Author: Giskin Day

I am a senior teaching fellow in the Centre for Co-Curricular Studies at Imperial College London. I teach medical humanities and communicating science, and co-ordinate the Science, Culture & Society field of courses within the Imperial Horizons programme.

Wellcome on board

So, I’ve just accepted an offer from King’s College London to start my PhD in October. Professor Anne Marie Rafferty has agreed to be my supervisor. With her help with my proposal, I’ve been very lucky to receive a Doctoral Studentship from the Wellcome Trust.

Writing a research proposal for a funding application is very different to hypothesising a project in your imagination. Suddenly, everything has to be a lot more concrete. Vague ideas about what I planned to do needed to be properly thought through and justified. I found it most difficult to triangulate my sampling methods, collection and analysis for each phase of the project. The National Institute for Health Research has a Research Design Service who gave me excellent advice on how to make all the pieces fit together in sensible ways. Advisors at King’s were also very helpful.

I’ve refined my research question, and it now looks like this: What can we learn from past and present practices of gratitude in healthcare, and how it can enhance the wellbeing of those who give and receive it?

Supporting questions include:

  • In what ways is gratitude expressed, received and displayed?
  • How do healthcare professionals respond to different forms of expressed gratitude, and what are the contextual factors that shape these responses?
  • What role does gratitude have in shaping human relationships in institutional environments?

I’m looking forward to getting going!

 

 

#BlueLightHappy campaign

Being a paramedic is one of the world’s most stressful jobs. Being exposed to the trauma of others on a daily basis and having to respond calmly in time-critical situations are difficult enough. Combine these with widespread incompetent management practices and a crisis in recruitment, and it is no wonder that the suicide rate in paramedics is widely believed to be amongst the highest in any profession. This moving account of the stresses faced by a paramedic provoked an outpouring of appreciation on social media. Similarly, in response to a snippy comment left on an ambulance windscreen, and other stories of paramedics receiving unwarranted abuse, paramedic Rob Moore used Twitter to urge the public to share good news stories using the hashtag #BlueLightHappy. “It’s time for a morale boost,” he said.

What is noticeable about the hundreds of expressions of gratitude flooding in on Twitter is how few paramedics are thanked by name. When people are in extremis, they are hardly ever able to focus clearly enough to find out or remember the names of the paramedics that have come to their aid. The result is a lot of generalised gratitude. But that thanks rarely makes it back to the paramedics at whom it is aimed. Even if paramedics recognise themselves from the patient’s description of the incident, gratitude cannot gather momentum within their organisation unless those individuals are named.

If you are unlucky enough to need to services of a paramedic, here is some advice:

(1) Hospitals will have records of the paramedics who admitted you. When you are well enough, find out who they are and make sure your gratitude reaches them. Or if you have friends or family who say, ‘How can I help?’, you know what to ask them to do. Your detective work will be much appreciated.

(2) Social media is great. Proclaim your gratitude on Twitter, Facebook and Snapchat. Write to your local paper. But personal expressions of gratitude are so worthwhile too. Cards are treasured by health-care professionals. Especially if they are personally addressed.

(3) Be specific about what you are grateful for. Most health care professions find it difficult to accept gratitude because, they say, ‘I was just doing my job.’ And they are right. But you probably aren’t thanking them for just doing their job. You are probably thanking them for particular instances of kindness, or something small that made a huge difference to you when you were in crisis. It is helpful for paramedics to have that feedback. It helps them to help others.

Patient gratitude will not solve the multiple crises facing the emergency services. But when the system is broken, we need to fall back on individual, communicative acts of kindness. Saying “thank you” is a small act that makes a big difference.

Lessons for education from what I have learned, so far, from gratitude

This week I gave a research seminar in my department, the Centre for Language, Culture & Communication at Imperial College London, in which I synthesised some of the ‘lessons learned’ in the course of my research and how this has informed my teaching. It was streamed live, and Julian Lecoeur from ProlificTV has kindly made a recording available here.

Irony-assisted significance

I am a great admirer of Paul Fussell’s ‘The Great War in Modern Memory’. Fussell writes eloquently and persuasively about the relationship between language, literature, action and cognition. Interviewees, he found, often recalled incidents from the war precisely because they were ironic: the irony of a man being ‘comforted’ by a friend, oblivious to the terrible injuries sustained by the friend; the stumbling across of a corpse of a family member; and so on, and so on.

This resonates with ironies about how gratitude is received and remembered. Many of the anecdotes told to me by doctors involve irony. The irony of a mental health patient railing against being sectioned by a doctor who feels dreadful about the situation, only to be profusely thanked for ‘saving my life’ by the patient some months later. The irony of doctors being sincerely thanked when their efforts have proved futile and the patient has died. I can’t think of other situations in which failure prompts gratitude in an analogous way.

