Wednesday, November 13, 2013

On Giving Gifts to Patients: Where's Your Line?

There is an interesting article in the New York Times by Abigail Zuger called When Healers Get Too Friendly.  The author talks about giving a patient her old laptop, stripped clean, with no other useful destination but the back of a closet, and most likely, ultimately the trash. Dr. Zuger writes:

And now it is suddenly decades later, his H.I.V. has long been perfectly controlled, and he is still fomenting revolution. He used to march and holler; now he works social media with a miserable old desktop computer that keeps breaking down.
As it happens, about a week before one of our infrequent appointments — he barely needs me any more — I had treated myself to a brand new laptop, sending an old perfectly good model into the back of the closet.

Of course I wiped its hard drive clean and gave it to him — for he is my old friend. But (also of course) we met furtively in a back corridor and I carefully concealed the contraband in a nest of old grocery bags — for he is my patient, and gifts to patients …well, we don’t usually do that.

Once again, apparently, we were dealing with two incompatible positions. Everyone knows that professional boundaries guide all medical activity in hospital, office and clinic. But aside from indisputable sexual and financial depredations, no one agrees exactly where these boundaries lie.

She goes on to write about a physician who was reprimanded for violating boundaries:

The incident that it set it off: Dr. Schiff (now 63, an experienced senior clinician) had tangled with an insurer on the phone for two hours before he gave up and handed an impoverished patient $30 to pay for her pain pills. A resident observed the transaction and turned him in. But Dr. Schiff is a proud repeat offender, whose past infractions include helping patients get jobs, giving them jobs himself, offering them rides home, extending the occasional dinner invitation and, yes, once handing over a computer.

He was told physicians should stay away from “random acts of kindness” — an activity that may sound harmless but is quite distinct from the practice of medicine, and has its risks. Patients might get too familiar, expect too much.  

You can read Dr. Schiff's response here -- well worth it.

Oh, my, we're all in this world together as sometimes wretched human beings trying to eek through the pea soup of life.  Isn't it nice if Dr. Zuger's trash can help someone's life be a bit more comfortable,  pleasant, or productive?  Isn't being a doctor about being kind to others or do we need to confine it to whichever activities are randomly designated as "healing"?  

With psychiatry, it gets stickier, because we care about the meaning the transactions have with out patients and how our actions can be interpreted and misinterpreted.  Still, I like being helpful to people and the line is not clear.  For me, there are a couple of lines here that are very clear: I would never give a patient cash.  I think money is too loaded a subject, and as the doctor writing pointed out, she once gave a patient $20 and the patient, who needed care, did not come back for a very long time because she was waiting to be able to repay the doctor.  But I don't give cash to anyone but charities (--except as holiday/birthday gifts to select individuals) because the issues of how it might effect a relationship are so complicated.  This is why people give gift cards (which  limit the giftee's spending options) or a pay a premium to give an American Express gift card (which is paying a fee to essentially give cash).  And I don't transport patients, because I'm not comfortable doing that.

But where's the precise boundary?  I'll hunt for samples for an uninsured patient.  When my computer works, I may download a form and sign off on someone's need for a handicap parking permit, even though it's not for a psychiatric reason -- but I like to be a nice person and it saves someone a trip to their doctor with the mobility issues and expense, and if they've been talking about it and just not getting there, I like being helpful.  I don't prescribe pain meds, at all, ever, but they can't be called in and I once wrote for a few for a cancer patient whose oncologist was an hour drive away.  If it's cold and I'm making myself a cup of tea, I may put one out for my next patient.  I often suggest articles or books I saw that a patient might enjoy, and I once emailed along a job listing -- nothing bad happened from that but the patient didn't apply for the job and I decided I shouldn't do that anymore because I don't want to be one more person he disappoints by not getting a job.  I've recommended other doctors in other specialties and other psychiatrists (Jesse! being one) for relatives of patients, and I've asked people I know with medical problems about their experiences and shared them with my patients.  I wish I could serve homemade cookies at the holidays.  Another psychiatrist once asked me what I thought of his hiring a patient who wanted the job as his assistant and I said, "You can't hire your patient."  In psychiatry, that seems obvious, if for no other reason than the relationships would conflict and one patient would have access to another's information and that seems wrong.  It turned out the other doc wasn't really asking because he was considering this, but he wanted to say to the patient "I consulted a colleague and who said this is unacceptable."  

Don't sleep with or kill your patients.  That's pretty clear. 

Where's your line?  What have you done, or not done, for a patient?  What has your psychiatrist done for you and how did you feel about it?  What do you wish they'd do for you? 


Dinah said...

Actually, in rethinking this, I may have once given a clinic patient the $1 or $2 Medicaid copay to get a medication. When someone would tell me they couldn't afford a medication co-pay, I'd grill them about their smoking habits..and suggest a few less cigarettes a day to cover the cost of the copay. (The medicaid co-pay for one month of a medicine is less than the cost of one pack of cigarettes) When a patient said they had no money, no access to the copay, and didn't smoke, I handed over a few dollars and said "use it for the medicines." Not to make the point of my exceeding generosity here but I did say "never" so change that to I almost never give patients cash.

jesse said...

