Psychiatric Annals

CME Article 

Consultation-Liaison Psychiatry for the VIP Patient

Michael Marcangelo, MD

Abstract

Psychiatrists who work as consultants in the general hospital evaluate and treat a wide variety of patients who often demonstrate a much broader range of complaints and behaviors than is typically seen on an inpatient unit or in an outpatient clinic. Inpatient admission is generally prompted by a fairly limited range of psychiatric symptoms, such as suicidal ideation and psychosis. Outpatient visits, however, may be for treatment of less severe depressive disorders, or for psychotherapy for interpersonal difficulties. People with the full range of personality traits and psychopathology are admitted to the general medical hospital, and they may require psychiatric consults.

Abstract

Psychiatrists who work as consultants in the general hospital evaluate and treat a wide variety of patients who often demonstrate a much broader range of complaints and behaviors than is typically seen on an inpatient unit or in an outpatient clinic. Inpatient admission is generally prompted by a fairly limited range of psychiatric symptoms, such as suicidal ideation and psychosis. Outpatient visits, however, may be for treatment of less severe depressive disorders, or for psychotherapy for interpersonal difficulties. People with the full range of personality traits and psychopathology are admitted to the general medical hospital, and they may require psychiatric consults.

Michael Marcangelo, MD, is Director of Medical Student Education; and Assistant Professor, Department of Psychiatry and Behavioral Neuroscience, University of Chicago Medical Center, Chicago, IL.

Dr. Marcangelo has disclosed no relevant financial relationships.

Address correspondence to: Michael Marcangelo, MD; fax: 773-702-4297; email: mmarcang@yoda.bsd.uchicago.edu.

Psychiatrists who work as consultants in the general hospital evaluate and treat a wide variety of patients who often demonstrate a much broader range of complaints and behaviors than is typically seen on an inpatient unit or in an outpatient clinic. Inpatient admission is generally prompted by a fairly limited range of psychiatric symptoms, such as suicidal ideation and psychosis. Outpatient visits, however, may be for treatment of less severe depressive disorders, or for psychotherapy for interpersonal difficulties. People with the full range of personality traits and psychopathology are admitted to the general medical hospital, and they may require psychiatric consults.

Psychosomatic subspecialty training prepares the psychiatrist to work with patients who are unaccustomed to seeking mental health services, but even the experienced clinician encounters patients who are hostile to psychiatry, extremely unpsychologically minded, or unaware of how psychiatric treatments work. One group of patients that in particular may present problems on a consultation-liaison service is the VIP patient. In this paper, we review who these patients are, why they present difficulties for medical and nursing staff as well as the psychiatrist, and strategies for providing them the best care possible.

The Demanding Patient

Patients assert their VIP status through a few different avenues. Perhaps the most common and problematic of these patients are the ones who define themselves as VIPs. Often, they present as demanding, entitled, and haughty.

Psychiatrists are often called upon to assist with such patients when their demands impinge on the provision of care. Before evaluating the patient, it is helpful for the consulting psychiatrist to discuss the situation in detail with the referring physician to ensure that there is a clear understanding of the reason for the evaluation. A request such as “This patient is difficult and I need help,” is too vague and places the psychiatrist in the difficult position of going on a fishing expedition just to determine what is needed.

Rather, clarity about the referring physician’s goal for the consultation should be achieved before seeing the patient. Questions such as, “The patient has refused an important test because they say that it interferes with their sleep schedule — please help us help the patient,” or “The patient is fighting with the nursing staff and nobody wants to take care of him any longer — please help us work better with the patient,” provide the consultant psychiatrist with an organizing principle for the evaluation.

By the time the consultation is requested, the referring physician may wish to have as little as possible to do with the patient due to possibly justified anger or resentment; the consultant should work with the referring doctor to make the conversation productive.

Reframe Situation

The consultant’s next challenge is to actually evaluate the patient. Due to their psychopathology and the situation at hand, such patients may state immediately that they do not require a psychiatric evaluation and refuse to cooperate. Rapid reframing of the situation to inform the patient that the consultant would like to assist him or her with their problems with the hospital can sometimes encourage an entitled patient to submit to an evaluation.

