Is the best medical care money can buy the best thing for your health?

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    An artist's rendering of a marble-accented VIP suite. (Courtesy of Johns Hopkins)

    An artist's rendering of a marble-accented VIP suite. (Courtesy of Johns Hopkins)

    VIP medical care is a rising trend for hospitals, but bending the rules for patients with special status could be a potential pitfall.

    The dress code for today is strict: no skirts, dresses, or open-toed shoes—and there will be hard hats.

    I’m walking through a construction zone inside the Johns Hopkins Outpatient Center in Baltimore. The floor is covered in brown paper and sawdust. Electrical wires hang from the ceiling. The path ahead is paved with ladders and giant cans of paint. Ashlea Barrett, the director of the Johns Hopkins Executive and Preventive Health Program, is walking me through the construction site.

    “As we move down the hallway, now we’re in what will be the new Executive Lounge,” she says enthusiastically.

    In a few months, this space will be a modern, spacious patient care facility with floor-to-ceiling windows, a gym, and showers with marble accents. Think 5-star hotel or spa.

    “We’ve moved it to the corner of the building so patients can have a view of the Baltimore skyline and also the harbor,” she explains. “We thought this would be a more appealing space for them.”

    By “them,” Ashley means their patients: executives, mostly, but sometimes politicians and even the occasional celebrity. Some have a special benefit through their insurance plan that pays for this medical care, which can run up to several thousand dollars a visit. But many people pay out of pocket.

    Ashlea leads the way to the VIP suite.

    “This is for very high profile or recognizable patients who need a more private area,” she tells me. “This suite has its own exam room, its own waiting room, and its own restroom,” she says.

    VIP Syndrome

    Whether a high-profile patient goes to a special, private office or a regular hospital, there’s the issue of the medical care itself: the evaluation and making decisions about treatment. Here is where VIP syndrome may happen—and in this case, “VIP” stands for “Very Important Patient.”

    “It’s basically a catch-all phrase for when a person who is rich or influential is treated differently because of the special status,” says Liz Kowalczyk, a medical reporter at the Boston Globe.

    She spent months investigating this phenomenon at one Boston hospital. She says that in VIP syndrome, the power differential between doctor and patient can shift. Care providers may defer more to the patient’s requests, even if these requests aren’t good for them.

    “And that can involve giving the person more care than you would normally give another patient, such as more tests,” Kowalczyk explains. “Or it can involve giving them less care, such as skipping an embarrassing exam like a prostate exam.”

    The medical literature is full of examples of VIP care gone wrong—when special treatment leads to worse outcomes. Kowalczyk told me about the case she researched. It involved a prince from another country.

    “This patient had a multidrug-resistant infection, a serious infection that wasn’t treatable by normal antibiotics. And policy calls for anybody who goes into that room to wear a gown and gloves to protect themselves from infection and also to protect other patients. This patient was offended by that. He felt it was insulting and requested that people not wear that protective gear. And so they didn’t. So, in this situation, caregivers were endangering themselves as well as other patients.”

    Then there was the catheter issue.

    “Caregivers suspected that his catheter might have been contaminated and causing an infection,” says Kowalczyk. “Normal policy would be to change that. But he didn’t want it changed, so they didn’t change it. So the special treatment was really endangering the patient himself.”

    There were other concerns, too, about the thousands of dollars in cash gifts the patient gave staff members, and about how many painkillers the patient was on. The over-prescription of narcotics for pain comes up a lot in VIP syndrome.

    “There’s a mantra: we treat all patients the same. And that’s sort of the public statement,” says Kowalczyk. “I think it’s important for institutions to examine if that’s really true in a clear-eyed way.”

    VIP2

    An artist’s rendering of an examination room. (Courtesy of Johns Hopkins)

    “When I Do That, I Provide My Best Care”

    I understand what Liz means when she talks about that “clear-eyed view.”

    I’m an internist, and, I’ll be honest, it can be a little overwhelming if someone powerful is sitting in the exam room with you. I’d love to say that it makes no difference at all. But, at first, you may second-guess yourself, or even let the patient dictate their own care.

    Sarah Clever, an internist at Johns Hopkins who recently wrote about caring for influential patients, offered me this advice.

    “Hopefully towards the beginning of the meeting, I say, ‘I know that you have this status.’ And I say, ‘I have a certain algorithm that I follow in how I care for patients. And I know that when I do that, I provide my best care.'”

    Clever draws from her work as a physician, but she’s also had a personal experience with VIP syndrome.

    About six years ago, she was pregnant with twins and on vacation in Mexico when her heart started racing. She couldn’t breathe, she broke out into a sweat. She knew it was an emergency. Clever had to be airlifted back to Baltimore, to her own hospital’s cardiac ICU, where she became the VIP.

    “What I saw were errors of overtreatment and interestingly under-asking,” Clever told me. “I had a very fast heart rhythm which can be provoked by stimulants. And no one asked me if I had used any drugs! Cocaine, alcohol. No one even asked me if I drank coffee. It made me wonder, what else are they not doing because I’m a physician?”

    On the flip side of that coin, she also realized, nobody wanted to be that doctor who missed something—who didn’t do enough.

    “It pushes us to go farther with diagnostic procedures, treatment than we might otherwise and that might be in their best interest,” laments Clever. “Because all of the care we provide, everything we do has risks.”

    The Cleveland Clinic Principles

    When it comes to patient care, Sarah Clever recommends being mindful in the moment and asking colleagues for advice when it feels like there’s pressure to do things differently.

    There’s also another resource for VIP care. Liz Kowalczyk of the Boston Globe reporter says, “The Cleveland Clinic deals with a lot of high-profile patients. It became enough of an issue there that they wrote a guide, sort of nine principles for dealing with VIP patients.”

    These include how to communicate with the media, protecting patient privacy, and how to accept (or decline) cash gifts. Another principle says to “Resist Chairperson’s Syndrome.”

    According to Kowalczyk, “VIP patients or a lot of times their families or their entourage will sort of demand the chair of the department but, again this is an example where being treated in a special way is actually to the VIP’s detriment.”

    Because sometimes, the doctor you want may not be the boss, but the one really involved in hands-on clinical work, day after day.

    According to the Cleveland Clinic, the number-one principle of caring for VIPs is “Don’t bend the rules.” Stick with tried-and-true practices that are based in evidence and that generally work pretty well. VIPs are often relieved when their doctor says, “I am going to treat you the way I would any other patient.”

    After all, every patient should be treated as very important.

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