Fussell argues that, ‘the art of memory organizes into little ironic vignettes, satires of circumstance’ (p. 32 of ‘The Great War and Modern Memory’, OUP, 2000, f.p. 1975). I have a feeling that this is true of instances of gratitude that come foremost to mind for doctors and other healthcare professionals.

Top oncologist says gratitude pays off

In an interview for the Oldie magazine, oncologist Prof. Karol Sikora has recommended being as nice as possible to those that treat your health conditions. “If someone is particularly helpful be appreciative – everybody likes positive feedback,” he told John Sutherland. Sikora is promoting his new book The Street-wise Patient’s Guide to Surviving Cancer in which he advises patients to charm their doctors if they hope to persuade them that they are worth ruinously expensive cancer drugs. NHS staff are “dedicated and remarkably caring”, he said, “and they naturally respond well to pleasant patients.” His advice,though to “tell someone they have a lovely smile,” might come across as a bit obsequious though, not to mention downright creepy in some situations. Best, I think, compliment people on their actions rather than their appearance. But he’s probably right in saying, “The lower down the food chain you are the less you get thanks in the NHS – that’s where the unsung heroes are to be found.” Sikora advises getting a ‘small gift’ for the receptionist: a bunch of flowers, bottle of wine or box of chocolates. This, he says, will make all the difference in prioritising your case. “Don’t be too generous,” he says, for this will embarrass everybody.

Sikora’s book is undoubtedly a ‘consumers’ guide’. It characterises cancer as an ‘industry’ and provides advice on how to maximise personal gain from a system geared to the general good. There is a fine line between genuine gratitude though and blatant bribery, and I suspect staff at all levels are able to tell the difference.

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Beginning to map key theorists

image1(7)Happiness is an A3 page and a sharpie. I have made a start on mapping various theorists I’m reading against disciplinary areas. Two distinct camps are emerging: those that look at gratitude as a form of capital (the Maussian ‘gift’ literature, Bourdieu) and those that see moral generosity as a refusal of reciprocity (Levinas, and to some extent Bakhtin). The first camp sees gratitude as a form of accrual and the second a form of sacrifice. The ‘accrual’ camp as being quite cynical about gratitude: it is characterised as self-interested (although not always consciously). In contrast, those that view generosity as a form of moral perfectionism for which the recipient need not enact gratitude are very idealistic.

In parallel, I’m reading Goffman’s ‘Presentation of Self in Everyday Life’ as a way of thinking about gratitude as performative. Given that so much of the language that surrounds medical settings is suffused with acting metaphors (‘perform’ procedures, take on ‘roles’, operating ‘theatre’, ‘how is the patient acting?’), Goffman articulates the art of impression management very well.

Visit to the UCLH Archive

I recently paid a visit to the University College London Hospital (UCLH) archives in Euston to discuss gratitude and see some of the archive’s holdings. Annie Lindsay and Penny McMahon have charge of a vast amount of material. Some fascinating highlights are on public display in UCLH’s highly recommended heritage trail. Annie and Penny gave me an insight into the kinds of documents that are preserved. Patronage, of course, is well documented, and this has an enduring legacy in a number of wards in hospitals being named for their donors. Complaints are also kept on record although, interestingly, Annie pointed out that in the past this largely depended on the diligence of the superintendent in charge. I was shown a formal complaints form from 1890. Complaints were often lodged by the patient’s sponsor on their behalf if it was felt that treatment was not up to the expected standards that the sponsor had paid for. Does paying for treatment at the point of delivery make complaints more common, I wonder?UCLH archive

We also discussed how gratitude is given and received today. Social media is important at UCLH and tweets saying ‘thank you’ are printed in the staff magazine. Patients expressing gratitude in this way is clearly valued and noticed. There is also a ‘good deed feed’ on the staff intranet for saying ‘thank you’ to colleagues.

The UCLH archive has a great collection of photos. The pic on the right is one of staff participating in festive shenanigans to help raise money for the hospital.

Doctors’ views on gratitude

A few weeks ago I had the opportunity to present some of my work on the gratitude expressed in the Frimley correspondence to GP trainers and trainees from West Middlesex Hospital, whose two days away were delightfully themed around ‘happiness’. It was a nice way to hear some stories of gratitude from the frontline.

We had a lively discussion about whether patients are morally obliged to feel grateful. Lots of the delegates were uncomfortable about the word ‘moral’, although most agreed that patients had lots to be grateful for. The overwhelming majority felt that patients should be grateful for the NHS in general, rather than specific practitioners. This sits uncomfortably with some of the literature (e.g. Simmons, 1979, Moral Principles and Political Obligations) in which it is argued that there are difficulties with expressing gratitude to an institution, especially if the individuals that form it are merely carrying out their duties. Most of those joining in the discussion thought that gratitude was owing to the NHS because patients got a lot more out of it than they put in. Some invoked comparisons with other parts of the world, making the case that access to the NHS is a privilege and definitely something for which to be grateful.

