C L I N I C A L P E R S P E C T I V E S Associate Editor: Michael S. Jellinek, M.D.

The V.I.P.: Hazard and Promise in Treating“Special” Patients

ANDRES MARTIN, M.D., M.P.H., JEFF Q. BOSTIC, M.D., ED.D., AND KYLE PRUETT, M.D.

All animals are equal, but some animals are more equal than others.—George Orwell, Animal Farm

Principles of fairness in access to competent care havebeen woven into the very fabric of medical ethics andare canonized into core statements of professional iden-tity such as the Hippocratic Oath, the Prayer of Mai-monides, and the World Health Organization’scharter. Calling access or equality into question evokesdiscomfort, if not outright alarm. And yet the fact thatmajor discrepancies in the provision of health care ex-ist—and persist—should come as no surprise. But it isnot the world’s or our nation’s socioeconomic gap be-tween health “haves” and “have-nots” that is at issuehere. Rather, this column focuses on the special issuesengendered by the treatment of members of variouslydefined elite groups, collectively subsumed under thelabel of the Very Important Person (V.I.P.).Many of the particulars pertaining to the treatment

of the V.I.P. have been addressed extensively, albeitrarely in academic print. For example, prestigious hos-pitals the world over cater specifically to the needs ofsuch patients, at times in units designed with their veryneeds in mind. Popular magazines routinely advertise

for facilities that attend to the full array of medicalconditions (cosmetic surgery and weight control pro-grams being perhaps less surprising than those of otherspecialties, including psychiatry). High-quality medicalcare, sometimes affiliated with major teaching institu-tions, is delivered in elegant, attractive, non-institu-tional-style settings that offer a full complement ofamenities. There is nothing inherently wrong with suchsettings or types of care (unless funded by public mon-ies), but attending to the dynamics underlying the careof such patients can provide information that is clini-cally relevant.The fact that as clinicians we are less accustomed to

dealing routinely with the privileged few than with thedisenfranchised or disadvantaged should not make usskittish in addressing the needs of those in positions ofpower, celebrity, or academic or financial success. Un-comfortable as it may be, acknowledging and address-ing the fact that differences often exist in how weapproach and treat certain patients can be of practicalimport. Paying attention to such matters is relevant notonly to effectively deliver care to anyone coming to usin need, but also to prevent “occupational hazards”specific to this clinical subpopulation.

Dosing Care: Under- and Overtreatment asCountertransferential Risks

Patients deemed “special” under any classificationare vulnerable to receiving substandard treatment. Inlegitimizing the V.I.P.’s uniqueness, and under theguise of providing superlative care, clinicians can de-prive such individuals of the very benefits they are pur-portedly delivering. The clinician may attempt to be“special” along with the patient by skipping mundaneor seemingly extraneous diagnostic procedures. “Thor-oughness” may be construed in such circumstances asan unnecessary burden, or the intensity, depth, andintimacy required of clinical interviews or examinationsas overly intrusive. The complexity of these common

Accepted September 16, 2003.Dr. Martin is Associate Professor of Child Psychiatry and Psychiatry at the

Yale School of Medicine, and Medical Director of the Children’s PsychiatricInpatient Service at Yale-New Haven Children’s Hospital. Dr. Bostic is Assis-tant Clinical Professor of Psychiatry at the Harvard Medical School and Di-rector of School Psychiatry, Massachusetts General Hospital. Dr. Pruett isClinical Professor of Child Psychiatry and Nursing at the Yale School of Medi-cine, and Past President of Zero to Three: National Center for Infants, Toddlersand Their Families.

The authors appreciate the thoughtful comments of Susan Saccio, L.C.S.W.,Joaquın Fuentes, M.D., and David Rosen, J.D. This column, on another one ofhis certified areas of expertise, is dedicated to our mentor and friend, the lateDonald J. Cohen, M.D. (1940–2001).

Correspondence to Dr. Martin, Yale Child Study Center, 230 South Front-age Road, New Haven, CT 06520-7900; e-mail: andres.martin@yale.edu.0890-8567/04/4303–0366©2004 by the American Academy of Child

and Adolescent Psychiatry.DOI: 10.1097/01.chi.0000106853.88132.81

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traps is magnified in the context of parental involve-ment, as exemplified in the first of two clinicalvignettes:

The 14-year-old daughter of a prominent community businessleader was referred for evaluation of depression and “psychogenicvomiting.” In an effort to maximize her privacy, her parents hadarranged for an evaluation not through the routinely availablegroup affiliated with the boarding school where she was an honorsstudent, but by a clinician working at a far distance instead. She andher parents felt encouraged by the attention they received duringtheir lengthy joint session, and also by the initiation of anxiolytictreatment and proposed monthly follow-up visits. Unfortunately,she missed her third appointment, following an interim emergencyroom visit for vaginal bleeding. She was found to be 4 monthspregnant, tested positive for cocaine, and became actively suicidal,requiring both obstetric and psychiatric stabilization.

