1. Background
When patients visit a hospital, they should receive care and treatment tailored to their needs, and patients with similar needs should receive similar care. Nevertheless, recommended patients have faster and better access to health services and enjoy facilities that other patients do not. Preferential treatment of patients, called VIPs, is a behavior that is common in our treatment structure. Recommended patients are individuals who receive diagnostic and therapeutic services in a different and preferential manner due to their social and professional status or that of their relatives. This phenomenon was first introduced by Weintraub in 1964. VIP syndrome describes the challenges of treating important and famous people (1). Several studies have addressed the issue of the VIP patient in terms of the type of care that the patient receives (2). VIP patients receive a lot of attention, but ultimately the path to diagnosis and treatment may not lead to the best outcome for the patient (3-5). Sometimes these patients, due to their high influence on therapists, cause the treatment process to deviate from the standard path (6). The challenges of maintaining the privacy of these patients are also among the issues that are raised (7, 8). In addition to the quality of treatment of the famous patient, the impact of famous patients on the treatment processes, therapists, and other patients is of concern.
VIP patients, in addition to being a danger to themselves, are also harmful to others. The pressure placed on nurses by these patients not only harms them but also reduces the quality of services received by other patients (9). Most nurses consider the presence of VIP patients to be a cause of reducing the services received by other patients and an injustice (10).
The presence of recommended patients causes other patients to experience longer waiting times and receive less thorough explanations, which consequently reduces their satisfaction (11). Delays in pathology reports and surgical scheduling directly affect other patients’ health and create a sense of injustice. Moreover, the added workload and pressure to hasten pathology results increase the overall likelihood of errors (12).
Providing treatment and care to patients with referrals creates additional professional stress for therapists (13). This is especially important in emergency settings and for patients with psychiatric symptoms, addictions, and high-risk behaviors, as it can prevent patients from receiving appropriate care (14-16).
2. Objectives
Some studies believe that the presence of these patients has many effects on the entire hospital that need to be controlled (17). The phenomenon of the patient on demand is noticeable in most public hospitals in the country. Hospital managers face this issue frequently. Despite the breadth and importance of the issue, newspapers have paid more attention to it and limited research has addressed this phenomenon. This study was designed to answer the question of how recommended patients in clinical departments affect the provision of services to other patients, and the treatment processes and professional interactions in the hospital. The recommended patient phenomenon has multiple dimensions, some of which are based on culture and social structures. Limited studies have been conducted based only on the opinions and lived experiences of nurses, and it is necessary to examine this phenomenon from the perspective of different professional groups.
3. Methods
3.1. Study Design
A qualitative study using an inductive content analysis approach based on Graneheim and Lundman’s method was conducted to address the question of how recommended patients affect the provision of services to other patients. Face‑to‑face semi‑structured interviews were used to obtain rich and in‑depth experiences from physicians, nurses, and hospital administrators.
3.2. Participant
In this study, participants were selected through purposive sampling with maximum variation from individuals who had direct and continuous experience of at least 5 years in providing hospital services, which provided the opportunity to meet with recommended patients. The number of participants was 14, including doctors, nurses, and hospital administrators, whose different positions allowed them to understand this phenomenon at different organizational levels. The research setting was teaching university hospitals, and the participants had professional experiences in such an environment. A demographic presentation of participants is illustrated in Table 1.
Table 1.Demographic Presentation of the Participants (N = 14) and Their Roles
| Variables | Values |
|---|---|
| Gender | |
| Male | 6 |
| Female | 8 |
| Age | |
| Mean | 43.3 |
| Min-max | 33 - 57 |
| Role | |
| Hospital administrator/surgeon | 1 |
| Hospital executive director | 2 |
| Physician | 3 |
| Matron | 2 |
| Nurse | 6 |
3.3. Data Analysis
For this study, data were collected from April to August 2022 until data saturation through semi-structured interviews. The interviews were conducted by both researchers based on the interview guide as shown in Box 1. First, the questions for each interview were sent to those who met the participation criteria, and if they wished, interviews were conducted at a time and place determined by them. The duration of the interviews was between 15′ and 45′. All interviews were audio recorded and then transcribed. The texts were read several times and each interview was considered as an analytical unit to identify the meaning unit. All stages of coding were performed independently by two researchers. As the study progressed and the number of interviews increased, the extracted codes were added, and with the ongoing comparison of the codes based on similarity, difference, and relevance, the meaning unit became more concise and dense, and this process led to information saturation and the resulting categories were finalized.
