Facing challenging economic conditions, medical schools and teaching hospitals have turned increasingly to philanthropy as a way to supplement declining clinical revenues and reduced research budgets.
1
, 2
, 3
One approach to offset these diminished returns is to commit efforts to “grateful patient” programs that concentrate on satisfying patients and their families, especially families with significant assets.2
, 4
, 5
, 6
, 7
Support from grateful patients is the single most important source for substantive philanthropic gifts in medicine.2
When patients develop strong relationships with their physician or hospital, they may become deeply invested and resolve to support them.8
, 9
Involvement of physician faculty members in grateful patient philanthropy may be a complex undertaking with ethical considerations as patients evolve to become donors., 11
, 12
Some physicians may feel uneasy because there are no clear guidelines about norms or best practices. Moreover, most physicians have not received training in this area and have limited experience responding to inquiries about financial support of their programs from patients. For those physicians who lack preparation and skills, such discussions may feel inappropriate because of the shift away from the patient care focus.Perspectives Viewpoints
- •Our findings are of interest due to challenging economic conditions that academic health centers face.
- •Many have turned to philanthropy as a way to supplement declining clinical revenues and reduced research budgets.
- •We report a qualitative study identifying features that are thought to be associated with success in grateful patient philanthropy.
The medical literature contains few publications and essentially no empiric studies about the phenomenon of grateful patient philanthropy and its role in supporting institutional education, research, and patient care missions. Thoughtful and rigorous inquiry in this content area will advance understanding. To gain insight into grateful patient philanthropy, we studied physicians who have been successful in securing philanthropy to support their programs. This article characterizes perspectives about the factors that have translated into success in grateful patient philanthropy.
Methods
Study Design
This qualitative study involved in-depth interviews with study subjects. This approach allowed for the emergence of findings that researchers may not have anticipated.
13
In-depth interviews permit exploration to a greater extent than may be possible with closed-ended scales, surveys, or even focus groups.13
Study Sampling
This study used a purposive sampling strategy. Faculty members were recruited into the study because of their success in procuring substantive philanthropic gifts. Development professionals were asked to identify physicians judged to be particularly experienced and adept at grateful patient philanthropy within the Department of Medicine at Johns Hopkins University School of Medicine. An Institutional Review Board at the Johns Hopkins University School of Medicine approved the study, and written informed consent was obtained from all subjects.
Data Collection
From March 1 to May 31, 2009, 2 investigators conducted audiotaped, semi-structured, one-on-one interviews lasting about 45 minutes with each participant. Most interviews were conducted in person; a few interviews were conducted by telephone. The interviewer began by asking subjects closed-ended questions about demographic parameters; they also were asked to rate their comfort level with engaging patients in discussions about philanthropy on a 5-point Likert scale from “not at all comfortable” (1) to “tremendously comfortable” (5). The interview then switched to open-ended questions about grateful patient philanthropy. The interviewers, trained in qualitative interviewing techniques, used reflective probes to encourage respondents to clarify and expand on their statements. All interviews were transcribed verbatim.
Data Analysis
We analyzed transcripts using an “editing analysis style,” a qualitative analysis technique in which researchers search for “meaningful units or segments of text that both stand on their own and relate to the purpose of the study.”
13
Two investigators independently analyzed the first 4 transcripts, generating codes to represent the informants' statements, and created a preliminary coding template. This coding template was applied to all subsequent transcripts and revised as coding proceded. In cases of discrepant coding, 2 investigators successfully reached consensus after reviewing and discussing each other's coding. Atlas.ti 5.0 software (2005; Atlas.ti GmbH, Berlin, Germany) was used for data management and to facilitate analysis.Following accepted qualitative research methodology, sampling was discontinued after 20 interviews when it was determined that recent interviews were yielding confirmatory rather than novel themes (ie, “thematic saturation”).
13
This sampling size is consistent with other published qualitative studies.14
, 15
, 16
, 17
, 18
The authors reviewed all excerpts under each theme and agreed upon representative quotes that are presented in the Results section. To protect the privacy of participating faculty, descriptive details about the quoted informants are not provided.
Results
Informant Sampling and Demographics
During the process of recruiting the physicians identified by development to participate, one faculty member declined the request to meet. The participating physicians were primarily associate professors or professors (90%); 2 (10%) were women; and they represented a diverse range of specialties of internal medicine (Table 1).
