In 2009, gifts from individuals to academic health centers, health systems, and community hospitals in the United States totaled $4.8 billion.1 A substantial proportion of this total—nearly $1 billion—came from grateful patients.1 At academic health centers and hospitals, these monies help to fund varied needs including capital projects, research programs, educational initiatives, financial aid, and endowments. These gifts clearly support the tripartite academic health center mission of patient care, research, and education.2,3
Most physicians do not receive training in either how to respond to inquiries from grateful patients about philanthropy or how to handle other issues at the interface between patient care and development. Some physicians feel uncomfortable discussing philanthropy with their patients; others are concerned about the ethical considerations that arise when the doctor-patient relationship evolves from one of unidirectional giving to a more bidirectional exchange.4–8 Some ethical issues that may arise in the context of grateful patient philanthropy relate to the effect of gifts on the doctor-patient relationship, the possibility of caring for patients who donate differently than other patients, and the potential of unfairly taking advantage of the vulnerability of sick patients. Many institutions have developed guidelines to suggest best practices for interacting with patients who offer gifts in gratitude.9–11
To date, methods that some institutions have used for training academic physicians to be more proactive in grateful patient fundraising include holding workshops and engaging external consultants as teachers.12,13 Further, it has become common practice to discuss grateful patient philanthropy at divisional and departmental meetings in an effort to increase faculty members' consciousness of—if not commitment to—fundraising opportunities. As yet, there is no consensus on the optimal method for engaging physicians in grateful patient fundraising, nor is there an understanding of the relative success rates of different approaches. Thus, the purpose of this study is to test the hypothesis that individual coaching from a development professional would increase physician participation in grateful patient fundraising more than would two other, less interactive, educational methods.
Method
Study design
We conducted a randomized trial to determine which of three educational interventions would most effectively engage academic physicians in grateful patient fundraising. We measured effectiveness by determining the number of “qualified referrals” whose names participants submitted to the development team during the three months of and three months following the intervention. Dollars received was a secondary outcome.
Setting and participants
We conducted this study at Johns Hopkins University School of Medicine in 2010. We originally selected physicians from the departments of neurology and oncology for the trial because the patients treated in these departments generally receive longitudinal care (their physicians usually see them on a repeated basis over an extended period of time) and because the nature of the diseases treated by doctors in these departments frequently engenders strong physician-patient relationships. To increase the number of eligible participants, we invited other groups to participate as well. In response to interest and requests from physician leaders in the divisions of cardiology and internal medicine, we expanded the participant pool to include physicians from their groups. Eligibility criteria for all physicians were ongoing involvement in direct patient care and no prior participation in grateful patient fundraising. Using these criteria, departmental and divisional leaders identified 74 potentially eligible physicians. We invited all 74 of them to enroll in the study. We did not collect data to understand why some physicians declined to participate in the trial.
The Johns Hopkins University institutional review board approved the study, and participating physicians signed consent forms. We did not inform patients of the study, and we did not offer eligible physicians any incentives.
Interventions
Using a random sequence generator (www.random.org), we randomized participants into one of three cohorts, each of which was exposed to a different educational intervention. The physicians were not blinded to the differences among the cohorts.
The physicians in cohort 1, the “e-mail arm,” received during the course of the three-month intervention weekly e-mail messages (11 total) that included clippings highlighting large philanthropic donations to public and private institutions, general information about philanthropy in the United States, and articles specifically about philanthropy in medicine. (Please note that the e-mails constituted an intervention; physicians at Hopkins do not customarily receive e-mail about philanthropy. The clippings highlighting donations were not about donations to Johns Hopkins. The Fund for Johns Hopkins Medicine, which is the development arm for the institution, prohibits announcing via e-mail philanthropic gifts to its faculty and staff. When a donor does request public recognition, the media relations department coordinates the press release.) At the start of the study period, participants received a copy of the book The Millionaire Next Door: The Surprising Secrets of America's Wealthy,14 a compilation of research on affluent Americans which underscores the point that many wealthy individuals are not recognizable by outward appearance.
