Tips, status and sacrifice: Gift giving in the doctor-patient relationship

TIPS, STATUS AND SACRIFICE: GIFT GIVING IN THE DOCTOR-PATIENT RELATIONSHIP

JENNIFER DREW. JOHN D. STOECKLE and J. ANDREW BILLINGS

Department of Sociology. Boston University. Boston. MA 02215 and Department of Medicine. Harvard Medical School and Medical Services (Primary Care Program).

Massachussets General Hospital, Boston. MA 021 14. U.S.A.

Abstract-This study examines the gifts physicians receive from their patients. Internists in a hospital- based group practice kept diaries of gifts received and were interviewed about their responses and the reasons which they ascribed to the patient’s gift-giving. It describes how physicians avold reciprocating. categorizes the nature of gifts and. for the special instance of manipulative gifts. how these may be defused. Patient gifts are found lo be reciprocations for some action on the part of the physician. which the patient. in turn. perceives as a gift. Three categories of gifts. according to their nature and timing. are: (I) gifts as ‘tips’. given to promote personalized service. to assure the continued interest and the tolerance of the physician: (2) gifts to address the status imbalance in the doctor-patient relationship. either by imposing a non-professional identity on the physician or by redeeming status lost in the sick role: 13) gifts as a sacrifice to the physician who exercises his power on the patient’s bkhalf.

An elderly woman, on a fixed income. IS determined to give her doctor a gift of fifty dollars. Her doctor knows she cannot afford it. and based on her history. senses she is trying to manipulate him. After several attempts to dis- suade her have failed. he suggests a transfer to another physician. She relents and does not mention the gift again. Some ten days later. the doctor receives a note from a local priest. The note informs him of a mass. said in his name. in response to a generous gift of fift) dollars from a parish- ioner. ‘A doctor‘s long-awaited vacation coincides with a

worsening in the condition of his terminally ill patient. Arriving at the hospital on his last day before vacation. he finds a case of fine wine. left for him by the family of the dying man. The gift disturbs him. Is it a show of gratitude for doing all he could. or is it a desparate attempt to induce him to postpone his vacation?

This paper examines a social phenomenon which, although technically prohibited. is a common feature of everyday medical practice-namely. gifts from patients. HoLvever commonplace this gesture may be, gift-giving is an action which the medical profession traditionally has deemed a threat to physician integ- rity. This uneasiness centers on the important issue of physician impartiality. whether the physician applies a universal standard m the treatment of every patient. A prevalent view of social science and the profession itself characterizes doctors as affectively neutral, task- specific and immune to pressures which would have them give preferential treatment to one patient over another [l]. Certainly. medical work has special qualities. dealing with patients. as it does in life and death. health and illness. Such transactions dis- tinguish the doctor-patient relationship from others in \\hich consumers exchange fees for professional services. The general expectation is that physicians. through their education and \vork. develop a sense of the dangers of prqjudicial care: however. the medical profession has never whol,l\, relied upon an internal- ized awareness of responslbllit!. From the origins of the Hippocratic Oath to the present time. doctors

have adopted formal codes of ethics and regulations in order to watch over their own. Accepting gifts from patients is an action which has often been officially discouraged in this country, precisely because of its potential perils to objective and fair treatment.

The following excerpt from the House Officer’s Manual (1932 edition) of the hospital in which this study was conducted provides such an example:

No resident or House Officer shall accept a gift. fee. or gratuity for his services during his term of office.

Now it is unlikely that the profession would institute such self-regulating measures as this one if the physician was, in fact, impartial and universalistic in dealing with patients as an inescapable consequence of the nature of his work. It would appear that the profession is. at least, cognizant of the tension between the universalistic ideal and the everyday realities of medical practice. If the ideal were reality. patient gifts would pose no threat to impartiality and rules barring them would not be called for.

Even though gift-giving is officially frowned upon and largely hidden from view, it occurs commonly enough in everyday medical practice to. warrant study. Questions about this interaction remain un- answered. If the gifts within the doctor-patient relationship. for example. are significant, how, then. can we explain the consistent omission of this common feature of clinical practice from professional training and informal socialization? Also. a consideration of patient gifts may help explain why. although nearly every other aspect of the doctor-patient relationship has undergone close scrutiny. patient gifts pass vir- tually without mention. Finally. what is the nature and significance of gifts to the physician?

