Why the rich and powerful might get substandard medical care.
Posted Thursday, Oct. 30, 2008, at 6:26 AM
Not long after Sen. Edward M. Kennedy was diagnosed with brain cancer this summer, he summoned his very own group of national cancer experts, a "tumor board," to discuss his case and recommend treatment. The New York Times called his health care "extraordinary" for several reasons: Tumor boards are usually convened by doctors for complicated cases, not by patients, and rarely is it possible to summon "more than a dozen experts," as Kennedy did, on short notice. While it may not be surprising that someone with fame, stature, or wealth would receive more attention when ill, it seems unfair that he should get better medical care than the rest of us.
Actually, he doesn't. Although the senator has unlimited access to expert doctors, he suffers from a different disease that rarely afflicts soccer moms but can be even deadlier than cancer: very important person syndrome. VIP syndrome strikes when doctors and nurses treat VIP patients differently—and, in the end, the medical care is worse, not better. Because VIPs are special, doctors and nurses deviate from usual protocols. As a result, the patient receives something other than the standard of care.
Doctors act differently with VIPs because caring for celebrities is distracting. They know their decisions will be scrutinized not only by hospital administrators looking over their shoulders but also by the press and public. Doctors who would normally ask, "What's the best care for a 76-year-old man with a malignant glioma?" instead wonder, "What do we do now that Senator Kennedy has a malignant glioma?" The answer is sometimes different because of the tendency to overthink decisions and overemphasize treatments celebs think they need—even if those treatments are experimental and not necessarily the standard of care.
VIP syndrome affects not only treatment but also testing decisions. If Joe the Plumber requests a CT scan he doesn't need, doctors simply say, "No, Mr. Plumber." But Joe Biden can get any CT he wants. Some health care programs for corporate executives even involve routine full-body CT scans as screening tests as part of the "chairman's physical." The problem is that these expensive and detailed tests may actually increase the risk of cancer from radiation exposure and have never really been shown to improve anyone's health. And if there is an incidental finding, as there often is, more tests might be ordered, which may lead to unnecessary biopsies. And doctors perform heroic procedures on VIPs not just when there is clear benefit but when there is any question of benefit. After Harvard doctors recommended that Kennedy not have brain surgery, the doctors at Duke overrode that decision in favor of removing the tumor. Another problem: When procedures are performed, the most senior guy does it. The senior guy is not necessarily the most skilled at doing the procedure—because he has been busy being an academic chairperson and is out of practice.
So, who gets VIP syndrome? It can strike anyone who is clearly famous or important, like a Kennedy, a Baldwin brother, a big hospital donor, or the superrich. And much like other diseases, VIP syndrome can be contagious: Relatives of famous people can easily catch it. (Kennedy's family members also had their own tumor boards.) VIPs even have their own special hospital floors. While these units have better nurse-to-patient ratios, fluffier pillows, and concierge service, the nurses are not specialized. For example, a VIP with a broken hip may not get the nurse who usually takes care of orthopedic patients. And many VIP wings are located far away from the rest of the hospital. One prestigious academic hospital has a VIP section with oak-paneled rooms and high-thread-count bed sheets, but among medical students and residents, it's known as "Marberia," a conflation of its real name and Siberia, because of its remote location. As a result, VIPs may get seen last in the morning because doctors have to trek to different buildings on rounds. And if a VIP has a true emergency, like a cardiac arrest, in the comfy unit, doctors may be dangerously far away.
Zachary F. Meisel is a practicing emergency physician, a Robert Wood Johnson Foundation clinical scholar at the University of Pennsylvania, and a senior fellow at the Leonard Davis Institute of Health Economics.
Jesse M. Pines is a practicing emergency physician and an associate professor of emergency medicine and health policy at George Washington University in the Center for Health Care Quality.