V.I.P.s are patients with special status because of their standing in society (celebrities, politicians, wealthy individuals, etc.) or their influence within the medical center (major donors, social contacts of prominent medical center leaders, physicians, etc.). The existing literature on V.I.P. care primarily addresses the compromised care often received by V.I.P.s, the disruptive effects of V.I.P.s on the hospital team, and ethical considerations in V.I.P. care (1–8). As a group of junior faculty, we have found V.I.P. cases to be particularly challenging. Other authors have examined countertransference in treatment of V.I.P.s (2–4, 7), but the existing literature does not address countertransference specifically from the junior faculty physician's viewpoint. Our desire to understand our own countertransference in V.I.P. cases was the impetus behind this article. We wanted to understand what we were experiencing, why we were experiencing it, and, ultimately, how we might better manage our reactions and improve patient care.
We convened a group of junior faculty with experience treating V.I.P. patients to review de-identified cases. For this purpose, we wrote case summaries, alternating with group discussions, specifically reflecting on our emotional reactions and the influence of the academic setting on our perceptions. Drawing on our observations and psychodynamic literature (9, 10), we identified key themes present across cases: mirroring, idealization, and dichotomous thinking. From this process, we developed the strategies for elucidating countertransference distortions and the potential remedies presented in this article.
1. Mirroring: We propose that V.I.P.s may elicit a mirroring countertransference, analogous to the mirroring transference (10). Just as the patient with a mirroring transference seeks approval and admiration from the physician, the treating physician may seek approval and admiration from the V.I.P. Consequently, the physician may become overinvested in being “liked” or pleasing the V.I.P., in the service of perpetuating feelings of closeness and approval. This may lead to deviations from usual practice. For example, the physician may be overly accommodating and friendly, resulting in boundary-crossings. Also, the physician may avoid setting limits out of a reluctance to disrupt feelings of closeness and mutual admiration. Within the academic context, a mirroring triad may occur, which includes the junior faculty's wish for approval from involved senior faculty, who are also likely invested in the approval from the V.I.P. (Figure 1). The senior physician may support or even participate in deviations from usual practice in his or her own efforts to be liked. For example, the senior physician may participate in day-to-day care more than usual, offer “extra” care, or circumvent the usual treatment protocols in an effort to please. The senior physician may enlist the junior physician to provide similar care. In their shared participation, the junior physician may feel a kinship and admiration from the senior physician as well as the patient. Thus, the additional wish for approval from involved senior faculty intensifies the efforts to perpetuate feelings of admiration and further obscures true motivation or risks of these actions.
2. Idealization: The academic hierarchy may contribute to idealizing countertransference, particularly if the junior physician reveres the involved senior physician(s.) If the revered senior physician also idealizes the V.I.P., it may compound the distorting effects of idealization. Also, if the V.I.P. is a friend or relative of a senior physician, the treating physician may be even more predisposed to idealization because of the patient's association with the senior physician. When “blinded” by identification with an idealized object, the physician may not accurately appraise the V.I.P.'s clinical situation. The physician may avoid aspects of the case or misinterpret them in ways that maintain the idealization. Loss of clinical insight can result, with consequences such as minimizing abnormalities, overlooking risks, or missing serious diagnoses such as personality disorders or substance abuse.
3. Dichotomous Thinking: Caring for a V.I.P. may evoke intense anxiety, promoting dichotomous thinking. The simultaneous need to be a hero and the dread of failure may drive the physician to strive for unachievable outcomes. Both senior and junior faculty are susceptible to this dynamic. For example, the physician may feel a need to “save the day” and exceed the norms of clinical care to do so, resulting in overzealous care. In this “black-or-white” state of mind, anything less than complete treatment success represents utter failure, even if the case is treatment-resistant. Dichotomous thinking may color the junior physician's perceptions of his senior colleagues and possible ramifications of the case on career development. The physician assumes that the referring faculty member expects total treatment success, based on distortions about the senior faculty's expectations. Simultaneously, the situation arouses dread of losing face, disappointing mentors, or damaging one's prospects for promotion. The treating physician may anticipate blame, humiliation, or punishment. The physician's perception of the V.I.P. as a threat to his reputation or career stability undermines the therapeutic relationship. The junior physician may avoid or feel anger toward the referring party or the patient.