OBJECTIVES

This research is an effort to apply what has been learned about reciprocity and gift-giving within the

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context of the doctor-patient relationship in a general medical practice. Under ordinary circumstances, a gift initiates an ongoing exchange. That is, the one who accepts the gift is indebted to the one who has given the gift, until reciprocation occurs and the scales are balanced. [2,3] This holds true whether the context be the ritual potlatclz of Trobriand Islanders: or the exchange of greetings cards at holiday time [4.5].

Despite this, physicians routinely accept gifts without apparently reciprocating. In an effort to determine if physicians feel any discomfort in not reciprocating, we asked our participants to respond to the following hypothetical situation:

Let’s say Mr Jones brought you in a bottle of wine at his last visit. He’s due in again today, and after telling him how much you enjoyed the wine. you present him with a small token in return-say, a coffee mug-to show your appreciation.

Participating physicians responded vehemently:

I’d feel funny. . like I was trying to ingratiate myself. I’d feel like, being a good doctor, I wouldn’t have to do that.

If I did that. the patient would probably be angry, confu- sed.. and would probably go to another doctor or feel uncomfortable about further disclosure.

In any case. a reciprocation on the part of the physician was viewed by physicians as an extremely dis- ruptive act, one which they were loathe to carry out.

Yet, according to Gouldner, the norm of reciprocity is as compelling as the incest taboo [7]. Before con- cluding that this norm does not apply within the doctor-patient relationship, we sought a more adequate explanation. We would argue that while the patient’s gift, because it is tangible, appears to be the start of a gift exchange, it is, in fact, a reciprocation. That is, the patient perceives some aspect of’the physician’s per- formance as the initiating gift and reciprocates. As one physician put it. “I think they give me a gift for something I’ve already done-something about their blood count. the way their heart sounds”. Under- standing that the patient gift is, in fact, a reciprocation helps explain why patients give gifts. However, the perspectives of physician and patient on the gift differ. and these differences are rarely discussed di- rectly. This lack of shared meaning may present prob- lems for the physician.

For example, in their dealings with patients, physicians see themselves as simply doing their jobs. What appears to the patient as a gift, to the physician may be of little consequence, and, therefore, ‘invisible’ to him. Second, a reciprocation is always prompted by an initial gift, which appears spontaneous and freely given. To the one who is reciprocating, therefore, his gift never seems to measure up to the gift given him initially [tr]. The best he can hope to do is break even. This is exacerbated by the fact that patients sometimes imbue their physicians with the ability to ‘give’ health, a gift which is nearly impossible to repay. Third, at the next visit after accepting a patient’s gift, the physician may, in the course of his duties, ‘give’ again, prompting yet another reciprocation. Thus, the physician may unwittingly become involved in a continuous gift exchange, of which only the patient is aware. Finally, when the gift is lavish and inappro- priate, it carries with it hints of coercion, bribery or a request for unethical conduct.

The study addresses three questions: (I) HON do

physicians deal with the social obligation to reciprocate what ordinarily comes with receiving a gift. which could lead to preferential treatment. m viola- tion of ethical codes’? (2) As gifts retlect a relationship between the giver and the recipient. how. then. are patient gifts to be categorized and interpreted? (3) In the category of manipulative gifts. how do physicians deal with it’?

METHOD

The data were gathered in interviews with I4 staff physicians in a hospital-based practice of internal medicine and from diaries which each of the physicians kept on the gifts they received over a 4-month period. July-November, 1979. Fourteen of 17 physicians agreed to participate. The diaries required the physicians to answer a standard set of questions each time a gift was received: the gift, its estimated cash value. what was occurring in the patient’s treatment at the time of the gift-giving, and the reason the physician thought the patient gave the gift. Interviews (JD), ranging from 15 to 45 min, also sought the physician’s perception as to why the patient gave him a gift and his responses to it, e.g. those he liked. those that made him uncomfortable and his explanations. Interview time varied depending on how many gifts were received; older physicians reported more.

Categorization of gifts and gift-giving behaviors was derived from reasons recorded in diaries and eli- cited by the interviews which explored the reasons physicians ascribed to patients. The authors grouped the data by similarity until an analytic set of ‘categories of motives’ emerged; these were labelled by their most salient feature. The special influence of manipulative gifts was derived from physician responses.

