Month: June 2014

Gratitude for whatever

Angus D H Ogilvy has written a cycle of poems in response to his diagnosis and treatment for cancer, called Lights in the Constellation of the Crab. He performs his poem, ‘Gratitude for whatever’ here.

Gratitude for Whatever

I can’t be anything other
than grateful.

What’s the point?

Anger?
Hatred?
Jealousy?
Lamentation?

It is too hard work.

Gratitude is the point
of least resistance.

Through the casualness of ‘whatever’ in the title, and spelled out more explicitly in the poem, the poet suggests that gratitude is the default emotion – the one that requires least work to achieve. The tone of the poem is one of resignation. It is not clear at whom the gratitude is addressed: towards other people or even to the cancer itself. The poem is positioned in the cycle between ‘First Screening’ and before ‘How Long?’, both of which draw attention to small acts of nature, such as watching a tree ‘shed a leaf’ or the ‘fall of a feather’. This suggests that the gratitude might be for the diagnosis of cancer throwing into perspective of the hitherto ‘taken for granted’ aspects of daily living.

In an example of how gratitude for care often generates the desire to ‘give back’, Ogilvy has donated all the proceeds from the sale of his anthology to the Maggie’s Centre in Edinburgh.

NHS Scotland has published a video of Ogilvy reading his poems as a ‘Patient Safety Story’ on their Quality Improvement Hub so that, in the words of Fiona Gailey, from NHS Education for Scotland, ‘for use by colleagues to understand better patient experiences and perceptions’ (interview here). This is admirable – Ogilvy’s poems do address aspects of cancer care that are insightful and useful. However, it is unfortunate that patient narratives of this type are being subsumed into an agenda of ‘patient safety’. The semantics have gone awry.

Patients’ stories are seen as an important means of using ’emotive narrative’ to disseminate ‘a human side to patient safety work’ (according to the January 2014 leaflet entitled Making the most of patient safety stories). Ironically, the stories they have in mind are not about patient safety, but about patient danger – cautionary tales that pack an emotional impact. Although the leaflet acknowledges that lessons can be learned from ‘rewarding’ experiences, the overwhelming emphasis is on adverse events.

The use of the term ‘safety’ is a example of the misguided use of what is sometimes called ‘progressive language’: couching something in positive terms to suggest progress. The phrase ‘patient safety stories’, though, doesn’t make any sense: these are not stories by patients about safety. Neither are they stories about ‘patient safety’. They are best described as stories by patients that could be used to improve patient safety. Using ‘safety’ as an adjective in this context may be concise, but it is at the expense of good sense.

‘Yours gratefully…’: the Frimley Sanatorium correspondence

Frimley Sanatorium, established in 1905, was the country outpost of the Brompton Hospital for Consumption and Diseases of the Chest. Its purpose was to provide a healthy environment for patients who were deemed capable of making a good recovery from TB. After a few years it was realised that follow-up records were vital for understanding the impact of the changing treatment regimes at Frimley. It fell to the Lady Almoner at the Brompton Hospital to persuade patients to keep in touch with the hospital after they were discharged.

Report on the after-histories of patients discharged from the Brompton Hospital Snatorium at Frimley, in Surrey, during the years 1905-1910.
Report on the after-histories of patients discharged from the Brompton Hospital Sanatorium at Frimley, in Surrey, during the years 1905-1910, emphasising the need for follow-up.

Miss Lily Constance Marx, appointed in 1920, took this duty very seriously. She maintained contact with hundreds of patients through the course of her long career. The letters are a testament to the gratitude that many patients felt for the treatment they received at Brompton and Frimley. But the courteous and grateful tone of the correspondence from the almoner, thanking patients for keeping in touch, established a mutual cycle of gratitude. Here is one example, sent by Walter Woollett, writing over 40 years after he had received treatment at Frimley:

I must say Madam it is nice to know, that one knows that someone takes an interest in our old age & again I thank you for all past kindnesses […] If it had not been for Frimley & Brompton I am afraid I should not be acknowledging your kind letter. All good wishes for 1948.

Another example of mutual gratitude is evident from correspondence in 1945 between the almoner and Mr H E Watson, who had been treated in 1906. He sent a £25 donation to the hospital, and received this reply:

Dear Mr Watson

I am writing to thank you most gratefully for your generous donation of £25 for which a formal receipt is enclosed from the Secretary.

May I say how encouraging such an expression of gratitude from old patients can give to the hospital staff, as well as practical support?

I am glad to know you are keeping well and going on at business as usual. Please find the enclosed Annual Report which you wished to see.

Again with many thanks.

Yours truly,

Almoner

These types of letters are typical examples of the expressions of gratitude that abound in the archive of letters. They arose from institutional, yet personalised, correspondence. The correspondence became a lot less personal when the almoner’s letters were replaced by correspondence from ‘the Frimley follow-up department’ in the late 1950s.