Box 1.Interview Guide for Extracting the Necessary Information About How Recommended Patients Affect Other Patients
| Interview Guide |
| 1. Who are the “recommended” patients, and what expectations do they have of you? |
| 2. What factors influence the process of patient recommendation? |
| 3. How does a recommendation affect your clinical or professional decisions? |
| 4. Which aspects of service delivery are influenced by patient recommendations? |
| 5. How does the presence of a recommended patient impact other patients, the ward atmosphere, and the staff? |
| 6. In what ways do recommended patients affect hospital processes and personnel? |
3.4. Trustworthiness
In the process of this study, we adhered to the criteria of qualitative data collection. The first researcher was involved in data collection and analysis for more than six months and this time was used to ensure the credibility and acceptability of data. We also utilized a peer check member to ensure the credibility of the results. Part of the codes obtained by the participant were reviewed to ensure the research interpretation of data. To ensure dependability, both researchers independently conducted all stages of data coding and analysis. A code-recode procedure was applied, and discrepancies were resolved through discussion and consensus.
To ensure confirmability of the results, the research process is described in detail to provide an opportunity for others to continue the research. To improve transferability, the demographic characteristics of the participants are described so that readers can decide how to use the results.
3.5. Ethical Considerations
This study was approved by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.MED.REC.1401.145). The objectives of the study, the method, and content of the interviews were explained to the participants in advance and the interviews were conducted after oral and written informed consent. The participants were assured of confidentiality and anonymity and were free to withdraw at any stage of the study.
4. Results
In this study, different dimensions of the influence of recommended patients on the therapeutic process were explored using content analysis. A total of 142 initial codes were extracted, which ultimately resulted in four categories and twelve subcategories. The categories included “The Referring Authority and Strategies of Influence” (four subcategories), “Recommended Patient Reaction” (two subcategories), “Reaction and Effect on the Treatment Process and Health Care Providers” (four subcategories), and “Reactions of Other Patients” (two subcategories), as shown in Box 2.
Box 2.How Recommended Patients Affect Other Patients: Category, Subcategory
| Categories and Subcategories |
| The referring authority and strategies of influence |
| How organizations use executive structures for patient referrals |
| Non-official patient referral structures |
| Public beliefs reinforcing referrals |
| Organizational beliefs driving referrals |
| Recommended patient reaction |
| Divergence in interactional modalities |
| Expectation of a divergent procedure |
| Reaction and effect on treatment process and health care provide |
| Resistance from the treatment structure |
| The recommended patient as an opportunity |
| Perturbation of the treatment framework |
| Ethical rejection by staff of the conditions surrounding the recommended patient |
| Reactions of other patient |
| Reaction to witnessing this injustice |
| Sense of disorganization |
4.1. The Referring Authority and Strategies of Influence
The process of patient referral often begins with a call from an organization or an influential individual. Multiple individuals contact the hospital director or president to request that their patient be given special attention. Participants stated that some of these calls come from organizations and individuals who use executive structures with socio-political power to refer patients.
“The hospital has to do the work of the governor because its work depends on them. We also have orders from the university. There are also many orders from the Deputy Health Minister and MCMC. The municipality, the governor’s office, the Friday prayer leader’s office, and the governor’s office also call”.
In some cases, orders do not end with a phone call, and serious follow-up by powerful individuals or positions continues to the extent that hospital work processes become dependent on the outcome of these orders and the condition of the referred patients.
“One of the officials was born in a certain region of the country and he/she made a lot of recommendations, and we knew we had to please his/her patients. Because if we wanted to get funding, his/her dissatisfaction would be a problem”.
Other individuals were also involved in the referral process, such as therapists or their families, famous figures, and benefactors. The amount and type of demands made by this group were often more limited and rational than those of the previous group. The results indicated that the treatment team was more willing to cooperate with these individuals. Members of the treatment team were perceived as having easier access to medical services. Health donors were also considered deserving of easier access to diagnostic and treatment services, given their contributions to the community and the health system. Veterans and their families were among those who often attempted to receive services in the shortest possible time. In other words, health care providers prioritized certain clients in the provision of health services.
When a service or product is limited in a hospital, the number of calls for orders increases. During holidays, when surgeries are less frequent, or when there are shortages of surgical equipment, medications, or specialists, competition intensifies and orders increase. Under such circumstances, services tend to be allocated to those with the most power and influence rather than to those with the greatest need.
