Ethics Forum: Ethical Challenges Arise for Rheumatologists Pressed to See Patients of High Social, Professional Standing Before Others

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The Case

You’re working in a busy rheumatology practice with wait times of two to three months for new outpatient consultations. A hospital administrator requests that his daughter see you right away. All but one of your urgent appointment slots for the week is already filled, and there are several patients on a waitlist; these patients’ primary care physicians have also requested urgent appointments for suspected new-onset inflammatory arthritis. Your typical scheduling protocol would be to place one of the patients already on the waitlist into the single open appointment.

Upon review of the medical records of the administrator’s daughter, you note that she has actually been seen within the past year by another rheumatologist. A thorough history and physical examination are documented and extensive serologic and imaging studies were performed. A diagnosis was established, and the patient was provided with appropriate recommendations; she is now seeking a second opinion.

The Dilemma

Do you see this VIP (Very Important Patient) right away? Or do you see one or more of the truly urgent patients instead? Should you even put the administrator’s daughter on the urgent patient waitlist or ask that the VIP wait for the next open new patient appointment? Would your answer be different if the VIP had a more legitimately urgent need, but no more urgent than others on the waitlist ahead of her?

Discussion

VIPs are often political figures, celebrities, friends or family members of executives or healthcare providers. They may know you personally, or they may have ties to your employer, such as wealthy donors or members of the hospital board; often, they are wealthy, well connected and feel entitled to prompt access to your services. Physicians are often asked to see VIPs expeditiously for non-urgent issues. This may displace access to timely healthcare evaluation from another patient in need of more urgent medical attention.

Dr. Stellpflug

In many areas of the U.S., there is a shortage of rheumatologists. This commonly leads to delays in access to expert rheumatologic care, delayed diagnosis and poorer outcomes.¹ Early, aggressive treatment of inflammatory arthritis with disease-modifying anti-rheumatic drugs (DMARDs) has been shown to improve outcomes.² Unfortunately, many patients wait several months before they can be seen by a rheumatologist for diagnosis and treatment, resulting in more suffering, joint damage and disability.

Is it fair that social or professional status allow a patient to be evaluated sooner than medically necessary at the expense of longer wait times for other patients with more urgent medical needs? The principle of justice dictates that healthcare resources should be distributed equitably among all members of society. Prioritizing access to healthcare on the basis of social standing or who you know serves to perpetuate healthcare disparities, leaving patients who are most in need more vulnerable to poorer outcomes. The American College of Physicians Ethics Manual states that a patient’s social status should not negatively affect the physician’s care of other patients.³