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VIP Syndrome – a no-win situation

In my last post I described how VIPs don’t necessarily get better medical care. In this post I will describe a case study of a bully whose behavior wasted endless resources and time. This is a true story.

The son of a business tycoon experienced some diarrhea. He went to his local emergency room immediately, explaining to the staff who his father was, and that he required immediate treatment.

Because of his father’s influence, the man was indeed seen immediately. The physicians soon realized, however, that there was nothing emergent about this man’s complaints. After several blood tests and a stool sample were taken, he was administered some oral fluids and monitored for several hours, they chose to release him to recover from his gastroenteritis (stomach flu) at home.

The man complained bitterly and said that he wanted to be admitted to the hospital. The physicians, with respect, explained that he didn’t show any signs of dehydration, that he had no fever, his diarrhea was indeed fairly mild (he had only gone to the restroom once during the hours of his ED visit – and that was when he was asked to produce a stool sample). The man’s pulse was in the 70’s and he had no acute abdominal tenderness.

The man left in a huff, and called his father to reign down sulfur on the ED that wouldn’t admit him.

And his father did just that.

Soon every physician in the chain of command, from the attending who treated him in the ED right up to the hospital’s medical chief of staff had received an ear full. Idle threats of litigation were thrown about, and vague references to cutting key financial support to the hospital made its way to the ear of the hospital CEO.

The hospital CEO appeared in the ED in person, all red and huffing, quite convinced that the physicians were “unreasonable” and showed “poor judgment.” Arguments to the contrary were not acceptable, and the physicians were told that they would admit this man immediately.

The triumphant young man returned to the ED for his admission. Since the admitting diagnosis was supposedly dehydration, a nurse was asked to place an IV line. The man was speaking so animatedly on his cell phone, boasting to a friend about how the doctors wouldn’t admit him to the hospital so his dad had to make them see the light, that he moved his other arm just at the point when the nurse was inserting the IV needle. Of course, the poor woman missed his vein.

And so the man flew into a rage, calling her incompetent, cursing the hospital, and refusing to allow her to try again.

At this point, the ED physicians just wanted him out of the emergency room – so they admitted him to medicine’s service with the following pieces of information on his chart:

Admit for bowel rest. Patient complaining of diarrhea. Blood pressure 120/80, pulse 72, temperature 98.5, no abdominal tenderness, no white count, patient refusing IV hydration.

Now, this is code for: this admission is total BS. Any doctor reading these facts knows that the patient is perfectly fine and is being admitted for non-health related reasons. With normal vital signs, and no evidence of dehydration or infection, this hardly qualifies as a legitimate reason to take up space in a hospital bed. And when the patient is refusing the only treatment that might plausibly treat him, you know you’re in for trouble.

The man was discharged the next day, after undergoing (at his insistence) an abdominal CAT scan, a GI consult, an ultrasound of his gallbladder, and a blood culture. His total hospital fee was about $8,000.

Do you think he paid out of pocket for this? No. He submitted the claim for payment to his insurance company. Their medical director, of course, reviewed the hospital chart and realized that the man had no indication for admission, and refused medical care to boot, so he denied the claim.

So the son appealed to his father, who then rained down sulfur on the insurance company, threatening to pull his entire business (with its thousands of workers insured by them) from the company if they didn’t pay his son’s claim.

The medical director at the insurance company dug in his heels on principle, assuming that if he continued to deny the claim, the hospital would (eventually) agree to “eat the cost.”

In the end, the insurance company did not pay the claim. The CEO of the insurance company called the hospital CEO, explaining that it was really the doctor’s fault for admitting a man who didn’t meet admission requirements. The hospital CEO agreed to discipline the physician and eat the cost to maintain a good relationship with the insurance company that generally pays the hospital in a timely manner for a large number of patient services.

I ask you, my friends, does this seem fair? It’s because of these cases that doctors become (sadly) hard of hearing when it comes to patients who appear well, but may indeed have a serious condition.

In my next post, I will describe a true story of a baby whose life was saved because of her mother’s insistence.

P.S. There are many comments on this post, featured at Kevin MD.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Do VIPs get better medical care?

People often believe that the medical treatment that VIPs get is far superior to the care received by “common folk.” While it’s true that a VIP might get a nicer hospital room, the care received might actually be inferior.

Why? Because all of the anxiety and pressure to perform all possible tests to rule out all possible problems results in higher risk to the patient. Most tests are associated with some degree of risk – catheter infections, phlebitis, dye alleries, anesthetic reactions, and so on. Though these risks may be small, they are additive.

Beyond the risk of unnecessary tests, is the risk of unnecessary medications. When a VIP complains of an issue, he may get additional medicine. Medicine has side effects, and side effects can have serious consequences. Consider the deadly side effects of pain medicine that a dear patient of mine once had.

Then there’s the pressure that physicians feel to do what the patient requests, rather than exercising their clinical judgment.

In one particular case, a young executive came to the ER complaining of abdominal pain. The physicians ran all kinds of tests and concluded that he had a common stomach virus. The man was convinced that he had appendicitis and called in a favor from his “connection” who knew the CEO of the hospital. The hospital CEO questioned the physicians taking care of the man – whether they could say with 100% certainty that this wasn’t appendicitis. They said that it was highly unlikely, but that the only way to be 100% certain would be to remove the appendix and examine it under a microscope. The CEO asked them to take the patient to the OR. Of course, the executive did not have appendicitis. He did, however, undergo an unnecessary surgery, which his insurance company paid for in full, contributing to potential increased premiums for the others in his company’s group. Did this VIP get better care? I think not.