Patients who view themselves as special may respond more favorably to psychiatric intervention if the psychiatrist’s role as an intermediary between the hospital and the patient is made clear at the outset. If the patient describes treatment they experience as intolerable, the psychiatrist can make truthful and empathic statements such as “that sounds terrible for you.” Once rapport is established, a more complete psychiatric history can be obtained, assessing not only current or prior symptoms but also the effect that the current illness may be having on the patient’s self-concept. For example, their demanding and difficult behavior may be a result of unacknowledged fear and uncertainty. Discussing these matters can make these patients feel weak or inadequate, which is intolerable to them, and they may quickly retreat from the emotional content or minimize its importance.

On the other hand, allowing the patient to discuss his or her dissatisfactions may lead the patient to disclose that he or she is feeling uncertain about prognosis or treatment and can open up a more productive conversation between patient and physician. If the patient does admit to symptoms of anxiety or depression, offering treatment in the form of supportive psychotherapy or pharmacotherapy may help to decrease their problematic behaviors and enhance their care in the hospital.

Set Limits

One way to effectively work with entitled patients is to set clear limits on their behavior and explicitly communicate expectations. For example, if a patient refuses to work with any nurses other than the one they know best, setting a limit and telling the patient that other nurses will have to be involved is a necessity. For this to work, however, people other than the patient must be made aware of the situation and the limits set by the psychiatrist.

The primary attending physician must understand and endorse the limits so that they reinforce it with the patient and raise an alert if the limits are violated. Members of the nursing staff, who may have even closer involvement with the patient than the physicians, also need to be aware of the plan and assist with its execution. The patient may try to pit staff against each other to get what they want; if nurses or other hospital personnel begin to buy into the patient’s splitting, the problem can quickly escalate. Good communication with everyone involved to clarify the plan and the reasons why (“We are not going to allow this patient to refuse their medications at breakfast because it could worsen their clinical condition.”) can help to convince everyone to help out with the plan. If some staff members refuse to go along with the plan, involving their supervisors can help to get everyone to collaborate, although most cases do not reach this point if there has been effective communication along the way.

Psychiatrist as Advocate

Often, patients who view themselves as special become difficult or upset because of the breakdown of communication between patients, family members, and the medical team. Patients and their advocates may actually know something about their situation that is a valid concern; they can be labeled as “difficult” when they try to be assertive and bring it to people’s attention.

With the advent of the Internet and the widespread availability of medical information, families may believe that the best course of clinical action has been missed and noisily raise their point with everyone in the hospital. This can provoke a power struggle between frightened but essentially well-meaning patients and their families and busy, impatient physicians who feel that their authority has been threatened.

In this case, the psychiatrist can often work most effectively with the patient when they position themselves as an advocate. Discussing the situation with the medical staff and ensuring that the patient has been heard can lead to the patient receiving better care and being more amenable to psychiatric care.

On the other hand, working with the patient’s family may lead to a realization that the patient’s demands and concerns are totally unrealistic. In this case, assisting the hospital with setting limits on the behavior may help to get things back under control by providing support to the shaken or frightened physician.

The Physician-Patient

Physicians are usually uncomfortable being in the role of patient and often end up being viewed as difficult by their caregivers. They may try to manage their own care or make their own diagnoses. Because of their (often unexamined) assumption that they know as much or more than their physicians, they may not adhere to recommendations.

The consultant psychiatrist may find that the physician-patient is unwilling to accept a psychiatric diagnosis or receive treatment due to their own attitudes toward psychiatry or their attempts at self-diagnosis. Usually, such problems will be challenging but obvious.

More troubling can be the countertransference that takes place between the physician-patient and the treating psychiatrist. The psychiatrist may over-identify with the physician and distort the examination to fit some aspect of his or her self-image. For example, if the psychiatrist fears illness and sees it in the physician, he or she may avoid the patient or act as though the patient is not ill.

Alternatively, the psychiatrist may enhance the patient’s psychopathology due to his or her feelings about physicians from other fields or their views of themselves. The closer the psychiatrist can hew to the typical examination of the physician-patient, the less likely they are to fall into these traps, but if they are concerned about their findings with a patient, seeking a second opinion or additional supervision is always advisable.

The True VIP

Another group of VIP patients are patients who are VIPs in the eyes of others. These include successful professionals and a range of public figures, including celebrities and political figures. Depending on their notoriety, their stays in the hospital may be complicated by unusually high numbers of visitors or even media intrusion into their illness. Unlike the first group of patients, many staff at the hospital may find caring for these patients rewarding due to their status.

