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The Case
You’re working in a busy rheumatology practice with wait times of two to three months for new outpatient consultations. A hospital administrator requests that his daughter see you right away. All but one of your urgent appointment slots for the week is already filled, and there are several patients on a waitlist; these patients’ primary care physicians have also requested urgent appointments for suspected new-onset inflammatory arthritis. Your typical scheduling protocol would be to place one of the patients already on the waitlist into the single open appointment.
Upon review of the medical records of the administrator’s daughter, you note that she has actually been seen within the past year by another rheumatologist. A thorough history and physical examination are documented and extensive serologic and imaging studies were performed. A diagnosis was established, and the patient was provided with appropriate recommendations; she is now seeking a second opinion.
The Dilemma
Do you see this VIP (Very Important Patient) right away? Or do you see one or more of the truly urgent patients instead? Should you even put the administrator’s daughter on the urgent patient waitlist or ask that the VIP wait for the next open new patient appointment? Would your answer be different if the VIP had a more legitimately urgent need, but no more urgent than others on the waitlist ahead of her?
Discussion
VIPs are often political figures, celebrities, friends or family members of executives or healthcare providers. They may know you personally, or they may have ties to your employer, such as wealthy donors or members of the hospital board; often, they are wealthy, well connected and feel entitled to prompt access to your services. Physicians are often asked to see VIPs expeditiously for non-urgent issues. This may displace access to timely healthcare evaluation from another patient in need of more urgent medical attention.
Dr. Stellpflug
In many areas of the U.S., there is a shortage of rheumatologists. This commonly leads to delays in access to expert rheumatologic care, delayed diagnosis and poorer outcomes.1 Early, aggressive treatment of inflammatory arthritis with disease-modifying anti-rheumatic drugs (DMARDs) has been shown to improve outcomes.2 Unfortunately, many patients wait several months before they can be seen by a rheumatologist for diagnosis and treatment, resulting in more suffering, joint damage and disability.
Is it fair that social or professional status allow a patient to be evaluated sooner than medically necessary at the expense of longer wait times for other patients with more urgent medical needs? The principle of justice dictates that healthcare resources should be distributed equitably among all members of society. Prioritizing access to healthcare on the basis of social standing or who you know serves to perpetuate healthcare disparities, leaving patients who are most in need more vulnerable to poorer outcomes. The American College of Physicians Ethics Manual states that a patient’s social status should not negatively affect the physician’s care of other patients.3
Although physicians may feel pressured to see VIPs for various reasons—especially for fear of the consequences if a powerful person (or their advocate) is not satisfied with the appointment offered—it is ultimately the responsibility of the physician to recognize their time as a limited, valuable healthcare resource that ought to be distributed on the basis of need. How, then, should a rheumatologist triage requests for VIP consults?
Physicians are often asked to see VIPs expeditiously for non-urgent issues. This may displace access to timely healthcare evaluation from another patient in need of more urgent medical attention.
A Way Forward
In a case such as the one described above for which there may be little benefit in a second opinion and almost certainly no need for an urgent appointment, it may be appropriate to have a discussion with the patient’s father (the hospital administrator) regarding the reasons you feel you need to see other patients more urgently than his daughter.
As a default, physicians should strive to treat the VIP like any other patient. The effects of VIP syndrome—the risk of over-testing and over-treating—are well documented.4
Several authors have explored the use of prioritization tools, such as patient questionnaires, referring physician reports and autoantibody testing, to stratify new referrals by potential urgency.5,6 Such strategies attempt to offer a more objective means of determining the potential urgency for care over a traditional first-come, first-served approach.
How do you handle requests for VIP consults? Do you have a good way to triage multiple requests for urgent patient consultation? Let us know.
Karen Stellpflug, MD, is a rheumatologist at EmergeOrtho, a multispecialty group practice in North Carolina.
References
- American College of Rheumatology. Access to care position statement. 2013 Aug.
- Monti S, Montecucco C, Bugatti S, et al. Rheumatoid arthritis treatment: The earlier the better to prevent joint damage. RMD Open. 2015 Aug 15;1(Suppl 1):e000057.
- Snyder L; American College of Physicians Ethics, Professionalism, and Human Rights Committee. Ann Intern Med. 2012 Jan 3;156:73–104.
- Farrell TW, Ozbolt JA, Silvia J, et al. Caring for colleagues, VIPs, friends, and family members. Am Fam Phys. 2013 June 1;87(11):793–795.
- Villeneuve E, Nam JL, Bell MJ, et al. A systematic literature review of strategies promoting early referral and reducing delays in the diagnosis and management of inflammatory arthritis. Ann Rheum Dis. 2013 Jan;72(1):13–22.
- Cummins LL, Vangaveti V, Roberts LJ. Rheumatoid arthritis referrals and rheumatologist scarcity: A prioritization tool. Arthritis Care Res (Hoboken). 2015 Mar;67(3):326–331.
Acknowledgment: The author would like to acknowledge the input of Robert H. Shmerling, MD who provided input and guidance in writing and editing this column.
Editor’s note: This article was written for The Rheumatologist on behalf of the ACR Committee on Ethics & Conflict of Interest. If you have comments or questions about this case, or if you have a case that you’d like to see in Ethics Forum, email us at [email protected].