Table 1Characteristics of the 20 Physicians with Philanthropy Experience
| Characteristic | ||
|---|---|---|
| Women, n (%) | 2 | (10) |
| Number of years in practice, mean (range) | 25.8 | (12-47) |
| Number of years on faculty, mean (range) | 22.6 | (8-45) |
| Academic Rank,n (%) | ||
| Professor | 13 | (65) |
| Associate Professor | 5 | (25) |
| Assistant Professor | 2 | (10) |
| Specialty, n (%) | ||
| Geriatrics | 4 | (20.0) |
| Internal medicine | 3 | (15.0) |
| Pulmonary | 3 | (15.0) |
| Nephrology | 2 | (10.0) |
| Hematology | 1 | (5.0) |
| Infectious disease | 1 | (5.0) |
| Rheumatology | 1 | (5.0) |
| Gastroenterology | 1 | (5.0) |
| Cardiology | 1 | (5.0) |
| Endocrinology | (5.0) | |
| Estimated number of donations acquired by a physician, mean (range) | ||
| Total career | 31.8 | (2-100) |
| At Hopkins | 30.0 | (2-100) |
| Comfort level with making patients aware of financial needs, n (%) | ||
| Tremendously comfortable | 10 | (50.0) |
| A lot | 6 | (30.0) |
| Some | 1 | (5.0) |
| A little | 1 | (5.0) |
| Not at all comfortable | 0 | (0.0) |
In describing their current clinical efforts, the average percentage of time spent on clinical care was 31%. The mean number of years in practice was 26. With respect to comfort with engaging patients in discussions about philanthropy, 80% of physicians rated themselves as being “tremendously comfortable” or “a lot”—the 2 highest categories.
Results of Qualitative Analysis
Physician informant comments and stories were categorized into thematic domains relating to success in grateful patient philanthropy. These themes are presented and each accompanied by one or more representative quotes. The themes also are presented in Table 2, along with the number of times each was mentioned and the percentage of informants referring to the theme.
Respondents were not queried specifically about these themes and these counts represent spontaneous and unsolicited responses in each subcategory.
Table 2Total Number of Times and Numbers of Respondents Referring to the Major Themes Related to Strategies for Facilitating Grateful Patient Philanthropy, from Interviews with 20 Physicians with Experience Acquiring Philanthropy from Generous Patient Donors
| Theme | Total Number of Times Theme Mentioned in All Interviews | Number of Respondents Referring to Theme n (%) |
|---|---|---|
| Excellence in patient care | 70 | 19 (95) |
| Meaningful connections with patients | 75 | 19 (95) |
| Institutional support | 112 | 19 (95) |
| Listening for patient cues and articulation of the vision | 41 | 16 (80) |
| Recognizing potential donors | 33 | 14 (70) |
Excellence in Patient Care
The informant physicians explained that providing the highest quality care to patients was a common starting point in situations that ultimately led to a philanthropic gift. The physicians described their attempt to provide this level of care at every patient encounter and with all patients. Spending appropriate amounts of time with patients, based on clinical context, and ensuring that patients have reliable access to their physician were critical for patient satisfaction. Other elements believed to be particularly important in gaining patients' trust and respect were being fully present when interacting with patients, superior communication skills, and humanism.
Informants explained that full and undivided attention in patient care commonly results in profound gratitude.
“I think if you're a VERY good doctor, the patients are appreciative; for some that amounts to a warm thank you, and for some that amounts to them going on and doing fundraising for you.”
“I knew that she was very diligent, and when she called to cancel her appointment because she was feeling so terrible… was in such pain and experiencing such swelling that she couldn't come in. And so, I asked her if it would be OK if I drove to her house to see her, and I did. She lived in a modest middle-class neighborhood. She was grateful.”
Connecting Meaningfully with Patients
Fostering deep and meaningful relationships with patients is a critical step in acquiring donors but considered distinct from the provision of excellent patient care. Attentiveness to the uniqueness of each individual and being committed to understanding the patient as a person, particularly the effect of the illness on the person's life, was stressed repeatedly. While some relationships with grateful patients were built over a long period of time, others developed more quickly because of the intense circumstances under which the patient and physician were brought together. Informants described their efforts to fully understand the values and goals of the patients and they believed it to serve as a spark for benevolence and generosity. The following comments from informants illustrate these points.
“I took my time to get to know them, to understand what the problems were, to hear about how the illness affected their life and to be with them …”
“After maybe 4-6 months of very frequent visits, she began to improve and we became much more acquainted … . At the end of one of the visits, she said: ‘You know, I've been very pleased and impressed with your help and I'd like to do a little something to help.’”
