Elizabeth McIlduff Georges, MD, is a 2011 graduate of the Psychiatry Residency Program at Northwestern University, Department of Psychiatry and Behavioral Sciences; she is currently in private practice in Chicago. Joan M. Anzia, MD, is the Vice Chair for Education and Residency Program Director at Northwestern University, Department of Psychiatry and Behavioral Sciences. Stephen H. Dinwiddie, MD, is Professor of Psychiatry and Director of the Division of Forensic Psychiatry at Northwestern University, Department of Psychiatry and Behavioral Sciences, Chicago, IL.
Drs. Georges, Anzia, and Dinwiddie have disclosed no relevant financial relationships.
Address correspondence to: Joan M. Anzia, MD, via fax: 312-926-7612; or email: email@example.com.
The term VIP, very important person, is often attributed to Winston Churchill, although its use may in fact slightly predate his era. The term first entered the psychiatric literature in 1964, when Weintraub described problems he had witnessed during the care of prominent patients.1
Focusing on 12 patients who had been hospitalized in his university’s inpatient setting, he described three elements inherent to “VIP syndrome”: The admission of an “important patient” to a medical institution; the patient’s great need (or the need on behalf of a caregiver, family member, or referring physician) to be treated as “special”; and differential influence by hospital administrators or administrative procedures on the patient’s care.1
One of the central features of the VIP syndrome is that numerous parties become involved at inappropriate levels. Multiple agendas can operate at cross-purposes, often to the detriment of the patient, resulting in adverse psychological impact on staff due to perceived or actual pressure from superiors.
Provision of what should be routine care can be undermined by the effect of a “media circus,” and clinical decision-making subordinated to political and financial considerations operating at the institutional level.
The paradox in such situations is that, although the goal is to provide exceptional care, in fact any deviation from “standard” care can be dangerous: Important diagnostic procedures can be neglected out of deference to the individual’s status and fear of causing inconvenience (or insult); usual care paths can be unthinkingly altered; or, excessive and unnecessary diagnostic procedures performed because of heightened anxiety on the part of the clinician.2 The result can be missed diagnoses, iatrogenic complications, and profound harm.
Commenting on one type of the VIP patient (general officers in the military), one military physician noted:
“It is often assumed by most military and civilians that flag-ranking officers, and their families, enjoy privileged health care ... As an experienced physician in charge of a Major Command’s Executive Health Program, the author’s experience is far from that perceived and assumed. In fact, quite the opposite prevails … The result is less-than-optimal health care delivery ... In some instances, [care is] inferior to that provided to the lowest ranking individual in the service … ”3
By virtue of training and having an awareness of the issues involved, psychiatrists may play a prominent role in identifying, and preventing the development of VIP syndrome.
Presentation of VIP Patients
The VIP in the medical setting has been defined as “anyone whose presence in the hospital, by virtue of fame, position, or claim on the public interest, may substantially disrupt the normal course of patient care.”4 The recognition of the patient as a VIP can start in one of several ways. If the situation requires emergency care, the hospital CEO may call the emergency department (ED) and inform them of the patient’s imminent arrival; a department chairman may appear at the intake/triage desk; or another staff member may recognize the patient as a VIP.
The VIP may present to the hospital under other circumstances, of course; but once the patient is recognized (and accepted) as special, the series of events and interactions constituting the VIP syndrome begins.
However, the basis for the patient’s status as somehow special may influence care in different ways. Groves has suggested such patients may be classed in one of three groups: celebrities; potentates, ie, the well-known, the well-connected, and the very well-off; or “very impressive” VIPs.5
The Celebrity VIP
Celebrity is not easily defined — celebrity patients may include actors, authors, political figures, well-known athletes, or even “negative celebrities” (for example, criminals who have received much media attention). What they have in common is that these are people who live their lives in the public eye and attract media attention, and who can focus that media attention and scrutiny on the private world of caregivers.
