Attitudes of general dentists regarding the acceptance of gifts and unconventional payments from patients
Kevin I. Reid, DMD, MS,
Paul S. Mueller, MD and
Sunni A. Barnes, PhD
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ABSTRACT
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Background. Professional boundaries ensure that a dentist’s focus remains on the patient’s welfare. Such boundaries may be compromised by accepting gifts from patients.
Methods. General dentists attending a continuing dental education conference completed an anonymous questionnaire about professional boundaries and acceptance of gifts from patients. The authors compared subjects’ responses to questionnaire items and calculated descriptive statistics.
Results. Of the 333 dentists attending the conference, 219 (65.8 percent) submitted a completed or partially completed survey. Of the respondents, 81.2 percent endorsed receiving gifts, 82.5 percent thought accepting inexpensive gifts was acceptable, 79.7 percent would accept a dinner invitation from a patient, 52.1 percent would accept a $1,000 discount from a business owned by a patient and 59.0 percent would fabricate a set of dentures in exchange for house-painting services. More than one-third of respondents stated they would not accept a gift worth $25 to $100, and 51.1 percent would not accept a gift worth more than $100. There were no statistically significant differences in responses stratified by sex, age and years in practice, with the exception that female dentists were significantly less likely to accept a dinner invitation. Logistic regression models revealed that younger dentists and dentists with fewer years in practice were less likely to respond "agree" or "strongly agree" to accepting gifts worth $25 to $100, and female dentists were less likely to respond "agree" or "strongly agree" to accepting a dinner invitation.
Conclusion. A majority of dentists endorsed accepting gifts from patients, which may put them at risk of violating boundaries with patients.
Practice Implications. Our findings suggest that general dentists should establish policies regarding the receipt of gifts from patients and inform them of such policies.
Key Words: Dental ethics; gifts from patients
Expressing gratitude for your care, a patient offers you tickets to a professional sports event. Should you accept? Assuming you accept and attend the event, the patient then telephones the dental office and asks for a preferential slot in your calendar. Would you feel obligated? If other patients learned of your receipt of the gift, how might this affect their perception of you?
Accepting gifts from patients is an issue that requires ethical discernment by all health care professionals, including dentists. Systematic studies of this issue, however, have not been reported in the dental literature. Nevertheless, Chiodo and Tolle1 and Chiodo and colleagues2 reviewed the ethical aspects of dentists’ accepting gifts from patients. The authors suggested that although accepting modest gifts is acceptable, dentists should ask themselves if they would be willing to acknowledge publicly the receipt of gifts from patients and decide whether to accept gifts after reflecting on this question. In addition, the authors perceived an ethical difference between accepting inexpensive tokens of appreciation and accepting gifts of substantial financial value.
In this article, we report the results of a survey that explored the attitudes of general dentists with respect to accepting gifts and unconventional payments for dental treatment from patients. We also discuss how these attitudes might influence the dentist-patient relationship.
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SUBJECTS AND METHODS
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In 2005, we administered an anonymous 30-item survey about professionalism and professional boundaries to general dentists attending a 1
-day continuing dental education conference (consisting of topics integrating medicine and dentistry) at the Mayo Clinic, Rochester, Minn. For this study, we used a subset of seven items from the larger survey regarding gifts from patients and unconventional payment arrangements. For each item, respondents chose responses of "strongly agree," "agree," "neither agree nor disagree," "disagree" or "strongly disagree" (Box
). Throughout the 1-day period, conference moderators encouraged attendees to complete the survey. Their responses to the seven survey items, along with self-reported demographic information, make up the data set for this study.
In accordance with federal regulations, the Mayo Clinic Institutional Review Board granted permission to conduct this study.
We compared responses to the seven items and calculated descriptive statistics by using statistical software (SAS version 9.0, SAS Institute, Cary, N.C.). We performed the statistical analyses after pooling "strongly agree" and "agree" responses into an "agree" category. Similarly, we combined the "strongly disagree" and "disagree" responses into a "disagree" category. The third response variable included the neutral responses. We used 
2 tests to examine the association between the three-level response to survey items ("agree," "neither agree nor disagree" and "disagree") and respondents’ characteristics. We also used logistic regression models to test the association between the respondents’ demographic characteristics and their agreement with the survey items (that is, whether they responded "agree" or "strongly agree"). All statistical tests were two-sided, and we considered differences to be significant at P < .05.
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RESULTS
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Of 333 general dentists who were registered conference attendees, 219 (65.8 percent) submitted a completed or partially completed survey. Attendees primarily were from midwestern states, with more than one-half listing residency in Minnesota, Iowa, Wisconsin or Illinois. Of the 219 respondents, 184 (84.0 percent) were male. Table 1 shows respondents’ ages and years in practice.