Physicians randomized to cohort 2, “the lecture arm,” participated in one of three sessions taught by three different physicians—each of whom had a long history of successful fundraising at Johns Hopkins. These physicians had collectively raised more than $100 million for their clinical departments. Training sessions were held in conference rooms in the hospital, and each lasted approximately one hour—although the speakers stayed behind to answer question posed by participants. The training sessions were somewhat standardized in that these physician-speakers were instructed to share both their approach to grateful patient fundraising and the lessons they had learned from their experiences. Although the presenting physicians' specific content and styles differed, all three conveyed core fundamentals of successful fundraising including the importance of (1) delivering outstanding care to every patient, (2) cultivating close relationships with patients, (3) listening carefully for cues of interest in philanthropy, (4) thoughtfully considering, in advance of the discussion, answers that patients might have about ongoing initiatives and philanthropic needs, and (5) the ethical considerations that emerge when interacting with grateful patients. All three shared inspiring stories about the process, outcomes, and resultant initiatives that became possible as a result of gifts from grateful patients. Along with the physicians in the e-mail arm, the physician participants randomized to the lecture arm received a copy of The Millionaire Next Door and the weekly e-mails.
The physicians in cohort 3, “the coaching arm,” received one-on-one training through which development professionals (“coaches”) worked with them to prepare them for collaboration in grateful patient fundraising. The three coaches (not the physicians who presented the lectures to the physicians in the lecture arm) possessed more than 70 combined years of experience in fundraising. We developed a coaching curricular plan so as to ensure consistency across the three coaches. The curriculum covered the following topics: (1) a general understanding of philanthropy at Johns Hopkins, (2) factors that motivate people to give, (3) ethical considerations, (4) noticing cues that suggest an individual may want to offer a donation, (5) the difficulty of trying to guess who has potential to be supportive, (6) barriers to fundraising and strategies for overcoming obstacles, (7) the value of stewardship and the time commitment that this takes, and (8) action plans. Coaching began with a one-hour, individual training session, and additional coaching over multiple encounters followed. Communication between coach and physician occurred through in-person meetings, phone calls, and e-mails. To respect physicians' time constraints, each contact subsequent to the first hourlong session was brief and focused on identifying prospects and/or reinforcing the curricular content. Physicians in the coaching arm, like those in the e-mail and lecture arms, received the weekly e-mails and a copy of The Millionaire Next Door.
Outcome measures, data collection, and analysis
Primary outcome measure.
The study's main outcome variable was the number of qualified referrals whose names participating physicians passed on to the development office (all study participants received, via the weekly e-mails, the contact information of development officers in case they wanted to submit a referral). For purposes of this study, we defined a “qualified” referral as an entity (individual or family) capable of making a minimum gift of $25,000 across five years.
After a participating physician submitted the name of a referral, the development office ran (per usual practice) an analysis to determine whether the referred person or family was qualified. The development office calculated giving capacity using a standardized formula15 (personal communication with A. Scheurer, director, Resource Development, Office of Research, Johns Hopkins Development, April 4, 2011). Development officers accessed the financial data necessary for the formula through sources available to their office.15 First, they calculated the sum of total known published assets:
Annual income (estimated or actual), multiplied by five
Real estate assets total
Direct stock holdings
Pension plan value
Investment data estimation
Largest family foundation gift (in most recent fiscal year), multiplied by five
Next, officers multiplied the sum of total known published assets by 1% to 5%, depending on the referral's age, to determine the referral's five-year capacity. We evaluated qualified referrals submitted by physicians in the study for a total of six months, starting from the date on which we sent the first e-mail containing articles on philanthropy to all study participants.
Secondary outcome measures.