“The day mucormycosis came, there was a shortage of medicine. A thousand people would call a day, saying, ‘Give this to our relatives, kindred, and…’”
The results indicated that in situations where hospital processes are managed under limited resources, patients should still be able to receive the services they need. However, some orders render the efforts of hospital staff ineffective. One participant stated:
“You expect that person in charge to understand more than you that patients should receive equal opportunities, but they themselves order and expect their patients to be managed differently. It’s very difficult for me as a manager…”
Participants identified public distrust of the health care system as a factor contributing to the increase in recommendations. They believed that false advertising against therapists had exacerbated this situation.
“Trust has also decreased, and the advertising against the healthcare staff, saying that they only take money, has worsened people’s trust…”
On the other hand, recommending patients is considered a supportive behavior in Iranian culture. It is not viewed as unethical but rather as a sign of philanthropy and a caring attitude.
“It has a lot to do with culture. In some areas, this is very evident; they like you to customize…”
Some patients require additional support and care. Establishing and maintaining formal support processes for patients reduces the need for ordering to achieve patient-centered care. In the absence of specific policies for patients with complex conditions, support is often provided through ordering. Part of the orders aim to facilitate or verify such care. These issues represent a limited portion of orders from external organizations.
“There was a patient who had a letter referring him/her to several officials and organizations so that the patient’s costs would be reduced.”
4.2. Recommended Patient Reaction
The results showed that the behavior and interaction of recommended patients with hospital staff differ from those of other patients. Recommending a patient changes the behavior of the patient and their companions. Their expectations are significantly higher, including expectations for new, clean, and healthy equipment, immediate availability of nurses for any request, and repeated unreasonable or unnecessary demands. Expectations to receive services immediately and to interrupt care for other patients were also reported.
“A private patient comes expecting a new bedsheet and a new blanket, but many times we don’t have these…”
Demanding behavior and lack of cooperation, even in performing the patient’s own tasks, made service provision more difficult.
“When a patient feels that someone is behind them, their behavior changes, both toward the staff and the doctor…”
If recommended patients encounter conditions that do not meet their expectations, this may lead to conflict, threats, and complaints. Participants noted that these patients complain about even minor problems, creating fear and anxiety among staff.
“I’m going to take you to court. If I let you stay in this hospital for another hour, I’ll fire you…”
In limited cases, the behavior of recommended patients was respectful and cooperative. These individuals were often affiliated with doctors, benefactors, or intellectual figures.
One frequent request of recommended patients was to be moved up on the waiting list.
“There are 500 people on the waiting list for surgery. His/her turn is a year later, but he/she expects to be seen soon…”
Expectations for different procedures were among the reasons for ordering. Requests included expedited treatment, avoiding emergency department stays, transfer to wards, use of intensive care beds, treatment by well-known physicians, assignment of skilled nurses, immediate physician presence, exclusive hoteling, single occupancy rooms, and discounted hospital bills.
4.3. Reaction and Effect on the Treatment Process and Health Care Providers
The results indicated that some orders encountered resistance. Health care providers, including nurses and physicians, objected to implementing certain orders. In such cases, they either formally objected or appeared to accept the order while continuing usual care processes, or selectively complied with some requests. In other words, recommended patients were often treated according to standard hospital procedures. The physician’s opinion and diagnosis were the most important barriers to implementing custom orders.
“It’s a tumor! I say it needs surgery. He/she says no, without surgery. I say CT; he/she says why not MRI? The doctor says the treatment is surgery. Whether you like it or not, being the son of the prophet doesn’t change anything…”
This does not mean that patient preferences were ignored, but rather that physicians did not agree to expectations that conflicted with validated protocols.
In some cases, recommended patients created opportunities to improve care structures.
“Sometimes a recommendation is actually logical. We should have provided a service and didn’t. When the patient notices this and tells us, we try to correct it for this patient and, if possible, for future patients…”
Hospital managers and directors acted as intermediaries for orders from officials and influential individuals. Communicating dozens of orders daily to clinical departments damaged managers’ credibility and undermined staff trust.
“The director cannot constantly follow up on ordered patients and then ask staff why they did this…”
Not all recommended patients required additional facilities; some primarily needed reassurance, which could be addressed through communication and empathy.