Table 2 lists respondents’ overall responses (that is, "strongly agree or agree," "neither agree nor disagree" or "disagree or strongly disagree") to the seven survey items. Our decision to combine the "agree" and "strongly agree" categories and the "strongly disagree" and "disagree" categories was based on the primary objective of this research: to assess attitudes of dentists regarding the acceptance of gifts and unconventional payments from patients. Thus, we were not interested in differentiating between a response of "strongly agree" or "agree" to a statement. A majority of respondents agreed that it was acceptable for dental professionals to accept gifts. A majority also agreed that it was acceptable to accept an inexpensive gift, a dinner invitation or a discount on an automobile (from a patient who is an automobile dealer), as well as a patient’s offer to paint one’s house (from a patient who is a painter) in exchange for a full set of dentures. Respondents were divided with regard to accepting gifts worth $25 to $100, and a majority disagreed that it was acceptable to accept a gift worth more than $100.
Table 3 shows dentists’ responses to the seven survey items, stratified by sex. Significantly more male dentists than female dentists agreed that they would likely accept a dinner invitation from a patient. For the other six items, we found no significant differences in the responses between male and female dentists.
Table 4 (page 1131) lists subjects’ responses to the seven survey items, stratified by age. We found no significant differences in responses according to age. Similarly, there were no significant differences in responses according to years in practice (Table 5
, page 1132).
Recognizing the potential for confounding among patient characteristics, we calculated a full logistic regression model to assess the association between sex, age and years in practice and agreement (that is, a response of "agree" or "strongly agree") for each item. We found significant associations for only two items. For the statement, "Accepting gifts worth $25 to $100 from patients is acceptable," agreement was lowest among the youngest and least experienced groups (P = .010 and P = .020, respectively). For the statement, "If a patient invites me and a guest (for example, my spouse) to dinner, I would likely accept (assuming that I enjoy the patient’s company and he or she had no obvious ulterior motives)," male dentists were significantly more likely to agree than were female dentists (P = .018).
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DISCUSSION
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To our knowledge, this is the first report of a survey of general dentists regarding the acceptance of gifts from patients and unconventional payments for dental therapy. Overall, we found that the majority of dentists agreed that accepting gifts (especially inexpensive gifts), accepting a dinner invitation, receiving a discount on an automobile purchase from a patient or exchanging dental services for house-painting services was acceptable. If being a professional commits the dentist to "serve responsibly, selflessly and wisely,"3 then practitioners must consider the possibility that accepting gifts from patients and unconventional payments for treatment (such as house painting), as well as engaging in planned social activities with patients (such as dinners), represent potential conflicts of interest that may erode their ability to make objective decisions on behalf of their patients.4
Dentist-patient relationship.
The relationship between the dentist and patient should be protected by boundaries. As Peterson5 explained, "boundaries protect the space that must exist between professional and client [patient]" and are, in part, necessary because of the power differential in doctor-patient relationships. Unlike friendships, which are spontaneous and have no specified purpose, professional relationships are structured, have a specific purpose, require professional training, are time-limited and often involve payment.6 It is the dentist’s responsibility to create and maintain these boundaries and remain focused on the needs of the patient.
However, Bertolami7 argued that "physicians and dentists do not place the patient’s welfare before their own" and that while placing patients’ needs first "is a noble sentiment; it is also untrue." Although this claim can be challenged, people tend to be biased in favor of self-interests.8 Citing numerous studies that investigated the concept of self-serving bias, Dana and Loewenstein9 concluded that "even small gifts can ...be surprisingly influential." Thus, accepting gifts from a patient may influence the dentist’s future decisions with respect to the patient, even though the influence may have been unintentional and the dentist may not be consciously aware of it.
Nevertheless, accepting gifts from grateful patients is common in dentistry and medicine. In fact, the American Medical Association’s Code of Medical Ethics states that accepting gifts "can enhance the patient-physician relationship."10 Thus, perhaps it is to be expected that a majority of respondents to our survey believed that accepting inexpensive gifts from patients is acceptable. For example, rejecting a gift of homemade cookies or a box of chocolates may alienate a grateful patient who only wishes to express appreciation, or it may offend a patient’s cultural tradition of expressing gratitude. The patient does not perceive such expressions as influencing the dentist’s objectivity with regard to future clinical decisions or recommendations, nor is acceptance of such simple gifts thought to render the dentist indebted to the patient.
Accepting expensive gifts (such as those worth more than $100), however, may suggest to the patient a willingness on the part of the dentist to cross the boundaries of a professional relationship into one characterized more as a friendship.11 In addition, allowing the relationship to evolve into one characterized as a friendship may be inconsistent with the position statement of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs (see sidebar, "Gift Giving From Patients to Dentists").4 To accept anything other than nominal gifts from patients may convey a message that the relationship is more intimate than that which this position statement would support.
Moreover, such behavior is incompatible with the conclusion reached by Welie11: "Dentists are not their patients’ friends, even though they have their patients’ interests at heart, because the model of friendship does not do justice to the essence of the therapeutic relationship between dentist and patient." On the other hand, gracious rejection of expensive gifts conveys to the patient the dentist’s desire to maintain a highly professional relationship in which the entire focus is on the needs of the patient, and decisions about oral health care can be made without undue influence.
In deciding whether to accept a particular gift from a patient, dentists should consider the reaction of colleagues, the general public and other patients if receipt of the gift were publicized. If the dentist has any hesitation, he or she should graciously decline the gift. Alternatively, if the dentist feels obliged to accept the gift (for example, to respect a patient’s cultural traditions), it may be wise to offer to donate the gift to a charitable organization or to inform the patient that the gift will be shared with other members of the dental team.
