by Craig Klugman, Ph.D.
In an editorial in the Chicago Tribune, a physician tells the story of an underserved patient who owned a rib joint. The patient would bring ribs whenever he had an appointment. And once a year, the patient would come to the hospital just to bring a smoked Thanksgiving turkey to the physician.
The patient lacks insurance and thus is not able to get a badly needed hip replacement. As the story continues, the physician contacts an orthopedic surgeon in another health system in hopes of getting treatment for the rib-producing patient. After 4 years, a spot for a pro bono surgery opens and the “orthopedic colleague” sees the patient, who is now in intense pain and desperate need of a new hip. Recovery is successful and at the next clinical visit, the patient brings an “extra box of ribs.” A few months later, the patient dies.
The title of this piece is “Doctor-patient privilege yields rib tips,” a phrase that suggests that someone received privileged care—whether the patient got special care or the physician did is not clear—because of the ribs. Newspaper editors often write editorial titles, so the writer may have not had a say in this interpretation.
Most interesting is a paragraph from the beginning of the essay: “It was slightly unethical to schedule an extra clinic visit each year for those ribs, but they were worth it.” In one of the nation’s largest circulation newspaper, this physician states that he scheduled appointments not for the patient’s benefit, but for a delivery of ribs.
What does is mean that something is “slightly unethical?” That seems similar to being “slightly pregnant:” Either you are or you aren’t. The giving and receiving of gifts within the context of the physician-patient relationship occupies a grey area open to interpretation. But within a specific context an action either is or is not ethical. Patient giving a car to a physician to get a surgery is not ethical. Patient giving muffins to a physician as a thank you for good care, probably is ethical. This “slightly unethical” phrasing suggests that the physician knew that this exchange was wrong, but did not want to stop because he personally benefited.
Patients have given gifts to physicians for millennia for several reasons. Sometimes these gifts are payments in lieu of cash. Such bartering is common in rural and lower socioeconomic communities. Sometimes gifts are a genuine expression of gratitude given with no expectation of treatment in return. In some cultures, there is a tradition of patients giving gifts to physicians. Refusing such a gift is considered rude and a rejection of the patient.
And sometimes gifts are given in an attempt to secure preferential treatment. This is where a patient wants to grease the way to jumping a line, receiving better treatment, or gaining access to attention or services to which he or she is not ordinarily entitled. In the essay under review here, there is no evidence that this was the intent of the gift. However, consider that an uninsured patient who desperately needs a surgery and is on a waitlist continually gifts his physician with ribs. The physician contacts a colleague outside of the health system and over 4 years tries to convince that surgeon to see the patient. Would the physician have done the same for a ribless patient? Without knowing more information, it is hard to tell. But this case certainly does sound suspicious. And with gift giving, even if the intent is pure, the appearance of bias needs to be avoided. The physician should not have accepted the gift.
The American Medical Association’s Opinion 10.017 on gifts from patients discusses the lack of rules on accepting. However, it does mention that the value of the gift should not be “disproportionately large”—i.e. a Jaguar from a multi-billionaire might be pocket change, but what is the value of ribs to a patient without means? The Opinion suggests “one criterion is whether the physician would be comfortable if acceptance of the gift were known to colleagues or the public.” Obviously, this physician was comfortable since he publicly wrote about this exchange. The problem with this criterion, is that it presumes someone who understands that he or she should be uncomfortable.
A sampling of menus shows that a serving of ribs is about $16 per order. A whole smoked turkey runs from $60-$90. Could this patient afford to give such a gift? Given that the patient lacked health insurance of any sort or the funds to pay for health care on his own, the cost of this gift to the patient was likely higher than the physician considered.
What is not mentioned in this “heart-warming” essay is that if the ribs were that good, what prevented the physician from going to the patient’s restaurant? The patient with walking difficulty was inconvenienced by having to carry an extra package and by having to make some clinically-unnecessary (by the writer’s admission) trips at least twice a year (the aforementioned “extra clinic visit” and the turkey exchange at the hospital). The physician could have gone to the restaurant and gotten the ribs, for which the patient could have refused to accept payment. At least in that direction, the patient is not the one who is inconvenienced.
A physician is supposed to be altruistic and concerned with providing benefit for the patient. However, this article suggests quite the opposite—that the physician accepted unnecessary burdens for a patient for personal gain. The most concerning part is not the acceptance of the gift, but that this physician never even questions whether that is the right thing to do.