This paper set out to explore the content and meaning of forty years of unsolicited correspondence sent by patients and /or family members to one family doctor. It is not intended as a commentary on a specific physician; rather, an enduring incentive for retention of this material over such a lengthy time was the hope that its later examination as a collection might contribute to an understanding of what patients value in the clinical encounter.
The nature of Hermeneutics is to interpret human experience, whether through text, actions, stories or other forms of expressions, and thus provide insight into human expressions.  The philosophical hermeneutical approach used in this research was an interpretative one that looked at the meaning and experience of the doctor-patient encounter as interpreted from four decades of personal notes written by patients and /or family members to their family physician. While the words written on these notes denote a sense of gratitude and appreciation, their deeper meaning lies within the context and experience within each patient-physician engagement, which appears to have been the motivation for these writings.
Our use of the hermeneutic interpretative enquiry would thus seem to be a strength of this work. The correspondence chronicles challenging events that occurred in the lives of people, who while differing in backgrounds, ages, and concerns, may be seen as a definable community in that they sought help and care from a particular doctor. This may have been the result of chance, geographical factors, recommendation or referral by others, or perhaps preference for a particular doctor personality, practice style, or professional interest.
The notes were mainly written by women, likely the result of their predominant roles as caregivers to ill relatives, as well as family nurturers, and in some cases, having simply outlived their male spouses and relatives. These writings seem to bear witness to such roles and their related experiences. For others they may have offered the writers an opportunity to show their own humanities and uniqueness.
This individuality may be seen, for example, in the choice of when to write. Some corresponded specifically around the time of a secular or religious holiday; some showed additional thoughtfulness by doing this at a time they believed was meaningful to, or celebrated by, their doctor. The personality of the writer might also be surmised by how the notes were written, with just over half containing handwritten thoughts that completely filled a page or more. An additional third were commercial cards with printed messages, suggesting perhaps special effort had been made to purchase ones with specific personal meaning; interestingly, some of these also contained short hand-written comments to add to the personalization of these notes. Finally, a small number came typed, suggesting possible formality of the writers; however since the wording was not necessarily formal, the typing might have been a considerate means of sparing the reader a handwritten script that was difficult to read.
The correspondence from patients and families is noteworthy for the commonalities in words and themes that describe what was valued in the family physician-patient / family encounters. Iterative attempts were made to combine them within common groupings, and some disagreement may arise about any specific allotment since there was indeed, some potential for overlap within groups. We do not, however, believe that this affects the overall interpretations in this paper.
What patients and families appeared to have valued was quality of care, and physician characteristics such as competence, physical presence, positive personal traits, emotional support, and spiritual impact. These descriptors encompassed care that was knowledgeable bio-medically, and experienced as available, authentic, reality-based, supportive, professional, compassionate, offering of hope, and sensitive to suffering. As well, six distinct contexts or motivations for writing to doctors have stood out in this work: (1) opportunity for expression of appreciation for an established relationship; (2) acknowledging value / benefit of continuity of care; (3) a means of seeking catharsis, emotional release, and closure; (4) a chance to reflect on termination of care; (5) a recognition of care that extended into the Asklepian healing tradition  ; and (6) opportunity to share personal reflection, experience, or impact.
A limitation in this project may be that no negative comments or remarks have been cited; indeed, none were actually found in the 107 notes. Since it is reasonable to conclude that not all people are satisfied with care all of the time, what of their letters? Stimulated by relevant questioning about this from the other authors, MJY could not recall having discarded derogatory letters, although that remains a possibility. Four other hypotheses are suggested: Firstly, a feeling of discontent might not have been great enough to prompt writing a letter. Secondly, an unhappy patient might have addressed concerns, directly, face to face, with the doctor during an office visit. Thirdly, an unsatisfied patient might have left the practice without indication or notification. Finally, with the contemporary emphasis on quality assurance, patient representatives and ombudsmen, it is possible that some patient and /or family dissatisfaction got diffused at that level.
In summary, patients and /or their families in this study have used unsolicited correspondence to a family doctor to identify what they value in the doctor and in the process of care. It is reassuring that some of the concepts we identified appear to be generalizable in that they were also reported by Merenstein and Merenstein . Their work, however, was associated with a specific point in time, a physician retirement, when nostalgia might have influenced the content of the writings. Our findings are likely broader in that they are more numerous in number, the product of forty years of writing, and composed by both past and current patients. We have, as well, been able to take our analysis further by exploration of the contexts and motivations under which people to their doctors.
It is likely that letter writing may have provided personal psychological benefits for the writers. What might one surmise would be the impact of patient/family letters on physicians? The letters may serve as feedback about how the care they are giving is perceived. If positive, they may serve as validation, promoting positive mental health, possible personal resiliency and longevity in practice. On the other hand, even if generally laudatory, a doctor must be alert to the heterogeneity of patients in the practice and be cognizant that their needs and reactions may differ from those expressed in the letters. If the content is negative the challenge would be for the physician to maintain positive countertransference and engage the patient to explore where problems might exist.