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?