator — paid for directly by the patient — does not have a bias for one provider over another, or for one type of treatment over another, she said.

The core of the problem

Dr. Barbara McAneny, chief executive officer of New Mexico Oncology Hematology Consultants in Albuquerque, N.M., argued in a June 2009 opinion piece in Journal of Oncology Practice that the role of navigator should fall to family members or loved ones.

"And if there is information they don't understand, it is up to the oncologist to explain it," she wrote. "We have created such an inefficient system that we need to invent a new medical specialist to help us cope with it. If our system necessitates navigators, we need a new system."

Weder said most physicians provide some type of navigation service to their patients, but not at the same level as professional navigators, given the constraints of 15-minute office visits.

Weder said the treating physician can tell him what's going on in five minutes. Weder can then spend an hour or more explaining it to the patient and their family members. Clinical physicians will never have that kind of time and still remain profitable, he said.

Russell said she wishes the healthcare system would change in such a way that her services are no longer needed. But that’s unlikely to happen.

"I don't see healthcare in the U.S. getting better in terms of how complicated, expensive and efficient it is," she said.

But she doesn't want people to think those inefficiencies are leading to huge profits for those who choose to take on a navigator role. Navigators generally charge an hourly rate of between $50 and $250. Of all the navigators she knows, Russell said there are only three that she is aware of who are supporting themselves on the income they make.

Most navigators without a clinical background go into the field because of a past experience and their desire to help others in similar situations. This is especially true of physicians who enter the field, Smith said.

"[They] look at the practice they wanted to do and the practice they were doing," Smith said. "And they said, 'No, this is not the way I want to practice medicine. Helping people navigate through this very difficult situation — doing the research, helping them get second opinions — this is what I want to do.'"