In my next post I’ll discuss how one VIP bullied his way into the hospital without even being truly sick, causing all kinds of problems that dragged on for months!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

My medical heroes

On New Year’s Eve when many people are drinking champagne and worrying about who they should kiss at midnight, Dr. Brian Fennerty, Section Chief of Gastroenterology at Oregon Health & Science University is fighting to keep patients alive in the Intensive Care Unit. Severe internal bleeding has put these patients’ lives in jeopardy, and Dr. Fennerty stays with them all night, ordering blood transfusions and tamponading their bleeding.

Dr. Jack Cook, US Navy veteran and former submarine commander, is under a mountain of medical charts. At 67, he is spearheading the transition from paper records to an electronic medical records system for his group practice of primary care physicians in Virginia. He wants his patients to have the opportunity to experience chart portability – something he believes might save their lives in cases where they are brought to the ER in an unconscious state. Although this project will take his group 2 years to complete, and cost untold hours in lost wages (with no clear reimbursal benefit for his practice) he is making the investment for his patients’ sakes.

In the middle of a teleconference, Dr. Iffath Hoskins, Chair of Ob/Gyn at Lutheran Medical Center in Brooklyn, excuses herself to perform an emergency C-section on a young woman with a complicated pregnancy. Against all odds she saves both mother and baby, and reschedules the teleconference for late that evening so she can complete her interview on time for a feature article at Revolution Health.

Just returning from Africa, Dr. Leo Lagasse, Vice Chairman of Ob/Gyn at Cedars-Sinai Medical Center, is preparing for his next mission’s trip with medical residents and faculty. His non-profit organization, Medicine for Humanity, has been behind countless trips to Afghanistan, Kenya, and Eritrya – serving impoverished women with medical problems. Dr. Lagasse takes time out to explain to me the link between smoking and cervical cancer for an article I’m preparing.

Dr. Charlie Smith is spending the afternoon with his son Jordan in Arkansas. Jordan was accidentally shot in the chest by a child with a BB gun, tearing a hole in his heart that caused him to go into cardiac arrest. He was rushed to the hospital where surgeons resorted to cardiac massage to keep him alive – he survived the ordeal, but his brain never fully recovered from the temporary lack of oxygen. He was rendered permanently bed-bound, and raised at home by his loving parents. Dr. Smith created a company called eDocAmerica to allow him to work from home and spend more time with Jordan. eDocAmerica is devoted to answering consumer medical questions via email.

At Harlem Hospital, Dr. Olajide Williams works tirelessly to raise awareness of stroke symptoms in a high risk inner city population. He organizes outreach through musical youth initiatives, lectures nationally to narrow the racial gap in quality care, and declines all prestigious medical recruitment offers. He is steadfast in his devotion to his community – no matter what the cost. Dr. Williams spends part of his weekends preparing blog entries for Revolution Health.

These are only a handful of the wonderful physicians associated with Revolution Health. I hope you’ll enjoy getting to know them through their blogs, articles, and future contributions. They are here for you… to support your need for credible information, to answer your questions, and to help guide you towards optimum health.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Hip Fractures & Heartburn: Any Cause For Alarm?

Well, I fell for it again – that panic that follows breaking news that a drug once thought to be safe was now causing some horrible, unexpected side effect.  I nervously wrung my hands as I thought of all the proton pump inhibitors I had prescribed for heartburn in the past.  Did I hurt my patients?  Are they all lying in a hospital somewhere with pins in their broken hips?

I took a deep breath and decided to go back to the source of the news. There it was – the offending research study in the Journal of the American Medical Association.   I read it carefully – looking for the devil in the details.  And lo and behold, the caveats started slinking off the pages.

First of all, the “44% increased risk of hip fractures” sounds really bad, doesn’t it?  Well, what if I said that a person’s risk of getting a hip fracture (IF they were over 55 years old AND took a proton pump inhibitor for over a year straight) was 1.44 in 1000 whereas if they never took the medicine, their risk would be 1 in 1000.  Does that sound as bad?  Well, I’m actually saying the same thing.

There were some other interesting details – men were significantly more likely to get fractures than women 1.78:1000 compared to 1.36:1000.  There was no explanation as to why that might be.  Also, I noticed that there was no discussion of a potential confounder – which of these patients were in nursing homes?  In my experience, patients in nursing homes often automatically get proton pump inhibitors – and stay on them indefinitely as “GI prophylaxis.”  Now if you’re sick enough or demented enough to be in a nursing home, then you’re probably at higher risk for falls… which would be a good reason why people on proton pump inhibitors break their hips more frequently, right?  If you fall more frequently, then – bingo – there goes your increased risk for fractures.

Well, the research does seem to suggest that there’s a trend – people who take proton pump inhibitors for long times in higher doses may have a higher risk of fractures.  But the jury’s still out on why that may be.  For most folks in the US who are under the care of a watchful physician, their dose and duration of taking the medicine doesn’t put them at increased risk at all.

So to me the take home message is that people shouldn’t stay on proton pump inhibitors indefinitely, which isn’t really news to me.  I hope that this blog entry has reduced your anxiety level… stay tuned for more critical analysis of research findings.


This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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