As illustrated, “special” arrangements can go disas-trously astray and can be made more in response to adesire to please or to avoid conflict than to addresslegitimate clinical need. Deviating from standard ap-proaches to care should promptly raise the question ofwhat clinical purpose, if any, may be served throughthe invoked exception. For example, concerns overconfidentiality are usually not best served through geo-graphic remove: if anything, getting treatment at a dis-tance was, in this case, one of the factors contributingto its diluted characteristics. Further, the narcissisticgratification that can be a natural byproduct of beingchosen among many, or of being traveled to from adistance, may make it difficult to resist the temptationof “keeping the case” to oneself, rather than making amore appropriate and logistically convenient referral.Moreover, in the service of allegedly securing the fami-ly’s and the adolescent’s trust and working alliance, theclinician provided an unwarranted sense of comfortand calm, one that was meant to soothe his own dis-comfort and anxiety as much as theirs. Finally, avoid-ing basic “hard” questions about substance use andsexual activity, which perhaps the clinician fearedwould be insulting to this prominent family, only de-layed appropriate treatment and, ironically, ended byexposing their painful predicament to a wider “audi-ence.” The clinical core was completely neglected, andthe inherent risks of such favored arrangements re-vealed.Just as avoidant and abridged care may serve to bind

the anxiety engendered by the treatment of V.I.P.s,overzealousness can provide a comparably damagingand opportunistic alternative. This common occur-rence is exemplified not only in the unnecessarily longand expensive workup or in the ordering of extraneousand redundant laboratory tests and consultations, but

in the indefinite and goal-vague prolongation of treat-ment that is also impervious to the constraints of third-party payment. Clinicians need to be alert to thepossibility of such “delay tactics,” which may reflect anunacknowledged reluctance to end special relation-ships: without their aura as a booster, the clinician toomay cease to feel special.In summary, under- or overtreatment can provide

comparably ripe settings of risk for both patient andclinician to become unwitting accomplices in a mis-placed focus: one in which the uniqueness itself, ratherthan the underlying pathology, claims clinical centerstage.

From the Outside Looking In: The Seduction ofLiving Vicariously

Clinicians working with V.I.P.s must contend withthe fact that those under their care can be not onlyfamous, talented, wealthy, or powerful, but alsoyounger and more attractive, physically fit, sexually ex-perienced, socially adroit, politically connected, intel-lectually gifted, or academically successful thanthemselves. One of the more challenging aspects ofworking with this population is the need to confront,rather than summarily disavow, the voyeuristic, seduc-tive, envious, or similar pulls that may naturally emergeduring the course of treatment. Confronted withglimpses of exciting possibilities in worlds rarely en-countered in their own lives, clinicians can too easilyfall into the trap of living vicariously through theirpatients. Unfulfilled fantasies may lead to cliniciansfalling, as it were, for glitz and glamour over clinicalprimacy. Such tensions are not unfamiliar to psychia-trists working with adolescents and young adults, as acommon challenge posed by those age groups resides intolerating without a sense of competition or loss, and inbeing able to see beyond, the ready appeal of youth andvigor, or of beauty, intellect, or untapped promise.

The 9-year-old son of a well-known television star was treated forsymptoms of inattention and poor academic performance. Follow-ing brief interviews with the child, the clinician pursued inquiriesabout his mother’s upcoming show. Even as he responded readily tostimulant treatment, medication refusal and resistance to go toappointments eventually necessitated a change of clinicians. Duringensuing therapy sessions, he revealed his distrust and anger with thefirst treater, whom he described as “yet another of [his] mother’sfans”—far too interested in her to be of much help to him.

It is not only parents’ lives that can be alluring, aschildren and adolescents can themselves provide thejustification for their own V.I.P. status: ever-youngertelevision, movie, and music stars, as well as elite ath-

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letes, are the most common cases in point. When mi-nors themselves are not only the identified patient butthe “identified V.I.P.” as well, additional consider-ations are brought into the clinical encounter. An un-toward focus on fame and accomplishments may derivenot only from the clinician, but from the caretaker aswell, and collusion in the shared and expansive admi-ration of such young stars may become a seduction tobe avoided. In such instances, untoward attention mayhave come to be placed on what the child produces,rather than on who he or she is. Treatment of the youngV.I.P. may on occasion require the disruption of aprofessionally successful partnership, if it is one occur-ring at the expense of a dysfunctional parent–child re-lationship.

