In the two weeks since Michael Jackson died, I've been asked many times whether I think he received proper medical care. I've punted the question because we don't have enough information and I hate to speculate. We're still awaiting the toxicology report and we have few details about his underlying health issues, medications, and the events leading up to his death. But I have offered the following thought: you would be amazed at the potential for VIPs to get lousy care.
While it's true that VIPs often get excellent medical care, with rapid access to top physicians and state of the art testing, they also are in danger of throwing doctors off their game. Derek Jeter of the New York Yankees goes through a ritual with every at bat. Change the ritual and he might be batting two hundred. Doctors go through a type of ritual too. We're trained to do an evaluation in a particular order: take a history, do a complete exam, think carefully about the clinical picture and then make recommendations. If a patient's status changes the way a doctor gathers information or thinks, the results can be deadly.
I understand that if you're one of the fifty million uninsured Americans, you may have little interest in the health care problems of VIPs. But you don't have to be rich and famous -- or even insured -- to get the same bad medical care that VIPs can get. You just have to have the wrong attitude and the wrong doctor. Here is my top five list of ways I've seen VIPs and doctors set themselves up for trouble:
1) There's no captain of the ship.
This is a fatal flaw. There has to be one person who knows the big picture and coordinates care. Wanting to remain in control and fearing the loss of privacy, a VIP may have multiple doctors who don't even know about each other. The physician is left trying to put together a puzzle without all the pieces. This is especially worrisome when medications are prescribed by doctors who are unaware of the patient's full medication list; drug interactions can be dangerous and even lethal.
2) The doctor is afraid to bother or upset the patient.
The doctor-patient relationship is a partnership that requires mutual respect and straightforward communication. It can be very tough to confront a patient with certain problems -- for example, drug or alcohol abuse. But you don't change the criteria for making a diagnosis because a patient is a VIP. And you never let a patient pressure you into prescribing an inappropriate medication, whether it's an antibiotic or a narcotic.
3) The doctor allows the patient to duck a crucial part of the evaluation.
I once had a patient with rectal bleeding try to talk me out of doing a rectal exam, to which I replied what I was taught in medical school, "There are only two reasons for not doing a rectal exam on a patient with gastrointestinal bleeding: no finger, no rectum." A test or a part of the physical exam may be uncomfortable for the patient but also lifesaving.
4) The patient's philosophy is "I can afford it. Let's do every test in the book."
There are downsides to excessive testing, including body scans that not only expose patients to radiation but can lead to unnecessary biopsies and other potentially dangerous procedures for what turn out to be benign findings (what doctors call "incidentalomas"). And patients may ask for or even demand new tests such as genetic profiling that we're not yet sure how to interpret. More is not always better.
5) The doctor or patient wants to operate in a vacuum.
Good thinking welcomes an audience. In a teaching institution, it may be the third year medical student who asks the crucial question that everybody else is too afraid to ask. A good doctor never shies away from asking a colleague for help.
For this week's episode of CBS Doc Dot Com, I interview an expert on the health care of celebrities. Dr. Barron Lerner, Professor of Medicine and Public Health at Columbia University Medical Center, is the author of When Illness Goes Public: Celebrity Patients and How We Look at Medicine.