Holiday gifts from patients: When do they spell trouble?

The oil painting shows a serene ocean view with mountains on the horizon. A holiday gift from a patient, the artwork hangs in the Belmont, Mass., office of psychiatrist David Brendel, MD, PhD. A note on the back reads, "Dr. Brendel, thank you for helping me to always see the long view."

Each year around this time, Ruth Haskins, MD, a Folsom, Calif., obstetrician-gynecologist, receives a White House ornament. She once did an ultrasound on a patient, allowing the woman's parents, who were visiting from Washington, to see their unborn grandchild.

"That was 7 years ago. They have given me a new ornament every year since," Dr. Haskins said. "Each reminds me of how my care affects a network beyond only my patient, extending to her circle of friends and family, near and far."

Patients give presents year-round, but gift-giving is heightened during the holidays as many physicians find themselves the recipients of patients' Christmas cheer. Some common gifts include scarves, bottles of wine and a variety of baked goods.

In most cases, presents from patients or their loved ones are genuine expressions of appreciation for medical care, guidance or a kind bedside manner. But medical ethics experts say doctors should think twice before taking that Christmas or Hanukkah gift -- and consider whether it could affect how they care for the patient.

"They do have to be thoughtful about it. Especially this time of year, it is good to anticipate that gifts may be coming," said Dr. Brendel, who teaches medical ethics at Harvard Medical School.

The complexities of doctor-patient relationships mean complications can arise from accepting or declining a patient's gift, said Elizabeth Gaufberg, MD, MPH, an internist, psychiatrist and director of the Center for Professional Development at Cambridge Health Alliance, a Harvard-affiliated public health system in Cambridge, Mass. Physicians should consider scenarios in advance so they'll know how to respond when the time comes.

"The vast majority of gifts are given out of a very generous place and can be accepted," she said. "You have to ask yourself, 'What's in the best interest of this patient, and what's in the best interest of your doctor-patient relationship moving forward?' "

Using common sense

As a young family physician, Richard Kovar, MD, drove 45 minutes up a rugged Virginia mountain road for a home visit to a 92-year-old woman who lived alone. Dr. Kovar was enchanted by her stories and they talked for some time. As he got up to leave, she went out to her garden, bent down and dug up two yams for him.

"That is probably up there in the top gifts in my life," Dr. Kovar said.

The story illustrates how doctors must be sensitive to patient feelings. Gift-giving may be an integral part of a patient's culture. If patients are poor, that yam or homemade pie may be a means of giving back in the only way they can. Each gift should be considered case by case, he said.

"There's no clear line of demarcation," Dr. Kovar said. "You have to use common sense."

Federal laws prohibit physicians from accepting gifts from anyone in a position to refer or generate business for them, or anyone with whom they have certain financial relationships, said health care attorney Ericka L. Adler. She is a partner with Kamensky Rubinstein Hochman & Delott LLP in Lincolnwood, Ill.

"When we talk about the average patient who wants to give something to a doctor, there are really not a lot of rules," Adler said. "If the person giving it to you has an ulterior motive and you know it, you shouldn't accept the gift."

American Medical Association policy, adopted in 2003, advises doctors to consider whether they would be comfortable if colleagues or the public knew about the gift. Patient gifts shouldn't be accepted if they are meant to encourage preferential treatment or if accepting them presents a hardship for the patient or his or her family.

"No fixed value determines the appropriateness or inappropriateness of a gift from a patient," the policy says.

Saying no the right way

In one instance, Dr. Kovar said a patient offered him a hot tub cover worth about $200. He needed one at the time, but he declined.

"That would have been totally inappropriate," he said. "I told him I just really wouldn't feel comfortable taking it."

Doctors should consider the monetary value of the gift, especially relative to the patient's income level and community norms. For example, a gift worth $200 from a wealthy patient may be OK, whereas a gift valued at $50 from a homeless patient would be unacceptable, Dr. Brendel said.

In other cases, patients may give something that is rare but doesn't necessarily cost a lot, such as highly sought-after sporting event tickets. "Judgment might be clouded in some way when the gift is so desirable," Dr. Brendel said.

Physicians also must ask themselves whether declining the gift would hurt the patient. Saying no "could be so hurtful that their treatment relationship with the patient may be broken," Dr. Brendel said.

Doctors should be sensitive when refusing a gift, said Dr. Gaufberg, also an assistant professor at Harvard Medical School. They should acknowledge and thank the patient for his or her generosity. They may cite a personal or institutional policy prohibiting them from accepting gifts, or explain that they don't feel comfortable accepting it.

Doctors also may choose to donate a gift to charity or share it with other medical staff. "It's a real skill to decline a gift in a way that feels respectful of the patient," Dr. Gaufberg said.

Early in her career, Dr. Haskins 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, Dr. Gaufberg said.

"In most cases, gifts are wonderful ways of showing appreciation," she said. "In a very human way it is the way we express gratitude."