VIP Medicine: A Double-Edged Sword

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COMMENTARY

There is a lot of fear about the impact of a psychiatric diagnosis in both the military and the civilian community. Service members and families can be resistant to the label and fear the professional repercussions that may come with treatment. However, without naming an illness, it can be nearly impossible to get the appropriate treatment, and poor health outcomes and ongoing suffering persist. This is only magnified in patients who are seen as “special.”

Here we share 2 stories of 2 different people. One was in the Army, and the other, in the Navy. One was a senior citizen, and one was young. One was a man, and one was a woman. They had widely different career specialties. Both had been impacted by serious mental illness while in the military, and both were initially undiagnosed because clinicians wanted to keep them under the radar and help preserve their careers.

Both were handled with kid gloves—the recipients of “very important person (VIP) medicine”¹ due to military rank or relationships within the medical system. These patients had potential, or long and successful careers in front of them. No one wanted to ruin that.

In the end, it took close to 2 years for either of these individuals to get the full, appropriate treatment that they needed. This lag led to illness exacerbations and delayed recovery. It could have led to death.

Lieutenant Quinn’s Story

I had been in the Navy for less than a year when a drunk driver nearly killed 2 members of my crew at the local volunteer fire department. I spent the better part of the next 2 years on short temporary duties (TDYs) as a medical student, intermittently touching base with a therapist but otherwise self-managing my posttraumatic stress disorder (PTSD) and depression as they developed into a full-blown eating disorder.

I was rarely around colleagues who knew me well, and since I kept meeting standards, I flew under the radar. It was only at the end of this time that my decline became rapid. I ate less and exercised more. I knew something was not right, but I did not want anyone to notice.

But people did notice, eventually. I brushed off comments and played dumb when concerns were brought up in medical appointments. It was only when I was directly confronted by a physician-mentor that I broke. But I refused to engage in treatment until my body quite literally gave up on me.

None of my clinicians had specialty training in treating eating disorders, and that was exactly what I wanted. I threatened to disengage from care if they asked me to get evaluated by an eating disorder treatment program or just see a dietician. I was so close to graduating from medical school that I was more worried about losing my future career than I was about losing my life.

My treatment team recognized that I had “promise” as a future military physician, and I did not want to do anything to compromise that. That desire ultimately drove my treatment plan forward. I refused recommended interventions if I thought they would put my career in jeopardy.

I recognize that I was very lucky. Although I was extremely resistant to making changes or engaging in formal treatment, I trusted my team and followed their recommendations, albeit slowly. It took 6 months for me to start seeing a dietician and 18 months for me to start an intensive eating disorder treatment program.

If I had accepted full treatment right away, full recovery would have started much sooner, and I could have saved myself so much pain and unhappiness. But if I had, I might not still be in the Navy, and I might not be a physician. I truly believed that I was choosing between my future as a military physician and my future physical health, which felt like an impossible choice at the time.

Major General Martin’s Story

After decades of successful Army service, the intense stress, thrill, and euphoria of combat leadership during the Iraq War triggered my genetic predisposition for bipolar disorder in 2003. For the next 11 years, my bipolar disorder was unknown, undetected, and undiagnosed. Although it initially boosted my performance, over the next decade, it led to higher highs and lower lows, ultimately rocketing into full-blown mania in 2014, followed by hopeless, debilitating depression and terrifying psychosis.

I was removed from my 2-star command of the National Defense University, ordered to undergo a psychiatric evaluation, and compelled to retire—a decision I support. After 3 misdiagnoses that found me “fit for duty” in July 2014, while I was acutely manic, I was properly diagnosed with bipolar I disorder in November 2014.

It seemed my military doctors were somewhat intimidated by my rank and did not know quite what to make of a 58-year-old, 2-star general with bipolar disorder. They respected the rank and my successful career and did not want to see me “hurt” by the treatment process.

They gave me the choice of treating my bipolar with strong medications, possible inpatient hospitalization, and a medical evaluation board, or “staying under the radar,” until my retirement 6 months later. This meant no lithium (the gold standard of bipolar medication and mood stabilization, but a clear “red flag” that I had bipolar), no inpatient care (another red flag), and no medical board—but I would get to retire with minimal attention and no bureaucratic delays.