For the purposes of this study, we also tracked monetary gifts that grateful patients and their families made, as well as gifts pledged, for the three months during and the three months after the intervention (although we have continued to track these gifts and pledges). The amount in dollars of actual gifts and pledges was a secondary (rather than primary) outcome measure due, in part, to the lag time at Johns Hopkins between initial contact by a development officer and receipt of a grateful patient's gift, which varies from one patient to another, but averages nine months (unpublished historical data).
We tracked outcomes for the three groups for six months and made comparisons using the chi-square test. Data were analyzed using STATA 8.0 (STATA Corp., College Station, Texas).
The development professionals reached out to qualified referrals, following the standard protocols and usual practices. On initial contact with the referral, the development officer explained that he/she was working with the doctor who generated the referral.
Results
Of the 74 physicians who were eligible for the study, 51 (69%) participated; 14 were in the e-mail arm, 18 in the lecture arm, and 19 in the coaching arm. One-quarter of participants were female (n = 13), 65% were at or above the rank of associate professor (n = 33), and about 80% have practiced at our institution for five or more years (n = 40). A slight majority of the participants (n = 26 [51%]) were from the neurology department. The 23 physicians who declined to participate were similar to the physicians studied in terms of gender and academic rank (both Ps = not significant).
Intervention exposure
All 18 physicians in the lecture arm attended at least one of the three lectures. Each of the physicians in the coaching arm had a mean of 15 separate contacts (in-person meetings, telephone calls, and/or e-mail exchanges) with the one of the three development professionals over the course of the three-month intervention period.
Qualified referrals
Physicians in the coaching arm generated 63 referrals of grateful patients who were still living. These referrals occurred across the duration of the study. Development staff deemed 41 of these (65%) to be qualified referrals—a mean of 2.1 qualified referrals per physician. Of the 19 coached physicians, 17 (89%) referred at least one qualified potential donor. In comparison, the physicians in the lecture arm generated only three qualified referrals (all of these occurred within two weeks of the lecture), and the physicians in the e-mail arm did not generate any qualified referrals. Significantly more qualified referrals came from the coaching arm than from either of the other two groups (P < .001).
Gifts received
Five separate gifts were secured from grateful patients whom physicians in the coaching arm referred; these gifts totaled $219,550. No new gifts or pledges resulted from any of the three referrals generated by physicians randomized to the lecture arm, and, of course, because the physicians in the e-mail arm generated no referrals, they were responsible for no gifts or pledges.
Discussion
Philanthropy plays a critical role in academic medicine. As our strained economy results in fewer funding streams for medical research and reduced reimbursement for patient care, the success of partnerships between physicians and development professionals in enlisting philanthropy becomes ever more vital. The academic medicine community should identify and emulate models of collaborations that attend to the ethical concerns associated with grateful patient philanthropy while also protecting patients' confidentiality and preserving the integrity of the physician-patient relationship.
In 2008, Johns Hopkins University concluded a capital campaign that generated $3.7 billion in gifts and pledges.16 Of this total, Johns Hopkins Medicine raised $2.1 billion, a record in academic medicine.16 Following the campaign, Johns Hopkins Medicine conducted a yearlong review of the sources of gifts generated during the campaign and established projections for the future. Areas identified for future growth were “pipeline” development (i.e., the cultivation of a pool of existing prospects who might make future gifts) and identification of new prospects. Grateful patients generate the vast majority of philanthropic donations given to Johns Hopkins Medicine; thus, the academic health center needed a systematic and effective method to increase the number of grateful patient prospects. To increase the pool of prospects and to secure more gifts, the institution needed to engage a larger proportion of physicians in the philanthropic process.
