Dennis Quaid’s Kids: Are VIPs Safer?

The Entertainment Blogosphere was atwitter yesterday with the story of actor Dennis Quaid’s twin newborns, who reportedly received a 1000-fold heparin overdose at Cedars-Sinai Medical Center in La La Land. Cedars’ Chief Medical Officer Michael Langberg may win this year’s Oscar for fastest public apology – having learned the lesson from the 2003 Duke transplant error, where the hospital stonewalled for a week or so, adding chum to the media feeding frenzy.

The error came during heparin line flushes, when a 10,000 units/ml solution of heparin was mistakenly substituted for the intended 10 units/ml solution. Although the cases required pharmacologic reversal of the anticoagulant effect, thankfully there were no bleeding complications.

These cases come on the heels of last week’s report out of Dallas that the state-supported UT-Southwestern kept an “A-list” of potential donors and assorted bigwigs. Apparently, when these folks come to the hospital or clinic, they may get a personal greeting, a preferential parking spot, perhaps even an escort to their appointment. My friends at Health Care Renewal, who chronicle and condemn healthcare’s corporate influences, were shocked. Shocked!

I’m not. Every hospital I know keeps some sort of a VIP list, a tripwire to alert the organization of the arrival of a dignitary or billionaire. Even when there isn’t a formal list, you can be sure that a single call to the CEO’s office is more than enough to lift the velvet rope. That’s a simple fact of life, and to me not worthy of a big fuss.

Unless, of course, they’re getting better care than Joe and Jane Average. But are they? Believe it or not, I really doubt it. In fact, there is a sizable medical literature describing the “VIP Syndrome,” a disease you don’t want to have. In a fascinating article, the Israeli docs who cared for Prime Minister Ariel Sharon after his devastating brain bleed put it this way:

The VIP syndrome is characterized either by decisions to minimize the number of diagnostic and therapeutic procedures or, alternately, to work-up every minor abnormality to appear very thorough. Another aspect of this syndrome is fragmented care, i.e., care by multiple specialists each focusing only on their area of expertise.

And, I’d hasten to add, it often isn’t any specialist, it is the organization’s most famous, Nobel Prize-winning superspecialist – you know, the one who often needs a map (“you walk past the cafeteria, make a left at the dialysis unit, and you’re there!”) to direct him to the ward. Get a gaggle of these folks involved in someone’s care, and you’ve got one hell of a mess on your hands.

How can the VIP Syndrome be prevented? In 1993, the editor of the journal Chest suggested that:

The best decisions in reversing the ravages of the VIP syndrome are to take measures to ensure the privacy of the VIP, to place limits on the visitors, and to explain that the care will be identical to that given to all other patients with the same condition. There is nothing biologically different about a pope or a president, and there is no need to alter one’s thinking in caring for them.

This is all very nice, but one still wonders whether VIPs and their families get safer, more attentive care. My favorite story about this pertains to Dr. Don Berwick, probably the world’s most revered quality and safety leader. As I described in Understanding Patient Safety, Berwick writes poignantly of his wife Ann’s harrowing string of hospitalizations for an obscure, progressive neurological illness. Berwick took her to some of America’s greatest teaching hospitals, where, as the wife of a famous physician and patient safety advocate, she was as VIP as you can be. And yet, wrote Berwick:

The errors were not rare; they were the norm. During one admission, the neurologist told us in the morning, “By no means should you be getting anticholinergic agents [a medication that can cause neurological and muscle changes],” and a medication with profound anticholinergic side effects was given that afternoon. The attending neurologist in another admission told us by phone that a crucial and potentially toxic drug should be started immediately. He said, “Time is of the essence.” That was on Thursday morning at 10:00 A.M. The first dose was given 60 hours later—Saturday night at 10:00 P.M. Nothing I could do, nothing I did, nothing I could think of made any difference. It nearly drove me mad. Colace [a stool softener] was discontinued by a physician’s order on Day 1, and was nonetheless brought by the nurse every single evening throughout a 14-day admission. Ann was supposed to receive five intravenous doses of a very toxic chemotherapy agent, but dose #3 was labeled as “dose #2.” For half a day, no record could be found that dose #2 had ever been given, even though I had watched it drip in myself. I tell you from my personal observation, no day passed—not one—without a medication error.

There is no evidence that Dennis Quaid’s kids were harmed because they hail from a VIP bloodline, but it wouldn’t surprise me if it was a causative factor. Everybody just tries a bit too hard, and in doing so, they throw off their natural rhythm. In any case, when we get a VIP admission at UCSF and the residents ask me how they should approach the case, I always say the same thing: let’s work our tails off to be sure that nobody hurts them.

Whether you’re a VIP or not, have a safe and happy Thanksgiving.

