Gratitude on Repeat: Handwritten Notes and the Science of Thanks
A handwritten note costs a stamp and ninety seconds. Research shows people badly underestimate how much it means to the person who receives it. Concierge practices that make gratitude a habit have stories to prove it.
Start here: the questions this brief answers
Tap a question for the short answer, then jump to the evidence.
People underestimate the power of saying thanks. In experiments published in Psychological Science, people who wrote letters of gratitude underestimated how surprised and happy the recipients would feel and overestimated how awkward it would be. Recipients cared about the warmth, not the wording. That gap explains why so few practices send notes, and why the few that do stand out. In CMT's books, a dentist found it “so easy to impress patients,” and a managed care network got about a dozen personal callbacks for every fifty notes it tucked into payment envelopes. Make gratitude a system, not a mood: two or three notes a week to patients, staff, colleagues and referral partners. Keep health details off anything others might see.
“Doing nothing is what people expect from a medical office. Doing something, a note, a call, a few kind words in your own handwriting, changes the relationship. It's the cheapest, most underused growth strategy in medicine.”
Do handwritten notes really matter?
Research says people consistently underestimate how much recipients value gratitude. Recipients were more surprised and happier, and felt less awkward, than writers predicted.
Go to the full answer ↓What should a note say?
Five parts: their name, what specifically you're grateful for, a warm tone, how it made you feel, and a simple closing. Part 3 has the template.
Go to the full answer ↓Who should get notes?
Patients, staff (mailed to their homes), spouses, colleagues and referral partners. Part 3 lists occasions.
Go to the full answer ↓Are there privacy or gift rules?
Yes. Keep health details off postcards and envelopes, and know the limits on gifts to Medicare and Medicaid beneficiaries. Part 5 explains.
Go to the full answer ↓We underestimate the power of thanks
Most people think a thank-you note is nice. Few send them. Research explains why.
In experiments published in Psychological Science in 2018, Amit Kumar and Nicholas Epley asked people to write a letter of gratitude to someone who had meaningfully touched their life, then predict how the recipient would feel. Writers underestimated how surprised and how happy the recipients would be, and overestimated how awkward they would feel.1 Practice Insight
Writers worried about finding the right words. Recipients were moved by the warmth of the gesture. As Kumar put it, “thoughts about how competently people can express their gratitude may be a barrier.”1
Doing nothing is what people expect. Doing something elevates the relationship.
From No More Waiting Rooms (2024).2
What happens when practices actually do it
“Before I opened my [concierge medicine] practice, I used to dread the calls to collect the unpaid payments in my practice… The secret I discovered was that I started using ‘thank you’ notes. I know it sounds silly. I wrote thank you notes to my patients. They were short and sweet and, in some cases, for the most random things.”
A concierge physician in Ohio, quoted in No More Waiting Rooms (2024).2
A managed care network’s operations supervisor began tucking handwritten notes to physicians into payment envelopes. If a check was under $10, the note might say, “Hopefully the next one will be bigger.” Within a week, doctors themselves started calling. She reported about a dozen callbacks for every fifty notes, and physicians began recommending the network to colleagues.
From No More Waiting Rooms (2024). Figures as reported to the author.2
An overworked chiropractic office in Georgia, running with two staff members, sent the same operations supervisor two boxes of cookies and a thank-you note after she spent 45 minutes on the phone, two days in a row, helping them understand claims and utilization management. She didn’t have to spend the time. They didn’t have to say thanks. Both did.
From Remark-ology (2025).3
Outside medicine, former Home Depot CEO Frank Blake was known for sending handwritten notes thanking associates for their work.4 Industry Research At the Concierge Medicine Forum, CMT built “Doable Wishes” into the program to recognize physicians’ spouses and team members for what they contribute to the practice.2
How to write a note in ninety seconds
Greet them by name
“Dear Maria,” not “Dear Patient.”
Be specific
Name the exact thing you’re grateful for: their trust, a referral, a kind word to your team, their hard work on a goal.
Keep it warm and simple
Write the way you talk. Skip formal language.
Say how it made you feel
“It made our whole week.”
Close simply
“Warmly,” and your first name.
Adapted from the note structure in No More Waiting Rooms (2024).2
Reasons to send one this week
Patients
- It’s been a while since you’ve seen them
- They reached a goal they worked hard for
- They said something kind to your team
- A graduation, new baby or milestone in the family
- Just because
Team, family and colleagues
- A staff member recovered a tough moment with a patient (mail it to their home)
- Your spouse, who sacrificed for the practice
- A colleague who referred a patient or spoke well of your team
- Someone who brought the team a gift
Occasions adapted from No More Waiting Rooms (2024).2
Start with your own team
If you want a grateful culture, start where patients can’t see it.