No interviews were conducted with patients because we sought to observe gift-giving without dis- turbing the doctor-patient relationship and to avoid possibly sensitizing patients to ‘hidden meanings’ behind their gifts. Moreover, while some discrepancies between the explanation patients might offer com- pared to physicians’ explanations would seem likely. the latter’s interpretation alone was deemed important enough to limit the study.

RESULTS

Seventy-two gifts were recorded. of which 65 could be interpreted. The itemized sample of gifts received included over $2000 in cash, 36 bottles of liquor, 24 gifts of food and 19 gifts of a miscellaneous nature, such as brief case, ash tray, ties. cuff links, flowers, pictures, books and others. including one dog.

Three categories of gifts emerged from the analy- sis: the gift as a tip to the physician; the gift to address the status imbalance of the doctor-patient relationship; and the gift as sacrifice to the physician. In the following discussion. these categories are treated as distinct, while. in reality, a gift may embody the characteristics of more than one category: moreover. the list is not meant to be exhaustive.

Tips. status and sacrifice 401

The word ‘tip’ seems an odd way to describe gifts which patients give their physicians. Tips are most often a source of income used by service workers to supplement skeletal wages. These service workers, therefore, consciously work to earn a tip and are offended and contemptuous when they do not receive one [9]. Strictly speaking, physicians are highly-paid service workers. However. occupational traits such as status, income and professional socialization cause the exceptions of physicians to differ from those of waiters, doormen and cabdrivers. Physicians need not supplement their incomes with tips and therefore, do not actively pursue them. How, then, can patient gifts be considered tips?

We would argue that the motives which influence the timing and nature of patient reciprocation are akin to the motives which prompt a tip from a diner to a a waiter. Consider. for example. a diner tipping for the following reasons: for personalized service, such as a menu substitution or a good table; to be remembered, should the diner plan to return and wishes to insure good service next time; to be tolerated. should the waiter make extra trips to the kitchen or the party linger longer than necessary at the waiter’s table. While the payment of the check is mandatory. the diner is likely to compensate the waiter for doing more than taking the order and serv- ing the meal. The same holds true in the eyes of the gift-giving patient. While payment of the bill in exchange for medical service is all that is required in the medical context. the patient exchanges a fee for the instrumental aspect of the physician’s perform- ance while tipping to compensate for the expressive components of the personal care and attention received. The tips are prompted by three motivations: for personal service. to be remembered, and to be tolerated.

Tippirlg,for personalized service. The intimacy of the doctor-patient relationship. with its personal attention. contrasts sharply with the bureaucratic setting of the hospital. where scheduled appointments in an out- patient clinic setting, while efficient, increase distance between physician and patient [lo]. Patients tip for ‘walk-in’ privileges and housecalls, occasions which they. like the diner after a menu substitution, rightly perceive as exceptions to the rule. One participant tells of an elderly patient whom he visited on his way home. The patient’s nephew pressed $50 on the physician. When the physician refused. the nephew mailed the gift to his home.

In the bureaucratic setting of the hospital. personalized service may imply that the patient is a special person. one who enjoys a more intimate and privi- leged relationship with the doctor. Some patients tlrrur& such personalized service. and come prepared \vith a gift to ‘pay’ for it. Of the patient who regularly arrives without an appointment. but never without a box of chocolates. one physician remarked:

He likes to have a personal relationship with the doctor-doesn’t like lo think of himself as a ‘clinic patient’.

‘Walk-in’ privileges and housecalls are a largely by- gone form of medical practice. It is. therefore. not surprising that patients perceive these services as gifts. and. thus. reciprocate. One physician told of a patient

who used a gift to circumvent the impersonal billing practice of the hospital :

One day he tried to give me a hundred dollars. He put it on the desk. and said, ‘You never send me a bill!!. it always comes from Hospital. I want something personal! ! !

Eighty-seven percent of the patients who attend the clinic in which this study was conducted reimburse their physicians via third-party payment (Blue Cross- Blue Shield, commercial insurance. Medicare and Medicaid). Although our data do not allow us to judge, as Mark Field noted, it is conceivable that other patients who give gifts do so to counteract the depersonalizing effect of third-party payment [ 1 I].