5 Responses to “Dennis Quaid’s Kids: Are VIPs Safer?”

  1. rcentor November 21, 2007 at 8:08 pm #

    Bob,

    You have written eloquently on the risk of being a VIP.  We wrote about this a few months ago on Medscape – Do You Treat VIP Patients?

    I finished my comments then with these words:

    In fact, VIP patients actually run the risk of providers making adjustments to their care that are not particularly beneficial. This is similar to when physicians care for other physicians. Often, when caring for such ‘special patients,’ we may treat them differently in a way that deviates from optimal care. Unfortunately, ‘different’ rarely means ‘better.’

    We must remember that good care should remain an ideal that all patients deserve. Treating patients differently often leads to worse care. In an effort to ‘protect’ special patients (especially colleagues) from uncomfortable but necessary care, we might actually be providing inferior care.

    Rereading them I believe that we are viewing this issue synchronously.

  2. SSingh November 26, 2007 at 12:25 am #

    I have always assumed that the classic VIP Syndrome error case is most often asymmetrical. A rank-and-file nurse or physician makes a medication or treatment error where the patient is a noted celebrity. While the institution providing care may be high profile and perhaps enjoying its own celebrity status to some degree (is Cedars Sinai represented by William Morris?), and while superstar specialists may be involved, I have assumed that the actual errors often trace back to an everyday provider or an everyday practice of the offending institution. In this setting, the VIP Syndrome seems most applicable. Because it is the everyday provider and everyday practice that are most easily swayed by celebrity.

    Not to say, as Dr. Wachter points out, that superstar specialists do not ultimately set the stage for errors, fragmenting care and, in some cases, disrupting the routine practice of medicine. And not to say that a superstar provider is immune to the VIP Syndrome, particularly given that medical celebrity is (unfortunately or fortunately) less galactic, so to speak, than the celebrity of the guy who played the quarterback and was coached by Al Pacino on Any Given Sunday. But I query whether, in the case of a superstar provider error (i.e. an error that is truly traceable to a superstar provider), is it really the VIP Syndrome or something else at play?

    Consider for a moment Donda West (the late mother of mega rap mogul Kanye West). Assuming that Donda West’s untimely death was due to medical error, and assuming for a moment it was Dr. Jan Adam’s error and not the error of a scrub nurse or recovery room error, what do we make of it? On first blush, we would think a VIP provider (to my knowledge, before the Donda West incident, Dr. Adams was featured in his own right on Oprah, NBC and Discovery Health), should be less vulnerable to VIP Syndrome and, all things being equal, less error prone.

    Less vulnerable to VIP Syndrome? Maybe. Less error prone? No.

    A few observations, all of which should be qualified by the fact that the cause of Donda West’s death is unknown and the fact that Jan Adams certainly is not the kind of Nobel Prize winning superstar provider Dr. Wachter envisioned. (Admittedly non-sequitur footnote: Though we may have hoped for some revelations as to Adams’ ultimate culpability on Larry King, Kanye West’s attorney pre-empted us. In my humble opinion, I am surprised Adams’ own legal team did not advise against the Larry King appearance or other interviews regardless. Though I am a corporate attorney by trade, even I know that the Jan Adams of the world should gag themselves in the wake of a potential liability—even if the liability is intertwined with media slinging on past sins that may be unrelated.)

    1. The VIP provider may have their own reverse VIP Syndrome with which to wrestle. In this case, it is awareness of their own celebrity that is the impeding factor. The superstar provider may be more prone to push a case through lest they appear greenishly incompetent, or may ignore the routine because their celebrity has detached them from the mundane but vital.
    2. The everyday provider may too readily defer to the VIP provider, and so error is born, even if not directly committed by the VIP provider him/herself. (And then factor in the fragmentation of care and detachment from routine medical care that seems to go hand in hand with superspecialist care, and error is imminent.)
    3. The VIP provider may, ironically, be less subject to scrutiny than the everyday provider. After all, their reputation precedes them and so, in the course of a long and accomplished career, irregularities may be drowned out by the noise of high profile accomplishments or a high profile patient roster. The non-board certified Dr. Adams, regardless of whether he is responsible for Donda West’s demise, may typify this. I defer to Dr. Wachter whether the same is true for the Nobel prize kind of VIP provider—I don’t know any personally and am still a babe in the woods in medicine.

  3. Bob Wachter November 27, 2007 at 1:31 am #

    More grist for the “VIPs are not any safer” mill: A recent discussion on the doctors-only Sermo website [ http://www.sermo.com/ ] regarding how docs discovered that their own medical records were riddled with errors — picked up by the Associated Press [ http://ap.google.com/article/ALeqM5jophmSjTNwlCyvhfctYIJbcrht0AD8T288Q07 ] and covered nicely in today’s Health Care Blog [ http://www.thehealthcareblog.com/ ]. In this case, I really doubt that the falsehoods are more common in the medical records of physician-patients than in those of real people; it’s just that we can read the Latin (and the handwriting) and separate fact from fiction.

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