Caring for VIPs: Nine principles

COMMENTARY

JORGE A. GUZMAN, MD

Director, Medical Intensive Care Unit, Respiratory Institute, Cleveland Clinic

MADHU SASIDHAR, MD

Respiratory Institute, Cleveland Clinic

JAMES K. STOLLER, MD, MS

Chairman, Education Institute; Executive Director, Leadership Development, Professional Staff Affairs Office; and Head, Cleveland Clinic Respiratory Therapy, Department of Pulmonary, Allergy, and Critical Care Medicine,
Cleveland Clinic

ABSTRACT

Caring for very important persons (VIPs), including celeb- rities and royalty, presents medical, organizational, and administrative challenges, often referred to collectively as the “VIP syndrome.” The situation often pressures the health care team to bend the rules by which they usually practice medicine. Caring for VIP patients requires inno- vative solutions so that their VIP status does not ad- versely affect the care they receive. We offer nine guiding principles in caring for VIP patients.

KEY POINTS

Caring for VIPs creates pressures to change usual clinical wisdom and practices. But it is essential to resist chang- ing time-honored, effective clinical practices and overrid- ing one’s clinical judgment.

Designating a chairperson to head the care of a VIP patient is appropriate only if the chairperson is the best clinician for the case.

Although in some cases placing a VIP patient in a more private and remote setting may be appropriate, the patient is generally best served by receiving critical care services in the intensive care unit.

doi:10.3949/ccjm.78a.10113

Medical tourism is on the rise,1 and since medical tourists are often very important persons (VIPs), hospital-based physicians may be more likely to care for celebrities, royalty, and political leaders. But even in hospitals that do not see medical tourists, physicians will often care for VIP patients such as hos- pital trustees and board members, prominent physicians, and community leaders.2–4

However, caring for VIPs raises special is- sues and challenges. In a situation often re- ferred to as the “VIP syndrome,”5–9 a patient’s special social or political status—or our per- ceptions of it—induces changes in behaviors and clinical practice that create a “vicious cir- cle of VIP pressure and staff withdrawal”9 that can lead to poor outcomes.

Based on their experience caring for three American presidents, Mariano and McLeod7 offered three directives for caring for VIPs:
Vow to value your medical skills and judg-

ment

 Intend to command the medical aspects of
the situation

 Practicemedicinethesamewayforallyour
patients.7
In this paper, we hope to extend the sparse literature on the VIP syndrome by proposing nine principles of caring for VIPs, with recom- mendations speci c to the type of VIP where applicable.
PRINCIPLE 1:
DON’T BEND THE RULES

Caring for VIPs creates pressures to change usual clinical wisdom and practices. But it is essential to resist changing time-honored, ef- fective clinical judgment and practices.

      

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To preserve usual clinical practice, clini- cians must be constantly vigilant as to wheth- er their judgment is being clouded by the circumstances. As Smith and Shesser noted in 1988, “Since the standard operating pro- cedures […] are designed for the ef cient de- livery of high-quality care, any deviation from these procedures increases the possibility that care may be compromised.”5 In other words, suspending usual practice when caring for a VIP patient can imperil the patient.2–5,10,11 When caring for VIP physicians, for example, circumventing usual medical and administra- tive routines and the dif culties that caring for colleagues poses for nurses and physicians have led to poor medical care and outcomes, as well as to hostility.2–4

A striking example of the potential effects of VIP syndrome is the death of Eleanor Roos- evelt from miliary tuberculosis acutissima: she was misdiagnosed with aplastic anemia on the basis of only the results of a bone marrow as- pirate study, and she was treated with steroids. The desire to spare this VIP patient the dis- comfort of a bone marrow biopsy, on which tuberculous granulomata were more likely to have been seen, caused the true diagnosis to be missed and resulted in the administration of a hazardous medication.11 The hard les- son here is that we must resist the pressure to simplify or change customary medical care to avoid causing a VIP patient discomfort or put- ting the patient through a complex procedure.

