By Charles A. Pilcher MD FACEP
January, 2017
A prominent medical malpractice plaintiff attorney presents to the emergency department of his local hospital. Only months earlier this attorney represented a client in a well-publicized case against this hospital. The attorney is pale, sweaty and complaining of chest pain. ED staff, some of whom gave testimony in the earlier case, are aware of his status and apprehensive. “How should we treat him?” they wonder. “Will he sue US next?” “We have to be really careful,” they all think silently to themselves. Suddenly, a patient not unlike many others seen and appropriately treated on a daily basis by this same staff is now at risk of “VIP Syndrome.” This is a situation in which standard work goes out the window and routine approaches to care are trumped by fear and caution. Staff who wouldn’t miss a beat in caring for an anonymous patient now question their every move.
This is an example of what Guzman et al. discuss in their article “Caring for VIPs: Nine Principles.” This “Perspective” summarizes the key points of that paper.
The authors point out that a VIP need not be someone famous like a rock star or Saudi prince. In the hospital setting it may be the CEO, the Board Chair, a well-known contributor to the hospital’s foundation, a colleague or perhaps the local mayor. Whomever it may be, “VIP Syndrome” occurs when that person is treated differently than every other patient in the clinic, ED or hospital – whether the patient demands special treatment or the staff themselves change normal practices during treatment because of the perceived or actual status of the patient.
Certainly there may be times when practical considerations are appropriate for certain high-profile individuals (e.g., the President) for their own privacy and protection, but this mindset should never affect the actual care of the patient.
The authors point out ways in which staff, in their eagerness to please, may treat a VIP differently. As one reviewer noted, providers may “bend the rules, increase access to resources, change routines, skip some of the more annoying hospital processes, or take an unauthorized peek at the medical record out of curiosity.” That reviewer continues, noting that “skipping steps and allowing special privileges does not always produce better medical care. Routine practices exist for efficient, reliable delivery of care. Change can result in dysfunction and can even be lethal to the patient.” The case of Michael Jackson is a well known example.
The Guzman article addresses several ways to avoid “VIP Syndrome.”
- “Don’t bend the rules.” Ask if the request of change in protocol really benefits the VIP. Whenever routines are changed, mistakes are more likely to happen.
- “Work as a team, not in silos.” While it is important to have a single physician in charge of directing the patient’s care, all team members should communicate with the patient and each other as they normally would.
- “Communicate, communicate, communicate.” Clearly and respectfully communicate to the patient, family and one’s own teammates why sticking to routines is in the patient’s best interest, emphasizing that high standards apply to all patients while acknowledging the patient’s position.
- “Carefully manage communication with the media.” Do this while respecting the patient’s privacy, which all patients deserve. Assure that an “experienced communication liaison” reviews any social media posts and answers press inquiries.
- “Resist ‘chairperson’s syndrome'”: The patient should be cared for by the physician most appropriate for the patient’s situation, regardless of that person’s title or position in the organization.
- Certain patients may present with their own physician and security staff. In this case, collegial communication amongst all parties involved is critical to assuring standard processes are followed and all parties are comfortable with the course of care.
- “Care should occur where it is most appropriate.” While a sequestered setting may be appropriate, especially for the security of certain VIP’s, it should not result in any changes to the standard of care provided that patient. A patient needing intensive care should be in the intensive care unit. Excessive attention to the privacy of one VIP patient can affect the ability of staff to care for others.
- “Protect the patient’s security.” While actual physical security and safety for the patient is important and may even involve private security staff and access control, the security of information about the patient must be enforced. Other than immediate caregivers, no one should access the VIP patient’s medical record. [Editor’s note: In most organizations, doing so is a HIPAA violation and cause for termination.]
- “Be careful about accepting or declining gifts.” This can be a cultural and ethical challenge but can generally be avoided by “deferring” acceptance of a gift until the episode of care is over and the patient is ready for discharge. Understand that gifts and special requests raise ethical questions about justice and fairness.
- “Working with patient’s personal physicians.” Certain patients may present with their own physician (and security staff.) In this case, collegial communication amongst all parties involved is critical to assuring standard processes are followed and all parties are comfortable with the course of care.
Other points helpful in avoiding “VIP Syndrome” are:
- Appointing a staff manager – or even the director of nursing – to oversee caregiver access and assure compliance. Staff may appreciate if this person also serves as the primary patient-hospital liaison.
- Maintaining standard processes in other ancillary units of the organization, e.g., patient transport, billing, medical records, registration, lab, imaging, food services, etc.
Remaining aware that caring for VIPs can be overwhelming and affect one’s decisions is the best way to assure that the patient and staff conclude the episode of care with everyone pleased with the outcome.
As for the plaintiff attorney patient mentioned in the opening paragraph, sticking to a standardized team approach of history, physical exam, differential diagnosis, lab and imaging quickly led to a diagnosis not of myocardial infarction but of thoracic aortic dissection. A cardiovascular surgeon was called to assume care of the patient (not “attorney”) resulting in a successful outcome. High quality care is standardized, repeatable and should be the same for all, whether the patient is unknown, a family member, a colleague, a VIP – or even a plaintiff attorney.