The celebrity patient may be the least common but most potent trigger of the VIP syndrome. Unfortunately, psychiatrists are not immune to the “star-struck” phenomenon:6 after all, physicians spend most of their workday in tasks that demand altruism and denial of any special recognition of their work; psychiatrists even more than other specialists are barred from sharing most of their accomplishments with their significant others and close friends, so the excitement and secondary prestige of treating a well-known celebrity patient can be narcissistically stimulating.
It can be very tempting to divulge the identity of one’s special patient, despite the Hippocratic Oath and federal privacy laws, in order to gain the admiration and respect of family, friends, and colleagues. In today’s culture, celebrity is often a goal in itself, and with the ubiquity of social media access and cell phones — even in EDs and other critical care settings — the temptation to leak the news of a celebrity’s patient status can be powerful.
Less-than-ethical media outlets can encourage this violation of privacy by offering financial inducement to the health care provider. There are abundant recent news stories in which physicians of VIP patients have become news celebrities in their own right: facing news cameras on national programs for days and even weeks; however, being under the microscope of media, political powers, and large institutions can be both exciting and frightening, and has the potential to adversely influence clinical decision-making.
In addition to the excitement of acquired prestige, treatment of the VIP patient can stimulate significant envy and resentment in the treating clinician, who normally must assume a “behind-the-scenes” role, and who must often take responsibility for decisions that are not welcomed by the patient, his/her family and entourage. It is very difficult for a physician to witness a patient receiving special advantages, attentions, and accommodations while he or she must behave altruistically and perform the task of caring for the patient and maintaining appropriate clinical boundaries and ethical standards.
The next group (the “potentates”) may not be as well-known but often wield greater power, albeit perhaps in a smaller ambit. Included in this class would be the extremely wealthy, particularly those who have financially supported the institution; the defining characteristic of this group is the ability to convince the institution that they need and deserve to be treated with a great deal of deference. This may be accomplished by subtle (or not-so-subtle) hints of impact on future fund-raising, by reference to connections with the local power structure, or simply by threats of adverse publicity or legal consequences.
Another subset within this group are those who, by virtue of achievement or recognition, even if only (or mostly) within the institution, provoke a certain sense of trepidation among caregivers. This group might include a well-known attending physician at the hospital (or that physician’s family member) or a high-ranking officer at a military hospital.
In the case of the potentate, the demanding behavior can be a manifestation of dependent, but grandiose, feelings on the part of individuals who see themselves as special and deserving of special treatment.7 They tend to present in the midst of an urgent personal crisis, wanting immediate relief, and generally are not compliant with treatment. They may behave in an entitled, demanding manner, and seem to believe that any consideration they receive will come only as a result of their influence with powers other than the clinical staff, such as hospital leadership or a local politician.
Such behavior is difficult; but it is commonplace in psychiatric training and the feelings evoked (anger and resentment at least, not to mention a vast array of other countertransferential issues that may vary from trainee to trainee) can and should be dealt with in supervision during residency. What makes the potentate so difficult is that the stakes are higher: Administrators may quail before the potentate’s demands and undercut any efforts at limit-setting, and threaten, covertly or otherwise, the psychiatrist’s position.
Alternatively, the clinician may fall prey to fantasies of rescue, this time of the institution rather than just the patient, or may ally with administration rather than care staff who must deal hour-by-hour with the patient’s demanding behavior.
Thus, common clinician responses are frustration, anger, and conscious (as well as unconscious) withdrawal. If the clinician is not aware of his/her negative feelings about the patient, he or she may use defenses such as reaction formation (eg, become overly solicitous of the patient’s demands) or passive aggression (eg, neglect to write orders for analgesics). The clinician may attempt to transfer the case to another clinician or team; become overly punitive with the patient or his/her family and associates; discharge the patient prematurely; or fail to hospitalize a patient who needs inpatient care. The constant clinical challenge with an imperious VIP is to contain negative countertransference, respond with a balanced approach to their demands, and maintain primary focus on diagnostic and treatment concerns.
The “Impressive” VIP
Another type of VIP, the “very impressive person,”6 presents a different set of challenges to the treating or consulting psychiatrist. These individuals are generally respectful of clinical staff, psychologically astute, and adhere to appropriate boundaries; their behavior will not stimulate anger, resentment and withdrawal in the treating clinicians and clinical staff, as with the potentate. However, the presence of a “very impressive person” may generate apprehension in clinicians — fear that his or her skills may not be adequate, that he or she will not be seen as “competent enough” — leading to the sort of second-guessing and under- or over-treating that can lead to less than (or more than) standard care.
