The internet last week was full of coverage of the trial of Michael Jackson's doctor and "teasers" from the new authorized biography of Steve Jobs. These were two highly talented, incredibly creative individuals with little else in common, except, perhaps, that the death of both may well have been hastened by their celebrity status. In the case of Michael Jackson the story is clear. Surrounded by enablers and "yes men" his life spiralled out of control with seemingly no one to say NO to his ever-increasing, medically dangerous requests. It is never easy to speak truth to power and when the individual in question is your incredibly famous, incredibly wealthy employer, denying their requests, medical or otherwise, requires a level of integrity that many apparently do not possess. The parallels to the life and death of billionaire recluse Howard Hughes are obvious.
Things are more nebulous with regard to Steve Jobs. For most of his illness his medical care was state of the art, but, of his own volition, he delayed treatment of his pancreatic islet cell tumor for at least nine months after diagnosis. Did this delay convert a potentially curable tumor into an uncureable one? Of course, we don't know for sure. I haven't seen his tumor and have no feeling for its growth rate or any other microscopic features. For many islet cell tumors, nine months would NOT affect prognosis, but the delay in therapy is certainly suboptimal, and we know that the final outcome was not good. Because of his stature, were his clinicians a bit less forceful in their treatment recommendations than normal? Or was Steve Jobs' own persona totally responsible for the delay? Did his business successes create a false sense of omniscience or invincibility? Who knows?
Of course you don't have to be Michael Jackson or Steve Jobs to be affected by the "special care" phenomenon. How often have you, as a pathologist, been asked to deviate from the norm in some minor or major fashion because Mr/Ms X is a VIP? These requests usually come in the form a well-meaning request to rush this or that specimen or to make sure that a specific pathologist signs out the case because the person in question is a VIP. I've also been asked by residents if the grossing of a specimen should be handled in some way differently if a patient is a VIP. As an example, I was once asked if a prostate from a VIP with BPH should be entirely embedded and sectioned in levels, "to be certain that we didn't miss any carcinoma." My response was that, "If there were a BETTER way to treat a specimen than our normal procedures, wouldn't it be unethical NOT to treat ALL specimens that way?" And conversely, if our normal way is best then isn't any deviation from normal less than best?
What does seem clear is that special care is often sub-standard care even though it attempts to be just the opposite. When the VIP shows up in the emergency room with an upper GI bleed, the best person to perform the endoscopy is the person normally on call for this procedure who does lots of them routinely, not the chair of surgery or someone less familiar with the procedure who happens to be of higher academic stature but possessing lesser up-to-date skills.
Consider the autopsy of President John F. Kennedy. Instead of allowing the Dallas medical examiner to perform the procedure, the normal approach for every other forensic case at Parkland Hospital, special military personnel were brought from Washington in to handle the "ultimate VIP," and the result was a highly botched procedure leaving forever unanswered questions.
There are many other examples of "people of stature" getting special treatment that turned out to be worse than the normal routes of care. Many VIP's check into hospitals under pseudonyms to protect their identities from prying eyes. Maybe they need pseudonyms (and disguises) to protect themselves from those trying to give them special treatment! OK, that wouldn't really work, but at the very least they should strongly consider telling their clinicians that, "I want the same high quality care that you give everyone else, nothing special."