Thursday, June 5, 2014

Thoughts on VIP Medicine

The concept of VIP medicine came up in a discussion today and someone liked how I phrased my thoughts, so I figured it was time to kick off the Schutzblog once again!

I like to think of VIP medicine as how a clinician would deviate from his or her usual style of care for a given patient who is of some special status-- wealthy, famous, connected, in some supervisory position over the patient, etc.  The general teaching is that VIP medicine is generally disastrous for the patient, and can even be lethal; but why?  Why would thinking of a patient more frequently, wishing to spare them discomfort, unpleasant examinations, embarrassing diagnoses, waiting, or the performance of clinical tasks by anyone but the physician be dangerous?

Fundamentally, our job as physicians is to balance risk and benefits for our patients.  All of our tests and therapies are potentially harmful, or at least uncomfortable and expensive and carry the risk of false or true positives and negatives of uncertain significance.  If this were not the case, we would not need physicians to make the decisions-- a reasonable safe therapy or test in all situations would not need to be protected.  

Now, we are able to balance risk and benefit for our patients because we train like crazy, read a ton, have seen good and bad outcomes from our own clinical work over time, and understand what our patients will value based on our relationship with them.  In short, we bring our experience to bear for someone we know well, think only of them, and guide them to a decision.  Whatever happens, they bear the consequences, good or bad, not us.  

Enter the VIP Patient.  VIPs are VIPs only because they can do one of two things:
  1. Help you in some significant way above and beyond a typical patient with financial reward, positive commendation, donations, recognition, etc.
  2. Hurt you in some way if the outcome of your guidance is not beneficial-- get you fired, sued, defamed, executed, etc.
So why is this a problem? Because the VIP Patient, usually through no fault of their own, has you thinking about YOU. Now all of your calculations are askew.  You need a good outcome for the patient so that YOU avoid pain or obtain reward.  

You risk choosing tests and therapies that are pleasant, flattering, and mild and avoid diagnoses that are embarrassing, tests that are painful or therapies that are hard to tolerate.  

Once you have started thinking about yourself, you have terminally endangered your patient.  Perhaps not this one, but some future VIP will seek care from you and will lose.  And remember, VIPs are generally always VIPs, so they always run this risk?

So what to do?
  1. Be honest with yourself: Acknowledge, at least to yourself, that this person has you thinking about you and not them.
  2. Stop that: Focus on your patient, not their money/power/fame-- even if they flaunt it.  Presume they are delirious/demented and making wild unsubstantiated claims if it helps. 
  3. Get help: Talk the case over with colleagues leaving out the VIP part and see if they come to the same conclusions.