tag:blogger.com,1999:blog-26666124.post169733794535528046..comments2024-03-18T03:28:36.581-04:00Comments on Shrink Rap: On Giving Gifts to Patients: Where's Your Line? Unknownnoreply@blogger.comBlogger14125tag:blogger.com,1999:blog-26666124.post-7665377623857174762013-12-25T17:59:17.067-05:002013-12-25T17:59:17.067-05:00A further thought: one of the problems with barter...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. jessehttps://www.blogger.com/profile/11077223398907532291noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-55754334626415558392013-12-24T23:02:01.463-05:002013-12-24T23:02:01.463-05:00@Anonymous: These are good questions. The first pa...@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?<br /><br />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. <br /><br />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. <br /><br />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. <br /><br />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?<br /><br />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. <br /><br />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.<br /><br />It's Christmas Eve, though, and this is much too complex a subject to explore further tonight!jessehttps://www.blogger.com/profile/11077223398907532291noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-71863014622941966522013-12-22T00:55:32.222-05:002013-12-22T00:55:32.222-05:00What about bartering ,especially with long time pa...What about bartering ,especially with long time patients who have suffered financial downturns, who have skills or goods I need?<br />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?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-7848941629603651212013-11-26T13:13:34.885-05:002013-11-26T13:13:34.885-05:00Great topic (that I'm coming to late). Freud ...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.Steven Reidbord MDhttp://blog.stevenreidbordmd.comnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-91952646829653679792013-11-21T00:12:48.001-05:002013-11-21T00:12:48.001-05:00My second psychiatrist lent me an Ella Fitzgerald ...My second psychiatrist lent me an Ella Fitzgerald CD he hadn't opened yet, I've still got it (oops).<br /><br />Then I have another story but I'd rather share that story privately.<br /><br />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.<br /><br />8DSarebearhttps://www.blogger.com/profile/09208596053319110470noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-30136070017951170722013-11-17T00:21:37.212-05:002013-11-17T00:21:37.212-05:00Sorry I'm a few days late with this comment! Y...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. <br /><br />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. <br /><br />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.<br /><br />- Odd DuckAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-25334423759133353592013-11-16T01:51:20.917-05:002013-11-16T01:51:20.917-05:00My T loaned me a book to read once which I returne...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!<br />Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-67758192594748413972013-11-14T13:06:14.739-05:002013-11-14T13:06:14.739-05:00One of the problems with rigid boundaries is that ...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. <br /><br />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.<br /><br />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.jessehttps://www.blogger.com/profile/11077223398907532291noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-4220859625966855322013-11-14T07:07:56.518-05:002013-11-14T07:07:56.518-05:00Good post. My first thought was that I never give...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.PDF docnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-21048059514297862072013-11-13T19:11:58.751-05:002013-11-13T19:11:58.751-05:00Jesse, I agree. But if that ex-patient later feel...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.<br /><br />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 handout...in the clinics I've worked at, you don't get to request your doc.<br /><br />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. <br />He owes her nothing beyond a "thank you." <br /><br />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, etc...it should not be given. <br />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! <br /><br />Dinahhttps://www.blogger.com/profile/09227988351623862689noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-4220248664422160622013-11-13T15:52:27.326-05:002013-11-13T15:52:27.326-05:00A book related to something I'm going through,...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.<br /><br />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 <i>thinking</i> 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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-77253188644827925592013-11-13T13:07:40.497-05:002013-11-13T13:07:40.497-05:00Beware of giving money to patients, they network, ...Beware of giving money to patients, they network, and they will tell others who is a "mark" for getting cash from a provider.<br /><br />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?<br /><br />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.<br /><br />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".<br /><br />But, if you let the DSM and addiction psychiatry specialists control the debate...Joel Hassman, MDhttp://cantmedicatelife.comnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-89446613389526388052013-11-13T12:55:32.360-05:002013-11-13T12:55:32.360-05:00This is a great post, Dinah, and not just because ...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). <br /><br />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.jessehttps://www.blogger.com/profile/11077223398907532291noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-75788270054480614892013-11-13T10:01:44.025-05:002013-11-13T10:01:44.025-05:00Actually, in rethinking this, I may have once give...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. Dinahhttps://www.blogger.com/profile/09227988351623862689noreply@blogger.com