Why the rich and powerful might get substandard medical care.

Why the rich and powerful might get substandard medical care.

Why the rich and powerful might get substandard medical care.

Health and medicine explained.
Oct. 30 2008 6:26 AM

VIP Syndrome

Why the rich and powerful might get substandard medical care.

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.

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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.

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VIP syndrome is compounded when the patient is in critical condition. After President Ronald Reagan was shot, the doctors couldn't hear one another because so many people were shouting at the same time. Imagine trying to make a good medical decision or communicate when the E.R. is teeming with administrators, Secret Service agents, and gawking hospital staffers not involved with the case. Even when doctors have the time to think clearly, they still make mistakes when dealing with celebrities: Former President Gerald Ford was discharged from the hospital with the diagnosis of an inner-ear infection when, in fact, he had suffered a stroke.

As we have both encountered as practicing emergency physicians, some VIPs travel to the hospital toting their own doctors. While a trained advocate can be helpful, it can sometimes interfere with medical decision making and lead to diagnostic delays and mistakes. In this story from the Boston Globe, when a VIP came into the E.R. complaining of chest pain from swallowing a large pill, the "boutique bedside bodyguard" insisted on an immediate echocardiogram, a heart test rarely performed in the E.R. VIPs also have issues with privacy because everyone is interested in their health. In 2007, after super-VIP George Clooney was in a motorcycle wreck, 27 hospital employees were investigated for inappropriately peeking at his X-rays and leaking his test results to the media. VIP privacy is a common problem: UCLA Medical Center workers have snooped into the medical records of Britney Spears, Farrah Fawcett, and Maria Shriver.

Since most of us are not VIPs, why should we care? Because VIP syndrome can affect you, too, especially if you're in the same hospital—the VIP will get her MRI first, so you may have to wait a little longer. But if you don't happen to be waiting for the same MRI scanner, you can benefit from an ill VIP. When a celebrity comes down with your disease, the illness can suddenly become more important: VIPs sometimes start foundations when they get sick—like Michael J. Fox did with Parkinson's disease.

But the truth is that most VIPs, especially the very famous ones, actually want to be treated as regular patients. In addition to having to deal with clicking cameras and googly-eyed autograph-seekers, VIPs probably know that fame can also mean star-struck doctors and nurses. So, what can wary VIPs do to make sure that they don't get VIP syndrome? Alas, not much. Even when the VIP checks in under an assumed name, going incognito in a hospital can be next to impossible. Trust us. Sunglasses might help them avoid paparazzi on the street, but a thin hospital gown doesn't do the same trick. Word spreads quickly among nosy hospital staff.

Though doctors don't always do right by their prominent patients, VIPs do have ultimate access. And for anyone who has tried to navigate the U.S. health care system, access to doctors is paramount. VIPs don't wait for appointments, they don't get bounced to the E.R. for routine care, nor do they get boarded on E.R. hallway stretchers for 12 hours. But access and attention don't always translate into better outcomes, especially if the care team doesn't follow protocols. The truth is that there is probably a happy medium: If you are Joe Six-Pack, it may help to be mistaken for a VIP because you won't have to wait weeks for a doctor's appointment. But if you are a candidate for vice president, you'd be better off if hospital staff thought you were just a hockey mom.