VIP Medical Care

The Case for Transparency

© photo by Bertie

On December 22, 2022, the New York Times published an investigative article about NYU Medical Center titled, ‘Major Trustee, Please Prioritize’: How NYU’s E.R. Favors the Rich. 

The article relates how NYU bumps VIPs to the head of the line in the ER with perks such as a special trustee phone line, alerts in the medical record, and even a separate area - room 20 - reserved for critical cases and VIPs.

Since reading the article I’ve been thinking a lot about the phenomenon of VIP patients in medicine, and how it differs - or should differ - from VIP treatment in other areas of life.

It may be useful to divide VIPs into three categories: Friends and Family, Celebrities, and Benefactors.

Friends and Family is a good place to start because it reveals how the concept of VIP is to some degree inseparable from basic human nature. We all operate within a system of concentric social circles, beginning with family at the center, and extending outward to friends, professions, religions, nationalities, and other tribes and building blocks of identity. 

The VIP treatment that we give to friends and family is fundamental and ubiquitous. What kind of person would we be if we did not give our intimates a little extra attention or help them out in a time of need when we are in a position to do so?

Rachel delivered all our babies at the hospital where we had been residents, with the midwife who trained us. When I had viral meningitis I went to Columbia, where I was an attending. Years later, when our daughter Georgia was critically ill with congenital heart disease, we again went to Columbia, where we knew the players and the system.

Each time, we got a little extra care and attention - the same kind that we would have provided to any of our friends and family if they were to end up in our medical orbit, and the same kind, no doubt, that any of the NYU ER residents and attendings quoted in the article would certainly provide to any friends or family who rolled into their ER.

The second category, celebrities, are VIPs for two reasons.

The first reason is the increased scrutiny that comes with celebrity.

In 2004, when I was an attending at Columbia Presbyterian Medical Center, President Clinton was admitted for treatment of ischemic heart disease. The media dissected every aspect of his treatment, with updates provided by a hospital spokesman at special press conferences.

I remember similar questions being raised at the time about VIP treatment. The PR guy had this to say: “At Columbia, every patient is a VIP!” 

Well, maybe so, but not every case is put under the microscope, and not every outcome is known around the world. Let’s just say that, as I remember it, Columbia was a bit more interested than usual in preventing the slightest thing from going wrong and very eager to benefit from the good publicity.

The second reason we treat celebrities as VIPs is the lopsided way that people - doctors included - feel toward celebrities: how they mean more to us than we ever could to them; how we feel that we know them although they are actually strangers; how they masquerade in our psyche as friends and family. 

In a weird way, we feel like we owe them for something - and sometimes we do.

When I was an intern I admitted a man with a terminal illness who looked strangely familiar. Reviewing his chart, I quickly realized why. My patient was Allen Ginsberg, the famous poet. 

It’s a little embarrassing to me now, but as a college student I went through a Jack Kerouac / Beats phase, and Ginsberg was one of my favorites. I was on call that night, and after my duties were done, I circled back to his room and found that he was still awake. 

The few hours that I spent with him, from night into the early morning, sitting at the side of the bed talking and listening, was a privilege that I tried - I hope successfully - to repay with a little VIP care before he passed away.

Benefactors, the third category, is the NYU case - trustees and donors who are VIPs because they financially support the institution. 

It may seem obvious that a big donor would get the VIP treatment - after all, that’s the way it works in every other institution in American life - but NYU is loath to admit that it plays by the same rules.

Here’s what Dr. Fritz Francois, chief of hospital operations, had to say to the New York Times: “We do not have VIP patients. We do not have VIP floors. We do not have VIP clinical teams. We do not offer VIP care.”

The doctor doth protest too much, methinks!

Here’s what I would have said: “Of course we have VIPs, and as long as our survival depends upon philanthropy we always will.”

Back in 2007, NYU was in dire financial straits. Along came Kenneth Langone, the co-founder of Home Depot. He donated hundreds of millions of dollars of his own money and helped raise billions more to turn NYU into a world-class health center. 

Did he do this in order to cut the line in the ER? Unlikely - he could have built his own personal ER for a fraction of that amount. But what are they supposed to do when he needs to use it - let him lie on a stretcher in the hall?

To be clear, I think that giving private money for public benefit should be encouraged. And I can think of lots worse causes for American oligarchs to support than healthcare. 

But if, as a society, we have decided that this is as good (or better) a way to finance a hospital as taxes, for example, then let’s not act surprised when it results in such a thing as hospital VIPs.

The real problem with NYU is not that they have VIPs, but that they disingenuously deny it, which only precludes intentionality and reform.

The ER is the perfect edge case to illustrate this point: VIP care in that setting is intrinsically problematic, and has the potential to conflict with medical ethics and training. 

One of the main skills in emergency medicine is triage - the ability to prioritize and stabilize sicker patients first. The idea that a VIP can cut to the head of the line regardless of medical acuity will cause cognitive dissonance in any ER doc, which is exactly what happened at NYU.

Whatever you think about VIPs, no one wants a situation where doctors feel pressured to act against their better judgment. The right thing to do in such a situation is to listen, reassess and change.

But when you deny that a system exists, it becomes very hard to change. Not only that, but when something that is not supposed to exist actually does, you can end up in a situation where boundaries are impossibly porous and anything goes.

One historical analogy that comes to mind is the Soviet Union. Social divisions, privileges, and abuses of power were ironically (if arguably) more extreme under Communism than under Capitalism, partly because the fiction that they did not exist allowed them to flourish unchecked. 

This brings us to the best case against VIP medical care in general: professionalism - the notion that all patients are created equal.

Illness and death are the great equalizers. They are coming for us all, whether we are homeless, captains of industry, or even doctors. 

That universality was one of the things that attracted me to medicine, and I was pleased to find that its corollary - that all patients should be treated with respect, regardless of their status - was widely shared by my peers and taught as a basic and fundamental tenet of medical education.

Whether it always works out that way is another question altogether - let’s just say it’s a work in progress.

It is written in the Talmud that the best doctors are destined for Hell. The commentaries explain: eminent doctors do not fear sickness; they arrogantly decline to consult their colleagues; they sometimes cause death; and they refuse to heal the poor who cannot pay them.

That was over two thousand years ago. The more things change….

Anyway, balance the ideal against the reality of VIPs and it becomes clear that, at the very least, hospital VIP policies should be carefully thought out, implemented with intentionality, and open to reassessment.

So how should such a hospital VIP system work? 

I don’t presume to be an expert, but I’ll go out on a limb and say that it should exclude the ER, and maybe look a little something like air travel. 

First-class passengers get more space, softer blankets, and better food. But they take off, land, and - in the worst-case scenario - go down, with everyone else.

Similarly, let VIPs have bigger rooms with nicer views, gourmet food, and even hospital swag like comfy gowns and tote bags (actually a thing). But let doctors treat every patient to the best of their abilities - which happily, luckily, and generally speaking, is exactly what they want and are trained to do.