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.
An article on the Guardian’s ‘Comment is free’ website is attracting a lot of attention. Within two days of posting, it has been ‘shared’ on social media nearly 27,000 times and attracted 650 comments. The article is a first-person account of experiencing a miscarriage. The couple received excellent, sympathetic care, undermined somewhat by an automated text the next day asking, ‘How likely are you to recommend our A&E department to your friends and family if they needed similar care or treatment?’ The text presented a 5-point Lickert scale and asked respondents to text back 1 to 5 on the basis of how likely there were to recommend that A&E. This also happened with a follow-up scan at a different NHS site.
The couple felt the texts were ‘crass and inappropriate’. They did not want to be part of someone’s piechart being lauded at a meeting for improving ‘customer satisfaction’ (again the economic language that has proved so potently divisive given the debates about privitisation in the NHS). Instead it was the sincere, human interchange which this couple saw as their meaningful feedback: ‘We had thanked the excellent doctor who witnessed our anguished hope, who entered into that space with us at the start of a long night in A&E and held our hands when our nightmare became reality. I can’t speak highly enough of her … That’s the place for feedback: face to face, sincere thoughts and feelings expressed from one human to another.’ It seems the intimacy of the expression of gratitude was violated by the imposition of a faceless, administrative measure by text. But the comment, ‘I cannot speak highly enough of her’, is revealing. It suggests that language is unequal to the task of praise in this instance, thus the negative framing: ‘I cannot speak.’ That the article has been written at all is a way of expressing gratitude, even if it is by way of condemning the feedback system.
The measure, known as the Friends and Family Test (FFT) was announced by the Prime Minister in 2012 and is gradually being rolled out across all NHS services. Various healthcare trusts publish their results on their websites, and NHS England aggregates the results here. Defenders of it see it as a cost-effective way of improving services: the statistical measures are published so that some services are ‘named and shamed’ presumably so they will try harder. The feedback does allow for comments which is presumably what really delivers value in terms of suggestions for improvements or singles out particular individuals or practices for praise. Do these positive comments get fed back to staff? I hope so.
The framing of the ‘would you recommend?’ question is not appropriate for A&E. No one ‘recommends’ a trip to A&E: it should be a place of last resort. One can’t imagine googling the stats before deciding on the A&E at which to turn up, or instructing an ambulance driver to head for a distant A&E department that has a higher FFT score. So how could soliciting feedback be done better?
Presumably there is some admin involved in which phone numbers need to be transferred to the system which sends out the text. If there is joined-up thinking here, someone would make a judgement call about what method of soliciting feedback would be best, or whether it would be appropriate at all. Might this be open to corruption with Trusts cherry-picking patients to survey whom they think will give positive feedback? Perhaps, but an audited system in which decisions about whom to survey are transparent would be preferable to the one-size-fits-all approach. In this case, it would have been far kinder for someone to ring the couple to ask if there was any further support they needed, and gently asking an open-ended question about their experience of A&E. If the Lickert scale must be brought into play, framing it with an apology for the bureaucratic style might minimise the potential offensiveness. “I apologise for seeming to reduce your experience to a number, but the government requires us to collect this data. Could I ask you, on a scale of 1 to 5…?” And if the couple did single out individuals for praise, my first priority would be to let them know that that his/her efforts had been appreciated and it was fed into their staff feedback.
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 love this poem by Sue Sun Yom (to whom I am grateful for permission to reproduce it here). It is published on p. 111 in an anthology called Body Language: poems of the medical training experience, edited by Jain, N., Coppock, D. and Brown Clark, S., published by Boa Editions, NY: Rochester.
Gratitude
Mr. H, taciturn and a little odd,
Whose wife preferred another man,
And who would come faithfully
Late by fifteen regular minutes
Each Friday. Mrs. V and her loyal
Veterinarian daughter, the other
An internet mogul in Hawaii,
Who wanted only for us to spare
The eyebrows, though she’d lost
All sense of self and hair. These images
Are the ones I remember, when the
Clock runs two hours early,
And the waiting room shrinks to
Maximum capacity. The chocolate and the cards
Are nothing compared to this — a touching —
My hands weaving their way through a life,
Splayed out like tendons, tense and playable,
The sweetest and most bitter of chords.
This is a sad story with a heartwarming ending. When Kellie Haddock’s son Eli was a few months old, the family was involved in a card accident that killed her husband and left Eli with serious injuries. A chance meeting at a prayer group led to a film being made of Kellie finding everyone involved in saving Eli’s life, thanking them personally, and inviting them to a concert to celebrate Eli’s recovery. The blog posting about how it came to be made is here.
The programme ‘Saturday Live’ on Radio 4 has a regular slot where listeners say ‘thank you’ for good deeds. Health care professionals are regularly thanked on the show. Today (3 January) there was a lovely item in which a nurse was interviewed about thanks expressed by patients. The story started some months ago when a patient, Rami Seth (sp?), came on to express thanks for a slice of warm toast smuggled in by nurse Rosie Wilson while he was recovering from major surgery. Rosie spoke eloquently about how touched she was to hear the thanks expressed. It brought home how a small gesture, such as delivering a slice of warm toast, can mean a great deal to patients. Rosie said the biggest thanks is when patients come back, restored to health. The item is available on the iplayer here, 48:00 to 53:00.
Rina Dave has found a wonderful way to celebrate the healthcare professionals and her friends and family who are supporting her through he treatment for cancer. She has created large-scale photographs of caregivers, each personalised by an ‘accoutrement’ that gives a glimpse of their personalities. Read more about the exhibition, on display from 17 to 30 November 2014 in the main entrance of Imperial College.
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.
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.