This is a great post, Dinah, and not just because I am mentioned. Yes, there are certain rules in which "never" applies but it is also the case that seemingly reasonable rules can be also quite unreasonable. Examples: don't give money to a patient (but it is totally ethical to reduce one's fee for a patient), don't provide transportation (years ago I heard this example: a psychoanalyst was driving in a snowstorm and saw one of his patients struggling along on the sidewalk. He drove on by, seen by his patient. The treatment collapsed due to the total lack of empathy. There are times when being a human being comes first, a doctor second, and a psychiatrist third), don't date a former patient (this usually very reasonable rule which is even part of the APA Ethics Guidelines can have bizarre outcomes: consider the psychiatrist who sees a psychiatric resident one hour only for anxiety before a conference and then fifteen years later meets that same person at a party and they start dating. A former patient! An ironclad rule! The loss of a license! I am making this incident up but it probably occurred somewhere - yes, it might remind you of Les Miserables).

So rules have exceptions. We should always consider the reasons and circumstances and consult with colleagues. The goal is to thoughtful and aware that all of our actions have meaning to our patients. The psychiatrist who considers himself the last and only word has a major problem.

Joel Hassman, MD said...

Beware of giving money to patients, they network, and they will tell others who is a "mark" for getting cash from a provider.

How would you feel if that $1 ended up being the last dollar needed to get that cheap 1/5, and after the patient got drunk that same night had a negative outcome?

That happened to a clinician I worked with years ago, and the patient had the nerve to tell the therapist it was the therapist's fault the patient drank and ended up with consequences.

Another reason to love working with primary substance abusers with secondary, if not situational Axis 1 issues. Note I did not say "Axis 1 disorders".

But, if you let the DSM and addiction psychiatry specialists control the debate...

Anonymous said...

A book related to something I'm going through, a grounding token that I need to return after breaks, serving a drink/snack you're having that is available to all clients... all things I would be comfortable with.

Money? An old laptop? A drive home? I could never, ever, accept that, and the discomfort in having to turn it down is insurmountable just in thinking about it. It feels like a massive boundary violation on my side of things as the patient - I'd rather be asked how I can obtain these things myself even if such is impossible than be put in a position where I feel like my therapist isn't just my therapist anymore and I now owe a debt to them that I'll be worrying about instead of how to resolve the issues I come in to discuss.

Dinah said...

Jesse, I agree. But if that ex-patient later feels slighted (because all love affairs don't end well) she may still use it against the shrink she saw once. I don't know how that might end, especially if he didn't remember having seen her. I always wonder how this works out with the no-affairs with patients idea in a small town with and ER doc or the only gynecologist. Can you see recruiting for that job: we have an extreme doc shortage here, you'll be the only one in your specialty and I see you're not married, so remember that you'll be treating all the women and you can't date anyone.

Joel, I would worry about a patient using money I gave them for things that might damage their health, and I do think that handing over cash is rather complicated, but maybe some gentle approach to the concept? And I personally would really not worry that I'd be sent a long list of referrals for a one-dollar the clinics I've worked at, you don't get to request your doc.

Anon, the laptop doc was not a psychiatrist. I think if she had something better to do with it, she would not have given it to the patient. I think he was doing her a favor by taking her clutter, letting her closet space go clear, and relieving her of the guilt she would have had for buying a new laptop when her old one was perfectly good.
He owes her nothing beyond a "thank you."

Boundaries can't be totally rigid (except no sex, no violence, don't do illegal drugs with your patients, and don't invest with them)... but if the doctor expects something in return for a gift, a favor, should not be given.
Personally, the doctor who got frustrated at 5 pm after 2 hours on the phone with the insurance company trying to get the $30/drug authorized is owed something by someone. It may not have been a gift, it may have been a means to get the problem solved so he could finish his work and go home already!

PDF doc said...

Good post. My first thought was that I never give gifts to patients...but I recently gave my two old file cabinets (headed for the dump if a better home wasn't found)to a patient. She is a longtime patient and on disability. My decision to give these to her was made purely on gut instinct, which I know can lead to trouble. It just seemed to be the reasonable thing to do! I have also sought out samples for this patient and others: I don't consider giving out samples as giving gifts though. So, yes I do give gifts to patients.

jesse said...

One of the problems with rigid boundaries is that at times we are faced with the extremes and we had not extrapolated enough to imagine them. There certainly are absolute boundaries, as Dinah said, but the problems too can come from over rigidity and turning colleagues in for just doing the human, kind thing.

The basic rule I follow is to try to see, or imagine, as to what any given thing means to a patient, and then see if the patient has been able to talk about it.

So if you let a patient take home a magazine he was reading in the waiting room, it is a good idea to think about what that might mean to the patient. Often times the most valuable insights come from examining the smallest things.

Anonymous said...