Although generosity from grateful patients constitutes a crucial source of financial support for academic health centers and allows them to invest in areas of great need,17 almost no prior empiric research examines grateful patient philanthropy. A lack of published or recognized best practices may inhibit institutions' ability to capitalize on the opportunities presented by thankful patients.18,19 Physicians play a critical role in this area of fundraising because patients are often motivated to donate in appreciation of the care they have received.20 Although the published literature contains anecdotes suggesting that collaborations between physicians and development professionals can result in successful fundraising from grateful patients, the manner by which these fruitful partnerships can best be cultivated is unknown.21
In this trial, we sought to test the hypothesis that a one-on-one coaching relationship between a development professional and a physician would yield more qualified referrals than would two of the other approaches that are currently being employed—pushing information (sending e-mails) or a didactic approach (a lecture presentation).12,13 Our results confirmed our hypothesis. Further, we increased grateful patient donations without the use of personnel or resources beyond that which the institution already funds. Our findings serve as a first step toward developing a standardized, best practice approach to grateful patient philanthropy in academic medicine. Although the development professionals interacted with the 19 physicians in the coaching arm for several hours cumulatively, the time spent is not unlike or antithetical to time spent in other aspects of the development process (e.g., proposal development, internal strategy).
The primary outcome of this study—that is, qualified referrals—was pragmatic. This specific outcome helps Johns Hopkins achieve its goal of identifying more donor prospects for the next fundraising campaign. The distinction between qualified and nonqualified referrals is not arbitrary; sophisticated programs are available to development offices to estimate individuals' giving capacity.15,22 Although “dollars-in-hand” might seem to be a more appropriate primary outcome measure, in reality relationships with grateful patients often blossom only after a sustained period of cultivation. The short period following our intervention—three months—prevented us from using the amount of actual dollars donated to gauge the results of our intervention in a meaningful way, though this measure does provide an interesting secondary end point.
Medical institutions are increasingly encouraging their faculty to think about grateful patient philanthropy.18 Physicians discuss the topic at departmental and divisional meetings; development officers, hospital leaders, and others recount and disseminate stories of success in e-mails or newsletters. In this study, we compared two passive educational approaches to a more participatory approach that involved longitudinal coaching by development professionals. Although the contact between the development coaches and their physician pupils was limited to a handful of in-person meetings augmented by phone calls and e-mails, this approach was more successful than either comparator. The coaching method applied to a random sample of physicians lacking prior experience with philanthropic fundraising resulted in impressive results, so we are excited to consider how much more successful the coaching approach might be if we target the most beloved physicians or those with the highest patient satisfaction ratings.
At this juncture, we must reemphasize the critical importance of protecting the physician-patient relationship and carefully examining any potential breach of trust or exploitation. Although many patients have a genuine desire to give either in order to help others who have the same or a similar disease or to support their physician's future endeavors, physicians and development officers alike must recognize that patients are a vulnerable population; their privacy and the bonds which they form with their physicians warrant respect. Professionalism is paramount. Physicians and development professionals must uphold patient confidentiality; they must also reflect on and understand the ethical issues and considerations of engaging patients in philanthropy, particularly concerns related to each patient's personal circumstances and interests. In this study, the partnerships between the development coaches and participating physicians were predicated on comfortable, respectful, and collaborative relationships. The development officers chosen to serve as coaches had proven themselves to be supportive facilitators; they themselves had undergone training around the ethical considerations of patient philanthropy. They not only explained but also modeled how to respond to patients who inquire about ways to offer support.