It has been suggested that much preferential treatment of VIPs “originates from the desire to be ‘smiled upon’” and that many providers hope that the VIP will later acknowledge their efforts.4 This is powerful enough even for a seasoned clinician. For a trainee, the motivation for recognition and respect can be even greater — the resident has incentives of future employment, awards, and promotions that could be enhanced by the favor of a celebrity, VIP, or wealthy donor. And the worries, of course, are correspondingly stronger as well, for there is always the fear that any blame for a bad outcome (or even a good outcome but a dissatisfied patient) will roll downhill.
Effect on the System
Many VIPs will legitimately need some accommodations to protect their privacy. Clinical leaders must balance the increased need for privacy while ensuring the appropriate standard of care for the patient. Achieving this balance can be difficult under the best of circumstances; it may lead to necessary but burdensome changes in the day-today operation of the hospital unit.
The situation is worsened when clinically unnecessary accommodations are demanded. It is perhaps the imperious VIP who most often triggers the system dysfunction that Weintraub1 first identified: “An upward transfer of authority within the hospital hierarchy for the purpose of creating special conditions for the [VIP] patient.” The VIP appeals to high-level administrators to request special accommodations; the administrators hear and respond (often without intimate knowledge of the effect of such demands on unit function) to the requests of the VIP because hospitals cannot function without financial, political, and public relations support.
As a result, the VIP who behaves in a condescending, threatening, and grandiose manner may alienate care providers, and “isolation of the patient leads to a vicious circle of increased demands and further staff withdrawal.” The patients then “manipulate their relatives and friends into bombarding all levels of the hospital hierarchy with complaints about the quality of treatment,” often leading to therapeutic impasse.1
There are multiple sources of tension between the clinician and administration during the care of the VIP. Providers’ top goals include “achieving excellent treatment for one’s patient, advancing knowledge, and improving medical training,”7 whereas administrators’ top goals are ensuring and increasing financial support for the institution, and engendering a positive public image for it. When administrative and clinical goals are in conflict, extraordinary tension can develop, adversely impacting the VIP’s care. Front-line care staff, in particular, may be subjected to intense and profoundly conflicting directives.
Because many VIPs possess power or access to the media, staff may be motivated by fear of the consequences of failing to comply with the requests made on them by administrators, the VIP, or other staff, surrounding the visit and treatment of the VIP. Care of celebrities is often closely scrutinized, and, again, clinicians may fear being blamed for a poor outcome.
Additionally, the clinician may be expected to provide (and demonstrate he or she is providing) excellent care while fielding questions and demands from hospital administrators, the hospital development office, public relations department, and many others external to the situation. From the first clinical contact, VIPs can contact any external power-broker from his or her waiting area or exam room, often prompting the arrival of a number of these individuals in the ED or the inpatient unit (the authors have witnessed VIPs text-messaging or “tweeting” about their experience from the critical care environment).
The addition of all of these extra people (either in person or by phone) attempting to influence the clinician’s decisions generates an atmosphere of confusion and turmoil at best, and potentially an outright power struggle for control of the VIP’s situation.
Some of the “external” individuals weighing in on the process have the potential power to influence the physician’s job status and career/training. It is extremely difficult in such situations to perform one’s best as a physician and to promote the best standard of diagnosis and care for the patient. Nonetheless, whether he or she becomes involved in the care of the VIP as the primary attending or as a consultant, by reason of training and experience the psychiatrist may be the clinician best-suited to recognize the nascent VIP syndrome and intervene early.
Defusing VIP Syndrome
Regardless of the type of VIP, clinicians face numerous challenges in caring for the VIP patient, including a host of personal thoughts and feelings about the patient (which may be both pre-existing and stimulated by interactions with the individual), the responses of the other members of the treatment team, and often difficult negotiations with the patient’s family, friends, associates, and members of hospital administration.