Deciding whether to decline a gift requires a good deal of discernment on a patient-by-patient basis. Elements of this refusal might include establishing an office policy that defines which gifts are acceptable and which are unacceptable, and then informing patients of this policy (for example, by posting a sign in the dental office waiting area). Also, the dentist should express genuine appreciation for the gesture and emphasize his or her commitment to remaining focused solely on the patient’s welfare. Sending a follow-up note to the patient to reiterate one’s gratitude for the gesture may allay any feelings of rejection that the patient may have.
We should point out that we found only one significant difference among the responses to the statements stratified by sex, age and years in practice (that is, fewer female dentists than male dentists agreed that they likely would accept a dinner invitation from a patient). This finding was confirmed by logistic regression. The meaning of this finding, however, is unclear and might represent a random statistical phenomenon. However, female dentists may be less inclined to accept a dinner invitation because of social traditions rather than professional attributes. We did not ask whether dentists would be more or less likely to accept a dinner invitation from a same-sex patient, which may have revealed less reluctance on the part of female respondents.
Although a majority of dentists responded that they would accept an inexpensive gift and reject an expensive gift from a patient, logistic regression revealed that older age and more years in practice were independent predictors of responding "agree" or "strongly agree" to accepting gifts worth $25 to $100. A number of reasons likely account for these findings. Unlike their younger and less experienced colleagues, older dentists who have been in practice for many years have had more opportunities to receive gifts worth $25 to $100 from patients and, hence, may believe they are not influenced by such gifts. Also, these dentists may believe that accepting such gifts enhances the dentist-patient relationship.
Study limitations.
Our study had several limitations. All of the items in our survey were hypothetical scenarios as opposed to statements about, or observations of, actual behavior. We cannot know whether these respondents actually would behave in the manner in which they indicated under similar conditions; this factor should be considered when assessing our results. Also, we should point out that these respondents primarily were from midwestern states, which may preclude generalizing our findings to other parts of the country.
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CONCLUSION
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A majority of general dentists responding to our survey endorsed the acceptance of gifts and unconventional payments from patients, which may put them at risk of violating professional boundaries with patients. Our findings suggest that general dentists should establish policies regarding the receipt of gifts from patients and inform them of such policies.
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FOOTNOTES
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Dr. Reid is chair, Department of Dental Specialties, Mayo Clinic, and an assistant professor of dentistry, Mayo Clinic, 200 First St. S.W., Rochester, Minn. 55905, e-mail "reid.kevin{at}mayo.edu". Address reprint requests to Dr. Reid.
Dr. Mueller is a consultant, Division of General Internal Medicine, Mayo Clinic, and an associate professor of medicine, Mayo Clinic, Rochester, Minn.
Dr. Barnes is a statistician, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn.
The authors thank the Section of Scientific Publications, Mayo Clinic, Rochester, Minn., for its assistance with editing, proofreading and reference verification.
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REFERENCES
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- Chiodo GT, Tolle SW. Ethical issues in the acceptance of gifts, part 1. Gen Dent 1999;47(3):248–50, 252, 254.[Medline]
- Chiodo GT, Tolle SW, Donohoe MT. Ethical issues in the acceptance of gifts, part 2. Gen Dent 1999;47(4):357–60.[Medline]
- Gardner H, Shulman LS. The professions in America today: crucial but fragile. Daedalus 2005:13–8.
- American Dental Association Council on Ethics, Bylaws and Judicial Affairs. Gift giving to dentists from patients, colleagues and industry: Is it a problem in dentistry today? Statement of the ADA Council on Ethics, Bylaws and Judicial Affairs. Available at: "www.ada.org/prof/resources/positions/statements/statements_cebja_gifts.pdf". Accessed April 26, 2007.
- Peterson MR. At personal risk: Boundary violations in professional-client relationships. New York: Norton; 1992:34–49.
- Milgrom JH. Boundaries in professional relationships: A training manual. Minneapolis: Walk-in Counseling Center; 1992.
- Bertolami CN. Why our ethics curricula don’t work. J Dent Educ 2004;68(4):414–25.[Abstract]
- Messick DM, Sentis KP. Fairness and preference. J Exp Soc Psychol 1979;15:418–34.
- Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA. 2003;290(2):252–5.[Free Full Text]
- American Medical Association, Council on Ethical and Judicial Affairs. Code of medical ethics: Current opinions with annotations. E-10.017 gifts from patients. Available at: "www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/E-10.017.HTM&&s_t=&st_p=&nth=1&prev_pol=policyfiles/HnE/E-9.132.HTM&nxt_pol=policyfiles/HnE/E-10.01.HTM&". Accessed April 24, 2007.
- Welie JVM. The dentist as healer and friend. In: Thomasma DC, Kissell JL, eds. The health care professional as friend and healer: Building on the work of Edmund D. Pellegrino. Washington: Georgetown University Press; 2000:35–48.
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ABSTRACT
SUBJECTS AND METHODS
