Friday, September 16, 2011

Guest Post: VIMP

When I was a resident on ICU, the staff physician mentioned that his mother needed an ultrasound. He asked the radiologist what the waiting list was like. This was in Montreal, so the answer was something along the lines of "Bad. Who's it for?"

"My mother."

"Oh, your mother! I'll squeeze her in."

"No, that's all right. We can wait our turn like everyone else."

I felt ambivalent, hearing this story. On one hand, I support a one-tier, publicly funded medical system, which is not the majority view among my more verbal friends. On the other hand, I think that if I can assist one of my colleagues in any way, I will do it. Our health care system is so tight and this is one of the last ways we can make it more pleasant for someone ill.

This comes up in the emergency room all the time, of course. I will see a nurse's relative, for example, ahead of the waiting throng, and usually, at my hospitals, this is not such a big deal. We don't have the 14 hour waits. But one day I saw several people ahead of time and I felt uncomfortable about it.

Meanwhile, I kept trucking along until, at 19 weeks of pregnancy, I passed some blood clots.
I woke my husband up and said, "I think I'll go use the bedside ultrasound in emerg. If the baby's okay, I can still make my appointment Montreal." Bedside ultrasound takes approximately zero skill after ten weeks of pregnancy, just to check on the baby.

I felt the baby roll—or was that the beginning of a cramp? After a minute, I felt a kick. And then two more. But then I remembered more about second trimester bleeding.

I woke Matt up again. "I have to get a real ultrasound. In first trimester bleeding, you want to know if the baby is alive. But in second trimester, you have to start looking at the placenta. If it's a placenta previa or an abruptio placenta..." My bleeding was painless. Therefore more likely a previa. Ultrasound was not always diagnostic, but it would definitely help. Me sticking an ultrasound wand on top of my belly was not going to help. I couldn't tell you whether there was a bleed or not.

"You may end up on six months of bedrest," said Matt.

I waited the marginally civilized hour of 6 a.m. to call one of my hospitals. The emergency doctor, who is also my friend, said she could arrange the scan.

I walked in just over an hour later and the nurse looked at my belly and asked, "Are you still bleeding?" So the word had gotten out.

That made it easier for me. I didn't have to explain, just let her take my vitals and breathe in relief when another nurse successfully found the baby's heartbeat with the Doppler. I ended up writing my own ultrasound requisition and paging the tech, who was already with the first patient, but the next slot was free.
The emergency doctor talked to the radiologist, who agreed to call me on my cell phone with the results. And pretty much immediately afterward, the ultrasound tech was ready for me.

And the baby looked good! The placenta was less than 2 cm from the cervical os, so that probably explained the bleeding.

Before lunch, the radiologist called me and said, "The baby looks fine." He wasn't convinced that the placenta was marginal, based on the views he'd seen, but he concluded, "Good news."

This is Very Important Medical Person treatment. Scanned two hours after I called, results another two hours after that.

Is this right? Should I just meekly line up at the ER and wait my turn with the doctor? By then, it would be too late for the 7:45 a.m. open ultrasound slot, so I'd have to wait and see if a spot opened up later that day. Then I'd wait for the radiologist to read the films in order. Then I'd wait for the ER doc to get the results. I'd wait for him to tell me said results, either before or after he called the ob for an interpretation.

I know that's the "right" thing to do, in some people's books. But I don't see the medical system like that. I see it as a resource that I understand and need to maximize. So yes, I could have hung around. But then I'd be one more patient clogging up the system. In and out and we're all happier.

I'm not a star. I don't get the red carpet rolled out for me. Paparazzi don't follow me around and sell my photo for thousands of dollars. But when I need medical treatment, I have doctors and nurses who will help me get it as quickly and pleasantly as possible.

Is that wrong?

-From an e-book by Melissa Yuan-Innes "The Most Unfeeling Doctor in the World and Other True Tales From the Emergency Room."


  1. This comment has been removed by the author.

  2. I found this post to be a bit misleading. In the beginning, you give the example of a long waiting list to get an ultrasound. But as you point out much later, for an emergency, people still get pretty expeditious care. I.e. you shouldn't *have* to pull the VIMP card to get the treatment you need promptly. The first part of your post made it seem like -- at least to me -- that you'd have to wait forever for ANY kind of ultrasound, which isn't actually the case.

