It brightens the day of any health care provider when a patient presents him or her with a personal gift. These thoughtful items express sincere appreciation and are evidence of a solid, trust-based provider-patient relationship. However, there is a significant ethical difference between accepting small gifts of appreciation versus gifts of great financial value. While the patient may be expressing the same appreciation with this substantial gift, he or she may also be attempting to curry special consideration or feel some pressure to please the provider. In addition, acceptance of these large gifts produces the appearance of an improper relationship between the doctor and the gift-giving patient. Patients who offer gifts of great value should receive a sensitive explanation as to why the gift cannot be accepted.