Tipping ro he rententhered. Some patients, like the diner wishing good service at his next visit, tip to insure continuing interest on the physician’s part., From the patient’s perspective, this pattern of reciprocation implies a continuous exchange with the physician. Sometimes these gifts are routine, given almost perfunctorily at each visit. This patient does not tip to gain favor in the physician’s eyes, so much as merely to maintain his position:

A new patient came for the first time and just asked me what I wanted. I said, ‘Nothing’, but he kept at it. so, I’d had a cannoli the night before, and it was the first thing that came to mind, so I said. ‘Cannolis’ Ever since then, he’s brought me a cannoli at every visit. I heard he used to bring Dr salami.

Vacation plans are typically made in accordance with factors which have little to do with a doctor- patient relationship. When the physician goes on vacation, however, his patient may fear that the separation will diminish the physician’s interest in his or her case. One way to bridge the gap caused by such leave-taking is with a gift-the tip to be remembered. Comments such as “Here’s something for your trip”, imply that, through the gift, the patient and the physician remain involved during the latter’s absence. Further, by making the final reciprocation, the patient hopes to ‘indebt’ the physician who is about to sus- pend the relationship. Similarly, when the patient goes on vacation and returns with a souvenir for the physician, the patient acknowledges the separation and seeks to resume the relationship anew.

Tipping to be tolerated. Some patients, like the diner who lingers at a table after the meal is com- pleted, tip in appreciation of non-medical needs met in the course of the doctor-patient relationship. The service provided may seem negligible to the physician-indeed, an inseparable part of his role as he has defined it. However, the patient, who used his relationship with his physician to ventilate personal concerns. may perceive it quite differently. For the patient whose cultural norms prohibit ‘hanging dirty laundry in public’ and discourage professional coun- selling, the opportunity to speak freely in the doctor’s office is invaluable. And the physician’s willingness to listen may to some seem a gift. One participant, speaking of an elderly patient. says:

I’m his sole confidant in the world. He tells me of his sexual liaisons and his bookie-I don’t know whether he’s bragging or confessing.

The tip which is a request for tolerance, when it

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comes from an especially demanding patient. may be intended to placate the physician and resemble a bribe:

I think the only reason he gives me gifts is because I’m the only one who will put up with his neurotic behavior. Every time he comes in. he wants an EKG.

In sum, patients tip to reduce the feeling of indebtedness engendered by something which the physician may do as a matter of routine. but which the patient perceives as beyond the absolute minimum. The “minimum” expectations of the patient seem to be in an inverse relationship to the level of bureaucratiza- tion.

The gift to address the irnbulance of the doctor-patient

relutiomhip

The doctor-patient relationship is characterized by an intimacy between relative strangers, in which one party is dependent upon the other. Not surprisingly, a portion of the gifts we studied can be understood as attempts to alter that relationship in two specific ways: in the first, the gift redeems the patient’s lost status; in the second, the gift imposes a familiar rather than formal identity on the physician.

The gift redeeming status. In a society which values independence, being sick can be as debilitating emotionally as it is physically [ 121. Many patients feel humiliated by their dependency on the physician, so that, upon recovery, they give a gift designed to remind both themselves and the physician of their ‘usual’ selves in health. For example, one patient. hav- ing just been released from the hospital, gave his physician a handful of ballpoint pens. Each pen bore the name of the construction company which the patient owned and operated, and to which he would now return. This gift helped the patient redeem the status lost during his earlier dependency.

The extent to which the patient feels a loss in status will determine the lengths to which he will go to redeem it:

I had a patient, an old man with prostate trouble. very proud. He was humiliated by his condition that really laid

him low for some time. When he improved. he asked me to come down to his fruit and vegetable store. I don’t want to take the time, but after a while, it was easier just to say I would. When I got down there. he was striding around there like the cock of the walk, ordering everybody around. He was clearly the boss-they’d bring him fruit and he’d say. ‘No! No! Nothing but the best for the doctor!!’

Gifts given in return for ‘professional courtesy’ fall within this redemption-in-status category. Our data include two gifts given by fellow physicians in payment for the clinical services of colleagues. Interest- ingly, both gifts were symbolic of the shared profession of physician and patient-one, a brief case, the other, a biography of an eminent physician. These gifts served as reminders of the patient’s status outside the sick role, and acted to emphasize the patient’s status as a valued colleague.

