The Treatment of VIP Patients in Academic Teaching Settings: Applying the “Difficult Patient Framework” to Guide Therapeutic Response

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• Recognize who is, or may become, a so-called difficult patient. In the case of the VIP patient, it is often the challenges arising from the complex set of psychosocial circumstances surrounding the patient that are perceived as difficult by the treatment team.

○ In this way, it is a relational difficulty between the VIP patient and members of the treatment team.

○ Understand that this relational difficulty is a clinical sign with a differential diagnosis that requires further evaluation and diagnostic interpretation.

• Identify the specific clinical and ethical challenges that may arise in the care of VIP patients in academic teaching settings:

○ Suboptimal clinical outcomes

○ Therapeutic abandonment

○ Distortions in professional boundaries and therapeutic alliance

○ Confidentiality breaches

○ Safety and administrative concerns

○ Unintended though ethically problematic messages for medical trainees

• Respond therapeutically

1. Maintain a nonjudgmental and professional attitude towards the patient

2. Obtain a complete history and physical

3. Schedule regular clinic visits

4. Avoid premature treatment interventions with aggressive medications or procedures

5. Remain open to new developments in the patient’s condition

6. Reflect on one’s own attitudes and beliefs in the patient’s care

7. Recognize one’s own limitations and seek consultation when needed

• Openly discuss the clinical rationale for this treatment approach with trainees to avoid sending unintended though ethically problematic messages.