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October 4, 2014

BehindTheMedspeak: V.I.P. medicine and its discontents

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A September 21 New York Times story focusing on the recent death of Joan Rivers several days after undergoing a "routine" endoscopy procedure explored what those in the medical profession call "V.I.P. medicine."

Long story short: Doctors do things differently when it comes to famous patients because there is intense scrutiny and the possibility of public second guessing if things head south.

I've long contended that an anonymous individual brought to an E.R. will likely fare just as well as a bold-faced name, because treatment will be what's standard rather than having corners cut and less painful procedures performed in an effort to "customize" care.

I remember very well when Elizabeth Taylor came to U.C.L.A. Hospital in 1973 for abdominal surgery and was on my surgical service (I was a fourth year medical student, not allowed to enter her room during rounds): talk about a circus....

Excerpts from the Times piece follow.

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As F. Scott Fitzgerald wrote, "Let me tell you about the very rich. They are different from you and me." It is an observation that holds true, apparently, even in the operating room.

The treatment of Joan Rivers at a Manhattan endoscopy clinic last month may be the latest example of what is known in the medical profession as "V.I.P. Syndrome," in which famous or influential patients get special treatment. And surprisingly often, it is not for the best.

Dr. Barron H. Lerner, an internist at NYU Langone Medical Center, said that when he was a young doctor-in-training at another hospital and famous patients arrived, "There was always a buzz." Doctors were warned in advance of the dangers of becoming star-struck. But in the same, albeit contradictory, breath, they were given special instructions "about what to do and what not to do, given that they were famous."

He was once, for example, told not to do a basic examination of a well-known man who was admitted overnight, to preserve his privacy. There was no harm done because he was stable, Dr. Lerner said. In another case, he was doing an electrocardiogram on a famous person, and 10 or 15 other people walked into the room, pretending to be part of the team when they were not.

Ms. Rivers died on September 4, several days after going into cardiac arrest following a routine endoscopy, a procedure that involved the insertion of a tiny camera to look down her throat into her digestive system. The doctor who performed the endoscopy allowed Ms. Rivers’s throat doctor to examine her as well, even though the throat doctor was not authorized to practice at the clinic. This was a violation of state law, according to people who have been briefed on the matter.

Several doctors said that if the clinic, Yorkville Endoscopy, had granted a privilege to Ms. Rivers that they would not have granted to a typical patient, it could be seen as a case of V.I.P. Syndrome. It is unclear who coined the term, but it was described in a 1964 article by a psychiatrist, Dr. Walter Weintraub, in The Journal of Nervous and Mental Disease, where he wrote, "the treatment of an influential man can be extremely hazardous for both patient and doctor."

For doctors, he said, "The V.I.P., cursed with the touch of Midas, arouses only resentment and fear." Physicians, Dr. Weintraub wrote, tend to perceive V.I.P. patients as demanding and manipulative and to resent them for it, which can diminish the quality of their care.

For hospital administrators, on the other hand, he said, "The V.I.P. is more than just a patient. He is also an object to be bartered for future favors."

In the throes of V.I.P. Syndrome, doctors may become overly deferential, suspending their usual medical judgment, experts say.

"Often with V.I.P. patients, doctors won’t say, ‘Joe Famous Person, look, you have to take your medicine or you have to come in for surgery immediately,'" Dr. Robert Klitzman, a professor of psychiatry and director of the masters of bioethics program at Columbia University, said.

Standing up to a V.I.P. patient can be difficult. Dr. Klitzman remembered once taking care of the daughter of a "household name" writer. “The household name was a very powerful presence and wanted things their way,” he said. "It took more gumption than I usually had to stand up and say what was best for the patient."

Dr. Lerner said he first became interested in V.I.P. Syndrome while writing a book about breast cancer during which he researched the cases of Betty Ford, Happy Rockefeller, Shirley Temple Black and other famous women with the disease. Mrs. Ford was given a radical mastectomy, which had been the procedure of choice but was falling out of favor as women and some doctors began calling for less aggressive operations, he said. "But as the president’s wife, there was no doubt that she would receive the traditional operation," Dr. Lerner said.

He became so fascinated that he wrote a book in 2006 about the problem, "When Illness Goes Public: Celebrity Patients and How We Look at Medicine."

Dr. Lerner said of Ms. Rivers's care, "If things were going on there that were outside of the protocol, it's certainly possible that there was V.I.P. Syndrome." But he also cautioned against jumping to conclusions.

"Sometimes just bad things happen to famous people with very good doctors," he said.

October 4, 2014 at 08:01 PM | Permalink


Comments

Mr. & Mrs. Neil Young have both had surgery for AVM - and very, very little is mentioned about their physicians or care.

On the other hand, Mr. Young has two sons with Cerebral Palsy - born of two mothers in the prime of their reproductive lives - with no known risk factors. Both young men are aphonic and one is grossly ataxic. What does a VIP do when faced with this challenge? He and his spouse create and endow a school for children with severe speech and physical impairments. Every year there is a Benefit Concert held in October (this year a two-day concert) on the 25th and 26th. www.bridgeschool.org

If you are a VIP - you can take advantage of your status to provide medical care for others: Danny Thomas (the St. Jude's Children's Hospitals), Jerry Lewis ($2.45 B donated for MD), Bob Geldof (anti-famine campaigns), and, Elizabeth Taylor - who was among the first to use her VIP status to raise funds and public awareness of the HIV/AIDS epidemic.

Mr. Young's Bridge School and Farm Aid (formed with John Mellencamp and Willie Nelson) charities are unique these days. We see the occasional charity event - but the class of VIP with the commitment of a Danny Thomas, Jerry Lewis, Neil Young, and Bob Geldof - their decades of support of medical causes - is not continuing.

Posted by: 6.02*10^23 | Oct 8, 2014 4:01:17 PM

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