Paediatric Cardiac Surgery, Department of Cardiovascular Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
The popular term VIP (very important person) describes people perceived as being somehow of a higher status and deserving special treatment and privileges. Such prominent individuals are often difficult to manage when they require medical care and are admitted to the hospital. Indeed, such patients appear to be prone to complications and treatment failure. This phenomenon is well known to doctors and has occasionally been referred to as “the VIP syndrome”. However, since its mechanism is rarely discussed, it is rarely neutralised, potentially explaining why this is a recurring problem.
When discussing the VIP syndrome, two questions arise:
- Which patients are VIPs?
- Why might they be prone to poor results when receiving medical treatment?
The first question may be particularly upsetting since we are trained to consider all patients equally important. Nevertheless, some patients are occasionally treated as “special” (i.e. they are given VIP status) because of some naively harmful forces that come into play. How does this arise?
The term VIP usually evokes images of well-known personalities and celebrities. However, in a medical sense, it applies to a much broader spectrum of people. It applies to all patients who, deliberately or inadvertently, cause tension and anxiety in the staff treating them, creating pressure to give them “special” treatment. Being a celebrity is only one example. Celebrities are interesting because they cause a state of alert even when they do not claim any particular status or demand special treatment since the healthcare team is aware of being closely examined by many observers. However, this effect may also be caused by patients who are well known only within the hospital, such as staff members and their families, patients whom the staff are asked to “look after well” by some influential people, or people who have donated money to the hospital. Another good example of patients being granted VIP status is when they happen to be doctors who, equipped with medical knowledge, may easily create tension by making the healthcare staff feel scrutinised, particularly when these patients interfere with their treatment. The healthcare staff members, feeling apprehensive, often overcompensate by trying to give these patients “special” treatment. Some patients create tension by simply being mistrustful, making the healthcare team feel like they have something to prove. Other patients may be simply cynical, viewing the world as a cruel place where nobody will help them unless they pressure them, which they readily do. Some are naturally strongly opinionated and cannot resist the temptation to interfere with and criticise everything, putting everybody on the defensive. Generally, all demanding patients readily acquire VIP status by making their healthcare team feel scrutinised and anxious. They are all at increased risk of poor medical treatment outcomes, leading to the second question: why would scrutiny and increased tension in the healthcare staff lead to a poor outcome?
Good outcomes in medicine result from rigorous coordination among many healthcare team members. It is a well-established system involving a clear chain of command with one person leading it (“the boss”) who has the final say in all aspects of care but who delegates various tasks to different team members according to their expertise and abilities. This system creates a pyramidal bottom-up approach whereby the ward staff and junior doctors look after the patients closely on the wards and report to, and are guided by, their senior colleagues. This responsibility includes detecting problems and early warning signs of complications, which they also report to their seniors. This approach makes sense since the ward staff and junior doctors see patients much more frequently than their senior colleagues. Seniors are often away from wards due to their many other commitments and rely on their juniors to function as their eyes and ears on the wards. Unless this working system is respected, it will break down, as it often does when dealing with patients given VIP status.
By generating a state of alert, patients with VIP status often disrupt existing systems. The most interesting disruption is that doctors appear driven by the need to be seen as “doing something”, which is often bad medicine. Good medicine may well indicate observing the patient for a certain period, seeing how things go, reviewing them at a later stage, and then deciding what course of action to take based on more information that will have revealed itself. That decision may be to continue observing or that no treatment is required. However, some may misinterpret this approach as “doing nothing”, insinuating that the doctor does not care or is not taking the patient seriously. Consequently, this very sound medicine is often denied to these patients. Even when no particular action is indicated, the doctor may feel pressured to perform various tests they may not normally do. These tests occasionally produce spurious results, which doctors with sound judgment dismiss. As the old humorous medical saying goes, a perfectly normal individual is an insufficiently investigated individual. Indeed, when enough tests are performed, it is only a matter of time before something “abnormal” appears. This outcome is unimportant since doctors are aware of this and recognise and overrule irrelevant test results. However, for patients with VIP status, such results may become common knowledge and cause turmoil. Doctors may be pressured to do something about them when perhaps they should not since it may not be beneficial. On occasion, it may even be harmful. Indeed, poor outcomes should be unsurprising when a particular treatment with doubtful indications is used based on tests that were not necessarily relevant or needed.
When doctors do intervene, this is within the context of the tension that surrounds these patients (i.e. the usual working system is not followed). These patients may easily make the nurses and junior doctors anxious. The juniors become fearful and hesitant and call on their seniors to deal with issues they would normally deal with themselves. Occasionally, this is in response to the explicit demand of the patients or their relatives that nothing is done until they see the “boss”, invariably delaying treatment. It also undermines the quality of care since staff start doing things they would not normally do and are likely to do them less well than those who do them routinely, such as the boss writing the fluid and drug prescriptions or changing a dressing. The boss often complies, and the junior doctors and nurses are effectively removed from the equation. The bottom-up approach is turned on its head and becomes top-down. The nurses may feel undermined, frustrated, and angry, likely affecting their performance and judgment. Matters are made worse by potential confrontations among healthcare team members who may object to varying degrees to the “special” treatment offered, further undermining the quality of care.
Despite all the potential disagreements among the team members, they never appear to disagree about one issue they all share: a strong desire to discharge these patients as soon as possible. Therefore, these patients are at risk of being discharged prematurely. However, while these patients are still in the hospital, all team members look for excuses to minimise their contact with them to avoid confrontation. Consequently, these patients may be isolated, potentially leading to a vicious cycle since isolation leads to poor quality of care, increasing their anxiety and making them exert even more pressure by complaining at many hospital hierarchy levels. This behaviour inevitably causes more tension and apprehension among ward staff and junior doctors who may become even more withdrawn, isolating these patients further. This situation severely undermines our vigilance system and clinical information flow. Early warning signs of complications may be missed, and preventive measures cannot be taken. Consequently, complications may only be noticed when they have fully developed. The management of these patients becomes reactive rather than proactive.
Ultimately, both sides (patients and healthcare teams) are unhappy and frustrated. Treatment offered by an unhappy healthcare team in which there are disagreements among members is unlikely to be optimal. Similarly, unhappy patients are less likely to comply with treatment. Their VIP status fails in its intended function of obtaining privileged and supposedly better healthcare. Instead, it becomes a risk factor for complications and treatment failure.
Ironically, this syndrome is a by-product of the best intentions on everybody’s part, including the patients. Everybody thinks they are optimising treatment. In reality, they are undermining it.
We should all bear this syndrome in mind. We must remain sensitive to its mechanism to recognise and neutralise it. Patients who put us under scrutiny will always exist. Many do not even intend to do so, but others around them cause this. Nevertheless, all patients deserve good healthcare, irrespective of their personality. We as doctors should recognise the danger associated with such patients and that they carry an additional risk factor, the VIP risk factor. We must not allow this to undermine our system, which is well-tried and tested and there for a good reason, to protect our patients. Most patients do trust that process. Those that do not should be encouraged to do so. This outcome should also remind us doctors that, when we happen to be patients, it is worth remaining cooperative, not claiming special treatment, and allowing healthcare team members to do what they do best.
Professor Amir-Reza Hosseinpour
Chief of Paediatric Cardiac Surgery
Department of Cardiovascular Surgery
Centre Hospitalier Universitaire Vaudois (CHUV)
Rue du Bugnon 46