The gift itnposi~ly un iderrtity. The relationship between patient and physician in large, urban hospital-based practice is unique, at once extremely personal and yet, in most cases, patient and physician are initially strangers, paired without regard for common

background. race. ethnicity or lay referral. The initial interpersonal distance between physician and patient may be considerable. Consequently. patient gifts sometimes accentuate that aspect of the physician‘s identity to which the patient can most comfortably relate. the attributes which put the patient most at ease. Gifts may even be designed to generate such an identity where non exists. [I3].

One physician reported a long-standing relationship with an elderly Jewish lady. When she dis- covered, to her delight. that he was also Jewish. she began to bring him food at each visit. He noted that she brought him bits and pieces of several dishes. almost as if he had. like a young relative. ‘raided her refrigerator’. Another Jewish physician was given a religious tract by an ardent Christian. In his words. “I’m certain she was trying to convert me”. For one physician. the implied meaning of the gift was am- biguous:

A female patient gave me a book on St Luke. the physician I didn’t know whether she was comparing me to him. or providing me with an example to follow.

Another physician told of a regular patient who. at one visit. was treated by his physician assistant. As was the patient’s custom, she had come with a gift; but rather than give the gift to the assistant who had treated her, she left it for the physician. Her gift was an attempt to reinforce her physician’s identity as her doctor and to deny any potential for a relationship with the physician assistant.

The gift as sacrifice to the physicim

To primitive people, a sacrifice is a gift made to a god for the purpose of homage or ingratiation [l4]. Patients sometimes indulge in a similar form of ‘magi- cism’ when they attribute great power to their physicians [ 151. A patient may view the physician as hav- ing more power to ward off illness than the physician feels he or she possesses. When anticipated consequences of illness do not materialize, the patient assumes that the physician has been instrumental. One physician recorded a gift given by a young woman, because she “did not have TB as she feared”. The physician reported that he had done little more than order the tests and tell her the results. Yet in her view, he became the intermediary between health and illness, for which she offered him thanks and a gift.

In a similar vein, there are gifts for performing cer- tification services. The physician’s signature on the proper form is required to obtain Workman’s Com- pensation, disability benefits. release from jury duty, special housing and transportation, to name just a few. To the patient, these periodic forms are essential, and to the physician, they are a nuisance. considered a trivial exercise or misuse of professional time and skill. However, as these forms may have profound consequences on the patient’s livelihood. a physician who will see a patient just to sign a form is valued. One physician. who had long experience with these requests of patients, stated, “I know what those bureaucrats want to hear and can fill out the form as they want it”; moreover, he signs certificates with his full compendium of titles to insure that the form will be easily processed. Acknowledging the physician’s use of his power on their behalf. patients give thanks

Tips. status and sacrifice 403

with a gift, just as a primitive might for a plentiful harvest.

As these three categories and examples of them illustrate. patients give gifts for reasons which are very important to them. From the perspective of exchange. gift-giving as a tactic of influence may, at times, be manipulative in ways which impair the doctor-patient relationship. This instance deserves special comment.

Harding the gift-giving relatiorlship

When the casual. small gift is accompanied by a few words of explanation at its offering, it poses little threat to the universality of the physician’s treatment. Physicians report that most gifts are a welcome break in the routine of encounters with patients, easily handled by an expression of appreciation and thanks. However, when the patient’s motive for giving is not shared with the physician, or the gift is lavish, dealing with it can be confusing and awkward. In such instances, the traditional medical cautions concerning gift-giving are well-founded. Accepting lavish gifts without information or clues is analogous to treating a symptom without a diagnosis. Yet most physicians, with the possible exception of psychiatrists, are rehc- tant to confront the gift-giving patient with a request for the motive. For the most part, it may be less dis- ruptive to accept the gift, respecting the patient’s intentions than to engage in endless efforts at dis- suasion. Our observations indicate that it is nearly impossible for physicians to reject the gift of a determined giver; to reject the gift is perceived as tanta- mount to rejecting the giver. [6].

Yet what about a gift which poses a very real threat to universality? In the course of this study, these were most often gifts of cash. Gifts of cash. such as the $50 foisted on her physician by the elderly woman on a fixed income. bear the greatest resemblance to bribery and are also the most difficult gifts to reject. A sum of money can be mailed to the physician’s home. left with his secretary or donated to a worthy cause in the physician’s name.

