Caring for 'Very Important Patients'--Ethical Dilemmas and Suggestions for Practical Management.

The care of Very Important Patients (VIPs) is different from other patients because they may receive greater access, attention, and resources from health care staff. Although the term VIP is used regularly in the medical literature and is implicitly understood, in practice it constitutes a wide and heterogeneous group of patients that have a strong effect on health care providers. We define a VIP as a very influential patient whose individual attributes and characteristics (eg, social status, occupation, position), coupled with their behavior, have the potential to significantly influence a clinician's judgment or behavior. Physicians, celebrities, the politically powerful, and philanthropists, may all become VIPs in the appropriate context. The quality of care may be inferior because health care professionals may deviate from standard practices when caring for them. Understanding the common features among what may otherwise be very different groups of patients can help health care providers manage ethical concerns when they arise. We use a series of vignettes to demonstrate how VIPs behavior and status can influence a clinician's judgment or actions. Appreciating the ethical principles in these varied circumstances provides health care professionals with the tools to manage ethical conflicts that arise in the care of VIPs. We conclude each vignette with guidance for how health care providers and administrators can manage the ethical concern.

Nonurgent use of the emergency department.

Emergency department (ED) overcrowding by low-acuity patients is a recognized problem. There is little in the literature on why patients with minor problems and an established primary care physician (PCP) present to the ED. Two hundred forty low-acuity patients with a PCP were surveyed regarding their reasons for presenting at a University of Colorado ED. Inability to schedule a rapid clinic/office appointment, advice by PCP to utilize the ED, and high self-perceived severity of illness were the primary reasons for ED usage. Increased patient education about the range of conditions appropriate for care in the PCP office and more availability of office appointments could potentially decrease the ED usage by patients with low-acuity problems.