Approach to VIPs during the COVID-19 pandemic and beyond

Dear Dr Dermatoethicist: During the coronavirus disease 2019 (COVID-19) pandemic, in-person dermatology appointments have been restricted to urgent cases in our clinic. A health care executive overseeing the COVID-19 intensive care unit at our hospital requested an urgent in-person visit for treatment of an asymptomatic plantar wart. Should I prioritize seeing this very important patient (VIP) in person?

—Dr Conscientious

Dear Dr Conscientious: A VIP is defined as “a very influential patient whose individual attributes and characteristics, coupled with their behavior, have the potential to significantly influence a clinician's judgment or behavior.”¹ VIPs in health care are not limited to the wealthy and famous; health care providers and executives are prototypical VIPs because their medical knowledge or institutional status can significantly influence their providers.

Dermatologists caring for VIPs may find themselves unconsciously respecting the autonomy of the VIP at the expense of beneficence. This may be out of respect for a colleague's medical knowledge and experience or may stem from the desire to please a reputable colleague who “chose” the dermatologist. This starstruck countertransference (physician's feelings toward a patient) can also be stirred in physicians caring for celebrities and wealthy donors and can trigger them to seek the VIP's approval (mirroring countertransference) and to perceive anything less than a cure to be a failure (idealization and dichotomous thinking).² In the case of “powerful” VIPs (eg, politicians, executives), dermatologists may feel compelled to uphold the patient's preferences to avoid the negative consequences of refusing his or her request. Thus, dermatologists may not follow their usual clinical judgment and may agree to unnecessary interventions or dismiss prudent precautionary testing.^{3 , 4}

To prevent this phenomenon from clouding their clinical judgment, dermatologists caring for VIPs should be transparent and discuss with the VIP the challenges of maintaining clinical objectivity in this context.¹ For example, the dermatologist may begin the visit by candidly acknowledging, “I want to express my concern that my objectivity as your provider may be affected by our relationship as colleagues but I will make every effort to remain clinically objective in your care.”¹

Additional ethical principles must be considered when VIPs are cared for during the COVID-19 pandemic. During pandemics, health care professionals constitute scarce health care resources, reinforcing their VIP status. Ethicists argue that health care professionals should be prioritized to encourage and reward social benefits to others.⁵ Failing to prioritize health care providers may have far-reaching detrimental effects for patients and may discourage providing care during times of crisis.⁵ However, this prioritization applies to problems that limit the ability of health care workers to help others and would not generally apply to requests for cosmetic enhancement.

In summary, clinicians should be aware of the potential for bias in the treatment of VIPs and openly share these challenges with VIPs who are colleagues. Prioritization of health care workers is based on their ability to care for others, and problems not interfering with that ability should not necessarily be assigned special status. Exceptions can be evaluated on a case-by-case basis, balancing the health care needs of the VIP with justice and utility for the population.

—Dr Dermatoethicist