Business, gifts and boundaries in the physician patient relationship.

A senior community-based physician practicing in Rhode Island established a physician-patient relationship with a wealthy patient. Over the course of several years, the patient, who happened to be both his neighbor and insurance agent, lent $177,000 to this physician. These loans were documented as part of the medical record. As the patient’s health declined, the physician provided home care, at which point the patient’s son became more involved in his father’s financial affairs. The son subsequently became aware of the outstanding loan to the physician. The son made several attempts to collect payment from the physician; however, the physician was unable or unwilling to repay the debt. Despite the lack of repayment, both patient and family were pleased with the medical care provided and happy for the physician’s willingness to provide home visits which allowed the patient to remain in the community until his passing. The unpaid loans, however, were a lingering source of concern. Sometime after the patient’s death, a complaint was filed with The Board of Medical Licensure and Discipline. The Board investigated and substantiated the complaint through interviews with the physician, son, and review of the medical record. In its review, the Board recognized the son’s dilemma in wanting to pursue collection of the overdue debt, but fearing that in doing so he would jeopardize his father’s care and ability to remain in his home. The Board found that the physician’s behavior constituted unprofessional conduct in the practice of medicine. In view of the physician’s considerable volunteer teaching and community work, the Board limited the sanction to a year of probation and required the completion of a personalized ethics program. Ideally, the physician-patient relationship is a binding social agreement in which a physician agrees to place the patient’s welfare ahead of his own self-interest. Physicians are granted special access into their patients’ lives: patients undress physically and emotionally to reveal highly personal and private information with the expectation that it is to be used to benefit their own health. This vulnerability makes them particularly susceptible to manipulation and potential abuse. Ethically, while the physician is expected to honor patient autonomy, it is the physician who is viewed to be in the “power” position. Patients are entitled to a relationship with their physician safe from financial manipulation. This case also raises several concerns akin to those that arise around gifts to physicians. Some gifts, typically of token value, represent appropriate expressions of appreciation from patients and can act to enhance the physician-patient relationship.2 Others have the potential by either intent or unintended consequence to influence care or to secure preferential treatment and thereBusiness, Gifts and Boundaries In the Physician Patient Relationship