When I was a very young attending physician on call in the PICU in the Department of Anesthesiology and Critical Care Medicine at the Johns Hopkins Hospital, an emergency transport to the PICU changed my life. A young, approximately 6-year old child, was transported to the PICU after being hit by a car. The back story: his father was a United States senator, as was his grandfather. The injury occurred after the kid bolted from his parents into the street following an Orioles game at the old Memorial stadium. Fortunately, there was no traumatic brain injury but he did have orthopedic and other injuries. After stabilization in the PICU, he was scheduled for the OR the next day. As it happened, I switched to my OR hat that next day and had to discuss the anesthetic plan with the senator, his wife, and the kid’s grandfather. An amazing transformative event occurred. The father said “I have only one request”. I dreaded what was coming. I was expecting the father to say that “he didn’t want residents or fellows involved in the care of his child”. Instead, he said: “treat my son as you would any other child. Don’t do anything differently than is your normal routine”.
Another story told to me by my friend and colleague Dr. Paul Colombani, the former chief of pediatric surgery at Hopkins, about the time he was chief resident in trauma surgery in Washington DC and was directly involved in this tale. When President Reagan was shot on the street in Washington DC, he was immediately transported to the pre-planned, assigned, and designated trauma hospital for treatment in just such an emergency. Paul told me that the “President Reagan was much more seriously wounded than the press and the government ever let on”. Nancy Reagan, who accompanied her husband in the ambulance, insisted that the chief of surgery take control and take care of her husband the President rather than Paul. Mrs. Reagan was no stranger to medical care. Her father and brother were famous surgeons. The chief of surgery was actually waiting in the ER but told Mrs. Reagan and his security detail that under no circumstances would he take the lead. He instead stated that Paul take command as the primary physician because “he did this everyday and the best care the President could receive would be by the team that did it routinely”. He also added that “it had been years since he managed a trauma patient”. The President survived because he was treated like anyone else. (One final note: Paul would neither confirm nor deny the legend that after the chest tube was placed and he was being wheeled into the OR, President Reagan said to him “I hope you’re not a Democrat”.)
Today’s PAAD comes from an on-line article from the American Academy of Neurology’s news outlet, Neurology Today®. It raises many important issues that I’m hoping will spark a brisk reader response. Myron Yaster MD
Original article
Gina Shaw. When the Patient Is a ‘Very Important Person’. How to Handle the Ethical and Clinical Minefields of VIP Syndrome. American Annals of Neurology, Neurology Today
In today’s PAAD, Gina Shaw an award winning medical journalist, discusses “When neurologists are asked to prioritize care for so-called VIPs—donors, trustees, politicians, and celebrities—it can complicate medical decision-making. Neurologists who focus on neuroethics discuss the ethical and clinical issues that emerge when providing VIP treatment to patients and how health care providers can address those concerns”.
Basic tenets of American democracy are that “No person is above the law” and “All people are created equally” and theoretically should be treated equally. Nice in theory but in practice, when very important persons, VIPs, including you or your family, come for medical care they are often shunted to the front of the line and treated by your hospital’s best, occasionally to the detriment of other, sicker patients. The possibility/probabiity of different care for patients with and without means is a major concern of the public. A recent New York Times article is worthy of your review to grasp how people view this issue. 1
The dark side of this preferential treatment is that VIP patients often receive care outside of the usual standards of care to spare them of discomfort or being treated by housestaff in teaching hospitals. This can have disastrous consequences as in the case of Joan Rivers, Prince, and Eleanor Roosevelt, who according to today’s PAAD, had miliary tuberculosis but was misdiagnosed with aplastic anemia to spare her the discomfort of performing a bone marrow biopsy.
As discussed in Myron’s introduction, breaking your normal routine and behaving differently with VIP patients is where trouble begins. For example, if you or a family member was going to have anesthesia for surgery or a procedure, would you micromanage care? Do you allow house staff or other members of the anesthesia team to participate in your, or your family members’, care? Further, with VIP patients, there may be “too many cooks”, each offering “advice” that may be counter to or even interfere with your normal care.
