The Christmas Card by Mike McMahon

She wasn’t my Auntie, in case you wondered.

A little before Christmas a patient gave me a red envelope. She smiled as she handed it to me, her manner suggesting she was perhaps a little embarrassed. I can’t pretend to be Sherlock Holmes, but I was pretty sure it contained a Christmas card. I thanked her for it. I don’t remember if I mentioned to her that I presumed it to be a Christmas card, but I set it on the desk and said I would open it later if that was alright with her.

 A clinical consultation followed. Then she left the room leaving the envelope behind.

 That afternoon, in my office, which was quiet enough to bring my tinnitus to notice, I read then deleted several emails, each deletion a small victory swelling my soul, then corrected and verified some letters, a slow process of  removing or inserting apostrophes which sapped my soul back to normal size, all the while glancing occasionally at the envelope.

 I have always recognised that I have a slightly atrophied curiosity, but perhaps it is just slow to awaken, since eventually I found myself reaching for the envelope.

Untitled A Christmas card. Just as I thought. A smiling snowman and a large star. “Merry Christmas”.  “Thank you for all your help” written inside. No “X”, thankfully, since that would be particularly awkward.

 But the card was not alone in the envelope. There was also a five pound note. Not a crisp new one, but a much folded one that had obviously had a story of its own.


 Perhaps you should know that she was not a wealthy woman by any stretch of the imagination.

 What should I do with the five pound note?

  1. Give it back?
  2. Write to ask what she would like me to do with it?
  3. Write a letter of thanks?
  4. Write a letter of thanks but hint that it was too much?
  5. Write a letter of thanks and enclose the trust guidance on gratuities?
  6. Donate it to charity?
  7. Put it towards biscuits/chocolates for the clinic staff?
  8. Place it in the endowment fund?
  9. Have it framed and hung on my wall?
  10. Disclose it, and my response, at my next appraisal?

Mike McMahon is a Consultant Physician and Rheumatologist for NHS Dumfries and Galloway

43 thoughts on “The Christmas Card by Mike McMahon

  1. Buy buscuits for the staff, a take a nice picture of the staff enjoying them, post the photo back to her with a thank-you card.

    1) The money was geniunely used
    2) The gift was enjoyed
    3) The thought was appreciated

    • I would have felt very uneasy giving it back. The gift was a compliment disguised as a gift, I think. I’m not sure she would understand returning the gift was not rejecting the compliment. But who knows? I hadn’t thought of disclosing this at appraisal, but I am sure you are correct that I should.

  2. if you are really asking # 3 send her a feeling letter of thanks
    Keep the £5 note in a special place to remind yourself of all the good work you do -and treasure it Someone cared enough about you to gift you !! by writying this you have already ‘declared’ it)

    • Clever. Does a five pound note have value if one choses not to spend it. Perhaps if I laminated it…but that might be not want the patient wanted. You have used a very interesting adjective for the letter, “a feeling letter of thanks”. I don’t know if I can manage that. I would only know by seeking feedback from her, but perhaps she would feel awkward about it.

      • Just read your reply to my comment – it wojuld be a feeling letter from you -letting your feelings be known -your gratitude, not your concerns! What she thinks of your letter is ‘none of your business’ The £5 note valuation has nothing to do with its worth -it is the thought and gift that count. If you have already used that actual note -get another one as its substitute and frame it -you will then remember her forever and all the fascinating thoughts and comments it caused by your conundrum -and also be a symbol of your caring and skill. Happy 2014 and all the other patients you will help…….

  3. Savour the moment. Send her a letter detailing how much her gesture meant to you, and having declared to the world on twitter that you received the card without knowledge of its content worry no more about the moral dilemma of keeping the £5.

    • Ah….twitter. I have one follower and suspect that is a bot. I feel inadequate in the letter writing department, but these comments have set me thinking. I need to get some high quality writing paper and use my copperplate pen. I used to use it, dipped ink and all, for signing letters. If I handwrite on deluxe paper perhaps my emotion will be more apparent.

  4. Interesting situation. NHS D&G’s policy says staff can accept gifts of items from patients up to £20 value, but can never accept money gifts. To follow that policy you’d have to give it back and explain why you were doing that. Yet I wonder if that’s best here. Seems to go contrary to the patient’s wishes and might adversely affect the doctor-patient relationship if she feels you’re rejecting her expression of gratitude. Ethically a better situation might to be to write a letter of thanks, say that this is not expected in the professional situation and that you are donating it to the endowment fund for the good of future patients.

    • Andrew, I agree with your comments. I wanted to be careful not to give the impression of rejecting the compliment in returning the money.

