Want great care in the hospital? Don’t try to pull rank!
True story: A man, let’s refer to him as Junior VIP, comes into a major hospital in the wee hours of the morning with abdominal pain, mostly located to the right and downward from the belly button. His lab values indicate he has some type of infection, and he has been running a slight fever. Appendicitis is suspected. A CT scan is obtained, which neither rules in nor rules out appendicitis. At this point, about two hours after presenting to the ER, Junior VIP has been seen by the ER physician, ER nurse, senior surgical resident and chief surgical resident. The attending physician now examines the patient and agrees that appendicitis cannot be ruled out and admits Junior VIP to the hospital, explaining to JVIP that we don’t want to miss anything but we also don’t want to do an unnecessary surgery for what may turn out to be a viral illness. Therefore, we will admit, obtain further labs, give fluids, keep him from eating, and observe his condition during the day. If he improves, there will be no need for surgery. If he gets worse, we will take him immediately to the operating room. JVIP agrees to this plan, but soon becomes agitated in the ER. “When am I going to get my room,†he complains to the ER nurse, followed by “It smells in here. Did someone crap their pants?†followed by “There are drunks in here, get me out of here right now!†The ER nurse, then the ER physician, as well as the residents, explain that the hospital is very full but they are working as fast as they can to obtain an available bed as soon as possible. JVIP tells them to hurry, and make sure it’s a private room. But after one more hour of being in the ER, JVIP decides he can’t stand it any more, and checks out Against Medical Advice.
Being a (Junior) VIP, he is incensed at his “shabby†treatment, and uses his connections to contact the local newspaper outlet, the local television news outlet, the mayor’s office, and several prominent friends who are tight with the hospital board members. The attending surgeon, who saw the patient two hours ago, and is now in the OR where he plans to finish his first case of the day and then check on JVIP to see how he is doing, gets a phone call from the CEO of the hospital, demanding that he break scrub to discuss this “unacceptable†matter. This, within five minutes of receiving a phone call from the surgical resident explaining that the patient has checked out AMA, another phone call from the local television news asking for a comment on a story they are doing about Delays In Diagnosis For Severe Medical Conditions, another phone call from a physician colleague in the hospital who wants to know what happened with her friend JVIP and why he didn’t get treated, and a phone call from JVIP’s lawyer. Two more phone calls from the Chair of Surgery—all this while the attending surgeon is trying to operate—and it is established that JVIP will be returning to the hospital, will go directly to preop and be taken immediately to surgery. No more tests, no observation, no more “flimflam†is the word from above.
Eight hours after checking out AMA the patient is seen by the attending surgeon in preop, advised that his problem may have nothing to do with his appendix and that this surgery may be unnecessarily exposing him to risks of infection, bleeding, and further surgery in the future, to which JVIP answers: “Get on with it!†He is taken to the OR, a diagnostic laparoscopy is performed, no intra-abdominal pathology is noted, and per protocol the appendix, although it does not appear inflamed, is removed. The patient is discharged home the following day. Final pathology on the appendix shows a normal appendix with no infection.
Not only is this story true, it is repeated every day in hospitals across the country. It even has its own name: VIP Syndrome. The VIP Syndrome has been a recognized phenomenon in medicine since at least 1964. It is described as generally poorer care that is given to a patient of particular influence—due to money, fame, political power, or connections to powerful community members—because of deviation from the standard of care. The changes made to the standard of care can be too much of something, too little, or things totally inappropriate. These decisions are made because of fear of causing discomfort, or embarrassment or lack of privacy to the VIP, the VIP’s own demands, and the feelings of caregivers that they must do something different for the special patient.
As a surgical resident, I spent many months on trauma rotation at a very busy “Level One” trauma hospital. As there were dozens of traumas every day, we got very good exposure to trauma care, and consequently became very competent at it. The Chief of Trauma used to admonish us often that he hoped if his wife was ever the victim of a motor vehicle crash and brought in as a trauma patient that we would treat her exactly like a Saturday Night Drunk. Starting at about 11 p.m. Saturday and continuing until dawn Sunday, the SNDs would crash their cars, sustain various injuries, and be brought to us by ambulance. They would he bloody, messy, smelly, often screaming and cursing, and reeking of alcohol. We followed the same procedure on everyone: Primary Exam, with a quick look at airway, breathing, major circulatory problems and immediate threat to life, with life-saving interventions as needed; Secondary Exam, head to toe, every body part inspected; standard labs; standard set of X-rays called a trauma series; a decision made to proceed to the OR or obtain further testing; followed by a series of CT scans determined by the findings of the X-rays, usually including head, cervical spine, chest, abdomen and pelvic CT scans; then admission to the appropriate ward of the hospital, followed by another complete head to toe exam several hours later, to ensure nothing was missed. To accomplish this took at least two ER nurses, two surgical residents, an attending trauma surgeon, an anesthesia attending, a nurse anesthetist, two OR nurses, an ER technician, a radiologist, as well as consults from many specialists, depending on their injuries (eg, orthopedics, head and neck surgery, neurosurgery). The process took hours to get through, often with the SND screaming and puking all over us, all in the middle of a busy, noisy, smelly ER, all of which we ignored and carried on with what we knew was the right thing to do. Yes, they were drunk and annoying, and many of them were repeat customers, but they were also very at risk for severe injury. Yelling and cursing, for example, might be due to the alcohol, or it might be a sign or severe pain or a head injury. We knew the protocol and we knew if we followed it we were not going to miss anything.