Patients who give money may do so when they are unsure of what else to give. a circumstance where the physician may persuade the patient to give a more traditional gift. Uncertain in the qualitative sense. patients exaggerate in the quantitative [16]. Cash is value in transferrable form; that is, in this culture the giver can be certain that the recipient will find a use for it. Sums tend to be inappropriately large since the patient seldom considers the cash value of. for example a batch of homemade cookies as sufficient. If the patients give money because they are unsure of \vhat else to give. some physicians respond by sug- gesting an alternative gift. in effect. recognizing and rechanneling the patient’s need for and forms of reciprocation.

Converting a gift of cash to a less costly one serves three purposes. First. it protects patients who cannot afford the gesture. while respecting their need to reciprocate and reduce their -sense of indebtedness. Second. it generally results in a more gratifying gift for both. and one xvhich does not threaten the physician’s ability to be impartial. Third. it relieves the physician’s concern for taking money in addition to the monetar! charge for the medical visit.

One \+a! physicians convert cash gifts is by provid-

ing specific knowledge of a suitable alternative gift. Our data include several gifts which appear to be responses to a bit of personal disclosure on the part of the physician. Equipped with this knowledge, patients knew what their doctors would be pleased to receive:

I had mentioned to (the patient) that my son collects fifty-cent pieces. Now. whenever a cashier gives her a fifty- cent piece. she saves it and brings it in for me to give lo my son.

Another physician and his patient discussed a shared hobby of deer hunting. following which the patient brought the physician a gift of venison. After a traditional Italian woman and her physician discussed cooking, she gave, with great pride, her homemade tomato sauce. Still another patient brought her physician a plant to augment his office collection, after they had discussed plant care. Gifts of cash, then, seem less likely when patients know another gift which they are sure will be well-received.

This remedy for cash gifts presents two difficulties for some physicians. First, personal disclosure on the part of the physician implies the reduction of social distance between physician and patient. For those physicians who maintain social distance as a means of patient management, disclosure conflicts with their professional style. Second, for those physicians who are not attuned to the patient’s need to reciprocate, their deliberate self-disclosure in an effort to discourage gifts of cash they view as unethical.

Many gifts, whether cash, or expensive liquor and clothing, go beyond an expression of simple gratitude to unmistakable efforts on the part of the patient to indebt the physician. Within the doctor-patient re-

lationship, it has been argued that the, balance of power rests with the physician while the patient has minimal resources at his disposal with which to exert control [ 171. The resultant relationship is, then, one of ongoing negotiation. One participant addressed this:

The doctor-patient relationship is just so much negotiation. with the doctor in the adversary position. The patient loves to play tennis. you tell him he has to stay off hi‘s knee. He asks for pills to take care of the Dain. Given this. a eift introduces a new currency of interaction into the relationship and throws the whole thing off balance.

The gift, then. can be a tool brought to the bargain- ing table by the patient. For the patient who places the physician in an adversary position, the gift allows the patient to ‘buy his way out’ of compliance with the treatment plan. To this patient, the only alternative to reciprocation is subordination [IS]. That is, without the gift, the only way to ‘pay his debt’ is to accept and comply with doctor’s orders. Reciprocat- ing with a gift, especially a lavish one, invalidates in this patient’s view the physician’s superior position in the negotiation.

One tactic in dealing with such gifts is the thank- you note. We have mentioned earlier the discomfort physicians feel with the notion of material reciprocation. and their difficulty in rejecting patient gifts. A thank-you note is a middle ground between these two extremes. It is a recognizable response to the receipt of gifts. for example. to wedding presents. A thank- you note from a physician is not commonplace. yet it

404 JEXNIFER DREW et d

is not so bizarre as to disrupt the relationship. The thank-you note treats a gift as what it appears to be on its face; hence, its powers to ‘indebt’ are greatly reduced.

SUMMARY

The study has applied what is known about gift- giving and reciprocity to the particular situation of doctor-patient relationships in medical practice. ‘Our observations indicate that patients give gifts for reasons not ejtclusive of, but more complex than,

simple gratitude. We have argued that patient gifts are reciprocations for services which, although the physician may perform them routinely, to the patient go beyond the minimum expectation for service. In the majority of cases, physicians are unaware of the continuous gift exchange of which these reciprocations are only a part. Beyond a generalized need to reciprocate, patient gifts are prompted by factors inherent in the doctor-patient relationship as it exists within industrial society and bureaucratized central- ized medicine. These include: a desire to personalize the relationship, to assure the continued interest of the physician, and to pay for non-medical needs met within the relationship; a reaction to the status and power imbalance within the relationship, and to establish common ground with the physician or to pay homage for the use of his power on the patient’s behalf. In the extreme, gifts may be designed to indebt and manipulate the physicia’n, but such gifts are con- verted or defused, a conscious effort undertaken by the physician.