      Thanks for your thoughts

  5. Mike What a conundrum! I think it might be a good idea to write her a letter of thanks and donate the £5.oo to the endowment fund.

  6. We always have direction from our organisations of what to do in these circumstances, however, be confident with the knowledge that your practice and intervention has made a difference to be remembered by a patient at this time of the year. A reason for both reflection and celebration.

    • Well said… “A reason for both reflection and celebration.” I think in all this philosophising, I had begun to overlook the more important aspects. This is a glass 99% full situation.

      Thank you for getting my feet back on the ground.

  7. I think you should write and let her know how much you have appreciated the thought however due to lpolicies regarding gratuities you are priviledged to be able to donate her appreciative gift to a charity – she may repeat this again if she is not aware of difficulites in accepting gifts.

    • “you are priviledged to be able to donate her appreciative gift to a charity”

      That is a nice way of putting it. I may start using a line like that.

      I do feel a bit uneasy about mentioning policies in thank you letters, though I am sure I would do for larger amounts. But how much larger I wonder?

  8. Spend it wisely and remember to pass on your gratitude to the next person who treats you well or makes you smile it has obviously touched you and made you grateful pass this feeling along.

    • Good advice that I might have overlooked if not reminded.

      If my soul is charged with happiness by a gift (the thought being more important in this sense than the physical gift), I am likely to be a nicer person. But perhaps I should be more critical and ask myself if I am sharing that gift of happiness as I should.

    • Abdulla, I seem to remember being told that it is better to give than to receive. I might feel even better in passing the gift on to you, and you might feel better for receiving it, but that gift would be psychological rather than physical.

      Thank you for taking the time to read the article and post a comment.

      I hope you will enjoy and appreciate my gift of thanks.

    • Thank you. I have been wondering if I would have felt better rolling that advice. Alas it’s too late now. Mind you I am an honest sort and would not have wanted to step outside my employer’s policies on the matter. It would have been a nice conversation starter, £5 framed on my wall.

      I did once work for a consultant who had a framed £5 note, the first private practice payment he had received.

    • Prof,

      Clear, straightforward and unambiguous advice (and no BS), as befits our handbook’s generalissimo.

      That’s why it’s so difficult to argue with you.

      If I can’t argue with the content, I’ll need to fall back on nit-picking. You seem to have lost your capitals. This isn’t youtube comments you know.

      Thanks for commenting

  9. That lovely lady, gave you the card and the fiver as she wanted to express her gratitude and being of that generation it often comes in fiver’s stuck in envelopes, you, the milkman, the bin man and the postman probably got one too. It’s called ‘giving back’ and she thought you were deserving and appreciated your care. Not everyone can manage a verbal ‘Thank you for your help’ and an appreciative handshake, which would have presented fewer problematic considerations. It’s important to be transparent but equally important to graciously accept patients thanks for ‘just doing our jobs’ for their benefit as well as ours. As a support worker I think a wee note of appreciation and biscuits for those that support you in your work would be perfect as well as another example of ‘giving back’ to those you appreciate.

    • Thanks for your insight Kirsty. You have analysed the situation very well. I had been a bit too big-headed to realise I am probably just one of the tradesmen.

      I suspect you have hit the nail on the head in recognising that not everyone can speak their thanks.

      Sharing the gift of thanks is something that has come up in these replies and I will try to be more aware of doing that.

  10. Etiquette and surprise demands that you always open a present before the patient leaves the room. That way if £100 drops out the ethical dilemma will hit you straight between the eyes and the look on your face will at least raise a smile from the nurses. Then mumble something about team effort, grateful, etc and tell her how you will share it.

    • John, you are right, I have learned that I should ask to open gifts there and then. It will give me an opportunity to give an immediate thank you, and I intend practising that having read the article I mention in my own reply.

      I would previously have mumbled but my aim is to be better at it in future (but I may not put that on my PDP….not SMART enough)

  11. You’ve not taken it from her; she’s given it to you. She’s done the sums and equated your concern and help as being worth a fiver. She’s perfectly entitled to do that. Reply using the time honoured phrase of “it’s not necessary but much appreciated” and then do what you want with it.

    • Thanks John,

      I like the ““it’s not necessary but much appreciated”. I just need to be able to get that out when surprised by the gift.

  12. Dear Mike
    More importantly than what to do with the fiver – which is covered in the policy on gifts and hospitality anyway – how are you going to get on typing your own letters? Given so far the only issue picked up by the secretarial staff is your slight of their skills. We now have many offended staff who are downing tools until provided with cake.
    So now you know what to do with the fiver!
    kind regards

    • Oh dear, lighthearted words without thinking how they might hurt. I had thought it was a conspiracy driven by the ghost of my old English Grammar teacher, or a curse he made before shuffling off his mortal coil.

