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Tips for Hospitalists Managing Care of High-Profile Patients


 

Hospitalists around the globe have cared for their share of high profile patients, also known as very important people, or VIPs. Many of us dread the prospect of admitting a VIP to our service, knowing that such patients tend to be demanding and entitled and often want to dictate their care.

The term “VIP syndrome” was coined as early as 1964 by psychiatrist Walter Weintraub, who described how “the treatment of an influential man can be extremely hazardous for both patient and doctor.”1 He found, even back then, that the admission of VIPs to an inpatient setting was “often followed by considerable turmoil within the institution,” which can unfortunately undermine the quality of the care that the patient receives.

Some high profile—and controversial—deaths that have at least partially been attributable to VIP syndrome were those of Michael Jackson and Joan Rivers. In both cases, physicians veered from normal or usual standards to meet the apparent needs of their high profile patients. The Jackson case represented a violation of care standards: Dr. Conrad Murray administered propofol, midazolam, and lorazepam simultaneously without monitoring his patient, and this treatment resulted in cardiac arrest. The death was considered a homicide, and the physician was convicted of involuntary manslaughter and sentenced to two years in prison. In the Rivers case, the entertainer’s private ENT physician was involved in her care at a site in which he was not privileged to practice; it is unclear if the clinic was equipped to handle the complexity of her case, and she died after her airway was lost. Countless other examples of VIP quality care concerns signifying alterations in care standards based on the patient’s social status have resulted in less dramatically poor outcomes.

Some hospitals have carved out wings or floors to cater to VIP crowds. In these cases, the room and board charges are extraordinary and are billed directly “out of pocket” to the patient, bypassing insurance companies or payers. These wards or units are often staffed “ad hoc” by nurses and other care providers at very low staff-to-patient ratios, so that they can be at the beck and call of the VIP. Some of these admitted patients even bring along their private physicians and nurses, practitioners who are not privileged to practice on site but who may try to dictate the care being delivered.

The real issue, when VIP syndrome is in full swing, is that it violates many codes of medical professionalism, including those found in the Physician Charter of the ABIM Foundation, which emphasizes the guiding principles of patient welfare, autonomy, and social justice.2 Because there exists a whole cadre of patients who qualify as “VIPs” (celebrities, politicians, royalty, local board members, community leaders, and fellow physicians or healthcare administrators), it is extremely likely that each of us will be called upon to care for such a population at some point. As such, we need to have a plan for how we will manage the emotions and care of such patients, without violating any care or professionalism standards.

The real issue, when VIP syndrome is in full swing, is that it violates many codes of medical professionalism, including those found in the Physician Charter of the ABIM Foundation, which emphasizes the guiding principles of patient welfare, autonomy, and social justice.2

Roller Coaster of Emotions

My hospital recently had a VIP in for a protracted and complex illness. The patient and family became so demanding and time-consuming that we considered “rotating” them to various other units to give the physicians and staff a break. The typical emotions affiliated with such VIP cases are resentment and frustration, even hostility at times, especially when we recognize the fact that the care we are delivering is not better than average, and may actually be worse. The resentment stems from the fact that we all like to think we deliver the best care possible to all patients, regardless of their personal characteristics, because we all want and deserve the best care, regardless of our bank accounts or public popularity.

So, while none of us can or should avoid taking care of a VIP patient or family, we do have to be thoughtful—in advance—about how we will approach their care. An article from the Cleveland Clinic offers advice to clinicians taking care of these VIPs, in the form of nine guiding principles:3

  1. Don’t bend the rules: Although VIPs can exert immense pressure to change our practices and procedures to meet their needs, we should resist any temptation to bend to their wishes. Often, practices and procedures are in place for operational or safety reasons, and veering from them can put both practitioners and patients in harm’s way. Practitioners should be explicit in their conversations with VIP patients, explaining that they will be treated within the boundaries of all the usual operational and safety safeguards that are built into the system, for their own good.
  2. Work as a team: It must be made very clear to the VIP that the attending is in charge of all medical decision-making, and all other providers will be consultants in their care.
  3. Communicate: Structured, regular, and predictable communication is a must for the patient, family, and all other providers involved in the VIP’s care. While this can seem very time-consuming, it will save time in the end if the patient, providers, and community understand how and when communication will occur. Predictable communication can also set boundaries on how and when it is appropriate for the patient’s family to contact the attending (e.g. cell phone, text, pager, and so on).
  4. Carefully manage communication with media: Just as with any patient, a VIP’s confidentiality is paramount. Any media coverage should be carefully planned with the hospital’s public relations department, and the only information that should be shared is that which the patient agrees to in advance.
  5. Resist “chairperson’s syndrome”: This happens when the family insists on being assigned the most senior physician on staff, even when that physician might not be the one best suited for the clinical scenario. VIP care should be as close to “business as usual” as possible, including being staffed by the “best fit” attending and trainees (in teaching hospitals).
  6. Care should occur where it is most appropriate: This includes care in an “open” ICU, if that is the level of care needed. This conversation should also be undertaken early in the hospital stay, to ensure that the patient and family understand the rationale and need for matching their level of care with the appropriate care setting, while being mindful of privacy and security needs.
  7. Protect the patient’s security: High profile patients often are heavily pursued by the media, and all measures should be taken to ensure their safety, security, and privacy. These patients should be listed under an alias or as a confidential patient, to reduce the risk of HIPAA breaches by hospital staff or visitors.
  8. Be careful about accepting or declining gifts: Accepting and declining gifts can both be hazardous; it would be best to avoid accepting any gifts during the hospital stay, but you can offer to accept a reasonable and appropriate gift after the stay has concluded.
  9. Work with the patient’s personal physicians: In the event the VIP patient has personal physician(s), it is best to invite their input and show them that you value their opinion; however, it must be clear that the attending has ultimate responsibility for the care of the patient during the hospital stay and that all ordering of diagnostics and therapeutics will be done solely by the attending.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

References

  1. Weintraub W. The VIP syndrome: A clinical study in hospital psychiatry. J Nerv Ment Dis. 1964;138(2):181-193.
  2. ABIM Foundation. Physician charter. Available at: http://www.abimfoundation.org/Professionalism/Physician-Charter.aspx. Accessed January 10, 2015.
  3. Guzman JA, Sasidhar M, Stoller JK. Caring for VIPs: nine principles. February 2011. Available at: http://www.ccjm.org/fileadmin/content_pdf/ccjm/content_2fd90f2_90.pdf. Accessed January 10, 2015.

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