Beware of Patients Bearing Gifts
Make sure it’s ethical to accept tokens of appreciation, and have a policy in place if it’s not.
By Julie E. Chicoine, Esq., RN, CPC, CPCO
The holidays are upon us. The season of giving starts weeks before Halloween, when store shelves are already filled with yummy treats. Then, before the last child rings your doorbell and screams “Trick or treat!” retailers are stocking up with Thanksgiving, Christmas, Hanukkah, and Kwanzaa inventory. The later end of the Western calendar is all about gift giving. And while patients give gifts year around, such habits intensify during the holiday season, which can sometimes create ethical issues for physicians.
Unlike guidance for physicians regarding gifts from pharmaceutical and medical device industries, there are no clear rules surrounding gifts from patients. Most often, patients’ gifts merely serve as a gesture of appreciation for a difficult episode in their life, or for ongoing support of a chronic illness. Unfortunately, some gifts can be too personal or pricey, causing uneasiness or embarrassment for the physician. The American Medical Association (AMA) long ago recognized ethical issues posed by patient gift giving, and offers guidance.
Is the Gift within Acceptable Bounds?
One way to determine if a gift can be accepted is whether, upon accepting the gift, the physician would have no problem with his or her colleagues, peers, or the public knowing about it. For example:
- Gifts that are of minimal value, or that can be displayed or shared with staff—such as chocolates, flowers, baked goods, etc.—are the least likely to cause any concern because they merely convey appreciation for a job well done.
- Gifts of nominal value, such as photos of a patient following recovery and returning to a normal life, serve as a keepsake and demonstrate gratitude for a successful outcome.
- Gifts that are clearly expensive or personal, not prone to sharing with staff or to putting on display, can lead to unease. For example, I was once consulted by a physician/client who unexpectedly received a large and expensive box of premium Kansas City steaks. Given the size and cost of the gift, the physician felt deeply uncomfortable, feeling that the gift exceeded professional boundaries and seemed too personal. The steaks were returned with a polite letter.
The AMA guidance generally counsels 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.
What Is the Motive?
The AMA recommends that physicians be sensitive to and aware of the circumstances surrounding patient gift giving. For some societies, gift giving may be a custom that reflects important personal values. In such situations, a physician needs to be sensitive to the patient’s cultural morés, so as not to offend the patient should he or she decline the gift.
In infrequent situations, gifts may be significant and conveyed with the intent to encourage preferential treatment or to influence desired patient care. This form of gifting creates conflict in the physician/patient relationship because the patient’s ulterior motive may undermine the physician’s ability to provide necessary patient care that the patient needs—not necessarily what the patient wants.
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 health care program (i.e., Medicare or Medicaid).
Learn to Say, “Thanks, but No Thanks”
Because there are no clear boundaries surrounding patient gifts, the AMA recommends considering each gift on a case-by-case basis. The physician should consider the value and timing of the gift. The more personal and expensive the gift, the more likely it will create complications or expectations for the physician. To avoid undue influence on the physician/patient relationship, the AMA suggests the gift’s value (relative to the patient’s or the physician’s financial means) not to be disproportionately or inappropriately large.
Best practices for handling gifts should include an office policy that sets limits on gifts for the practice in general, from both patients and industry representatives. Such a policy affords a physician the ability to politely decline an inappropriate gift without risk of offending a patient.
Further information about physicians accepting gifts can be found at the AMA’s website.