Three Practicalities: Privacy, Place, and Payment

Privacy issues take on a special dimension in thetreatment of certain V.I.P.s, a truism that can be alter-natively framed under the maxim not all confidentiali-ties are created equal. Even as the privileged nature ofmedical information is a tenet true across the entiresocioeconomic spectrum, the readily recognized natureof celebrities can make the ability to maintain theirinformation in strict privacy a significant challenge.The comings and goings of individuals of widespreadrecognition may require special arrangements that gobeyond traditional setups in order to deliver servicesconfidentially. Off-site care, aliases, minimalistic or“shadow” documentation, or payment by cash and intoanonymous accounts may be required in such in-stances. Lest it be misconstrued that all V.I.P.s arecelebrities basking in the public limelight, it must benoted that the vast majority are not. For example, acommon type of V.I.P., and one that particularly high-lights considerations of privacy, is the child of a col-league or mentor.Less dramatic than that of fame, but much more

common, is the issue of differential treatment of pa-tients identified as “special.” For example, a V.I.P. seenemergently on an outpatient basis can wreak havocwith a clinician’s schedule, and a “bumped” priority listcan affect an office’s established routine. Inappropriateor long disruptions during office hours may be accu-rately perceived by staff and other patients as prioritiz-ing of the V.I.P.’s needs over their own.But perhaps no issue crystallizes the unique chal-

lenges posed by the treatment of V.I.P.s as that ofpayment. Indeed, if unchecked, money can all tooreadily guide treatment decisions, and special money can

come to imply special care. At a time when for-profitmarket forces play an ever-larger role in shaping medi-cal practice, and as patients’ disaffection with managedcare grows, families who can secure care through cashincreasingly appeal directly to treatment providers. Itdoes not necessarily follow that this trend makes forbetter care: at the level of the individual, the seductionof money or special favors can supersede the clinician’sdiligence to the task at hand. At that of the institution,it can provide an incentive difficult to ignore, withexpectations that bringing “special” patients and theirpotentially major donations or endorsements may en-title the clinician to preferential status as well.While troubling, the notion that financial consider-

ations can differentially guide the treatment of V.I.P.sis not an insurmountable one. Specifically, three rec-ommendations may diminish this risk. First: treatmentshould not be provided free of charge in (self-acknowledged or not) anticipation of future gifts, fa-vors, or donations. “Being owed” provides a lure andtemptation that unnecessarily complicates the treat-ment relationship, making it less likely, rather than more,that any future appropriate gifts (such as those of philan-thropic engagement) might realistically ensue. Perhapsworse, when the clinician’s fantasies are not substantiatedthrough the patient’s generosity, potential resentment andcountertransference-based conflict may fester.Second: the “sliding scales” devised for the disadvan-

taged do not provide a justification for their “inverse”variation among the privileged. Payment should not beproportional to means, but rather consistent, save forthose patients with major financial limitations. To dootherwise threatens to turn the treatment of wealthypatients into no more than a thinly veiled form ofexploitation.Third, the thoughtful use of “split” arrangements in

the treatment relationship can be of special use in thecase of V.I.P.s. Specifically, exploring the possibility ofphilanthropic support to an institution is virtually al-ways best left to someone other than the involved cli-nician. In this way, the separation of clinical fromfinancial relationships can enhance the vitality of both.The fact that the two aspects typically function on verydifferent time and dollar amount scales makes for yetanother practical reason to justify such a “split” ap-proach.

The Clinician as V.I.P.

The care of prominent individuals and families hasbeen a key element of medicine from its very inception

MARTIN ET AL.

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and contributed in no small part to the respect, regard,and at times even political leverage that have been his-torically conferred upon physicians. The tension thatcan naturally ensue from having to be firm, to setlimits, and to be an open critic of the behaviors of thosein positions of power or strength can prove unsettling.In addition, clinicians may become tempted to “sharethe spotlight” with their celebrity patients and become

preoccupied with their own image among their clinicalpeers. In the end, few practitioners end up beingimmune from, or feeling entirely comfortable deal-ing with, the challenges posed by the treatment ofV.I.P.s. Even so, the needs and suffering of the V.I.P.are no different from those of the rest, and our ob-ligation as physicians, to all in need of care, one andthe same.

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