At the time I (LGM) presented to the labor and delivery unit of the Johns Hopkins Hospital in labor with my first child, I was a pediatrician faculty member, not yet an anesthesiologist. But my husband was a fellow in maternal-fetal medicine/high risk obstetrics at Johns Hopkins. Unbeknownst to me, my obstetrician called the attending on call for obstetrics to do my epidural. At that time, the same attending covered OR emergencies and the OB suite and the usual personnel who performed labor epidurals were residents and CRNA’s. The attending who was called had not done an epidural, for labor or any other procedure, in many months, if not years. When he started to attempt the epidural, I was 6 cm dilated and in active labor (on Pitocin) after membrane rupture had brought me to the hospital. After 9 (!) attempts over 45 minutes, he was unable to locate the epidural space. My obstetrician checked me, and I was fully dilated. Epidural attempts were abandoned, and I delivered without analgesia. For my subsequent two labors, my epidural was placed by a resident and CRNA, in a short amount of time with effective analgesia. I was the unknowing victim of being treated as a VIP, which had not been requested by me or my husband. The senator in Myron’s story was indeed correct. The best care is given by those who are doing it routinely every day, not rarely on request.
Guzman et al.2 in an article from the Cleveland Clinic J Medicine, discussed 9 principles of VIP care based on their extensive experience treating VIPs at the Cleveland Clinic.
Principle 1: Don’t Bend the Rules (preserve usual clinical practice)
Principle 2: Work as a team, not in silos. One physician must talk to all of the consultants and be the single voice communicating directly with the patient and his/her family and the media.
Principle 3: Communicate, communicate, communicate: I (AJS) wonder how you feel about communicating with an attending anesthesiologist telling them that you have a personal relationship with a patient, requesting not VIP care but rather a personal touch to relieve anxiety? When an anesthesiologist greets a patient with a “hello” from me, my personal relationship is acknowledged, and the patient feels less anxious being known. I only wish we could provide a similar personal connection greeting to all patients!
Principle 4: Carefully manage communication with the media. Confidentiality must be protected. Designating a hospital spokesman is crucial.
Principle 5: Resist “Chairman Syndrome” (see above).
Principle 6: Care should occur where it is most appropriate. Privacy is important but does not trump caring for the patient in the most appropriate location in the hospital like the ICU.
Principle 7: Protect the patient’s security. This includes not only protecting the patient from bodily harm but from attacks on the confidentiality of their care.
Principle 8: Careful about accepting or declining gifts. “Patients offer gifts out of gratitude, affection, desperation, or the desire to garner special treatment or indebtedness. VIP patients from gifting cultures may be especially likely to offer gifts that can be lavish. Refusing gifts can also be problematic in cultures in which this is routine. The American Academy of Pediatrics3 recommends appreciating appropriate gifts and graciously refuse those that are not.”2 I (MY) must admit that I often give bottles of wine as a thank you to physicians after treating me or my family members.
Principle 9: Working with the patient’s personal physicians. This should be viewed as an opportunity to validate current care and not as a threat.
How do you feel about all of this? What are your personal experiences with both VIPS and your own and your family’s health care. Please send your responses and Myron will post in an upcoming Friday Reader Response.
References
1. https://www.nytimes.com/2022/12/22/health/nyu-langone-emergency-room-vip.html?searchResultPosition=1
2. Guzman JA, Sasidhar M, Stoller JK. Caring for VIPs: nine principles. Cleve Clin J Med. Feb 2011;78(2):90-4. doi:10.3949/ccjm.78a.10113
3. Policy statement--Pediatrician-family-patient relationships: managing the boundaries. Pediatrics. Dec 2009;124(6):1685-8. doi:10.1542/peds.2009-2147