Even at 90 years old and 84 pounds, Ms. Z still had quite a presence. As her doctor, I admired the quiet strength she packed into her tiny frame. I wasn’t surprised to hear that she had lived independently until recently, when she was hospitalized with shortness of breath—a residual effect of the tuberculosis she had contracted as a youth.

In the hospital, her breathing improved, but not her strength. Working closely with her family, we came up with a plan to keep her out of a nursing home. By this time, I was worn out from all the logistics.

“Great, we have a plan to get you home,” I said, feeling frazzled as I left her hospital room. “Good luck—and thanks.”

In the hallway, I stopped and took a deep breath. It started to sink in how challenging it was going to be for her family to provide 24/7 care for Ms. Z. And also what a privilege it had been for me to care for her—to witness her family’s devotion, to ease her suffering, to imagine the course of her life as it neared its end, and to fulfill her dying wish to go home.

I re-entered her room and saw Ms. Z sleeping, her kids conferring around a stack of bills. I took a deep breath.

“I wanted to let you know that I think you have a beautiful family,” I said. “Your efforts to help your mom are inspiring. I want to thank you for letting me play a role in caring for her.”

As I walked toward the door, I felt a visceral surge of emotion in my chest that rose to my head. Off-balance and with tears coming to my eyes, I stood and wondered what brought on these intense yet wonderful sensations.

Why had these two separate “thank you’s” to the same family provoked such different reactions in me?

I found an answer to that question when I learned more about research on gratitude. That research clearly suggests that gratitude carries important benefits to mental and physical health: It boosts our mood and satisfaction with life; there’s even evidence linking it to improved cardiovascular health among people at risk for heart disease.

But for me, the research also helps to explain what constitutes an effective expression of gratitude, one that makes it more likely that we’ll enjoy those positive benefits. And I believe those authentic experiences of gratitude can revitalize the work of health professionals like myself—at a time when many of us need the help.

The need for gratitude in health care

  • What to Do: Individually
    • I slow down before each encounter, often with a deep breath, so that I will have the presence of mind to see the beauty in my patients’ struggles.
    • With intentionality, I thank them for letting me be involved in their lives at this important time.
    • I anticipate a rush of positive emotion, which gives me strength and compassion to carry on this important work!

I work as a hospitalist—that is, a family practice doc who works exclusively with those in the hospital. This has allowed me to see up close the epidemic of burnout afflicting so many of my colleagues.

Nearly 40 percent of physicians are affected by burnout, meaning that they feel physically and mentally exhausted, become less able to connect with their patients, and lose the ability to find meaning in their work. The technical, emotional, and time demands of the work can easily render care providers unhappy and unable to provide the empathic care their patients need.

I have come to believe that developing and expressing strong feelings of gratitude is one possible solution to this problem. My experience with the Z family crystallized this for me.

As a younger doctor, I thought “thank you’s” delivered at work were simply a forced, impersonal customer service tool—the kind of “emotional labor” described by sociologist Arlie Hochschild in her book The Managed Heart.

After 10 years of medical practice, though, I realized that I needed to do more to support my patients emotionally during their time in the hospital. I thought that familiar and reassuring language might comfort my elderly patients. So despite my reservations, I started thanking my patients with the hope that they would feel comforted by the exchange.

In fact, I found that these thank you’s didn’t only support my patients—they gave me an immediate burst of energy and renewed passion for my work. Though both my patients and I felt good after these short conversations, for quite a while I didn’t take the time to understand why this was, and what made for a truly effective thank you.

But once I did, the revelation was game-changing for me and my work.

The cycle of gratitude

  • What to Do: Organizationally
    • Say an affirmation prior to clinic or rounds, such as this one we developed with the chaplaincy at my hospital: “Let us take a moment to acknowledge the suffering of those under our care and acknowledge all the love and hard work we give each day to each other and our patients.”
    • Create a “gratitude wall” to encourage patients and staff to write down and post their thank you’s to one another.
    • Be a gratitude leader by thanking and acknowledging teammates for their compassion and care throughout the day. Along those lines, try to acknowledge those who have contributed to your own success, identifying the specific gifts they gave you.
    • Organize a program to offer support for providers who have had a bad outcome or difficult case. They will be grateful for the care they receive!

