How Do You Treat VIP Patients?

Robert M. Centor, MD; Nicholas Genes MD, PhD; Theresa Polick, RN; Graham A. Walker

Over the years I have cared for several VIPs (Very Important Persons). Of course, we might have different definitions of who qualifies as a VIP. But I have had patients who I considered to be 'very important.'
What makes someone a VIP? Do these people define themselves as VIPs? What standards do we use to categorize a patient as a VIP?
Some of my VIP patients have been poor and unknown. I considered them VIPs even though no one else would. They were VIPs because they became very important to me.
Fortunately, I do not care for many patients who consider themselves VIPs. While I am able to take care of such narcissists, I find it draining and unpleasant. I would rather care for ordinary patients and try to deliver extraordinary care. Those who declare themselves VIPs are the most challenging, for they expect a different level of attention.
I have also cared for some patients who would be considered VIPs by almost anyone: legislators, college deans, and even the best known radio announcer in town. Most VIPs ask for nothing special. They have selected you as their physician and are able to act appropriately, without making any extra demands.
However, other VIPs are a pain in the (pick your anatomic location). These people (who generally consider themselves VIPs, even if I do not) add a narcissistic edge to the doctor-patient relationship.
What adjustments do I make for VIPs? I believe the most notable difference is the access I provide to them. For someone who is truly a VIP (but not those who just consider themselves as such), I will always adjust my schedule to fit their schedule. I give them my cell phone number and my email address. In essence, I give them the concierge treatment.
In terms of the medical care I provide, I can recall no differences at all. I do my best to provide the highest quality care and attention to all patients.
In fact, VIP patients actually run the risk of providers making adjustments to their care that are not particularly beneficial. This is similar to when physicians care for other physicians. Often, when caring for such 'special patients,' we may treat them differently in a way that deviates from optimal care. Unfortunately, 'different' rarely means 'better.'
We must remember that good care should remain an ideal that all patients deserve. Treating patients differently often leads to worse care. In an effort to 'protect' special patients (especially colleagues) from uncomfortable but necessary care, we might actually be providing inferior care.

Nicholas Genes, MD, PhD: All Kinds of Very Important Persons Seen in the Emergency Department
I doubt that many of us chose medicine with a goal of providing anything less than egalitarian care -- and treating the same complaints with different care is a bothersome concept, to say the least.
Since I work in an emergency department (ED), though, I can safely say that the most important person is the sickest one; they will always get preferential treatment. Beyond that, we do give special considerations to certain individuals, although the specifics might vary from hospital to hospital about which individuals and which special considerations would be involved.
At the private academic centers where I've worked, a VIP could be anyone from a hospital board member to a world leader to a movie star. The ED attendings are always the first to be notified that such a patient has arrived, and the patient's degree of celebrity is inversely proportional to the chance that a resident will be tapped to collect the history and physical.
Still, I have been involved in a few such cases, and I've been pleased to see that the level of medical care provided was no different from that given to any other patient. No one is subjected to unnecessary tests, and no one is prescribed special medications that aren't indicated. Why not? Because more medicine is not good medicine. And, believe it or not, the "routine" level of care in the ED - the speed, the testing, the treatment -- is pretty thorough, and we do a good job of weeding out true emergencies from more benign presentations. When staff members are asked to deviate from that routine by cutting corners or by trying to rule out esoteric disorders, complications can arise.
However, celebrity VIPs do receive a little more bedside time with an attending. They might get moved to a quieter part of the ED. They might get wheeled to the computed tomography scanner by a doctor or nurse, instead of waiting for the hospital transporter. I usually try to take care of little things for all patients, like giving them a cup of water or a fluffy pillow, but for the celebrity VIP, I'll go even farther, making sure there's nothing they can complain about.
Because that's what is ultimately driving special care of VIPs. We don't think their lives count for more, but we worry that their opinions do. Taking a few small steps to make sure that a VIP's needs are met while they're in the ED is a small price to pay, to stave off a complaint or to earn good publicity.
To be sure, there are certain VIPs who do receive extra medical care, but it's only because they deserve it. Academic hospital EDs are often populated with "medical VIPs," such as the patient with multiple organ transplants, or one who has a rare, chronic disorder. These patients often are well known by the staff because of their frequent visits, and their presentation almost always warrants a prompt admission. Sometimes, other patients get jealous: "Why have a dozen specialists come to see that guy?" "Why was he admitted so quickly -- I thought he only had a cough?" I can never seem to console these patients enough, even though they're much better off with their routine, generic health problem.
When I work at public hospitals, I see a different kind of VIPs. Here, it's the police officer, or firefighter, or paramedic who got hurt on the job who gets the special attention, the stretcher in the quieter area, the extra visitors at the bedside. This might not seem fair to other patients, but it serves a purpose by bolstering relations between the hospital and vital community agencies. And sometimes, treating these patients promptly can aid in an investigation.
Finally, I must confess, there is one kind of patient for whom I do expedite my evaluation, testing, and treatment. This kind of VIP is someone I don't want sitting around for hours without being seen, the kind of patient who always needs a thorough laboratory and radiological workup. I'm referring, of course, to my fellow healthcare professionals.
If I have two 40-year-old patients waiting to be evaluated for chest pain, with no other risk factors or medical history, and one of those patients is a physician, there's no question who I'll see first. But it's not that I think doctors or nurses are more worthy; it's that no one is better at judging their own symptoms and determining whether they are really sick.

