Practice dilemma - An untimely gift

The Dilemma - You are discussing the day's patients with your GP registrar when she mentions how a lovely patient, whom she has been treating for hypomania, has given her an expensive watch. The patient is known to you and has not worked for three years due to his psychiatric illness. How would you handle the situation?

A GP's response - Dr Barney Tinsley is a GP partner in Harrogate, North Yorkshire
In this situation, the damage has already been done. The expensive watch, which must be seen as a gift, has already been given and accepted by your registrar, who, in turn, has formed a relationship with a vulnerable male patient.

The GMC's Good Medical Practice (2006) advises doctors that 'you must not encourage patients to give, lend or bequeath money or gifts that will directly or indirectly benefit you'.

This watch could be seen as a 'payment' for services rendered, but given by a patient who may not have obvious means to pay for it.

While all patients should receive an equal standard of care, from this point on, the patient may assume that he has 'divine right' to instant access to the registrar because of his gift.

The gift may also mean, to the patient, a possible emotional or romantic involvement, simply due to her acceptance of it. The registrar perceives this patient as 'lovely' - an innocent enough statement outside of a doctor-patient relationship.

In addition, I would have concerns that his illness state and/or possible criminal activity are involved in the procurement of the watch; this aspect is not, however, the job of a GP to judge or to investigate.

What is uncertain is whether or not this gift has been encouraged by the registrar. What is certain is that she should not keep it, and should return it at the earliest opportunity.

I would be keen to contact the patient, personally, to arrange an appointment with him at the surgery when both myself and the registrar are present.

This gives an excellent opportunity to explain the reasons for the return of the gift, while trying not to lose a solid and trust- ing relationship with a patient who is very likely to need regular GP access in the future.

I would also ask the patient to book with one of the partners in future, not the registrar.

A Medico-Legal Opinion - Dr Jayne Molodynski is a medico-legal adviser at the Medical Protection Society
Doctors sometimes face situations like this. The MPS regularly advises members about gifts offered by patients.

Doctors are often concerned that refusing such an offer can cause offence and potentially damage the doctor-patient relationship.

The GMC has produced guidance on this subject in Good Medical Practice. It states that doctors must not accept any gift or hospitality which may affect or be seen to affect the way they prescribe for or treat patients.

This gift raises other concerns. It may be related to the patient's psychiatric history and raise the possibility of a change in their condition, or alternatively they may be attempting to engage in an inappropriate relationship with the registrar.

You will need to discuss the situation with your registrar to find out more about the circumstances of the gift, especially whether the patient's condition needs to be reviewed. Regardless of the patient's current health, you will need to explain that it is inappropriate to accept this gift.

You could then arrange for the patient to re-attend so that any reassessment can take place, and the registrar can politely return the watch. You may feel that it is appropriate to accompany the registrar to assist in explaining the situation.

The registrar should be encouraged to reflect on these events and include what she has learnt in her training ePortfolio. This would also be a good opportunity to discuss the requirement for GPs to maintain a register of gifts, and when the PCT needs to be notified.

A GP trainer's response - Dr Prashini Naidoo is a GP trainer in Oxford
In this training situation I would like to see how the registrar demonstrates her professional and personal values.

It sounds as though the gift generated feelings of being valued and appreciated rather than embarrassment at its expense. Grandiose gestures such as extravagant gift-giving may be symptomatic of the patient's illness and I would be concerned if the registrar had not re-evaluated and documented the patient's mental state.

Had she considered how medical colleagues and the patient's family would respond to her accepting the watch? I would be uneasy if she had not asked herself if she was possibly being bribed by the patient to meet a hidden agenda.

If she accepted the watch as a token of gratitude for care given, had she considered whether care was due to team effort? A more appropriate gift may have been one that could be shared among the team.

Had she considered asking the practice to write a letter of thanks to the patient because a business-like letter may keep the relationship from straying beyond professional boundaries? If the registrar is minded to decline the gift, would she say she was declining for personal reasons or because not accepting personal gifts was practice policy?

It may not be applicable in this case, but to some patients, it may be worth suggesting that, instead of a personal gift, the practice prefers donations to help fund medical equipment.

I would, by asking a series of questions, expect the registrar to reach her own defensible decision. She should then accept or decline the gift as she sees fit after considering the impact the gift will have on the doctor-patient relationship, the patient's family and her colleagues.

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