Patients queue to thank GP Richard Hughes

Patients queued for hours to thank Dr Richard Hughes on his retirement. Image: The Mirror

This is a lovely story of how patients queued for hours to thank Dr Richard Hughes on his retirement. An ‘event’ such as retirement provides a focal point for gratitude – it seems a shame that many doctors receive a show of appreciation only at the end of their careers. One of the characteristics of the way we express gratitude, in Western societies at least, is that it often signifies the ‘closure’ of a particular transaction. (The word ‘transaction’ here seems freighted with economic meaning, rather unfortunately, but the rhetoric of gratitude is saturated with economic metaphors.) This closing shapes the framing of the act of gratitude as a ‘reward’ for past service: in terminis res, as it were, rather than in medias res.

Here is a round-up of news coverage of this story:

Daily Mail: The GP everyone in Britain wishes they had

Daily Mirror: Patients queue FOUR HOURS to thank GP retiring after 32 years serving community

Telegraph: Dr Richard Hughes: ‘I saw them through the best and worst times’ and A great family doctor is a treasure beyond price

The Times: Doctor’s prescription for a better health service

How frustrating must it be for the Hanway Medical Practice where Dr Hughes worked, to have received poor ratings (at time of writing) on the NHS Choices page for Ratings and reviews. Interestingly, in response to a complaint about difficulties in booking an emergency appointment, the practice manager invokes a comment received by the practice website:

The Practice regularly receives positive feedback from patients about the ability to get same day appointments and the helpfulness of staff; this is a written comment that was received via the Practice Website on the same day as the above comment ‘ Just wanted to express my thanks at the excellent service yet again from your staff. Have had to book 2 emergency appointments within the last week for my husband and your staff were friendly and helpful and my husband was seen both days by lunchtime’.

Gratitude is often expressed privately, but frustrated complainants are keen to use the public platforms provided by institutions further up the hierarchy (NHS Choices, rather than, or as well as, the practice’s ‘customer satisfaction survey’ on the website.

Take-home points:

  • Doctors often receive most appreciation when they retire.
  • Gratitude is more easily clustered around an ‘event’, whereas complaints are catered for at any time.
  • Although praise and criticism are both catered for under the banner of ‘feedback’ or ‘comments’, their rhetorical purposes are very different, and it is not surprising that public platforms are dominated by complaints.
  • Gratitude is more likely to be privately expressed at the closure of an encounter, whereas complainants want a more high-profile platform as a means to inducing change.

Introducing the Rhetoric of Gratitude project

This poster from the 1920s, displayed at the Royal Brompton hospital, reminds patients of their 'duty' of gratitude.
This poster from the 1920s, displayed at the Royal Brompton hospital, reminds patients of their ‘duty’ of gratitude.

The National Health Service (NHS) in the UK has come in for increasing criticism over the past few years, both from within and without the system. Newspaper reports tell of neglected patients and money-grubbing GPs, and concerns about a target-driven culture, privitasation and staffing levels create an impression of a system at breaking point. Yet, the NHS is a cherished institution about which many feel passionately defensive. One of the drivers of morale in a beleaguered NHS is the gratitude that patients express in a myriad of ways, almost all of which are informal. Whereas there are numerous systems in place for making a complaint, the ways in which people say ‘thank you’ are often ‘under the wire’ and rarely receive formal recognition.

My research, which I intend to form part of a PhD, will investigate the ethnography of gratitude within healthcare. How is gratitude expressed? How do expectations of gratitude square with a system based on entitlement to treatment? Do the informality of expressions of gratitude give them a sincerity that would be lacking if gratitude was encoded in the same procedural rhetoric that applies to ‘making a complaint’? How can we recognise that complaining does not imply a lack of gratitude, and that gratitude is often codified in ways that highlight deficiencies in a system as well strengths?

This research involves a historical dimension. I am investigating an archive of letters between former TB patients and the almoner of the Royal Brompton Hospital, a fascinating correspondence that spanned much of the twentieth century. The almoner solicited follow-up information from patients about their health, expressing gratitude for their continued cooperation in important work about the effects of treatments for TB. Patients in turn expressed gratitude for the hospital’s continuing interest in their health and circumstances, and often enclosed postage stamps or donations to help the hospital, especially in times of war. The reciprocity of gratitude is evident in the correspondence, and it is possible to explore changes in this relationship with the introduction of the NHS and more formal, and impersonal, follow-up arrangements. The letters are of interest, not only for their content, but also because they constitute a social and health history written by those whose voices have rarely been preserved in the historical record of healthcare in which almost all communication by patients is reinscribed in medical records written by health professionals.

I intend to explore ways of carrying out ‘gratitude audits’ in a number of healthcare settings in order to describe the ways in which gratitude is given and received.

Some of the avenues of investigation include:

  • ‘Message books’ often given to GPs on their retirement.
  • Cards and other gifts given to hospital staff.
  • Arrangements for recognising donations made by grateful patients and relatives.
  • Ways in which expressions of gratitude differ across specialties, e.g. those working in obstetrics are known to receive many more overt gestures of gratitude than those working in casualty or mental health.
  • Unusual expressions of gratitude, e.g. tattoos of doctors’ names, allotment produce, homemade gifts.
  • Registers of gifts, as prescribed by the GMC, for gifts over £100 in value.

I would be pleased to hear from anyone with an academic interest in this area or who has a narrative of generosity to contribute to the research.