      Without my secretarial support, I would by now have had a nervous breakdown.

      I’ll get on to Mr Kipling ASAP

  13. Luckily, we can debate this ethical dilemma in purely theoretical terms. The reality is that all staff are guided by the Board’s Gifts and Hospitality policy which is clear that individuals cannot accept cash gifts. So the money must be returned or treated as a formal donation to one of our appropriate endowment funds. Bah humbug!

    • Thank you for your thoughts, written and implied.

      I think those of you who have replied, or collared me at work, have given me plenty of useful advice to help me negotiate the varying requirements of hospital policies, patient’s wishes and preserve my own moral wellbeing.

      I hope this one small gift (of thanks) can be spread. I am gratified that the positive aspect of this has been highlighted rather than just the problems (which aren’t really problems) that I had raised.

  14. We don’t have this guilt in General Practice, often receiving cash or cheques
    you really should have a charity account for rheumatology and use it wisely
    i’m sure she isn’t expecting a written reply, so just remember to say thanks next time
    It’s nice to get thanks
    Only what you deserve for the wonderful service you give
    well done

    • Thanks for the thanks,

      It was actually quite a stressful meeting for me (first follow-up after the card) and I almost bottled out and said nothing. As it was I thanked her for the card and gift and I am pleased that I did. I told her I put the money towards “the department” and she continued smiling. She was a bit embarrassed I think. I couldn’t bring myself to say that she should not give us gifts of money. I had been planning to say it was not necessary to give the money, but didn’t.

  15. I’d like to thank everybody who has taken the time to think about this wee dilemma. It certainly tried me at the time. There is clearly a “correct” answer to disposing of the fiver; a policy designed to protect the recipient as much as anything. It may seem like humbug for so small a gift, but I wouldn’t want the policy changed. I cheated a little and chose to see this not as a personal gift but as a donation passed to me for the department. I haven’t spoken to the donor about this somewhat semantic classification in case she, like me, would feel awkward in doing so.

    I find accepting compliments, or more specifically telling the giver how I feel, quite difficult. Perhaps embarrassing would capture my feelings better. And I generally don’t feel I have encapsulated my feelings in a letter of thanks. Perhaps I’m too reserved. Perhaps I lack the writing skills.

    Accepting a compliment is a skill I wasn’t born with and one I have yet to master. I recently came across an article: How to Accept a Compliment With Class, by Brett and Kate McKay.

    It’s worth having a look at. Here’s some of it:


    Appropriate follow-ups to “Thank you”:

    “I really enjoyed it.” “I’m glad it worked out so well.” If you feel uncomfortable just leaving it at “thank you,” try a neutral follow-up statement.

    “It couldn’t have happened without Jason’s help.” Now, giving a knee-jerk response in which you deny all credit to yourself and transfer it to others is faux modesty. But, when other people really do deserve some credit for the things you’re being praised for, it’s appropriate to mention those folks, after accepting credit for your own role.

    “I am happy I could help.” This is a good alternative to the “Just doing my job” deflection. Maybe you were just doing your job, but don’t rebuff and deny someone’s desire to show their appreciation for you. Instead, offer a “thank you” and tell them you’re happy you could be of assistance.

    “You know, you also played great tonight; nice job!” The boomerang compliment can be appropriate when it’s truly sincere — praise you would have given anyway — and especially when you won’t see the person again (this is often the case in competition situations). Just be sure to offer your compliment after you’ve fully accepted the one you’ve been given.

    If a compliment is particularly heartwarming or special to you, there’s nothing wrong with following up your “thank you” with an amplifier that tells the giver what the compliment means to you, how it makes you feel, or why you value it:

    “That really means a lot.”
    “I really appreciate you noticing that. No one ever has before.”
    “I was feeling really down and this is just the encouragement I need to keep going.”

    Now go forward and offer many more compliments to others and acknowledge and accept the ones that come your way with class!


    Merry Christmas

  16. Give it to your two exceptionally long suffering associate specialists for a christmas coffee- Who clearly were doing all the work while you were pondering the ethics of it all! No vested interest !!!

    • Those exceptionally long suffering associate specialists? I presumed they took the jobs as penance so I have been heaping suffering upon them in the belief that that was their wish. But you are quite right, without them I would be ponderless.

  17. Go Fiona! Reading all of this has cheered me up no end, that Fiver was truly the gift that has kept on giving! So, Anne and I will look forward to our team Christmas coffee, and bask in the lovely warm feeling that this patient got a great service from our Department- that rubs off on us too!

  18. Pingback: A Bedlington Terrier, how to tell tales, and ethical issues | weeklyblogclub

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