Institutional Support
This theme addresses the notion that grateful patient philanthropy is a team effort, usually led by the physician. Development officers are extremely important in stewarding potential donors as well as in recognizing and thanking them. Because physician faculty members have not been trained in matters related to philanthropic contributions, development officers are a helpful and supportive resource. Many of the academic physician informants explained how collaborating with development professionals not only resulted in obtaining financial support from generous patient donors but also shielded physicians from specific discussions about timing and gift amount. In addition, institutional leaders (including deans, chairs, and chiefs) were described as being extremely supportive in helping faculty in their philanthropic efforts. Some informants also explained how their administrative assistant or nurse facilitated communication and interactions with the donors.
The first of the following quotes describe collaborations with development personnel and the latter ones illustrate assistance and guidance provided by leadership.
“We have had sessions within our faculty meetings … on recognizing donors, how to discuss philanthropic needs, and very importantly, how to work with the professionals – the development officers.”
“The development office has a cookbook thing that they've prepared for me. Like if a patient wants to give a small amount of money it could be used for this, if they give more, it could be used for this; if it's even larger, it would be like a chair.”
“The development professionals, and one's superiors … can sing your praises more effectively than you can, and reassure a potential donor that they really are investing in the right person and the right program, and their doctor is as good as they think they are.”
Listening for Patient Cues and Being Prepared to Articulate Your Vision
Physician participants underscored the importance of understanding the genuine interests of grateful patients who may be interested in directing philanthropy to the institution. The physicians stated that learning about patient interest usually occurred during conversations while providing care. Some physicians described how patient willingness and desire to support physician work was subtle and may have been easily overlooked. The physicians also expressed the idea that there may be appropriate times to respond to inquiries by making potential donors aware of the need for philanthropic support.
“She had come to appreciate what we were doing and saw it was somehow different, and thought others should be able to get this kind of thing, and felt the importance of creating an educational program that promulgates this in some way.”
“She was engaging me, my career, my hopes, it was a very easy thing for me to open up and tell her what I do and what I'm passionate about, and what research does and why I love it so much. Then, at the end of that process, she said she wanted to consider supporting this.”
Informants also talked about successes that have come about when they shared their enthusiasm for their work:
“I think patients, even sophisticated people, are often verynaïve about how the academic enterprise is funded … . They don't really understand that what we've got is a hunting license, and we need to go out and earn our salaries. In the current environment, the competition is so intense that to do something adventuresome is difficult for an established funding agency without some proof of concept, which philanthropic funding permits you to generate.”
Recognizing Potential Donors.
Awareness of the potential for philanthropic support is a critical step. Physician informants expressed that looks or outward appearances can be deceiving with respect to wealth; physicians must keep an eye and ear out for clues that patients have the desire and means to support the institution. Some informants explained that to be highly successful in grateful patient philanthropy, it was necessary to care for some patients with significant assets.
“There is no relationship between people's resources and their willingness to give. … many people who are more modest, are much more generous donors than the people who by appearance should be the biggest donors.”
“I think that the money discomfort is ours, not theirs. Donors are going to give money … . The only question is, who are they going to give it to?”
“He said: ‘I get it. Rich people have helped you take better care of me. Well, I'm a rich guy too. I can't send you $2.5 million, but I will tomorrow send you $50,000.'”
Discussion
Grateful patient philanthropy helps keep medical schools and teaching hospitals moving forward. Patient philanthropy can be especially transformative because it is often unrestricted, thereby allowing for new and creative ventures. While it may seem intuitive that excellent medical care serves as a driving force behind grateful patient philanthropy,
2
this qualitative study discovered other elements that complement excellence in patient care and enhance development efforts. Even for physicians who are not interested in or are uncomfortable about pursuing philanthropy, the strategies used by the informants, such as connecting meaningfully with patients, listening to patient cues, and being prepared to articulate your vision, should be helpful tips for any physician striving to achieve excellence in communication and interpersonal skills.8
, 9
There is almost no prior empirical research related to grateful patient philanthropy. If institutional leaders are interested in effectively tapping into this source of support, changes at medical schools and teaching hospitals may help to facilitate success in this area.