When you catch a staff member doing something right, saying something in the hallway is good. It’s also forgotten by Friday. A short note mailed to their home, arriving when they don’t expect it, says: someone noticed.2
No More Waiting Rooms makes the same case for the physician’s spouse, often one of the most underappreciated people in the practice, and for the colleague who quietly sent you a patient.2
Concierge physicians who do this well, the book observes, often started with one simple rule, such as one note a day, until it became a habit.2 Put a box of cards and stamps on your desk. Block ten minutes on Friday. Set a goal of two or three a week.
Put gratitude on repeat
- Buy plain cards and stamps. Put them where you sit.
- Write two notes before Friday: one to a patient, one to a team member, mailed to their home.
- Ask your team who deserves a note this week, and let them write one too.
Gratitude belongs in your community plan, too: referral partners, local physicians and the people who send patients your way.
Free. No sign-up. Your answers stay in your browser. Step 3 of CMT's Learn, Build, Lead tools. It helps you pick the patient segments that fit your practice, find where they are, plan conversations with local physicians, check that your message sounds like care rather than a pitch, and leave with a 90-day plan.
Keep diagnoses and health details off postcards, envelopes and anything others might read; when in doubt, keep the note general. Gifts are different from notes: HHS OIG limits gifts to Medicare and Medicaid beneficiaries to items of nominal value, which OIG set at $15 per item and $75 per year in aggregate in 2016, and never cash or cash equivalents.5 Never tie a note or gift to a referral without legal advice (see Brief No. 71). This brief is educational and is not legal advice.
Thanks is undervalued
Recipients feel better than writers predict.
Ninety seconds
Name, specifics, warmth, feeling, close.
On repeat
Two or three a week, every week.
How this brief was built
This brief draws on experiments by Kumar and Epley published in Psychological Science (2018), as reported by the University of Chicago; a trade report on former Home Depot CEO Frank Blake; HHS Office of Inspector General guidance on gifts to beneficiaries as summarized by a law firm; and stories from CMT's books (No More Waiting Rooms, 2024; Remark-ology, 2025). Figures in stories are as reported to the author and were not audited by CMT.
How to read the evidence types
Every key finding is labeled by evidence type. Labels describe the type of evidence, not its value. Each type answers different questions. Funding is disclosed on every source.
Randomized trials and systematic reviews.Best for cause and effect.
Large observational studies and government data.Best for trends at scale.
Surveys, smaller studies and expert consensus.Best for real-world experience.
Company-sponsored or company-reported data that is not peer-reviewed.Best for early signals and operating data.
Statutes, regulation and official guidance.Best for what is required.
What we don't know
- Whether handwritten notes measurably improve retention or referrals in medical practices; no controlled study in medicine was found.
- How patients of different ages and backgrounds respond to handwritten versus digital thanks.
How to cite this brief
External review: this brief has not yet been reviewed by an outside expert. When review is complete, the reviewer is credited by name above with any conflicts of interest, and the version number is updated. Reviewers check accuracy and fairness; CMT is responsible for the final content.
Corrections policy: when an error is identified, CMT corrects it in the open and updates the version number above. Send corrections to the editor through conciergemedicinetoday.net.
Related CMT Research Briefs
References
- University of Chicago. People underestimate value of sending letters of appreciation (on Kumar A, Epley N. Undervaluing gratitude: expressers misunderstand the consequences of showing appreciation. Psychological Science. 2018). September 5, 2018. news.uchicago.eduFunding: not stated (university news release)
- Tetreault M. No More Waiting Rooms: A Customer Service Road Map to Help Remarkable Medical Offices Navigate Their Way Towards an Irresistible Practice Where Gratitude Is on Repeat. Concierge Medicine Today, LLC; 2024. Stories are the author's own experiences and accounts told to the author.Funding: Concierge Medicine Today (self-published; no outside funder) CMT original
- Tetreault M. Remark-ology: Creating a Remarkable Patient Experience Worth Remarking About to Others. Concierge Medicine Today, LLC; 2025.Funding: Concierge Medicine Today (self-published; no outside funder) CMT original
- Retail TouchPoints. Former Home Depot CEO reveals rules for leadership at Aptos Engage (Frank Blake keynote). April 20, 2018. www.retailtouchpoints.comFunding: not stated (news report)
- McGuireWoods. OIG raises “nominal value” for gifts to Medicare and Medicaid beneficiaries (summary of the HHS OIG policy statement of December 7, 2016). December 16, 2016. www.mcguirewoods.comFunding: not stated (law firm analysis)
Educational and informational only. This CMT Research Brief does not constitute medical, legal, tax, financial, accounting or other professional advice, and it does not create a professional relationship of any kind. Statements about laws, regulations, tax rules and payer policies are general, may not reflect the rules in your state, and can change after publication. Consult a qualified attorney, accountant, tax adviser, compliance professional or licensed clinician before acting on anything here.
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