Therese Polick, RN: Illness Can Be a Great Equalizer
My first job out of nursing school was at a hospital that catered to the very rich. Our 'special guests' stayed in luxury suites, and they received their meals literally on silver platters. I had many preconceived notions about what it would be like to take care of millionaires, but much to my surprise, I found that most people -- even the ones with very deep pockets -- just wanted to be treated like everyone else.
I took care of my first millionaire patient back in the 1970s. 'Biff' was an 85-year-old man who was one of the richest men in the United States, and he had a reputation within our local business community for being ruthless. He had launched the first television station in the state, running it out of his garage in the 1950s. His business savvy eventually made him a very wealthy man.
The nurses drew straws to decide who would get Biff as their patient. I pulled the short straw.
I knocked on Biff's door before walking into his room. I found him lying in bed, surrounded by children and grandchildren. Then, I overheard Biff's son tell another visitor that it was a pity that his father had to be cared for by a middle-class nurse. I just smiled and took my patient's vital signs.
Later that day, after I ran off Biff's family, I started prepping him for some tests. The first order of business was to give him soapsuds enemas until clear. While Biff was in the bathroom expelling his third enema, the phone rang and I answered it.
Me: "Hello, this is the nurse, may I help you?"
Caller: "Yes, this is Governor 'Holier Than Thou.' I'd like to speak to Biff, please."
Me: "I'm sorry, Governor. Biff is ... hmmm ... indisposed right now. May I take a message?"
Caller: "Young woman, didn't I make myself clear? This is the Governor, and I demand to speak to Biff."
Me: "Governor, apparently I didn't make myself clear. This is Biff's nurse and I'm telling you that he can't come to the phone right now. I'll tell him you called."
I hung up the phone. From the bathroom, Biff called out, "Who in the hell are you yelling at?"
I replied, "No one important. It was just the governor. I'm sure he'll call back later."
There was laughter coming from the bathroom, followed by intense moaning. We called it a night, and I helped Biff back to bed.

Graham Walker: All Patients Have Very Important Person Traits
To be honest, I don't think I've taken care of any VIP patients yet. But how might I react if there was one on my service? I would surely treat him or her with the same high-quality care that I deliver to all my patients! (Of course, I find it hard to believe that the hospital team wouldn't act any differently with a real VIP. Come on. Even doctors and nurses get star struck.)
Is this VIP standard fair? No. Is it a bad thing? Maybe not. In fact, it's possible that having a VIP in the hospital might actually raise the level of care for all patients on the service. (If a resident realizes he's being extra nice to Ms. Diaz, he might also realize that he should show the same level of empathy and compassion to all of his patients.) The rising tide lifts all boats, so to speak.
But what does 'VIP' mean, anyway? It's a term we reserve for people who are important to society or to a certain group of people because of their accomplishments, fame, skills, or good looks. I imagine most people might not know or care who Norman Shumway was, for example, but I bet everyone caring for him at the hospital felt he was deserving of the VIP title. Or take Stan Lee, the famous comic book creator. Most of the world probably has no idea who he is, but I know a surgery resident who would be ecstatic if given the opportunity to care for him. So, VIP status is relative.
As cliché as it sounds, I think the key is to look for VIP characteristics in every patient. They have them, we just need to start looking: The World War II veteran, the accountant for a brothel in Nevada, the tow truck driver with funny stories about sobriety check points, and the joking patient with twin babies. I find that if I know something interesting or unique about a patient, he or she seems much more human. When you find out what makes them special, share it with everyone and the whole team will grant them VIP status. You'll remember them better, find it easier to recall their hospital course, and be more easily reminded that they've lived a life and aren't simply made up of the events that led to them to the hospital in the first place.