When it came to receiving gratitude, the most memorable gifts or cards came from patients from whom it was unexpected. An example was given of a man that had to be sectioned and was incredibly angry at the time, so a card saying ‘thank you’ a few weeks later was particularly touching. Homemade food as a currency of gratitude was also prominent, especially amongst the Asian community. Receiving gifts was confirmed as a particularly tricky issue for doctors with high potential to cause offence by refusing gifts, but sometimes it’s tricky to tell whether gifts do indeed come with strings attached.

Social media as a new outlet for gratitude

Cards displayed on the sayingthanksward, chocolates in the common room… but there is an increasing trend to use Facebook as a collective noticeboard to proclaim gratitude. Showing Thanks is a recently established webpage for conveying gratitude to healthcare professionals involved in maternity care and childbirth. Mothers have been posting their stories on this Facebook site and then Rachel Ellie Gardner has taken it upon herself to let healthcare trusts know when a member of their staff has been thanked.

Anecdotally, we know that staff involved in obstetrics get a lot of gratitude. Even if a birth has been dramatic (and, let’s face it, most births have elements of trauma), the outcome is usually happy. The thanks logged so far are revealing of what women value as being worthy of gratitude. These tend to be making time in spite of being busy, compassionate touch (like giving a hug or holding someone’s hand), being supportive of choices, and being reassuring. Even when the outcome was tragic, women have still thanked healthcare teams for being kind and supportive.

My reading lately has taken me into the realm of the ethics of gratitude. A conundrum when considering gratitude in healthcare is that patients are not obliged to be grateful. After all, healthcare providers are paid to do a job of work in an institution which is funded by taxpayers. Therefore the care provided is a duty rather than a benefit.  Alan Goldman (1980, The Moral Foundations of Professional Ethics, Totawa, NJ, Rowman and Littlefield), for example, argues that citizens have no debt of gratitude to the state because they collectively pay for public goods through taxes. This suggests the relationship between citizen and state resembles a commercial relationship (one does not feel gratitude to a store for selling you goods). However, it is clear that many patients do not see healthcare in this way. I think this is partly because there is a collective social resistance to political pressures to commercialise the NHS, but also because the benefit of healthcare is psychically distant from the funding of it through tax. Overwhelmingly though, gratitude is a culturally mediated, social action that takes place between people who have a shared emotional connection. Gratitude becomes an instinctive response to what we might generally call ‘humanity’ demonstrated that goes beyond obligatory professionalism.

Walker (1988, Political obligation and the argument from gratitude, Philosophy and Public Affairs 18: 359–64) argues that even if you have ‘paid’ for a service, gratitude may be warranted if the quality of the service is exceptional and the manner in which it is provided is special. This is borne out by the stories being told on sites like Showing Thanks.

What price a box of turkish delight?

Jonathan Tomlinson is one of the most eloquent, sensible defenders of the NHS today. Writing on his blog, A Better NHS, he recently tackled the embarrassment doctors feel about accepting gifts. Entitled Giving and Receiving, the post takes the form of a reconstructed dialogue between Jonathon and an erstwhile colleague who says, “Accept the presents graciously, it means a lot to them and it should mean a lot to you too. Your patients care about you, and caring for others is one of the things that makes a hard life a bit more bearable. For some of course, you’ll have gone the extra-mile or diagnosed them with something really important, and for others there’s precious little kindness in their lives and you’ve been a part of that. For you perhaps it’s just business as usual, but look at it from their perspective, it’s anything but business as usual, it’s incredibly important, and giving you a present is their way of letting you know that.”

It strikes me that the moral panic about receiving gifts from patients is probably quite peculiarly British. Is this because of the distance placed between the service rendered and the formal renumeration? Anything that could be perceived as renumeration from a patient feels rather furtive from the recipient’s point of view. For the giver, though,  the lack of an itemised bill may incentivise the expression of gratitude in other non-monetary ways.

Privatised healthcare does not seem to feel the moral angst about receiving gifts as keenly. The guidelines on gifts from patients from the American Medical Association date back to 2003. They are non-prescriptive and only urge discretion in accepting gifts to ensure that the patient (or patient’s family is it is a bequest) will not suffer financial hardship. Before healthcare was nationalised in Britain, patients often paid their local doctor in produce or services rather than cash (admittedly this can’t strictly be considered a ‘gift’, although it is akin to what anthropologists call a ‘gift economy’).

The gift-economy in healthcare is still common in non-urban healthcare settings all over the world. Ian Cross blogged about his receiving bananas, sweet potatoes and sugar cane from a grateful patient at his Medicine Sans Frontieres practice in Swaziland.

I wonder if doctors in private practice in the UK notice a difference in the ways in which patients express gratitude compared to that in the NHS? I have heard of lavish gifts being given by private patients, but presumably if they choose to pay for treatment, affordability is less of an issue.