We recommend discussing these issues ex- plicitly with the VIP patient and family at the outset so that everyone can appreciate the im- portance of usual care. An early conversation can communicate the clinician’s experience in the care of such patients and can be reas- suring. As Smith and Shesser noted, “Usually, the VIP is relieved if the physician states ex- plicitly, ‘I am going to treat you as I would any other patient.’ ”5

PRINCIPLE 2:
WORK AS A TEAM, NOT IN ‘SILOS’

Teamwork is essential for good clinical out- comes,12–14 especially when the clinical prob- lem is complex, as is often the case when people travel long distances to receive care. All consultants involved in the patient’s care

must not only attend to their own clinical is- sues but also communicate amply with their colleagues.

At the same time, we must recognize that medical practice “is not a committee process; it must be clear at all times which physician is responsible for directing clinical care.”5 One physician must be in charge of the overall care. Seeking the input of other physicians must not be allowed to diffuse responsibility. The primary attending physician must speak with the consultants, summarize their views, and then communicate the ndings and the plan of care to the patient and family.

Paradoxically, teamwork can be challenged when circumstances lead consultants to defer communicating directly with the family in fa- vor of the primary physician’s doing so. Simi- larly, consultants must avoid any temptation to simply “do their thing” and not communi- cate with one another, thereby potentially of- fering “siloed,” discoordinated care.

We propose designating a primary physi- cian to take charge of the care and the com- munication. This physician must have the time to talk with each team member about how best to communicate the individual nd- ings to the patient and family. At times, the primary physician may also ask the consultants to communicate directly with the patient and family when needed.

PRINCIPLE 3: COMMUNICATE, COMMUNICATE, COMMUNICATE

As a corollary of principle 2, heightened com- munication is essential when caring for VIP patients. Communication should include the patient, the family, visiting physicians who ac- company the patient, and the physicians pro- viding care. Communicating with the media and with other uninvolved individuals is ad- dressed in principle 4.

The logistic and security challenges of transporting VIP patients through the hos- pital for tests or therapy demand increased communication. Scheduling a computed to- mographic scan may involve arranging an off-hours appointment in the radiology de- partment (to minimize security risks and dis- ruption to other patients’ schedules), assuring the off-hours availability of allied health pro-

The challenges of transporting VIP patients for tests

or therapy demand increased communication

GUZMAN AND COLLEAGUES

    

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CARING FOR VIPs

        

Protect confidentiality, despite the demand for information by news media

viders to accompany the patient, alerting hos- pital security, and discussing the appointment with the patient and the patient’s entourage.

PRINCIPLE 4: CAREFULLY MANAGE COMMUNICATION WITH THE MEDIA

Although the news media and the public may demand medical information about patients who are celebrities, political luminaries, or royalty, the con dentiality of the physician- patient relationship must be protected. The release of health information is at the sole dis- cretion of the patient or a designated surrogate.

The care of President Ronald Reagan after the 1981 assassination attempt is a benchmark of how to release information to the public.10 A single physician held regularly scheduled press conferences, and these were intentionally held away from the site of the President’s care.

Designating a senior hospital physician to communicate with the media is desirable, and the physician-spokesperson can call on specialists from the patient care team (eg, a critical care physician), when appropriate, to provide further information.

Early implementation of an explicit and structured media communication plan is ad- visable, especially when the VIP patient is a political or royal gure for whom public clam- or for information will be vigorous. A success- ful communication strategy balances the pub- lic’s demand for information with the need to protect the patient’s con dentiality.

PRINCIPLE 5:
RESIST ‘CHAIRPERSON’S SYNDROME’

“Chairperson’s syndrome”5 is pressure for the VIP patient to be cared for by the department chair- person. The pressure may come from the patient, family, or attendants, who may assume that the chairperson is the best doctor for the clinical circumstance. The pressure may also come from the chairperson, who feels the need to “take com- mand” in a situation with high visibility. Never- theless, designation of a chairperson to care for a VIP patient is appropriate only when the chair- person is indeed the clinician who has the most expertise in the patient’s clinical issues.

As in principle 1, in academic medical cen- ters, we encourage the participation of trainees

in the care of VIP patients because excluding them could disrupt the usual ow of care, and because trainees offer a currency and facility with the nuances of hospital practice and rou- tine that are advantageous to the patient’s care.