Philanthropy has been and continues to be important in advancing medical education.2,3,23 At our institution, philanthropic contributions have facilitated many educational innovations in recent years.24–27 A portion of the monies that have already been received from the coaching arm will be directed to educational activities, and some of the qualified referrals whom we have contacted have also expressed interest in supporting educational programs. With limited funding for advancing medical education or medical education research, philanthropy can allow clinician-educators to develop creative programs and to study their effects.27
Several limitations of this study should be considered. First, it was conducted at a single institution; results may not be generalizable to other institutions. Second, the number of physicians studied was small. Nonetheless, participation of physicians from several departments shows that the coaching intervention may be effective across specialties, and the statistically significant differences in outcomes among groups seem to have practical relevance (face validity). However, the small sample size precluded hypothesis-driven analyses such as whether individuals of more senior rank are more effective in identifying or generating qualified referrals. Third, the sizes of the three study arms were slightly uneven—fewer participants were in the e-mail arm than in the lecture or coaching arms—despite our use of a random sequencer. We did not see any compelling reason to alter the distribution of participants after the randomization process; in fact, if we had done so, we may have inadvertently introduced bias. Fourth, the physicians targeted in this trial were inexperienced in grateful patient philanthropy; our data do not indicate how much added value the coaching would impart to physicians already engaged in philanthropic efforts. We selected a purposive sampling strategy in order to explore the result of various interventions on “philanthropy-naïve” physicians—an untapped source of referrals. Fifth, if physicians who declined to participate differed from those who participated in ways other than the two for which we tested for (gender and academic rank), their omission may have skewed results. Sixth, the coaches were seasoned development “veterans”; less experienced coaches might have altered the study results. Seventh, because we were not able to collect data on whether or not physicians in the e-mail arm actually read the e-mails (versus deleting them without reading them), we do not know whether the results from this arm accurately reflect the potential of the e-mail-only intervention. This point is largely irrelevant, however, as our intention was not to determine the efficacy of the e-mail intervention but, rather, to evaluate whether or not the e-mail approach is effective in a real-world setting, one in which busy clinicians may delete e-mails that are not, to them, a priority. Finally, the primary outcome, qualified referrals given to development professionals, is a physician behavior, and may not be as meaningful as the terminal outcome, dollars banked.28 Although the study time frame did not permit us to use dollars-in-hand as a primary end point, we believe there is, and our results support, a correlation between qualified referrals and gifts.
This randomized trial shows that deploying development professionals to act as one-on-one coaches for physicians will result in behavioral changes among the latter with respect to grateful patient fundraising. Medical institutions interested in increasing their contributions from grateful patients may wish to encourage these sorts of collaborative partnerships between physicians and development professionals. At Johns Hopkins, the study's findings have prompted the creation of a new performance metric for development officers; Johns Hopkins intends to track development officers' interactions with faculty members to examine how the nature and number of interactions relate to the number of new referrals as it prepares for the next capital campaign. In an effort to maximize the effect of the coaching intervention, we have planned further analyses: (1) responder analysis, to determine whether the intervention is most effective when targeted to physicians on the basis of specific characteristics, (2) predictor analysis, to explore whether intermediate outcomes such as the physician's perception of a mutual philanthropic goal or the physician's view of the patient's authentic desire to contribute are predictive of an eventual gift, and (3) financial analysis, to calculate the return on investment of allocating development resources to the coaching intervention.
Acknowledgments:
The authors wish to thank Dr. Edward Miller, Dr. Patrick Walsh, Dr. Walter Stark, Dr. Morton Goldberg, Ms. Kim Morton, Mr. Chuck Turner, Ms. Kathy White, and Ms. Jane Wheeler for their efforts and support of this project. Additionally, Martina Grunwald, Ellen Stifler, Michael Zini, and the staff from the Fund for Johns Hopkins Medicine were critical to the success of this project.
Funding/Support:
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 was supported by the Miller-Coulson family through the Johns Hopkins Center for Innovative Medicine.
Other disclosures:
None.
Ethical approval:
This study was approved by the institutional review board of Johns Hopkins Medicine.
References
1Association for Healthcare Philanthropy. FY 2009 AHP Report on Giving. Falls Church, Va: Association of Healthcare Philanthropy; 2010.
2Cooper J. Tapping the river of grateful patients: Principles and techniques for best practices in patient prospecting. AHP J. Fall 2006:32–35.
3Haderlein J. Can you bank on philanthropy? Healthc Financ Manage. May 2006;60:102–105.
4Teigen KH, Olsen MVG, Solås OE. Giver-receiver asymmetries in gift preferences. Br J Soc Psychol. 2005;44:125–144.