When such situations arise, it behooves the psychiatrist to first take a moment to reflect on what pressures are felt internally and what feelings are evoked. Consultation with a trusted colleague not involved in the situation, even briefly and informally, can provide a “reality check” and allow a more measured assessment of the primary objective: providing optimal patient care. Even if acting in a consulting capacity, the psychiatrist may have a role in ensuring that all members of the clinical treatment team share an understanding of their various roles and responsibilities. It can be of great benefit to allow team members to openly acknowledge their feelings; a meeting to coordinate efforts can also be used to defuse hostility or frustration that might otherwise undermine care.
Of equal importance is recognizing and dealing with forces external to the clinical situation. Given the pressures that can exist, it is crucial that the clinician (whether resident, junior attending, or seasoned faculty member) have the explicit support of the department chair and/or director of clinical services. Lines of clinical authority should be clarified so that well-intended but clinically inappropriate suggestions or directives from administrative figures do not undercut care, and the clinician must be ready to firmly address such incursions should they occur.
At the same time, the psychiatrist must be aware that some deviation from usual care may be appropriate. Although the patient’s privacy should be protected, under some circumstances higher-ups in the hospital administration may need to be informed of significant clinical decisions or changes in status, particularly in the case of the celebrity. In this regard, it is useful to identify one contact person within the hospital administration (likely a public relations professional) who in turn may work with the patient’s publicist or other associate to appropriately manage any public sharing of information.
Train Residents in VIP Care
How to best manage such circumstances is far from intuitive, and learning to do so only after the situation has arisen can be disastrous. Thus, residents should be instructed to involve department or clinical services leadership early in any VIP situation. In addition, it may be useful for psychiatry residents and new faculty members to have some education early in training about the special challenges of working with VIP patients: basic principles and processes to follow, as well as inoculation to some of the common transference and countertransference dilemmas. Residents should learn about special accommodations for VIP privacy, as well as the need for careful attention to confidentiality and boundaries. Trainees can practice VIP interactions in “ethics in context” seminars, using vignettes and role-playing.
Clinician leaders must have training to negotiate the treatment of “special patients” and strong support from their department chairs and directors of clinical services throughout the course of treatment. The clinical director must deal directly with the patient, his or her treatment team, and the hospital administration. The clinical director must also protect his or her treatment team from being intimidated by either the VIP or administration, and enable them to do their work well.
Most experts agree that the clinical team should meet very early during a VIP treatment course to explain the purpose of any accommodations (which should be in the interest of the patient’s treatment) and to clarify roles and boundaries. In addition, the clinical director should keep designated members of the hospital administration appraised of the course of the patient’s care.
- Weintraub W. “The VIP Syndrome”: A Clinical Study in Hospital Psychiatry. J Nerv Ment Dis. 1964;138:181–193. doi:10.1097/00005053-196402000-00012 [CrossRef]
- Block AJ. Beware of the VIP syndrome. Chest. 1993;104(4):989. doi:10.1378/chest.104.4.989b [CrossRef]
- Simpson CG. Executive Health Care in the Air Force. 1998. Paper presented to the Air War College, Air University, USAF. . Available at: www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA397186&Location=U2&doc=GetTRDoc.pdf. Accessed Jan. 3, 2012.
- Diekema DS. The preferential treatment of VIPs in the emergency department. Am J Emerg Med. 1996;14(2):226–229. doi:10.1016/S0735-6757(96)90137-0 [CrossRef]
- Groves JE, Dunderdale BA, Stern TA. Celebrity patients, VIPs, and potentates. Prim Care Companion J Clin Psychiatry. 2002;4(6):215–223. doi:10.4088/PCC.v04n0602 [CrossRef]
- Schenkenberg T, Kochenour NK, Botkin JR. Ethical considerations in clinical care of the “VIP.”J Clin Ethics. 2007;18(1):56–63.
- Parker G. Should a psychiatrist give the ‘special patient’ VIP treatment?Acta Psychiatr Scand. 2009;120(6):411–413. doi:10.1111/j.1600-0447.2009.01497.x [CrossRef]