Now imagine a scenario in which the Trauma Chief’s wife comes in to the trauma bay, with the following results: We can’t cut her clothes off, it might embarrass her, meanwhile missing a major injury. Or: We can’t put this cervical collar on, because it might be uncomfortable, and then it turns out she has a c-spine injury and is paralyzed because of our “nicenessâ€. Or: Don’t put such a big IV into her, it might hurt, meanwhile having no way to resuscitate her when it turns out she has a major bleed. Or: Let’s not get so many CT scans, it’s too scary for her to be in there all alone, meanwhile missing any number of internal injuries. Examples abound, but the bottom line is VIP = substandard care. In the end, the SNDs were getting the best care, which is what the Trauma Chief wanted for everyone, including his wife.
I had many opportunities to witness this phenomenon as a resident. Many patients have the idea that residents are not “real” doctors and therefore provide a lower level of care, and insist that the attending physician is the only one who they will talk to. What these people never realized is that they are hurting their own health. The general practitioner “one doctor for everything†phenomenon works fine when all the GP has to do is prescribe physics and pull teeth, but that concept has no place in modern medicine. Medicine today is a team sport, involving, in a typical hospital stay, 50-100 professionals—attending physicians, consultants, residents, nurses, technicians, physician assistants, pathologists, lab assistants, radiologists and a host of other hospital personnel. It’s expensive but comprehensive. Removing integral parts of that team is like trying to fly an airplane that’s missing several of its components, or having a patient tell me to operate blindfold and with one hand tied behind my back. Both can be done, but with similarly disastrous results.
The greatest irony in the case of Junior VIP is that the reason the hospital was full on that particular day and he didn’t get a room right away—beyond the bed shortages that are now endemic to hospitals that must operate at 100% occupancy or go bankrupt—is that another VIP, let’s call him “Super VIP,†had given the hospital a substantial donation so that he could have an entire wing to himself for recovery after an elective surgery. The wing was needed to accommodate all his guards and gofers and general hangers-on, all of whom provided a blockade to his health care providers. Which meant that nurses and residents and fellows and lab techs were sent away, which added up to care way below the standard for Super VIP. A homeless drunken man who trips and falls in front of the hospital will receive better care than either Junior or Super VIP, because Mr. Homeless Guy will get the standard of care with no deviations, while the VIPs use their power to hurt themselves.
The most annoying part of all this is that Junior VIP is probably going to sue. For what? It doesn’t matter. Lawyers know that juries often hand out large cash awards, not because the doctor did anything wrong, but because they feel sorry for the patient. After all, it’s only insurance money, those insurance companies have plenty of money, and who cares if the doctor’s career is trashed. And who writes the laws that allow this foolishness? Other lawyers, of course. So JVIP will sue for Delay of Care (even though that was his own fault) or Pain and Suffering (never mind that he caused way more of that to the people around him than he suffered himself) or Unnecessary Surgery (even though he demanded it). And caught in the middle of all this is the surgeon, who just wants to do his job, treat his patients, make them well, and send them home healthy.
Even for those rich enough or connected enough to have a personal physician follow them around the world, that’s not going to help with anything except little stuff. For anything major, someone needing medical help is going to end up having to talk to a specialist, a surgeon for example, or a neurologist or whatever, and then have to be seen by that doctor either in a clinic, if it can wait a few days, or in an ER, if it’s an emergency. And on any given day in any ER in this country, even to foo-foo private ones that cater to the rich and powerful (like the Frist family’s Hospital Corp.), there are going to be drunks, and nasty smells, and noise, and lots of chaos. And bed shortages. Screaming and complaining and calling your congressman won’t change that.
This is not to say that patients shouldn’t be advocates for their own health, of course they should. They should ask questions, and read all about their diseases, and get second opinions (or third and fourth opinions if they’re not satisfied). But anyone who thinks that pulling rank is going to improve care should conduct the following experiment: The next time you get on an airplane, first go to the air traffic control tower and fire everyone in there, since you know so much; then fire the aircraft mechanics and service the plane yourself; then fire the pilot and fly the plane yourself. And afterwards, if you survive the crash, consider not making those same mistakes when you get sick.
We may not be as well-connected as politicians, or as famous as celebrities, or as rich as lawyers, but we do know about health, and we do try to do our best for our patients’ health, even those patients who do everything they can to prevent us from helping.