It is the rare provider who lacks blind-spots—physicians may fail to recognize their countertransference and its behavioral impact. Given the stakes involved with V.I.P. cases and the forces they sometimes unleash, caring for a V.I.P. may impair one's reflective abilities. In order to deliver effective care, physicians must regain the ability to realistically observe their own reactions, the clinical situation, and the influence of their relationships with involved senior faculty. The purpose is to generate a roadmap of intrapersonal forces affecting decision-making and improve the provider's ability to choose mindfully. Furthermore, such recommendations must be sufficiently flexible to allow for creative thinking. Below, we offer suggestions for providers within academic settings.
1. Define the dilemma: One might use the following questions to make the pressures involved more transparent:
Who is making the V.I.P. request? Who are the stakeholders?
Are senior faculty among the stakeholders?
What relationships do I have with senior faculty involved in this case or other stakeholders?
Are they in a position to evaluate me?
What are the expectations?
What are the repercussions if I accept or decline to care for the patient?
How does this compare with my usual clinical practice?
In the best-/worst-case scenario, what do I fear might happen?
How is this situation affecting me emotionally?
2. Review standards of care: In V.I.P. cases, the physician may feel a pull to deviate from “usual” care, causing confusion as how best to proceed. We suggest starting with the customary standards of care as a baseline. That is, what would be the usual course of action with a (“non-V.I.P.”) patient in this situation? Review of best-practice guidelines may be a reassuring and grounding step. Armed with a clearer sense of standards, the physician may be better able to safely consider any deviations from usual practice. Not all deviations are problematic, and some may be necessary to maintain the V.I.P.'s privacy (6, 11–14). Other authors have described and even recommended selected departures from standard care protocols in V.I.P. care (2, 4, 6, 13, 15, 16). Nonetheless, the decision to deviate from the usual standards would suggest a need for consultation and careful documentation. Potentially, management of V.I.P. cases can be addressed at the institutional level (12, 13, 15–18). Many systems have established protocols for V.I.P.s, designed to provide optimal medical management, protect privacy, and avoid media interference with the patient and care-team members. The physician should inquire about existing policies or procedures.
3. Seek consultation: Powerful feelings such as shame, anger, or grandiosity, may obscure one's clinical insight. Consultation with colleagues may help resolve blind spots (2, 7). Optimal consultation should offer a combination of distance from the specifics of the case and experience in the department. Ideally, the consultant should be someone who is less aroused by the specifics of a case and does not share the same intense reactions. Concerns about confidentiality compound the complexity of V.I.P. cases (11, 14). If possible, the case should be discussed in a fashion that “de-identifies” or strips specific identifying information in case-review. Consultation with a colleague who is equally enmeshed or enthralled could worsen provider decision-making. Assessing countertransference requires consideration of feelings about the involved senior faculty by the treating physician. When departmental dynamics or relationships with referring providers are part of the picture, a consultant may help identify distorted ideas about others' expectations or potential consequences. A trusted senior colleague or mentor may well provide a grounding perspective. Consultation with peer colleagues may help by offering alternative interpretations of events, discussion of similar experiences, and needed emotional support.
4. Communicate with stakeholders and other providers: Experts assessing barriers to quality note the degree to which a hierarchical medical culture can impede effective action (5, 19–21). Good communication can clarify everyone's expectations and correct erroneous assumptions, thereby reducing anxiety and improving clinical care. At the start, the treating physician may wish to talk with referring provider and/or stakeholders. The treating physician might discuss usual care, typical outcomes for similar clinical situations, and expectations. For example, in the case of a personality disorder, a discussion of realistic risks and benefits of inpatient psychiatric treatment may help temper demands for a “quick fix.” When senior faculty will be involved in the direct care, the junior and senior physician should strive to delineate each person's role, come to agreement about the care plan, and explicitly discuss the rationale for any deviations from usual-care protocols or provision of “extra” care. For complex cases involving treatment teams, group reflection and discussion is a requirement (2, 7). These cases notoriously elicit dissension. Specifics of the situation may affect individual team members differently—not every team member may find a particular V.I.P. equally compelling, and individual reactions and ideas about treatment may reflect that difference. Getting providers “on the same page” is essential in the setting of group dynamics.
Caring for V.I.P.s can be difficult because of physician countertransference and anxiety. When junior faculty members provide “frontline” care, countertransference pressures may be amplified by the existing academic hierarchy and relationships between the involved physicians. When faced with this clinical situation, junior faculty physicians may approach the problem by answering the recommended questions to spur reflection and help to pinpoint their dilemma. From this point, physicians may need to review standards of care, pursue consultation with peers or senior colleagues, and/or talk with involved parties about expectations and usual clinical outcomes.