When I was a medical student, I often found myself in the hospital gift shop. The gift shop was an oasis for me, not only because of the expansive candy selection that palliated my sugar cravings, but also because I could see gift-givers in cross-section. Loved ones came in and out, buying balloons for newborns and flowers for their parents or children. One would buy a newspaper for her spouse to read; another doting husband would buy a scarf for his wife to hide the scar from her recent surgery. Through their gifts, they were not only showing their love, but also their hope and yearning for health, for success, for life. I found myself in the gift shop again on the day of my patient’s planned discharge to home hospice. She was an elderly woman with metastatic cancer. She had been admitted for nearly a month. As a third-year student, I had followed the course of her care throughout my time on the service. Every morning for that month, I walked into her room to ask how she was doing. I had watched her reach the limits of medicine; her disease was incurable. Perhaps it was just an instinct ingrained in me from my Italian-Jewish family, but I knew I could not leave the gift shop empty-handed. I settled on a stuffed animal, a black puppy. Gift-giving to physicians is a relatively common practice, albeit a controversial one. One study in the British Medical Journal found that 20 percent of physicians in Britain had received a gift in the previous month. The study was conducted from May to July and therefore did not include the holiday months, when gift-giving may be even more frequent. Some doctors believe that patient gifts may predispose them to favoritism; others are willing to accept small gifts of low monetary value. Giving gifts to patients is a much less frequent practice. We often hear anecdotes of our physician colleagues who offer a few dollars to a homeless patient so he can buy lunch from the cafeteria after his office visit. My father, a primary care doctor, once gave money to two patients, a husband and wife, so they could afford a Christmas present for their grandchildren during the holiday season. “You can’t get a patient a present,” one of my fellow medical students had said to me at the time I bought the plush puppy for my patient who was dying. He said I would set a “bad precedent” and traverse a “slippery slope.” I gave one to my patient anyway. I excused myself then because I was a medical student. I figured that I could create boundaries and rules for myself when I was a “real doctor.” Then I graduated to residency. One time, the gift I bought was for a gentleman with worsening heart failure. He had a large catheter in his neck, administering strong medications to keep his heart squeezing while providing his doctors with invaluable information about the pressures in his heart. He was waiting for surgery. The line in his neck tethered him to the bed or chair. His mind would race all day. So I slipped him a word search puzzle book without telling anyone. The next time was for a young woman who had been admitted for weeks awaiting a heart transplant. One day we heard the good news: a healthy young donor heart had become available for her. I commemorated the moment the only way I knew how: with an anatomically correct heart plush toy from the hospital gift shop. Patients give their doctors gifts for many reasons. Most often it’s to express affection or gratitude. But, as some point out, gifts can also be a means to gain attention or to manipulate physicians. According to the American College of Physicians Ethics Manual, the physician should consider the nature of the gift, its value to the patient and the potential implications for the patient-physician relationship. But what about the ethics of giving gifts to patients, whether it be a stuffed animal, a small amount of money or an old winter coat? Dr. Gordon Schiff, a primary care physician at Brigham and Women’s Hospital in Boston, gave a patient $30 to fill a prescription he could not afford and was reported for being unprofessional by a trainee who was shadowing him. Dr. Schiff subsequently wrote a compelling editorial in JAMA about the implications for physicians and patients of crossing boundaries. As he points out, physicians’ views on this topic vary widely, and are likely to be influenced by their practice setting, the culture of the institution, and perhaps the geographical region where they work. Personal belief systems also play an important role. Many doctors feel our moral and professional duties extend beyond just prescribing medications to alleviate pain and suffering. I believe that alleviating suffering involves providing comfort, solace and coziness, even if that takes the shape of a fluffy golden teddy bear. Erecting walls and fine lines in the sand may serve more to divide us from our patients. So, what were my motives for giving gifts to my patients? And what were the potential implications for my relationships with patients? Maybe I felt powerless or sad. The physical side of medicine can go only so far. In the hospital, people are isolated from their loved ones. The walls are cold, white and bare. Many wear hospital gowns rather than everyday clothing. Maybe I thought a small token would help my patients connect their days in the hospital to the outside world. Maybe a gift was my way of expressing hope and good wishes for the future. I am now finishing up my residency in internal medicine, but when it comes to gift-giving, I still have not created those boundaries that my medical school self had envisioned. Boundaries serve a few purposes: They avoid improper expectations, legal liability and confusion of personal and professional relationships. But they also can disconnect us from the patient experience, from the human experience. Source