PRINCIPLE 6: CARE SHOULD OCCUR WHERE IT IS MOST APPROPRIATE

Decisions about where to place the VIP pa- tient during the medical visit can fall victim to the VIP syndrome if the expectations of the patient or family con ict with usual clinical practice and judgment about the optimal care venue.

For example, caring for the patient in a setting away from the mainstream clinical environment may offer the appeal of privacy or enhanced security but can under some cir- cumstances impede optimal care, including prolonging the response time during emergen- cies and disrupting the optimal care routine and teamwork of allied health providers.

Critical care services and monitoring are best provided in the intensive care unit, and attempts to relocate the patient away from the intensive care unit should be resisted. We recommend a candid discussion of the impor- tance of keeping the patient in the intensive care unit to ensure optimal care by a seasoned clinical team with short response times if ur- gencies should arise.

At the same time, a request to transfer a VIP patient to a special setting designed for private care with special amenities (eg, ap- pealing room decor, adjacent sleeping rooms for family members, enhanced security) avail- able in some hospitals15–16 can be honored as soon as the patient’s condition permits. The bene ts of such amenities are often greatly ap- preciated and can reduce stress and thereby promote recovery. The bene ts of enhanced security in sequestered venues may especially drive the decision to move when clinically prudent (see principle 7).

PRINCIPLE 7:
PROTECT THE PATIENT’S SECURITY

Providing security is another essential part of caring for VIPs, especially celebrities, politi- cal gures, and royalty. Protecting the patient

    

92

from bodily harm requires special attention to the patient’s location, caregiver access, and other logistic matters.

As indicated in principle 6, the patient’s clinical needs are paramount in determining where the patient receives care. If the patient requires care in a mainstream hospital loca- tion such as the intensive care unit, modi ca- tions of the unit may be needed to alter ac- cess, to accommodate security personnel, and to restrict caregivers’ access to the patient. Modi cations include structural changes to windows, special credentials (eg, badges) for essential providers, arranging transports with- in the hospital for elective procedures during off-hours, and providing around-the-clock se- curity personnel near the patient.

As important as it is to protect VIP pa- tients from bodily harm during the visit, it is equally important to protect them from attacks on con dentiality via unauthorized access to the electronic medical record, and this is perhaps the more dif cult challenge, as examples of breaches abound.10,17–19 Although the duty to protect against these breaches rests with the hospital, the use of “pop-ups” in the electronic medical record can ash a warning that only employees with legitimate clinical reasons should access the record. These warn- ings should also cite the penalties for unau- thorized review of the record, which is sup- ported by the Health Insurance Portability and Accountability Act (HIPAA). Access to celebrities’ health records could be restricted to a few predetermined health care providers.

PRINCIPLE 8: BE CAREFUL ABOUT ACCEPTING OR DECLINING GIFTS

VIP patients often present gifts to physicians, and giving gifts to doctors is a common and long-standing practice.20,21 Patients offer gifts out of gratitude, affection, desperation, or the desire to garner special treatment or indebted- ness. VIP patients from gifting cultures may be especially likely to offer gifts to their provid- ers, and the gifts can be lavish.

The “ethical calculus”21 of whether to ac- cept or decline a gift depends on the circum- stances and on what motivates the offer, and the physician needs to consider the patient’s reasons for giving the gift.

In general, gifts should be accepted only with caution during the acute episode of care. The acceptance of a gift from a VIP patient or family member may be interpreted by the gift- giver as a sort of unspoken promise, and this misunderstanding may strain the physician- patient relationship, especially if the clinical course deteriorates.

Rather than accept a gift during an epi- sode of acute care, we suggest that the phy- sician graciously decline the gift and offer to accept the gift at the end of the episode of acute care—that is, if the offerer still feels so inclined and remembers. Explaining the rea- son for deferring the gift can decrease the risk of misunderstandings or of unmet expecta- tions by the gift-giver. Also, deferring the ac- ceptance of a gift allows the caregiver to af rm the commitment to excellent care that is free of gifts, thereby ensuring that the patient will be con dent of a similar level of care by pro- viders who have not been offered gifts.