    Anyway, that point aside, I can completely understand using this "privilege" if you can't make it to a regular appointment because of your call schedule. In that case, I wouldn't even view it as a privilege, but something you have to do to keep yourself healthy enough to do your job.

    One question though -- why go through the ED? Why didn't you call your Ob instead? Do they not do same day emergency appointments? Do Obs automatically refer 2nd trimester bleeding to the ER? Just asking because I don't know....

  3. This just happened to me. I'm a PGY 1, and became sick at work one day with an ectopic pregnancy. My senior resident called someone over in emerg, and by the time I got there the triage paramedics said, "are you the resident?" and whisked me right in. No waiting in the waiting room. I had my scan before my bloodwork even came back, about 1 hour after I got there. On admission, I was given a private room "for privacy", even though my insurance didn't cover it. There you have it, VIMP.

    Ironically, I returned to the ER one week later with pain and bleeding, and at that time no one knew I was a resident. No special treatment then!

    I don't know how I feel about this, although it was certainly nice to feel so well cared for while sick.

  4. Yes, this is wrong. I don't think it's so wrong for a physician to be seen sooner so they can get on with their day and see their patients - but it's terribly wrong to say that you agree with socialized medicine and then give preference to other physicians' family members. Either you have a one payer system where everyone is treated equally, or you allow the market to dictate how healthcare is distributed so that everyone has a chance to buy better care for themselves.

  5. To the last anon: so, even if she actually made care marginally faster for everyone else, it's still wrong? Because that's what she did. She had an emergency and would have to be seen at the top of the list at least until the US results came back good. So none really had a longer wait because of her. If anything, the wait was shorter, because she arrived pre-worked-up, did her own paper work and off she went, as opposed to having to take up the time of the ER staff to do that. Marginal for everyone else, yes. But still: a time saving, not a time loss.

  6. I don't think this poster should get attacked for doing something that people do all the time, that is, give preferential treatment to relatives of employees. It happens in all fields, so if you work long and hard to become a physician or a nurse, you should be able to "maximize the resources" that you know inside out.

  7. I agree with Kathy. "Professional courtesy" is certainly not limited to medicine. People in all fields give preference to others in their field, others that they know, etc. Think of how many places offer a "friends and family" discount. How many lawyers do you know that don't get expeditious and seriously discounted legal counsel? There's no reason to act like it's a crime just because it's medicine. At least half of my doctors discount my copay. Just professional courtesy.

  8. I agree with Kathy, etc, too. This happens in every field. It doesn't bother me that DMV members and their family likely don't have to wait 2 hours on line to get a drivers license, so why is this different? When I was a resident nd got pregnant, an OB attending I knew told me if I was bleeding, just come right over for an US. (Never took her up on the offer, but still.)

  9. Thanks for the comments, everybody.

    @OMDG: It never even occurred to me to go through OB, I guess both because I wanted to start the ball rolling ASAP (~6 a.m.) instead of waiting for them to get back to me (starting around 8 a.m. after change of shift). Maybe that's my ER bias. I wanted to get the U/S and then talk to OB after.

    Thanks also for telling me it's a misleading beginning. I did my residency in Montreal, where it's much more of a wait for an U/S, especially an elective one, but I'm in Ontario now, so it would be more same-day service.

    @Anon #2, I agree it's a gap between my ideals (equal care for everyone) and my practice (something's wrong with my baby, get out of my way). It worked out that I didn't impede anyone else's care significantly, but it could have. It's not what I would have predicted, going into medical school, but that's how it worked out.

    @Anon #1, it does feel good to be cared for, doesn't it? And you didn't pull the resident card, they chose to do it for you, when they recognized you.

    @Snarkyscalpel, Kathy, oumedbride, Fizzy, yes, professional courtesy exists in every field. I also didn't realize this until I started practising. So is this just a fact of life we should accept, without feeling guilty?

    Thanks again!

  10. One more thing.

    Some people may think the VIMP card is okay under certain conditions, like if you have to get back to your medical duties (OMDG), or if you aren't making other patients wait (SnarkyScalpel), or maybe if it's for a family member or life-threatening circumstances.

    So when is it okay and not okay? I just think there are more shades of grey than you may first realize.

  11. All things being equal, meaning the level of urgency, it is only fair that this professional courtesy is extended. It happens in every field and I don't think medicine should be any different. If someone were more urgent that you, then of course she should be seen before you.


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