5Capozzi JD, Rhodes R. Gifts from patients. J Bone Joint Surg Am. 2004;86:2339–2340.
6Spence SA. Patients bearing gifts: Are there strings attached? BMJ. 2005;331:1527–1529.
7Gaufberg E. Should physicians accept gifts from patients? Am Fam Physician. 2007;76:437–438.
8Freeman J. Gifts from patients—CEJA provides guidance. Iowa Med. July-August 2003;93:22.
9Development and Alumni Relations, Johns Hopkins Institutions. Impact of giving.
http://www.giving.jhu.edu/impactofphilanthropy. Accessed September 21, 2011.
10American Medical Association Council of Ethical and Judicial Affairs. Gifts from Patients to Physicians. CEJA report 4-A-03.
http://www.ama-assn.org/ama1/pub/upload/mm/code-medical-ethics/10017a.pdf. Accessed September 21, 2011.
11American Medical Association. Opinion 10.017—Gift from patients. AMA Code of Medical Ethics.
http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion10017.shtml. Accessed September 21, 2011.
12Advancement Resources Web site.
http://www.advancementresources.org/. Accessed September 21, 2011.
13Advancement Resources Seminar. AAMC Workshop for Faculty on Strategies, Skills Building and Best Practices in Philanthropy. Los Angeles, Calif: February 10, 2011.
14Stanley TJ, Danko WD. The Millionaire Next Door: The Surprising Secrets of America's Wealthy. New York, NY: Pocket Books; 1996.
15Howley L. Prospect rating for fundraising success. APRA Connect. 2008;19:11–14.
16Philanthropy News Digest. Johns Hopkins capital campaign raises near-record $3.7 billion. January 26, 2009.
http://foundationcenter.org/pnd/news/story.jhtml?id=242200011. Accessed September 21, 2011.
17DeMaria AN. Philanthropy and medicine. J Am Coll Cardiol. 2006;48:1725–1726.
18Roberts LW. Ethical philanthropy in academic psychiatry. Am J Psychiatry. 2006;163:772–778.
19Barr P. Gift wrapped: Hospital, health systems work to make donations a larger portion of the bottom line. Modern Healthc. 2005;35:28, 30, 33.
20Elj TJ. Grateful patient programs: Current trends, strategies and tactics. AHP J. Spring 2007:8–9, 11, 13 passim.
21Shinkman R. The science of giving. Modern Healthc. 2001;31:44–48.
22Bloomberg Business Week. Target America Inc.: Snapshot—Company overview.
http://investing.businessweek.com/research/stocks/private/snapshot.asp?privcapId=9708876. Accessed September 21, 2011.
23Griffin GE. He who pays the piper—Creation of the modern medical (drug) establishment.
http://www.sntp.net/fda/piper_griffin.htm. Accessed September 21, 2011.
24Stewart RW, Barker AR, Shochet RB, Wright SM. The new and improved learning community at Johns Hopkins University School of Medicine resembles that at Hogwarts School of Witchcraft and Wizardry. Med Teach. 2007;29:353–357.
25Wright SM, Kravet S, Christmas C, Burkhart K, Durso SC. Creating an academy of clinical excellence at Johns Hopkins Bayview Medical Center: A 3-year experience. Acad Med. 2010;85:1833–1839.
26Ratanawongsa N, Rand CS, Magill CF, et al. Teaching residents to know their patients as individuals: The Aliki Initiative at Johns Hopkins Bayview Medical Center. Pharos Alpha Omega Alpha Honor Med Soc. 2009;72:4–11.
27Johns Hopkins Medicine. Anne and Mike Armstrong Medical Education Building.
http://www.hopkinsmedicine.org/som/curriculum/armstrong.html. Accessed September 21, 2011.
28Reed DA, Cook DA, Beckman TJ, Levine RB, Kern DE, Wright SM. Association between funding and quality of published medical education research. JAMA. 2007;298:1002–1009.