If psychiatric consultation is requested for these patients, there is a much higher likelihood that it is for typical psychiatric reasons such as depression, delirium, or anxiety.

Evaluation may reveal that these patients are essentially similar to those seen in a typical psychiatric consultation in presentation and diagnostic categorization or it may quickly encounter problems similar to those outlined above. The range of attitudes the VIP patient demonstrates toward psychiatric evaluation is as wide and unpredictable as that seen in typical consult work.

Because of their social status and financial means, VIPs are often accustomed to getting what they want and being in control. If the psychiatric evaluation was their idea or they have utilized mental health services in the past, they are likely to view the consult as a service.

On the other hand, if it is unwelcome or unexpected, they may respond in a dismissive fashion or even an angry ejection of the consultant from their room.1 Before evaluation, unless the psychiatric condition is dangerous or life-threatening (ie, delirium with hallucinations and increased psychomotor activity or active suicidal ideation), the VIP should consent to the evaluation. While this general rule applies to all patients, it is of greater importance with a VIP precisely because they expect to be in control and reject anything that limits their autonomy.

Once the psychiatrist starts the evaluation, the consultant should strive to balance the patient’s usual expectations with the professional obligation to perform an accurate and thorough examination. A major factor that sets VIPs apart from other patients is the potential to make a mistake because of excessive deference to the patient’s status. For example, the consulting psychiatrist may neglect to ask about important and standard elements of the psychiatric history (eg, substance use, including any history of abuse) because of an assumption that such problems could not affect the individual, or out of fear of causing offense. If a truly essential element of the examination, such as assessment of suicidal risk, is left out, serious and even deadly consequences can ensue.

Reaction of Staff

Staff may actually vie for the right to take care of these patients, but in this process lies risk to both the patient and the hospital. VIPs may receive so much attention that minor issues may get magnified into major clinical matters with all the attendant interventions. Real risk starts to emerge once a patient begins to receive exceptional care and excessive provision of diagnostic studies and treatments can be even more dangerous than underuse.

A good starting point when working with both medical and nursing staff is to ask if they would perform this test for any patient or if they are doing something special because of their status as a special patient. If the real reason is the latter, they should be educated about the dangers of overtreatment and their attention refocused on the appropriate care of the patient.

Another way in which care can be compromised is by staff remaining distant from patients that present as VIPs due to resentment about their special treatment. This can lead to clinical events being missed or ignored because staff elects to have minimal contact with the patient. Frontline clinical staff members such as nurses are often the most aware of the patient’s VIP status and try to maintain some semblance of normality in the hospital; if nurses give up on the process of caring for the patient, things can get out of hand quickly. Ultimately, since the nursing staff and their support have the most clinical data about the patient, they should be encouraged to remain involved with the VIP even if the demands seem unreasonable or the special treatment irks them.

The policies and procedures that govern hospital work often seem arbitrary or unnecessary, but when changes are made to the way patient care is administered there can be a range of unforeseen consequences. If a patient’s status leads to him or her being evaluated by someone who is not experienced in consultation psychiatry, important elements of the case may be missed. Care provided even by the most highly skilled clinician, if unfamiliar with the specific hospital’s routines and culture, can be inadequate.

On the other hand, the patient may demand to be seen in a way that deviates from the usual protocol. In a teaching hospital, this might involve the patient refusing to see the resident physician or medical student, while in a community hospital this may involve the patient refusing to see the nurse practitioner or the psychologist. This disruption in routine can lead to important elements of the exam, such as labs or a detailed social history, being missed.

Flexibility can help the VIP patient feel comfortable with the exam and build rapport, but too much variance from protocol can raise the risk of the VIP having a poor outcome. Data from other fields of medicine suggest that VIPs have worse outcomes precisely because they are treated differently; in the general hospital, there is no reason to think that this would not be the case in psychiatry.2

Role of Administration

A delicate aspect of the care of the VIP patient is the role hospital administration may play in the process. For the hospital administrator, a VIP patient carries both considerable risks and significant rewards.

Because of the importance of some VIPs, administrators may exert pressure on physicians to change their routine and provide “better” care, even though experience suggests that complying with such pressures is both ethically and clinically perilous.