Advanced Chronic Disease Patients Want Good Reasons for Therapy

NEW HAVEN, Conn., Aug. 9 -- Older patients with advanced chronic diseases may reject medical or surgical interventions unless clinicians provide a cogent rationale for them.
In a study of 226 community-dwelling adults with advanced cancer, chronic obstructive pulmonary disease, or congestive heart failure, 16% reported refusing at least one physician-recommended treatment, reported Marc D. Rothman, M.D., of Yale and the Connecticut VA Health System, and colleagues.
The most common reason for refusing treatment was a fear of side effects, the authors wrote in the July issue of the Journal of General Internal Medicine. Those significantly more likely to turn down medical or surgical therapy either wanted more prognostic data or thought that they had less than two years of life remaining.
"This frequency of refusal suggests that physicians may be recommending treatments to these patients that pose unacceptable burdens or that fail to meet patients' goals," the authors wrote. "These patients may require a broader range of treatment alternatives, so that they can select the option that best meets their goals of care."
In the observational cohort study, patients were interviewed in their homes by trained research staffers at least every four months for up to two years, and patients were also called by phone each month. They were asked about changes in their health status, defined as a new disability in a basic activity of daily living, hospitalizations of seven or more days or a hospitalization requiring a discharge to a nursing home, sub-acute facility, or rehabilitation facility, or the introduction of hospice services.
At baseline patients were asked, "Have there been any treatments that your doctor recommended for you that you decided not to have?" At all follow-up interviews the patients were asked, "Has there been any treatment that your doctor recommended that you decided not to have since the last interview?"
The patients were also asked to describe the category of refused intervention, and were prevented with options such as surgery, dialysis, cardiac catheterization, chemotherapy, transplantation, and other procedures.
The authors divided the patients into retrospective and prospective cohorts, with patients in the retrospective cohort being those who reported at the first interview that they had refused an intervention and survived long enough for follow-up, and the prospective cohort including all patients who refused treatment regardless of outcome.
For each treatment refused, patients were offered a list of possible reasons why, with patients allowed to choose multiple answers for each refusal.
The authors found that 36 of the 226 patients (16%) reported refusing one or more physician-recommended medical or surgical treatments, with cardiac catheterization the most often refused procedure, followed by surgery. In all the rate of refusal of catheterization among patients in the retrospective cohort was 13%, and in the prospective cohort it was 12.5% The rates of refusal of surgery were 10.9% and 13.3% for the cohorts, respectively.
The most common reason for refusal was fear of side effects, cited by 41%, followed by "thought the treatment would not work"(19%), and "did not want to do anything to prolong my life"(12%). In addition, 7% said they thought they would do better with a different treatment, and 12% had "some other reason."
Patients who wanted more prognostic information than they had been provided were significantly more likely to refuse treatment than patients who felt themselves well-enough informed (P=0.02). Patients who estimated their longevity to be two years or shorter were also significantly more likely to turn down an intervention (P=0.02).
The patients who turned down a procedure were twice as likely to die as those who acquiesced (hazard ratio 1.98, 95% confidence interval, 1.02-3.86).
"The frequently cited reasons for treatment refusal in this study expands on prior work showing that fear of side effects plays a major role in treatment decision making for prescription medications," the authors wrote. "Over 17% of Medicare recipients reported skipping doses or stopping medications outright because of side effects, and more than 15% of patients with lupus nephritis stated they would prefer a less efficacious medical regimen to avoid the toxicity associated with cyclophosphamide."
The findings suggest that patients are strongly influenced by their own preconceptions of side effects, even when physicians think an intervention offers a clinical benefit, and support other studies showing that patients base decisions about their treatment on a wide range of personal experiences, the authors commented.
They noted that their study was a secondary analysis and was not powered to examine the effects of treatment refusal on outcomes. In addition, the cohort was largely male and white, which could limit the ability to generalize results, and there could have been recall bias because the study relied on patient reports of treatment refusal. The authors also did not have data on what treatment patients were offered, if any, when they refused an intervention.
The study was supported by the National Institute on Aging, Claude D. Pepper Older Americans Independence Center at Yale, and a Paul Beeson Physician Faculty Scholars Award. The authors had no conflict of interest disclosures. Primary source: Journal of General Internal MedicineSource reference: Rothman MD et al. "Refusal of Medical and Surgical Interventions by Older Persons with Advanced Chronic Disease." J Gen Intern Med 2007. 22;7:982-87.