2
, 3
Our findings indicate that training physicians to feel comfortable discussing donations and preparing them to have well-thought-out responses when a patient inquires about their professional interests are essential components for success.9
Freeman and our study subjects agree that some patients feel compelled to give back following exceptional care experiences. Respect and admiration for the physician augmented by appreciation of effort makes the physician a critical cog in the grateful patient philanthropy wheel.8
Both the duration and quality of the relationship, as well as physician comfort in discussing philanthropy, may inform the extent to which development professionals need to be involved and the optimal approach for securing grateful patient philanthropy.3
, Making the referral and turning over the entire process to trained development professionals may be appropriate in specific situations,9
however, it was not the preferred approach described by the physician informants.While the themes described in this article relate most closely to a first contribution of support, some informants described follow-up activities that were valuable for keeping patient donors engaged. Components of this stewardship included measures such as expressing appreciation to the donor and keeping them updated about the progress and outcome of their supported initiatives.
This research and the emergent themes stimulated us to reflect upon the fact that institutions may be more or less “philanthropically friendly.” Our medical school has benefited tremendously from philanthropic support and it has established an infrastructure, including a team of development professionals that is readily available and skilled in successful philanthropy. Institutional leadership also is extremely obliging and available to meet with donors.
Several limitations of this study should be considered. First, this study relied exclusively on self-report. However, it is the most direct approach for understanding attitudes and beliefs of informants. Second, this qualitative study is limited to a small number of physicians from one department with philanthropy experience and as such, findings may not apply to other departments or institutions. Third, one physician declined to participate and it is possible that his or her perspectives may have been different. Finally, the frequency with which some of the themes were described by informants was 50% or less. However, it is important to note that the responses emerging from the open-ended question were spontaneous. Qualitative analysis does not really allow us to know whether one theme is more important than another merely because it was mentioned more frequently. If all subjects were specifically asked about each theme, the number of comments related to each would certainly be much higher.
Perhaps there is a successful formula for procuring grateful patient philanthropic donations. At the core, according to our informants, everything appears to start with providing excellent patient care and establishing meaningful connections with patients. At a time when private donations are an increasingly helpful source of support, medical schools and teaching hospitals could provide guidance to faculty about how best to capitalize on potential philanthropic gifts if and when such opportunities present themselves. The “pearls” and approaches used by physicians who have been successful in attracting and securing philanthropic donations from grateful patients may be of benefit in guiding faculty colleagues with less experience.
References
- Funding for medical care research.J Gen Intern Med. 1987; 2: 113-118
- Philanthropy and medicine.J Am Coll Cardiol. 2006; 48: 1725-1726
- Gift wrapped: hospitals, health systems work to make donations a larger portion of the bottom line.Mod Healthc. 2005; 35 (30, 33): 28
- Creating pediatric trauma systems.J Pediatr Surg. 1989; 24: 149-152
- Can you bank on philanthropy?.Healthc Financ Manage. 2006; 60: 102-105
- Tapping the river of grateful patients: principles and techniques for best practices in patient prospecting.AHP J. 2006; : 32-35
- Opinion.AJR Am J Roentgenol. 2003; 180: 925-928
- Grateful patient programs: current trends, strategies and tactics.AHP J. 2007; : 8-17
- Hamilton Health Sciences Grateful Patient Program.AHP J. 2006; : 31-32
- Gifts from patients—CEJA provides guidance.Iowa Med. 2003; 93: 22
- Gifts from patients.J Bone Joint Surg Am. 2004; 86: 2339-2340
- Should physicians accept gifts from patients?.Am Fam Physician. 2007; 76: 437-438
- 2nd ed. Doing Qualitative Research. Sage Publications, Thousand Oaks, CA1999
- Defining clinical excellence in academic medicine: a qualitative study of the master clinicians.Mayo Clinic Proc. 2008; 83: 989-994
- Excellence in role modeling: Insight and perspectives from the pros.CMAJ. 2002; 167: 638-643
- Decision making and counseling around mammography screening for women aged 80 or older.J Gen Intern Med. 2006; 21: 979-985
- Why do residents fail to answer their clinical questions?.Acad Med. 2005; 80: 176-182
- Third-year medical students' experiences with dying patients during the internal medicine clerkship: a qualitative study of the informal curriculum.Acad Med. 2005; 80: 641-647
- The science of giving.Mod Healthc. 2001; 31: 44-48
Article info
Footnotes
Funding: This study was supported by a grant from the Osler Center for Clinical Excellence. Dr. Wright is a Miller-Coulson Family Scholar and this work is supported by the Miller-Coulson family through the Johns Hopkins Center for Innovative Medicine.
Conflict of Interest: None.
Authorship: All authors had access to the data and played a role in writing this manuscript.
Identification
Copyright
© 2011 The Association of Professors of Medicine. Published by Elsevier Inc. All rights reserved.
