VIP Syndrome and DPC
Physicians are warned against treating themselves, their family members, and their close friends and romantic partners since they may not be able to remain objective. In Direct Primary Care, or DPC, we develop close relationships with our patients, and some of us have advertised “It’s like having a doctor in the family.” As DPC doctors, are we at risk of losing our objectivity and giving our patients the treatment they want rather than the treatment they need?
Many physicians who are employed under the insurance model believe that accepting cash payments for medical services is unethical and will inevitably lead to inappropriate care. However, it’s actually the insurance model which incentivizes overtreatment through fear of liability and desire to obtain high patient satisfaction scores, which can affect physician reimbursement and job security. Independent self-employed DPC physicians have more autonomy and the ability to set their own rules and boundaries, so this model makes it easier to treat patients appropriately and ethically. However, DPC physicians may feel pressured to treat their patients as VIPs, especially with a new DPC practice which is not yet profitable.
VIP Syndrome is a phenomenon whereby patients with high status receive preferential treatment, and deviations from usual standard of care result in paradoxically worse outcomes. The most famous example of VIP Syndrome is Michael Jackson, whose death was caused by his concierge physician administering the anesthetic propofol to treat his insomnia. Numerous other famous performers have died of prescription drug overdoses and can attribute their deaths to a combination of addiction and VIP Syndrome. The CEO of a hospital may be allowed to break the rules, such as eating before surgery or smoking in the hospital. A starstruck physician may be too embarrassed to broach topics such as substance use and sexual history or to recommend positive lifestyle changes or screening tests like a colonoscopy to a Hollywood actor.
When physicians become patients, they often experience VIP Syndrome as other physicians allow them to guide their own care, expecting them to make their own diagnoses and treatment plans. Physicians may feel like the usual patient consent and education insults the intelligence of their physician patients, so they skip over these conversations as a sign of respect. In some states, seeking treatment for a mental health condition or substance abuse can put a physician’s license at risk, which may lead to one or both parties avoiding these topics altogether. Physician patients may feel like the rules do not apply to them, and they can struggle with boundaries when their physician caregivers are also colleagues and friends.
Are DPC patients at risk of VIP Syndrome? It depends. Most DPC memberships cost far less than a typical health insurance premium and are affordable for most patients. However, some DPC practices charge concierge prices, and these practices would be at a higher risk of VIP Syndrome, especially if a physician could not afford to lose an unhappy patient. DPC practices who cater to large employers may also be at risk of VIP Syndrome, especially if they fear loss of an entire company. DPC often attracts patients with high levels of health anxiety, and easy access to affordable labs and imaging can lead to unnecessary testing, which begets additional testing for the assessment of incidentalomas, further increasing health anxiety and increasing costs for the patient. Finally, DPC practices that offer additional cash services must be vigilant about prioritizing patient wellbeing over profit motive, especially if these services require expensive equipment, increasing overhead costs which need to be recouped.
Advantages of DPC include easy communication and scheduling with longer appointments, which allows for thorough evaluations, as well as early assessments, which increases the probability of prompt and accurate diagnosis and treatment, thus decreasing morbidity and mortality. Another advantage of DPC is continuity of care with a physician who knows each patient’s health history well, rather than fragmented care by a revolving door of variably-trained practitioners in a primary care clinic for “one problem only” appointments interspersed with urgent care visits. Since becoming a DPC doctor, I have diagnosed multiple patients with “rare” conditions such as Ehlers Danlos Syndrome and Hereditary Hemochromatosis, which I never diagnosed during my years in an insurance-based primary care practice, despite caring for thousands of patients during that timeframe. I also have time to discuss the advantages and disadvantages of various diagnostic and treatment options, including their cost, so that patients can make informed decisions about their care. My current patients are not interested in taking antibiotics when they have a viral infection or getting an MRI for muscular back pain because they have been educated, and they know that I will be there for them if their symptoms change. They no longer experience insurance-based FOMO, with the urge to binge on prescriptions, imaging and referrals after waiting months for a primary care visit or hours in an urgent care waiting room. In this way, DPC patients are less likely to overutilize medical care and their costs are much lower.
As long as DPC physicians are aware of the risks of VIP Syndrome, it can be prevented through careful consideration of both medical and business practices. I believe that DPC is the most ethical, cost-effective, and compassionate way to practice medicine, which allows physicians to abide by the Hippocratic Oath while delivering the very best care to their patients.
That advice was true for a run of the mill practice in the old days with just a few exceptions.
This is a wonderful article and well timed! Thank you for addressing something we can sometimes encounter. This is really great!