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.
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.
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’).
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.
These amazingly creative cupcakes were made by the aunt of a young tonsillectomy patient for the surgical ward and theatre team. It meant a great deal to the staff. Dr Ruj Roplekar, who was one of the recipients, said, ‘I was delighted that someone had shown that degree of appreciation for all those involved in the care of someone she loved.’ When Ruj posted this image on Facebook, it was interesting to see that one of her fellow medics urged her to save the photo as evidence for the ARCP of the ISCP (that’s Annual Review of Competence Progression for the Intercollegiate Surgical Curricular Programme). Indeed, thank you cards and other ‘evidence’ of patients’ appreciation are considered when competency is being reviewed. All the more reason to say ‘thank you’ creatively when good care has been received.
… and concludes that it is not a good idea. The article, which cites this blog, is here. It looks like sensible research on gifts from patients has not been done since the 1980s. The ethics of accepting gifts are well rehearsed and there are clear guidelines. An understanding of why gifts are offered, however, is lacking. There is much speculation about cultural reasons, or potential bribery, but getting the heart of the supererogatory actions that inspire acts of gratitude would help to inform policies on these issues, and also give us an insight into what patients think about the issue.
There is also a discussion on gifts inspired by the article here on doc2doc.
He says, ‘the unselfishness of the act speaks louder than words. It is behavior like this that makes me forget the injustices of the system, the small and large tragedies that I encounter daily in the practice of medicine, and keep going.’ Gratitude for gratitude.
I have been reading an influential essay by Arjun Appadurai, ‘Introduction: commodities and the politics of value’ from Appadurai, A. (ed.) (1986) The Social Life of Things: Commodities in Cultural Perspective. Cambridge: CUP, pp. 3–63.
Although focused on ‘commodities’ which implies an economic context that is missing (overly at least) from the NHS context, points in the essay have made me think about how one might frame a critical study of gratitude and the giving of gifts to healthcare professionals.
It is not customary to give gifts in the NHS (although this needs further research). Most anthropological studies of gift-giving are focused on the trajectory of gifts within relatively isolated, small-scale societies. Whilst a hospital environment, or a GP practice, could be viewed as analogous to a non-capitalist society (at least at the patient-facing end), gifts are meant to be ‘terminal’ (or ‘enclaved commodities’) rather than circulating. There may be very interesting things to say about how gifts are usually consumables or have a short shelf life. According to some studies (cited in this excellent article by Spence on patients bearing gifts), chocolates and wine are most often given. These are ‘luxury’ items that are relatively low priced and thus less potentially threatening to the professional/private boundary than more personal gifts.
Gifts given at Christmas are customary, and possibly more acceptable because they form part of rituals surrounding celebration and one need not be suspicious of ulterior motives on behalf of the giver. In an article for the RCGP’s The New Generalist publication in 2005 (quoted here), de Zulueta describes a range of reasons why patients give gifts, including:
to show genuine gratitude
to redress the balance in terms of power sharing
out of affection
to attract attention
to manipulate the practitioner to carry out preferential treatment or some other treatment they would not normally give
to expiate guilt for burdening the practitioner.
Anthropological studies are woefully inadequate when it comes to addressing motives for giving, yet assumptions made about motive is what drives policies about gift giving, including widespread advice not to accept any gifts at all. ‘Gifts’ also see to be treated as a homogeneous category regardless of the giver, so that gifts from patients are treated as if they are the same as gifts from pharmaceutical companies (which are unlikely to be stimulated by genuine gratitude – the most ‘sincere’ motivation for gift giving – and inevitably carry a whiff of moral taint).
My hunch is that the nature of gift giving in the NHS has changed in response to the way healthcare is organised. I predict that the rise of teams responsible for care has meant that fewer patients identify a single individual as being particularly worthy of gratitude. Gifts that can be shared are likely to continue to predominate (chocolates especially). I think (hope!) that a greater awareness of religious sensibilities of healthcare providers make a gift of wine a less popular choice (about 10,000 workers in the NHS are Muslim and eschew alcohol).
The role of patronage is important here too. Gifts from patients are often channelled though charities associated with hospitals or particular fund-raising initiatives. This separates the gift and any possibility of it contributing to individual gain. Initiatives like the ‘giving tree’ at the Brompton Hospital helps to bridge the gap between the impersonal cash contribution and the expression of gratitude to individuals or teams within the hospital.
A series of ‘giving trees’ at the Royal Brompton Hospital allow patients to express gratitude publicly whilst donating money to the hospital charity rather than an individual.
Appadurai’s essay examines ‘instruments of value’ and reminds us that status participates in the economics of exchange. League tables, and specific ranking of individuals, could be seen as a rather insidious form of what Appadurai calls ‘tournaments of value’, involving status, rank, fame, reputation and ‘central tokens of value in the society in question’ (in the NHS, that could be analogous to ‘patient safety’): ‘Tournaments of value are complex period events that are removed in some culturally well-defined way from the routines of economic life. Participation in them is likely to be both a privilege of those in power and an instrument of status contest between them.’ The worrying aspect is that league tables treat people and skills as commodities, whose worth can be quantified by simplistic measures. In the context of concerns about the privatisation of the NHS, the use of league tables is held up as an example of transparency and accountability, and in the interests of patient choice (however illusory that may be), whereas the rhetoric of the hierarchy which is entrenched in the very notion of ranking reinforces the metanarrative of the NHS as a ‘market’ in which value is distilled into a set of indicators reminiscent of the trading floor.
Perhaps the most salient take-home message from Appadurai’s essay is that politics govern the contexts of value-based exchanges: ‘not all parties share the same interests in any specific regime of value.’ It is those interests that are woefully understudied.