My T loaned me a book to read once which I returned the next session. She buys fresh cut flowers for the office every week, which is a kind-of-a gift that I always take a second to appreciate. I like that she has boundaries… keeps it easier for both of us. I did have a really dry throat once and was coughing and had trouble talking -- she didn't offer any water, which I noted, but I did have water in my purse. When the same happened to her once, she simply left the room for water -- I guess i could have done that, too, but felt tied to the couch for some reason!

Anonymous said...

Sorry I'm a few days late with this comment! You mention about not hiring a patient for a job, but what about seeing someone who recently worked for you as a patient? That's what happened to me. They were the first psychiatrist I ever saw (as a patient). Maybe I'm not the norm, but when I worked for my psychiatrist as the office person I saw our relationship as a business relationship only. I knew we weren't friends even though we got along great. Now that I see them as a patient, it is a patient/doctor relationship period. I'm able to distinguish the two and not cross boundaries by thinking we are more than just patient/doctor. Maybe that is one of the reasons why my doctor felt comfortable enough to give me a bicycle they got from a friend. This happened after seeing them for years as their patient, so they knew that I wasn't one to misinterpret the gift as anything other than them trying to help me out.

I can completely understand why it can be a dangerous line to cross though. In my case, they knew me and what I was like outside of a clinical setting way before seeing me as a patient. I'm sure that played a big part in the decision to give me the bike.

I'm not a big fan of no tolerance rules (except for obvious things like sex & murder) because there are always grey areas that need to be addressed on a case by case basis. Otherwise, you have things going on like at schools where 5 year olds are expelled because they brought a toy gun to school.

- Odd Duck

Sarebear said...

My second psychiatrist lent me an Ella Fitzgerald CD he hadn't opened yet, I've still got it (oops).

Then I have another story but I'd rather share that story privately.

I tried to comment a few days ago but i hate it when i get one written up and then the whole thing gets erased just as I'm about to post . . . . But it worked this time.


Steven Reidbord MD said...

Great topic (that I'm coming to late). Freud himself gave his patients hot drinks and blankets on cold days in his consulting room. As Jesse said, "rules" are not important in themselves, it's the meanings and associations attached to those rules. Some patients appreciate small gifts (e.g., taking home a magazine from the waiting room), while others find it an uncomfortable boundary violation. I personally would not offer anything of significant value to a patient, aside from the therapy itself, before carefully considering whether it is a countertransference enactment. But in some cases, I'm sure it's a win-win all around.

Anonymous said...

What about bartering ,especially with long time patients who have suffered financial downturns, who have skills or goods I need?
Another question- a long time pt. was impaired from a new med, and sideswiped a few cars on her drive to my office. As she lives only a few miles away, and i was going in her direction, and she had no one available to pick her up, I drove her home. Was that ok?

jesse said...

@Anonymous: These are good questions. The first part is "bartering, especially with long time patients who have suffered financial downturns, who have skills or goods I need?

The devil is in the details. The basic concept is that we should take no advantage of our patients and that the terms be clear, and without hidden entrapments. So if a patient said "I owe you a thousand dollars which I cannot pay, would you accept this ceramic vase which sells in stores for seven hundred" that would be different from his saying that the vase sells in stores for two thousand but the store gives him a thousand. It would be taking advantage of the situation to get a bargain price, and that would seem to me contrary to the best interests of the patient.

Similarly, if a patient were a house painter and offered to paint your house in trade, what do you do if the work is not to your liking? How would the value be determined? What are the consequences of the patient being in your house? The patient is at a disadvantage, and the doctor might be, too.

So a simple one time trade of the work for a vase worth no more or even less than the work might be OK, but if there is any hint that the patient could be at a disadvantage or that the doctor is profiting from the trade it is a bad idea.

These are situations to be discussed in detail with colleagues! One legal wrinkle: how does the doctor declare this on his taxes? Does the patient think this is an "under the table" deal and that the doctor is not declaring taxable goods? What does this do to the treatment?

The second part: "a long time pt. was impaired from a new med, and sideswiped a few cars on her drive to my office. As she lives only a few miles away, and i was going in her direction, and she had no one available to pick her up, I drove her home. Was that ok?" Wow. Again the details are all important: She acknowledged sideswiping a few cars? Did she stop and give them insurance information, or if they were parked, leave a note? What were the options available? What specifically were the circumstances? What were the possible alternatives? Imagine two scenarios: a female psychiatrist driving home an elderly female patient. The session was at night, bad weather, and she is afraid to drive home, may still be "under the influence," and no one else is available to pick her up. The second is a male psychiatrist driving home a woman or girl, depressed, who has an attraction to him. Or he to her.

The basic principle is that we need to act in the patient's interest, not our own. It is frequently the case that supervision or simply discussing the situation in detail with a colleague is very helpful.

It's Christmas Eve, though, and this is much too complex a subject to explore further tonight!

jesse said...

A further thought: one of the problems with bartering is that both parties are not completely free. The doctor might not really want that vase, would not have bought it on his own, and so on, and so may feel some resentment. The patient may feel the same way, that he did not get what he deserved. There are many pitfalls.