The key for me lies in how Robert Emmons, a leading researcher of gratitude, defines gratitude: as a recognition of the gifts that others give us, a recognition of the source of those gifts, and an appreciation of those gifts.

That experience can often lead grateful people to “pay it forward.” In a well-known study led by Emmons, people who kept a journal of things for which they were grateful enjoyed a more sustained sense of well being in their lives—and became more motivated to help others.

In the health care setting, understanding this cycle can be tricky and a little counter-intuitive. Who is doing the giving? And exactly what are the gifts? 

Recognizing gifts

When I mention gratitude to my colleagues, I often hear, “I sure wish that more of my patients were grateful for all I do.” We are giving meds and advice and, at times, saving lives. So providers can easily get caught up in all they are doing—and fail to see that the real story is the patient’s life, and thus they miss the gift that is the beauty of the lives before them.

Crises from serious illness provoke existential struggles among patients and their families. Witnessing them firsthand is as rich an experience as life offers; being able to heal in this setting transforms a rich experience into a profound privilege and a gift. These gifts can be missed if we don’t take the time to recognize them.

The sources of these gifts lie in the openness and trust of the patients who let us into their lives. I have learned to see a beautiful story in almost every room I enter: the love between an elderly couple, the faith and optimism in those facing a grave diagnosis, the unflinching care and support of a devoted daughter. With each visit, I am afforded an intimate view into our fundamental emotions and struggles. That is a precious gift indeed.

Appreciating the gifts

To appreciate the gifts we are given, we need to receive them properly.

Time demands and high-stakes situations mean that many health care professionals are running all day. Research has found that deep breaths calm the stress-driven sympathetic nervous system and activate the parasympathetic nervous system, which helps us bond with others, partly thanks to the hormone oxytocin.

A moment to slow down with deep breaths and reflect, which I took before the second time I thanked the Z family, can do more than prepare us mentally for gratitude; it can prepare us physiologically. With a calmed nervous system, I could recognize and appreciate the gifts the family had given me, opening me up to a wave of gratitude and a parasympathetic–oxytocin system rush, which left me in tears.

By taking time to make ourselves mentally and physiologically receptive, we can experience gratitude more profoundly.

Paying it forward

The GGSC’s coverage of gratitude is sponsored by the <a href=“http://www.templeton.org/”>John Templeton Foundation</a> as part of our <a href=“https://ggsc.berkeley.edu/what_we_do/major_initiatives/expanding_gratitude”>Expanding Gratitude</a> project. The GGSC's coverage of gratitude is sponsored by the John Templeton Foundation as part of our Expanding Gratitude project.

Burnout is characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. I’ll admit that I’ve been in that downward spiral.

What gratitude offers is a positive cycle. Upon receiving a gift, one feels a surge of positive emotion and a desire to give back, which can motivate us to “pay it forward” by helping someone else. Feelings of gratitude make us more likely to help a stranger. In one study, health care providers who twice weekly wrote down things for which they were grateful reported less stress and depression. Those who wrote down things that bothered them at work only became more frustrated.

I needed that ability to give back just moments after leaving Ms. Z’s room the second time. My next patient, Mr. J, was just across the hall, and I could see his son pacing in the room with evident frustration. Mr. J had come in the night before with pneumonia; overnight, he became more short of breath, then so confused and combative that we had to restrain him and give him a little medication to calm down. With his father weak and not responsive the next day, wrists tied to the bed, Mr. J’s son had reason to be confused and angry.

Because I felt uplifted from my experience with the Z family, I had the patience to empathically listen to the son’s frustrations and concerns. If I had walked into that room feeling stressed, as I had felt after the first thank you, I could have potentially clashed with him, saying something stupid in frustration like, “You think you’re having a bad day? Well, I still have dozens of patients to see and am going to be way late driving the soccer carpool!”

Best-case scenario, I would have barely been able to suppress my frustration, then finished my workday feeling burned out. Mr. J and his son—and the rest of my patients—would have been denied the best care possible.

Since that day with the Z family, I have been struck repeatedly by the power of gratitude. Understanding how gratitude works has transformed the way I experience my work as a health care provider.

Now, if I have not teared up by the end of a shift, I wonder what gifts I missed that day. Contrary to what some may think, I believe this has only made me a stronger care provider, not a weaker one.

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