We noted that neither formal training nor informal professional socialization provides physicians with insights regarding the gifts they receive, and suggest that the implicit threat to ethical codes posted by patient gifts may account for this. Finally, we offer patient gifts as an illustration of the differing views of physician and patient on their shared relationship, and suggest that gift-giving may be another way to understand the complex dynamics of the doctor- patient relationship.

Like most exploratory studies, this examination of gift-giving in the doctor-patient relationship answers some questions while raising still more. A most obvious question is, “Why do some patients give gifts while others do not?” The patient population involved in this study was primarily Italian or Jewish, of lower-middle to middle income and middle-aged or older, Are gift-giving patients likely to be older and more traditional. transposing to the hospital setting a cultural norm molded during an earlier era?

To what extent does gift-giving reflect the characteristics of the physician, as well as the patient? An investigation of this question would entail an examination of the nature and frequency of gifts received in relation to the age, sex, length of doctor-patient re-

lationship and the professional ideology of a sample of physicians.

Do patterns of gift-giving vary by the speciality of the physician and the nature of treatment? Our participants were internists. treating a largely chronic. older population. How might their experience com- pare with that of surgeons, psychiatrists. oncologists. or pediatricians? These and other questions need examination in future studies.

Ackrlowledgemenrs-For advice and suggestions. we wish to thank Professor John B. McKinlay. Department of Sociology, Boston University; for information. the staff of the Internal Medicine Associates. Masachusetts General Hospital. who kept diaries on their gifts from patients.

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REFERENCES

Parsons T. Social structure and dynamic process: the case of modern medicine. In Tl~e Socicd System. pp. 428-479. The Free Press, New York. 1951. Malinowski B. Afggo,muts of the Westeru Pkjic. p, 167. Routledge, London. 1922. Mauss M. The G$ftc Forms atld Fumiom of Esc/tur~~~r in Archaic Societies (Translated by Cunnison I.). W. W. Norton, New York. 1967. Levi-Strauss C. The principle of reciprocity. In Socio- logical Theory (Edited by Coser L. A. and Rosenberg B.). pp. 75-102. Macmillan. New York. 1965. Shurmer P. The gift game. New Society 23 December. 1242-1244, 1971. Homans G. C. Social Behaciow: Its Elementary Forms. p. 299. Routledge & Kegan Paul. London. 1961. Gouldner A. The norm of reciprocity: a preliminary statement. Am. social. Rev. 25. 176-l 77. 1960. Simmel C. Faithfulness and gratitude. In Tile Socioloy of George Summel (Edited by Wolff. K.). pp. 37&396. The Free Press. New York. 1950. Davis F. The cabdriver and his fare: facets of a fleeting relationship. Am J. Social. 65, 158-165. 1959. Lazare A.. Eisenthal E. and Wasserman L. The cus- tomer approach to patienthood: attending to patient requests in a walk-in clinic. Archs yen. Psychiat. 32. 553-558. 1975. Field M. The doctor-patient relationship in the perspective of “fee-foi-service” and “third-party” medicine. J. HIth Hum. BeAuu. 2. 252-262. 1961. Parsons T. Definitions of health and illness in the light of american values and social structure. In Patienrs Physicians and Illness (Edited by Jaco G.). second Edi- tion, pp. 107-127. The Free Press. New York, 1972. Schwartz B. The social psychology of the gift. Am Social. 73. l-l I. 1967. Hubert H. and Marcel M. Sucrijicr: Its .Ytrtwe wd Funcriorl (Translated by Hall W. D.). University of Chicago Press, Chicago, 1964. Shuval J. Tke Social Funcrior~s of .Llrdictr/ Prtrctwe. Jossey-Bass. San Francisco. 1970. Bursten B. The expressive value of gifts. ,Jm. Imuyo 16. 437-446. 1959. Balint M. The Doctor. His Ptrtient tmd t/w Illwss. In- ternational Universities Press. New York. 1957. Homans G. C. op. cit., p. 319.

Documents

Tips, status and sacrifice: Gift giving in the doctor-patient relationship