Hugh Tunstall-Pedoe
Dundee, Scotland

It was Christmas Day in Guy’s Hospital, London. Two months into my first house-physician post, I was completing a morning round with the staff nurse on my female ward. At the far end of the open ward was a bed with closed curtains. A small face peered round them with increasing frequency and excitement as we approached. Eventually, I was presented with a soft toy my young patient had cut out, stitched, and stuffed as a surprise Christmas present for me. She received a hug and a kiss in return. Well chaperoned, I nonetheless broke two medical no-nos: kissing patients and receiving presents from them.

Her age qualified for an adult ward, but other patients were much older. She had subacute bacterial endocarditis, which meant an antibiotic drip for weeks, but an embolism prolonged it through Christmas. She stopped eating and turned her face to the wall. My consultant suggested I have a good talk with her. She was a fastidious girl who treasured her privacy and found the penetrating voice of the ward sister disconcerting. Sister had insight and moved her to the end of the ward, keeping her bed curtains closed to create a private world. Appetite and morale returned. Years later, the toy entertained my children, until shredded by our puppy on their playroom floor (see image).

Receiving gifts and kissing patients are rarely discussed. Here I debate gifts. I remember kissing one other patient forty years later—at a retirement farewell after twenty years of eventful follow-up for congenital heart disease. Receiving gifts was rare, in both welcome and unwelcome circumstances, and nearly always occurred in the early years of practice.

Receiving gifts is discouraged by medical organizations for good reasons but is difficult to police. The practice should be dying out, as continuity of care by one person has declined and medicine has progressed. Surviving serious illness is now routine. Medical and surgical practice are team games and the teams are enlarging. Individual devotion is outperformed by group competence, good communication, coordination, and absence of errors.

Outside private practice, patients may hope to jump the queue and gain attention by payments or gifts. There is a difference between making gifts prospectively in anticipation of favors, versus doing so to mark the end of a relationship. If a gift from a patient comes to the attention of other patients, they may think it is generally expected. A present may go to the least deserving member of the team. It may be unwanted and embarrassing, but difficult to refuse. Better to leave a perishable box of chocolates on the ward on departure or make a gift of money to the institution—but the latter is not the same as marking the conclusion of a relationship with someone which is valued, when it is the patient who takes the initiative.

My own experience of presents was limited, but I heard of the bad and the acceptable from others decades ago:

• One of my consultants in the 1960s was presented with a puppy from a Cruft’s pedigree champion dog. He regretted accepting but did not want to upset his longstanding patient.
• A student contemporary, known for his ostentatious religiosity, promised a patient of his having major surgery that he was going to pray for her. Afterwards, he accepted a car from her to our general disgust.
• A house-surgeon colleague looked after a patient during cardiac surgery, who left an “over-the-top” gift of a crate of whisky for him at the hospital. The houseman shared his surname with a consultant surgeon who accepted the gift, not recognizing the patient’s name. The truth came out, one bottle was transferred, and the fate of the rest is unknown!
• A general practitioner golfing acquaintance told me of a valuable painting he had admired in a patient’s home, later bequeathed to him. One can imagine an innocent bequest, but also a visiting doctor being over-interested in valuables on a home visit. If the painting was a truly expensive heirloom, were relatives involved?

Gifts I regretted:

• An outpatient wrote a complaint about me, which baffled me and the hospital. Next visit she produced a gift, which was inexplicably accompanied by a strange, awkward manner – neither an apology, nor thanks. Both actions, to me, were from someone seeking special attention, having difficulty accepting she was a routine patient.
• While redecorating my study at home one evening, I was half in and out of the window, in stained overalls, when a car pulled up outside. Out poured a former patient of mine with his wife and family, bearing various delicacies as gifts. I had recommended him for valve surgery but not done anything special. He had researched where I lived and was celebrating his survival, besides showing off his doctor to his family. It was an invasion of privacy— besides, my painter-work needed continuing! However, I could not see how to bring him down off cloud nine without discomfiting him in front of his wife and family. He also implied that my home-decorating was beneath me and disappointed him.

Potential embarrassment:

• A flight engineer I saw in the NHS cardiac clinic insisted I should claim a fee. I said I did not see private patients or know what to charge, so forget it. He said, “No! Leave it to me.” Next visit, I was told there was a cardboard box for me. I did not want other patients, not knowing the story, to find out, so waited until the clinic emptied. The box was full of tropical fruit, purchased in Nairobi within the previous twenty-four hours.

No regrets:

• An anecdote with an amusing sequel. As house-physician I admitted a French boy from a school trip to London. He had been unwell before he came, was given a strange diagnosis, and prescribed calcium tablets. In London he was worse. He had acute rheumatic fever, brought under control with aspirin. His father phoned me each morning on going to work: “Allo, ‘ow is our boy?” The time difference made this 5am—I got to bed near 2am. When his son improved, I suggested phoning later. The calls stopped. Soon after, the ward bed was surrounded by sad French children—abandoning him, homeward-bound. I informed the French embassy of their stranded citizen, who alerted their consular section. Next day, “our boy” had two visitors, a pile of French books, and other distractions by his bed. I went on holiday and returned to a carrier bag containing a bottle of brandy and some cigars. Guy’s, like other London medical schools at that time, had a minority of women in training, including rare daughters of medical missionaries—formidable young women of character. At supper, one told me that she had never tasted brandy. I opened the bottle and shared a dram with her back in my room. She sipped it slowly. “Very nice, Hugh, but I think, in the future, I will save brandy for medicinal purposes only!” “Medicinal purposes” then was an alibi often used by tipplers, but I guessed her puritanical conscience allowed her, just once, to safely sample the earthly temptation that she was conditioned thereafter to forgo!
• The most valuable present I had—in what it represented. As a houseman I looked after a woman with gross edema unresponsive to orthodox treatment. A colleague told me you could use the new oral drug, furosemide, in large doses, which I did, although this involved complexities with juggling electrolytes. The consultant returned from holiday to find the patient he had left, as he put it, “sitting in a bath of fluid,” now edema free, and offering to race him down the ward. He credited me with saving her life (although she was readmitted, and the regime modified after I left). Her management necessitated vigilance. After an evening off for a formal dinner, I returned late at night and went up to the ward to check all was well, but found the drip was blocked. In flushing it, I inadvertently squirted some blood-stained fluid onto my dress shirt—embarrassing for me, but no big deal—heading for the laundry anyway. My patient was distressed despite reassurance. Later, I received a smart leather toilet case in her name, with contents, which I kept for years. There had been a family conference. They retrieved the teapot, into which they put their silver loose change, from the dresser where it lived—savings for treats, holidays, and extras—and spent the contents on me.
• Last present. Presents stopped completely, bar one, during my final quarter century in a cardiac clinic. I had no personal achievements to match the intensive and devoted care I gave as a junior doctor. Times had changed. Arguably you do not give presents to a mature professor, in comparison with an impecunious young house doctor, anyway. A pleasant elderly woman was much distressed by palpitations, whose cause and prognosis were benign, but they seriously demoralized her. Recently widowed, I suggested that her symptoms might have appeared worse because she lived alone and had nobody to tease her and help put things in perspective. Some weeks later, I received a bottle of whisky and a note to say that she had thought about what I had said, convinced herself that I was right, felt so much better, and “please accept this bottle of whisky as confirmation.”

Generally discouraged, gifts raise ethical issues, but sometimes appear proportionate and appropriate. In my first and last cases (query others?) they may have been therapeutic to the donor—although I hesitate to suggest it out loud!