“Sometimes they’re just worried. We reassure them and tell them someone recommended you. This is comforting for the patient…”
Recommended patients created significant stress for staff. Participants stated that these patients required several times more attention than others, leading staff to prefer admitting them to wards to avoid emergencies. Strict supervision accompanying these patients increased tension and anxiety.
“During a shift, a nurse has 8 - 9 patients. A customized patient needs work like ten patients…”
Limited staff time and energy meant that excessive attention to one patient reduced care for others, leading to delays and moral distress.
“We fall behind. Because of this patient, other patients’ work gets delayed…”
Health professionals perceived patient referrals as questioning their professional competence, explaining their resistance to such practices.
4.4. Reactions of Other Patients
The presence of recommended patients affected the emotions and behaviors of other patients. Nurses often tried to conceal preferential treatment to avoid anger and protests. Although differences in patient conditions were apparent, patients and families were highly sensitive to perceived discrimination.
“Sometimes we even have to lie. If we say this is private, they will kill us!”
Patient protests sometimes escalated, crowding wards and triggering collective anger. A notable phenomenon was the contagious or domino effect, whereby other patients sought influential contacts after observing preferential treatment.
“They say we have to know someone to get our work done faster…”
Despite best efforts, recommended patients sometimes experienced complications, a phenomenon known as VIP syndrome. Participants attributed these events to tension, dissatisfaction, and hostility from other patients. Overall, the consequences of having recommended patients included feelings of dissatisfaction, disorganization, discrimination, and injustice among other patients, manifested through strong protests and anger.
5. Discussion
A limited portion of patients referred to hospitals are custom patients. The results of this study indicate that custom patients affect healthcare processes in different ways and at different levels. This study describes the impact of custom patients in a teaching hospital healthcare facility.
The results indicated that the major group of referring authority were administrative structures. This group imposes their demands on the treatment structure through relationship building or pressure and hostage-taking, and depending on the success and level of influence, they have different expectations and tone. Other studies have also shown similar patterns in healthcare settings. Powerful and influential individuals force hospitals to consider them. Influential individuals are not limited to those with important jobs and social status, but many people are simply recruited through the support of an administrative structure. This type of client has not been reported in other studies.
Some of the patients were referred by benefactors and health professionals who, according to the participants, deserve different treatment because of the services they have provided. A person who benefits the health system deserves to be treated differently (15). Providing different services to those who benefit the hospital and health structure is acceptable as long as it does not cause harm to other patients (18). Nurses and health care providers also prioritized such patients (19).
The reason why people are willing to refer their patients is their distrust of healthcare structures. False advertising about the ineffectiveness of the healthcare system has created pessimism and distrust, and in such circumstances, people are looking to refer to hospitals even for routine care (20).
The culture of referral as a supportive behavior is common, especially in some ethnicities. Other studies have also suggested that ethnicity is a factor in patient referral, which would seriously affect the equitable provision of health services. This behavior is not only prevalent at the level of the people but also at the level of health system managers, which is done by approving the provision of care to a specific ethnicity in order to support them (19, 21). Other non-Iranian studies had not mentioned this issue.
Becoming customized by a patient causes a change in his behavior towards nurses and doctors and the emergence of demanding and abusive behaviors. The amount of arguments and conflicts as well as complaints against the staff are high among these patients. If their demands are not met, they threaten the staff and proceed with insults and fights. These patients have higher expectations and unrealistic perceptions of hospital facilities and conditions (12). VIP patients often create legal problems and challenging complaints for nurses and doctors, making it even more difficult for health professionals to provide services to these patients (7, 13). Instances of this kind were observed in other studies as well; however, it appears that the scope and intensity of such interactions were more pronounced in this study.
This study elicited several specific requests from the referred patient, including being prioritized on the operating room waiting list, receiving prompt transfer to the ward, and experiencing expedited procedures within the hospital and clinic settings. In addition to these, the patient also expressed requests for enhanced hoteling services and improved facilities, as well as for greater time and attention from physicians and nursing staff. Patients who are recommended desire to receive services and facilities that are different from others and have the ability to achieve their desires by applying pressure. They use their influence to access better resources and facilities faster (9). Scientific evidence is consistent with the results of this study in this regard. This study identified a request for discounted hospital costs among the referred patients, an aspect not documented in prior research.
Health professionals may show resistance toward recommended patients, as clinical decisions are primarily based on the severity of the patient’s condition (18). In line with ethical principles, priority is always given to critically ill and emergency patients (4). Nurses and physicians do not alter diagnostic or treatment routines but interact with recommended patients more respectfully and provide additional explanations, which can enhance patient satisfaction (4, 11).
