Oncologist Pays for Patient's Meds: A 'Boundary' Crossed?

Generosity Adds Meaning to Work, Says Doc

Nick Mulcahy

November 04, 2020

It was an act of kindness: while overseeing a patient through a round of chemotherapy, an oncology fellow at Johns Hopkins University's Kimmel Comprehensive Cancer Center in Baltimore, Maryland, paid a modest amount of money (about $10) for that patient's antiemetic medication and retrieved it from the center's pharmacy.

Co-fellow Arjun Gupta, MD, witnessed the act and shared it with the world September 23 on Twitter.

"Just observed a co-fellow pay the co-pay for a patient's post-chemo nausea meds at the pharmacy, arrange them in a pill box, and deliver them to the patient in the infusion center. So that the patient could just leave after chemo."

https://twitter.com/guptaarjun90/status/1308773196770942977

Healthcare professionals applauded the generosity. "Phenomenal care," tweeted Carolyn Alexander, MD, a fertility physician in Los Angeles.

It's a common occurrence, said others. "Go ask a nurse how many times they've done it. I see it happen weekly," tweeted Chelsea Mitchell, PharmD, an intensive care unit pharmacist in Memphis, Tennessee.

Lack of universal healthcare brings about these moments, claimed multiple professionals who read Gupta's anecdote. "#ThisIsDoctoring. This is also a shameful indictment of our medical system," said Mary Landrigan-Ossar, MD, an anesthesiologist at Children's Hospital, Boston, Massachusetts.

However, one observer called out something no one else had ― that paying for a patient's medication is not allowed in some facilities.

"And sadly that fellow could actually get in trouble for this act of kindness," tweeted Fumiko Ladd Chino, MD, a radiation oncologist at Memorial Sloan Kettering Cancer Center, New York City, referring to policies that disallow such extensions of the provider-patient relationship.

To be labeled "unprofessional" after looking out for a patient ― whether it is a medication purchase or some other act ― is "absolutely soul crushing," Gupta tells Medscape Medical News. "I have had co-residents drive to a patient's house to feed their dogs," he adds. "These small instances add meaning to our lives as physicians.

"When do boundaries become barriers to care?" asks Gupta about patient-physician relationship restrictions. He was paraphrasing Gordon Schiff, MD, who discussed the issue in a 2013 essay, "Crossing Boundaries—Violation or Obligation?"

An internist, Schiff detailed his experience of giving $30 to a female patient to fill a prescription at 5:00 PM on a Friday (after 2 hours of calls to her insurance company and an ultimate denial of coverage). A resident reported Schiff to clinic directors at Brigham and Women's Hospital in Boston, and he was reprimanded for "unprofessional boundary-crossing behavior" ― an ethics violation.

Schiff suggested that his gift would have been okay at his previous place of employment, a public hospital in the Midwest, where material and practical generosity from staff to patients was common.

He wonders whether strict "boundaries" protect patients (against a potential sense of obligation or debt) or physicians (and their time and consciences). Such rules may help doctors sidestep painful inequality or avoid needed moral action, he writes: "Let's not pretend we are imposing limits for patients rather than [for] our own best interests."

Memorial Sloan Kettering's Ladd Chino says she has a work-around for the problem of inappropriate giving. She donates money to cancer centers by giving directly to social workers via prepaid credit cards, which are classified as "unrestricted funds."

"The Happiest Doctor I Know"

Steve Joffe, MD, a pediatric oncologist and bioethicist at the University of Pennsylvania in Philadelphia, says that "there are things that everybody agrees are completely out of bounds," such as a doctor-patient sexual relationship. And there are things everyone agrees are appropriate, he says, such as when a patient dies and the doctor attends the wake or funeral.

Between these two situations, there is uncertainty, he suggests: "The lines [demarcating acceptable doctor-patient relations] are not always obvious. That's where the controversy comes up."

In an interview with Medscape Medical News, Joffe brought up one of Schiff's points: the distance needed to keep patients at arm's length varies by locale. "My dad was a practicing physician in a medium-sized town. I can tell you that there were varying kinds of relationships ― personal and professional ― and different ways people took care of each other."

Gupta's father was also a physician ― and someone who routinely paid for his patients' medicines.

"I grew up in Delhi, and my father, a pediatrician, has a home clinic. Affluent parents would pay the full 2000 rupees for a routine visit ($30). Poor patients would be seen for no charge, and their vaccines were funded by dad. Literally they would pay nothing," he says.

These are ties that bind ― and are highly satisfying, Gupta suggests.

"My father sees the third generation of loyal patients now. Some, whose parents were poor, are rich now. They donate money for others' vaccines. My dad is the happiest doctor I know."

Have you ever paid for a patient's medication? What do you think of this practice? Please let us know in the comments section.

Nick Mulcahy is an award-winning senior journalist for Medscape. He previously freelanced for HealthDay and MedPageToday and had bylines in WashingtonPost.com, MSNBC, and Yahoo. Email: nmulcahy@medscape.net and on Twitter: @MulcahyNick. For more from Medscape Oncology, join us on Twitter and Facebook.

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