‘You over-treat or under-treat’: the problem of VIP patients like Trump

You over treat or under treat 1
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Trump’s medical team will face a minefield as they attempt to form an alliance with the president – a notoriously demanding, publicity-conscious patient

Here is a statement taken for granted: Donald Trump will have the best care available for his diagnosis of Covid-19. In a literal sense that is true – he will have an attentive, round-the-clock medical team. This is essential for any ill president.

But in medicine there are many cautionary tales of “VIP syndrome” – the special treatment given by doctors to the wealthy, famous, powerful or politically connected and how that does not always lead to the best medical outcomes.

“In the case of President Trump … you can see the countertransference,” said Dr Andrés Martin, a professor of psychiatry at Yale School of Medicine’s child study center, referring to the feelings a doctor might have toward a patient. “If I screw up, or if I piss him off, is he going to treat me like Biden?”

Trump’s medical team will face a veritable minefield as they attempt to form an alliance with the commander-in-chief, a notoriously demanding, publicity-conscious patient who views disease as personal weakness, and diet and exercise with suspicion.

“All physicians are also humans,” said Dr Shoa Clarke, a preventive cardiologist at Stanford University who has written about VIP patients, called “red blanket” patients in some hospitals. “We’re influenced by our own biases, conscious or subconscious, and we can be influenced by the people we see when we’re trying to take care of them.”

“That certainly applies when dealing with patients who are politicians,” Clarke added.

Trump announced he was Covid-19 positive early Friday morning. He was transferred to Walter Reed National Military Medical Center the same day, a move White House physician Dr Sean Conley later said, was out of “an abundance of caution”.

Sowing confusion, the president’s condition was later described in more serious terms, even as he recorded videos and rode in a much criticized motorcade to greet supporters. The president has now left the hospital to be treated at the White House medical unit, likened to a “mini-urgent care”.

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In a video shot moments after his return, Trump addressed the American people as if he had already beat the disease. “Don’t let it dominate you,” he said, not wearing a mask, despite almost certainly still being infectious. “Don’t be afraid of it, you’re going to beat it, we have the best medical equipment, we have the best medicine.”

Trump has certainly had the most advanced medicine. He was treated with at least three drugs – an experimental monoclonal antibody from Regeneron, antiviral remdesivir and steroid dexamethasone – which are usually reserved for patients with “severe” Covid-19 or a “life-threatening” condition.

Average Americans will not have access to Regeneron’s antibody cocktail, and certainly not at the dose Trump took, which was three times greater than what is being studied. Regeneron’s chief scientific officer George Yancopoulos acknowledged this special treatment.

“If I had to treat one patient, I’d give the high dose,” Yancopoulos said, according to Science magazine. “From a societal point of view and the need to treat as many people as possible, I’d give the lower dose.”

Remdesivir has been in short supply for months. It only became available for hospitals to buy from the distributor, rather than the US government, the same day Trump is believed to have received his first positive Covid-19 test. Dexamethasone is normally reserved only for severely ill patients.

All of this special treatment underlines the inequality in America’s medical system – regular people have to jump through bureaucratic hoops and pay exorbitant prices for healthcare. But special treatment is not necessarily healthy for the patient it is bestowed on either.

“You over-treat or you under-treat, but rarely do you treat as a usual patient,” who is a VIP, said Martin. “Why is he leaving now? Well, they’re under-treating him. Why did he get [monoclonal antibody] plasma and steroids? Because they’re over treating him. It’s certainly not treatment as usual.”

This paradox, that treating the privilege can leave the privileged worse off or lead to medical missteps, can be traced far back into our history, according to Dr Walter Weintraub, the venerated University of Maryland psychiatry professor who coined the term “VIP syndrome” in 1964.

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“The well-known cases of King George III of England and King Ludwig II of Bavaria can clearly demonstrate that the treatment of an influential man can be extremely hazardous for both patient and doctor,” he wrote in that seminal paper referring to two famously mentally unbalanced European monarchs.

The term has also been referenced following the deaths of many celebrities, including everyone from Michael Jackson to Prince to legendary comedian Joan Rivers. VIP syndrome can lead doctors to be star struck, attempt to be too thorough or too hands off, or hope to please the prominent person.

In an academic paper, Martin gave one example of the treatment of a prominent person’s 14-year-old daughter. A thorough joint psychiatry appointment with her parents led to a diagnosis of depression and “psychogenic vomiting”. But before her third psychiatry appointment, she went to the emergency room. Once there, staff discovered she was both positive for cocaine and pregnant, requiring stabilization.

Research has also backed up these anecdotal cases. A 2012 study published in the Journal of the American Medical Association Internal Medicine found, conversely, higher patient satisfaction was associated with the both greater drug spending and increased mortality.

Among the American political class, there are also tales of treatments gone awry. Former first lady Eleanor Roosevelt lost her life to a rare form of tuberculosis, which some argue could have been caught if a more aggressive (and painful) bone marrow biopsy were performed.

Doctors at the Cleveland Clinic, where the institution’s academic esteem attracts royalty and political luminaries from around the world, set out principles to care for VIP’s. The first one is “don’t bend the rules” of clinical practice.

“In other words, suspending usual practice when caring for a VIP patient can imperil the patient,” wrote the group of physicians. Cleveland Clinic doctors continued: “Usually, the VIP is relieved if the physician states explicitly, ‘I am going to treat you as I would any other patient.’”


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