Physicians generally reject VIP patients’ requests for treatment changes and provide care identical to that of other patients, as evidence indicates that adherence to clinical guidelines is the optimal approach for managing such cases (5). It is essential to avoid unnecessary consultations, diagnostic and therapeutic services, and to implement common treatment procedures. Planning and care should be taken to avoid deviations from the treatment path in recommended patients (3).
Custom patients create a lot of pressure and stress for medical staff, which can affect their decision-making and performance. The stress placed on physicians when a custom patient is present is one of the causes of errors in medical decisions and is considered a challenge (2, 3). It is clear that stress-induced errors may also include other patients.
The study revealed that fulfilling the demands of recommended patients considerably increases nurses’ workload, sometimes requiring up to twice as much time as that spent on other patients. Consequently, the care and follow-up of other patients may be compromised, as the presence of a recommended patient can reduce both the quality and quantity of services provided to others (9, 18). This issue demands close supervision to ensure that the care of recommended patients does not diminish the services received by others. Beyond negatively influencing other patients’ health outcomes, such circumstances also generate moral distress among nurses, leading to additional strain, burnout, and reduced service capacity (17, 18). Therefore, treatment centers should regard any negative impact on the care of other patients as a strict boundary. Acceptance of a recommended patient should only occur when it does not interfere with the delivery of care to other patients (15). The findings of this study emphasize that the presence of recommended patients can affect the treatment of others, crossing this critical boundary and requiring serious attention.
In this study, it was observed that other patients perceived and expressed their dissatisfaction with disparities in the delivery of healthcare services in various ways. Feelings of discrimination, injustice, disorganization, discomfort, and ultimately anger were identified as consequences of inequities in healthcare provision. Previous research has also examined patients’ perceptions of the care provided to recommended or VIP patients, identifying such cases as a major source of perceived discrimination within the healthcare system (21). Consequently, the separation of VIP patients from others has been suggested as a beneficial strategy (11). This approach has been shown to reduce disruption and workload in emergency and treatment departments, while promoting calmness and preserving the human dignity of other patients (7). Nevertheless, challenges such as limited resources and patient congestion in triage areas make the establishment of VIP units difficult; however, the experiences of other patients and their perceptions of discrimination and injustice should not be disregarded.
The strength of this study is that with an appropriate diversity of participants, it provides a broad understanding of the phenomenon of recommended patients in the hospital. We have described the strategies through which the recommended patient enters the treatment processes and how it affects the processes within the hospital. Although a small number of patients are recommended, its impact on the structure and treatment processes is one of the issues addressed in this study.
5.1. Limitations
In some interviews, due to the political dimensions of the issues raised, it was not possible to record and transfer them to the text of the article. The patient's preferences affect the treatment process in various ways. The degree of influence and weight of different issues was not examined in this study due to the qualitative methodology and it is appropriate to examine them in other studies.
5.2. Conclusions
This qualitative study describes how recommended patients are perceived by healthcare staff to influence hospital service delivery and everyday professional practices. Participants reported that such patients are commonly introduced through administrative‑political channels, influential individuals, or internal staff networks. Within the Iranian context, factors such as resource scarcity, limited trust in the healthcare system, and a prevailing culture of patronage were perceived to intensify these dynamics.
According to participants’ accounts, recommended patients often express heightened expectations regarding the speed, quality, and cost of services. While physicians generally reported adherence to established clinical protocols, pressures associated with recommendation were perceived to shape non‑clinical aspects of care, including scheduling priorities and accommodation‑related services. These situations were described as increasing workload, ethical tension, and emotional strain among healthcare staff, potentially diverting attention from other patients.
Other patients were reported to perceive these situations as unfair or discriminatory, sometimes responding with dissatisfaction or attempts to obtain similar privileges, thereby contributing to broader tensions within the hospital environment. Overall, although recommended patients constitute a relatively small proportion of hospital admissions, participants perceived their presence as influencing staff workload, interpersonal dynamics, and the general atmosphere of care delivery.
These findings highlight the importance of transparent administrative procedures and organizational safeguards to support equity in service provision. Future research may further examine this phenomenon across different hospital settings and explore context‑specific strategies to manage recommendation‑based pressures while maintaining fairness and quality of care.
