A 44-year-old woman requests a same-day appointment due to poor sleep. The patient says that when she goes to bed, her "brain can't shut off" and she feels "too wired" to fall asleep. She has been spending hours playing online games and buying things from the Internet. The patient is well known to the physician and has a long history of bipolar disorder. Her medications include valproate and ziprasidone. Physical examination is normal. On mental status examination, the patient is very animated, laughs frequently, and speaks very rapidly. She has no hallucinations, and no delusions are elicited. The physician increases the patient's valproate dosage and prescribes a 1-week supply of zolpidem for sleep, with a planned follow-up in a week. At the close of the visit, the patient thanks the physician profusely and presents a gift of a sterling silver pen, saying she is so appreciative that her visit could be scheduled on such short notice. Which of the following is the most appropriate response by the physician?

Question

A 44-year-old woman requests a same-day appointment due to poor sleep.  The patient says that when she goes to bed, her "brain can't shut off" and she feels "too wired" to fall asleep.  She has been spending hours playing online games and buying things from the Internet.  The patient is well known to the physician and has a long history of bipolar disorder.  Her medications include valproate and ziprasidone.  Physical examination is normal.  On mental status examination, the patient is very animated, laughs frequently, and speaks very rapidly.  She has no hallucinations, and no delusions are elicited.  The physician increases the patient's valproate dosage and prescribes a 1-week supply of zolpidem for sleep, with a planned follow-up in a week.  At the close of the visit, the patient thanks the physician profusely and presents a gift of a sterling silver pen, saying she is so appreciative that her visit could be scheduled on such short notice.  Which of the following is the most appropriate response by the physician?

Quizplus · Accepted Answer

Accepting gifts from patients often raises complex issues. Although some physicians may decide to adopt a no-gift policy, others maintain that gifts of low value given with no expectation of preferential treatment are acceptable and that rejecting the gift can damage the physician-patient relationship. In the absence of absolute guidelines, most physicians make decisions on a case-by-case basis and consider multiple factors, including the cost, type, and timing of the gift; the apparent motivation behind giving it; and the nature and longevity of the physician-patient relationship. Gifts that are clearly extravagant, inappropriately intimate, or given to secure preferential treatment should not be accepted. In this case, the primary concern is the patient's unstable mental state. She has a known diagnosis of bipolar disorder and her difficulty sleeping, racing thoughts, elevated mood, excessive online spending, and pressured speech are consistent with a hypomanic episode. The physician must consider that this patient's gift was purchased within the context of impaired judgment due to her hypomanic state. The gift should be politely declined with an expression of appreciation for the patient's thanks. (Choice A) It would be inappropriate for the physician to accept a gift that may have been purchased as a consequence of hypomania. (Choice C) There is no definite monetary value that determines the appropriateness or inappropriateness of a gift. The main issue in this case is the mental status of the patient, not the value of the gift. (Choice D) There is no absolute prohibition on accepting gifts, and it would be inaccurate to tell the patient otherwise. However, if the physician has a personal rule not to accept gifts, this could be communicated to the patient. (Choice E) Physicians should ensure (and communicate) that accepting gifts will not alter the patient's level of care. However, because of this patient's condition, it is not appropriate to accept the gift. Educational objective: Decisions about whether to accept gifts from patients include the cost, type, and timing of the gift and the motivation behind giving it. Gifts should not be accepted from patients experiencing a mood episode potentially affecting their judgment. References: Accepting gifts from patients. (http://www.ncbi.nlm.nih.gov/pubmed/24336530) Is it ethical to accept gifts from patients? (http://www.ncbi.nlm.nih.gov/pubmed/29314810)

A 44-Year-Old Woman Requests a Same-Day Appointment Due to Poor