On the other hand, declining a gift may cause more damage than accepting it, partic- ularly if the VIP patient is from a culture in which refusing a gift is impolite.22 A sensible compromise may be to adopt the recommen- dations of the American Academy of Pediat- rics23—ie, attempt to appreciate appropriate gifts and graciously refuse those that are not.

PRINCIPLE 9: WORKING WITH
THE PATIENT’S PERSONAL PHYSICIANS

VIP patients, perhaps especially royalty, may be accompanied by their own physicians and may also wish to bring in consultants from other institutions. Though this outside in- volvementposeschallenges(eg,providingac- cess to medical records, arranging brie ngs, at- tending bedside rounds), we believe it should be encouraged when the issue is raised. Fur- thermore, institutions and caregivers should anticipate these requests and identify poten- tial outside consultants whose names can be volunteered if the issue arises.

Again, if VIP patients wish to involve phy- sicians from outside the institution where they are receiving care, this should not be viewed as an expression of doubt about the care be- ing received. Rather, we prefer to view it as an opportunity to validate current management

Declining a gift may cause more damage than accepting it

if the patient is from a culture in which refusing gifts isimpolite

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CARING FOR VIPs

or to entertain alternative approaches. Most often, when an outside consultant con rms the current medical care, this can have the bene cial effect of increasing con dence and facilitating management.

In a similar way, when VIP patients bring their own physician, whose judgment and care

they trust, this represents an opportunity to engage the patient’s trusted physician-advisor in clinical decision-making and thus optimize communication with the patient. Collegial in- teractions with these physician-colleagues can facilitate communication and decision-making for the patient. ■

REFERENCES

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6. BlockAJ.BewareoftheVIPsyndrome.Chest1993;104:989.

7. MarianoEC,McLeodJA.EmergencycarefortheVIPpatient.Intensive
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8. SchenkenbergT,KochenourNK,BotkinJR.Ethicalconsiderationsinclini-
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10. WeissYG,Mor-YosefS,SprungCL,WeissmanC,WeissY.Caringfora
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11. LernerBH.RevisitingthedeathofEleanorRoosevelt:wasthediagnosis
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12. LeeTH.Turningdoctorsintoleaders.HarvBusRev2010;88:50–58.

13. ClemmerTP,SpuhlerVJ,BerwickDM,NolanTW.Cooperation:the
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14. MoreyJC,SimonR,JayGD,etal.Errorreductionandperformance
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training: evaluation results of the MedTeams project. Health Serv Res

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15. VIPwardatWalterReedgetsscrutiny.USAToday.http://www.usatoday.
com/news/washington/2007-03-15-walter-reed-vip_N.htm. Accessed
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16. RobinsRS,PostJM.WhenIllnessStrikestheLeader.TheDilemmaofthe
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17. CarrJ.BreachofBritneySpearspatientdatareported.SCMagazine,
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patient-data-reported/article/108141/. Accessed December 27, 2010.

18. CollinsT.SirBobbyRobson’selectronichealthrecordsviewedillicitly
by NHS staff. ComputerWeekly.com, September 24, 2007. http://www. computerweekly.com/blogs/tony_collins/2007/09/bobby-robsons-medical- records-1.html. Accessed December 27, 2010.

19. OrnsteinC.Kaiserhospitalfined$250,000forprivacybreachinoctuplet case. Propublica.org, May 15, 2009. http://www.propublica.org/article/ kaiser-hospital-fined-250000-for-privacy-breach-in-octuplet-case-515. Accessed December 27, 2010.

20. LeveneMI,SirelingL.Giftgivingtohospitaldoctors—inthemouthof the gift horse. Br Med J 1980; 281:1685.

21. LyckholmLJ.Shouldphysiciansacceptgiftsfrompatients?JAMA1998; 280:1944–1946.

22. TakayamaJI.Givingandreceivinggifts:oneperspective.WestJMed 2001; 175:138–139.

23. CommitteeonBioethics.FromtheAmericanAcademyofPediatrics: policy statements—pediatrician-family-patient relationships: managing the boundaries. Pediatrics 2009; 124:1685–1688.

ADDRESS: Jorge A. Guzman, MD, Respiratory Institute, G62, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail guzmanj@ccf.org.

  

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