To ensure that I stayed under the radar, the bipolar diagnosis was not entered into my military medical records until just prior to my retirement. In retrospect, it was probably a choice that never should have been offered to me because it delayed the treatment I needed and caused my condition to deteriorate badly.

On the other hand, it prevented me from undergoing the stress and bureaucratic “torture” of a medical evaluation board, which might have lasted many months, even years, and kept me in a limbo-like holding pattern, as opposed to allowing me to retire cleanly in just 6 months.

All in all, my bipolar illness continued to get worse during those last 6 months of active-duty military service. I could have become a statistic and another tragic story of unexpected senior leader death by heart attack, car accident, violent encounter, or suicide. For the next 2 years, I was in a fight for my life, crippled with visions of my own gruesome, violent, and bloody death, known as “passive suicidal ideations.”

After 2 years of medical treatment, the love and support of my wife, my family, and friends, God’s grace, weeks of hospitalization in a VA psychiatric facility, and the natural element lithium, I began to pull myself out of the pit of bipolar hell.

In principle, I believe that all service members should receive the same standard of care, whether junior enlisted or flag officers. But when faced with my unique situation, the doctor made what he believed was the best choice for the patient: to get me cleanly to retirement and avoid what he saw as the worst case, which was undergoing a lengthy medical board.

We even queried another flag officer who faced the same decision. He strongly advised me to avoid the medical board at all costs, as the stress and pain it induced was awful and severely exacerbated his already serious mental condition.

The good news is that I made it cleanly to retirement, underneath the radar. The bad news is that my bipolar condition got dramatically worse—and even could have killed me—since I had not received the required treatment. I also retired and entered the civilian world as a complete zombie, with no continuity of care plan to speak of, and I was completely incapable of navigating myself through the non-military health care world. I count myself lucky to be alive. Could all this have been avoided had I not received VIP medicine?

Conclusions and Recommendations

So what went wrong in the handling of our cases? We ask this not to find fault, but rather to share lessons learned through our combined hindsight, education, and experience.

VIP medicine recognizes that celebrities, political leaders, senior physicians, and other patients who command respect (or cause intimidation) suffer worse health outcomes than their everyman peers due to the special treatment they are given. These patients are often able to direct their care, and the treating medical teams are far more deferential to the patient than they would normally be.

This is not to say that medical teams intentionally make decisions that lead to worse outcomes. In most cases, they are trying to do the best for their patients in situations when remaining purely objective is difficult. Remaining objective in medicine can be challenging when physicians form relationships with their patients, and even more so in small communities where there is interaction outside of the clinic setting. Standards of care were developed because they work—and every patient deserves to receive the standard of care.

Within the structure of the military, it can be difficult to separate individuals from their ranks. But in medicine, it is crucial to be able to do just that. Treatment should not vary just because the patient is a civilian, a non-commissioned officer (NCO), a mid-grade officer, a junior enlisted, or a flag officer.

Physicians everywhere need to be able to stop and ask themselves, “Would I offer the same treatment if I did not know who my patient was?” If there would be a difference in treatment, then they need to ask why. There is room for individual practice in the art of medicine, but it should never come at the cost of patient outcomes.

Dr Martin is a 36-year Army combat veteran, a retired 2-star general, and a bipolar survivor, thriver, and warrior. As the former president of the National Defense University, he is a qualified airborne-ranger-engineer and strategist. He has commanded troops in combat and led organizations ranging from a platoon of 30 soldiers to a base of 30,000 civilians and military. A graduate of West Point and MIT, he is an ardent and full-time mental health advocate. He lives with his wife in Cocoa Beach, Florida, where he writes, speaks, and confers. His forthcoming book, entitled Bipolar General: My Forever War With Mental Illness, will be published by the US Naval Institute Press.

Dr Quinn is a psychiatrist in the US Navy. She is a graduate of the University of Maryland and the Uniformed Services University, and she is the 2022 recipient of the Albert J. Glass Award for Excellence in Military Medicine Research. She is a 15-year veteran of the volunteer fire service and currently serves as a lieutenant in her local fire department.

These views are those of the authors and do not necessarily represent the views of the US Department of Defense or the US government.

Reference

1. VIP medicine. Wikipedia. Last updated January 3, 2023. Accessed October 20, 2022. https://en.wikipedia.org/wiki/VIP_medicine