Ah, the holidays – the season of giving. It’s the time of year when patients want to express their gratitude for your care with gifts that may range from the ridiculous to the sublime. They are all given with good intentions, but should you accept them? And if you do, are all gifts created equal? Is a tin of cookies the same as a gift certificate or a day of golf? Federal law makes the decision for you in some cases, but in others, the judgment call will lie squarely on your shoulders.
Federal law regarding gifts is very clear; if the person giving you the gift is in a position to refer or generate business for you, or someone with whom you have a financial relationship – you cannot accept it; end of discussion.
When it comes to deciding whether to accept a gift from a patient, there is no federal law to guide you and the waters are much murkier. Your decisions have to be made based on the size and intent of the gift and the relationship you have with the patient. That means that every case will have to be decided on its own merits. Accepting a homemade sweater from an elderly patient might be appropriate whereas accepting game tickets from a well to do patient would be unseemly. There are no real guidelines here except your gut and your relationship to the patient. In an effort to help your decision making, here are some philosophical guidelines.
What is the patient’s motivation?
If there is an ulterior motive in giving you a gift then your answer should be “No thank you”, especially if the patient is seeking preferential treatment. The AAPC (Advancing the Business of Healthcare) explains it well saying, “If a patient provides gifts with the expectation of receiving something in return, such as medically unnecessary care, this creates the impression that the physician is making medical decisions, including utilization of and using medical services, based on gifts provided by the patient. Such gifting not only undermines the physician’s reputation for providing objective, medically necessary care, but could potentially implicate the federal anti-kickback statute, which makes it a crime to knowingly and willfully solicit or receive any remuneration (including gifts) in exchange for services reimbursable by a federal healthcare program (i.e., Medicare or Medicaid).”
“If a patient provides gifts with the expectation of receiving something in return, such as medically unnecessary care, this creates the impression that the physician is making medical decisions, including utilization of and using medical services, based on gifts provided by the patient.”
Is the gift within acceptable boundaries?
If you would have no problem telling your friends and colleagues about the gift, then it is probably ok to accept it. The AMA’s general advice is that the more unique and expensive the gift, the more likely it is to fall outside of professional boundaries surrounding the physician/patient relationship and to create ethical issues.
Does price matter?
It depends. Let’s say a corporate executive wants to give you courtside basketball tickets, or football playoff tickets. You know they probably didn’t pay for the tickets because they receive them as a corporate perk. It doesn’t matter; say no for two reasons. First, because it is a highly desirable gift that might cloud your judgment subliminally regarding this patient; and second, it is a gift that is rife with corporate conflicts and gifting rules.
How does the gift impact your relationship with the patient?
If refusing the gift will be so hurtful to the patient that it will damage your ability to treat them, then find a way to accept it. This scenario usually occurs with elderly patients who will be insulted if you say no. Advice printed in the New York Times expressed this well: “In some cases, to reject a gift could be very disruptive to the relationship,” said Dr. David Brendel, assistant professor of psychiatry at Harvard Medical School and chair of the institutional review board at McLean Hospital in Belmont, Mass. “What if someone has spent weeks knitting a beautiful sweater for their psychiatrist? To reject that kind of gift could be so hurtful it might actually destroy the treatment relationship.”
So, how do you say no?
When you have decided that refusing a gift is the right thing to do, say no gracefully and kindly so as to protect the patient’s feelings.
- Acknowledge the kindness of the gift and the thought behind it
- Thank the patient for his or her generosity
- Explain why you cannot accept the gift- personal, practice or hospital policy
- If it is a personal choice to say no, explain why you don’t feel comfortable accepting the gift
- Say no with warmth and sincerity and make eye contact with the patient
When nothing else matters but saying yes
Sometimes the gift is bigger than the patient or the physician. When it is given in recognition of a milestone or serves as a memorial to a life event, it should be accepted. A story published in American Medical News highlights these exceptional circumstances:
“Early in her career, a doctor treated a patient who had a complicated pregnancy after 11 years of infertility treatment. The baby was born by emergency cesarean section. The parents later gave the doctor a bronze statuette of an infant inscribed with the child’s birth date. Such gifts are cherished keepsakes that help remind doctors why they went into medicine in the first place — for the connections they have with patients.”
When considering whether or not to accept gifts from patients these factors will guide your decision. Only you know your patients. Your ability to treat and care for them is tantamount and safeguarding that relationship is the most important consideration.
On the other hand, some gifts will simply be easy to accept and then regift, such as the one that a doctor described to the BBC news service in the UK: “I once received a pair of socks with pictures of condoms on them, with the slogan ‘safe socks’.”