If the psychiatric consultant is caught in the middle of this type of situation, a recommended approach is to talk directly with the hospital administration about the reasons an approach is being used and how changing the current approach is most likely to harm the patient. If the practice being promoted is standard practice, then the patient’s chances for success are optimized and the hospital should feel more at ease — particularly if the decision process is carefully and explicitly documented.

Outcomes for VIPs

Information from psychiatry about the outcomes of VIPs is more limited, though there is evidence to suggest outcomes are not necessarily satisfactory.3 One of the most intriguing suggestions is the idea that such individuals cannot accept care from an institution because of who they are (ie, they cannot see themselves simply as patients) but only for what they have accomplished and who they know. This helps to explain why VIP patients can be seductive or confrontational with those who are trying to help them; these are means by which they can gain an advantage and thus know that the care they are receiving is a type of debt repayment rather than typical clinical care.

The privacy of the VIP patient deserves special consideration. People always want to know what is happening with a well-known figure, whether that is a celebrity, a prominent physician, or a politician. As with anyone, confidentiality is an ethical responsibility, but in the case of VIP patients, celebrity is more likely to lead to breaches of privacy. Thus, the highest level of privacy should be afforded the psychiatric evaluation.4 Documentation made available to other services should include only essential information, such as diagnosis and treatment recommendations, and should leave out details that may be sensitive.

While it is assumed that computerized record systems are secure, there are numerous examples of security breakdowns resulting in medical information leaks. Even if such transgressions result in the offenders losing their jobs, the information has still been leaked. More detailed notes of the sessions can be made in the psychiatrist’s process notes outside of the computerized system to help with protecting privacy.

Trying to decide which boundaries can be safely crossed when working with a VIP patient and which cannot is a difficult process. Because of their status or the way they are being cared for in the hospital, VIPs may need to be seen at odd hours. They may require extra time due to feelings of entitlement.5 However, if the consulting psychiatrist finds that he or she is spending much more time with the VIP patient than with other patients, or if deviations from the norm are encouraged (such as having the patient call treaters by their first names), the risks of an inappropriate relationship increase.

Warning signs of a developing inappropriate relationship include: gaining some advantage from working with a patient such as financial incentives; prescribing controlled substances such as stimulants or benzodiazepines when not indicated; or continuing the relationship with the VIP outside of the hospital.

If anything along these lines takes place between the psychiatrist and the patient, their therapeutic relationship is at best deeply imperiled and must be addressed, or the psychiatrist will become open to malpractice action and loss of professional privileges. Much more importantly, an ethical transgression has occurred, thus harming the patient, the physician, and the profession as a whole.

Conclusion

VIP patients can present challenges to the consultation psychiatry service and to the hospital. Being prepared and having an approach to working with these patients can make the process easier. Sticking to common clinical practice, accommodating reasonable requests stemming from the patient’s unique needs and situation, and working with the rest of the hospital staff to keep patients safe and optimally cared for are cornerstones of effective treatment.

The rewards of working with these patients, such as alleviating suffering and helping patients understand themselves and their illnesses better, are, in the end, the same as those found in working with all patients. Keeping focused on these goals can make working with VIPs a better experience for all involved.

References

  1. 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]
  2. Block AJ. Beware of the VIP syndrome. Chest. 1993;104(4):989. doi:10.1378/chest.104.4.989b [CrossRef]
  3. 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]
  4. Martin A, Bostic JQ, Pruett K. The VIP: hazard and promise in treating “special” patients. J Am Acad Child Adolesc Psychiatry. 2004;43(3):366–369. doi:10.1097/00004583-200403000-00020 [CrossRef]
  5. 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]

CME Educational Objectives

  1. Identify different types of VIP patients and the clinical dilemmas they create.

  2. Understand the roles that boundaries, limits, and adherence to typical practice play in the role of caring for VIP patients.

  3. Appreciate the modifications to a clinical evaluation that may be necessary with a VIP patient.

Authors

Michael Marcangelo, MD, is Director of Medical Student Education; and Assistant Professor, Department of Psychiatry and Behavioral Neuroscience, University of Chicago Medical Center, Chicago, IL.

Dr. Marcangelo has disclosed no relevant financial relationships.

Address correspondence to: Michael Marcangelo, MD; fax: 773-702-4297; email: .mmarcang@yoda.bsd.uchicago.edu

10.3928/00485713-20111229-05

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