Joan Rivers, actress, comedy icon and a devotee of plastic surgery, died earlier this month. She was 81-year old. She went in for a ‘routine’ procedure to a well established clinic. During the procedure, she suffered a cardiac arrest and never recovered, dying after a few days. Exact reason for what happened is not known. So far there is no evidence of any wrongdoing involving the care she received while at the clinic.

In a recent article "The Famous Can Present a Minefield for Doctors" by Anemona Hartocollis published in The New York Times on September 21, 2014, the author suggests that Joan River’s ‘treatment seen a possible example of ‘V.I.P.’ syndrome’.

Yes there is a VIP syndrome in medicine, not a disease but rather how VIPs can sometimes end up not doing well because they can influence the type and ‘amount’ of medical treatments they might want for themselves.

Of course before VIPs can get away with things, they do need compliant physicians who are willing to prescribe medications or perform procedures, usually plastic surgery but also other types that the VIP patients don’t really need but insist on having.

Perhaps the worst example of this sort of a relationship is that of Michael Jackson (the King of Pop) and his personal physician. Jackson died from an overdose of medicines prescribed by his personal physician who was later on accused of ‘involuntary manslaughter’.

Such situations are really a misuse of the doctor-patient relationship that occurs quite often between the very rich and famous and their doctors. But these ‘improper’ relationships between doctors and their patients are not what is usually meant by the VIP syndrome.

Before I go on with the discussion about the VIP syndrome, I do want to make a point about what happened to Joan Rivers.

She was more than 80 years old, albeit apparently in good health otherwise. Often healthy looking elderly patients are treated the same way as those that are much younger and the patients also want to be treated as such. But the problem is that the elderly do not always behave as doctors expect younger patients to behave both in response to different medicines as well as things like anaesthesia and even minor operations.

However, it is important to point out that in serious medical problems where treatment can not only prolong life but also improve the quality of life, advanced age though a consideration does not mean that such patients should be denied appropriate treatments. During my practice as a cardiac surgeon, I have often performed heart operations on patients in their eighties but only after making both the patients and their families aware of the fact that age does increase the risk from even so called routine procedures.

Over the years medical care has become much better and there are some physicians, especially surgeons and medical ‘interventionists’, that actually believe that advanced age by itself does not pose a reason to deny patients any treatment that is available to younger patients. That is a discussion for another day.

Now to the real problems of taking care of VIPs.

Many years ago I was asked by a cardiologist friend if I wanted to perform a heart bypass operation on a well-known Pakistani ‘entertainer’. I declined ostensibly for the reason that even if there was only a small risk that things could go wrong during the operation but there was always a risk and as such if the entertainer in question did not survive, I would go down in Pakistani history as the surgeon that did her in.

The real consideration in my opinion was that if I accepted the entertainer as a patient, knowing that I was a Pakistani, I would be taken advantage of by the ‘entourage’ of that patient. The entire family and friends would descend upon the hospital and camp out in the waiting areas and expect to be with the patient even immediately after her surgery thus interfering in the normal care of the patient. This would also create a generally unpleasant environment for other patients and their families. The entertainer went down south and had her operation performed by a famous heart surgeon and did well. More importantly the number of visitors allowed and visiting hours were strictly enforced.

Personally, I have always avoided taking care of VIPs but there are surgeons as well as physicians that look forward to such opportunities.

In Pakistan where the VIP culture is the bedrock of our society, relationships with VIPs serves many purposes especially bringing ‘fame and fortune’ for the physicians that take care of such patients. Interestingly, taking care of other physicians also falls into a similar category of increased risk as is taking care of VIPs.

The question then is why the increased risk to VIPs and such during procedures.

Most people will presume that VIPs will receive the best possible treatment available and that the surgeons especially will do their best and perform the ‘perfect’ operation. But then there is an old surgical aphorism that states ‘best is the enemy of good’. What that means is that when trying to do the ‘best’ operation or procedure possible, physicians might go a step too far and end up with unforeseen complications. Simply stated, what it means is that doing more than what is necessary can become a problem. And that perhaps is the basic reason for the VIP syndrome.

In the Pakistani context, taking care of VIPs has some unique problems.

First is the one I alluded to above when talking of the famous entertainer that needed an operation while she was in the United States. Pakistani VIPs always move around with an entourage even when they are in a hospital. If being treated in a ‘local’ hospital, armed gunmen lurk around in the corridors and a large number of family and friends descend on the hospital. Besides this close family members insist on being present even in the intensive care units (ICUs) thus interfering with and restricting the ability of the medical and nursing staff from taking proper care of the patient especially in an emergency situation.

Also, multiple visitors immediately after a major operation pose a health hazard for the patient. A common cold caught from a visiting family member can become a serious problem for a patient recovering from a major operation. Besides this, most VIP patients are used to carrying a ‘poly pharmacy’ with them. This means a multitude of medicines they take whenever they feel like it and this includes anti-anxiety pills, sleeping pills, stimulants and other such stuff. So, often these patients will take these un-prescribed medicines whenever they want in the immediate recovery phase. This can become a problem because of interactions with medicines that they might be receiving on their doctor’s orders.

Realising all of the above problems, my advice to all my VIP type friends is that if anybody in your immediate family needs any major operation even if it can be done well enough in Pakistan, take them abroad. The unsaid suggestion being, take them somewhere where they will not be treated as VIPs.