Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2025;15(4):5527 1 GRINCH Index: Measuring Patient Satisfaction During Christmas Holiday Gift Programs Giulio Gualdi1, Laura Bigi2, Clara De Simone3,4, Paolo Amerio1, Francesco Loconsole5, Federico Bardazzi6, Lidia Sacchelli6, Michela Starace6,7, Andrea Conti8, Manuela Baldari9, Anna Balato10, Giovanna Brunasso11, Giacomo Caldarola3,4, Anna Campanati12, Gabriella Fabbrocini13, Maria Concetta Fargnoli14, Claudio Guarneri15, Piergiorgio Malagoli16, Andrea Paradisi3,4, Francesca Prignano17, Mario Puviani18, Valentina Dini19, Simone Soglia20, Ilaria Salvi21,22, Martina Burlando21,22* 1 Dermatology Clinic, Department of Medicine and Aging Science, University G D’Annunzio Chieti-Pescara, Chieti, Italy 2 Division of Dermatology, Modena University Hospital, Modena, Italy 3 Section of Dermatology, Department of Translational Medicine and Surgery, Catholic University of the Sacred Heart, Rome, Italy 4 Dermatology Unit, Agostino Gemelli University Polyclinic Foundation, IRCCS, Rome, Italy 5 Department of Medicine Dermatology Section, University of Bari, Bari Italy 6 Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy 7 Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy 8 Dermatology Unit, Department of Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy 9 Unit of Dermatology, Civil Hospital of Sestri Levante, Sestri Levante, Genoa, Italy 10 Dermatology Unit, University of Campania L. Vanvitelli, Naples, Italy 11 Unit of Dermatology, Villa Scassi Hospital, ASL3, Genoa, Italy 12 Department of Clinical and Molecular Sciences - Dermatological Clinic, Università Politecnica delle Marche, Ancona, Italy 13 Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy 14 Dermatology, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy 15 Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy 16 Dermatology Unit, IRCCS Policlinico San Donato, San Donato, Italy 17 Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy 18 Dermatology Unit, Nuovo Ospedale Civile di Sassuolo, Sassuolo, Italy 19 Dermatology Unit, Department of Clinical and Experimental Medicine, Ospedale Santa Chiara, Pisa, Italy 20 Department of Dermatology, University of Brescia and ASST-Spedali Civili, Brescia, Italy 21 Section of Dermatology, Department of Health Sciences (DISSAL) 22 IRCCS San Martino University Hospital, Genoa, Italy * Corresponding Author Key words: patients’ satisfaction, grinch index, holiday gifts, hospital reputation, patient experience Citation: Gualdi G, Bigi L, De Simone C, et al. GRINCH Index: Measuring Patient Satisfaction During Christmas Holiday Gift Programs. Dermatol Pract Concept. 2025;15(4):5527. DOI: https://doi.org/10.5826/dpc.1504a5527 Accepted: June 11, 2025; Published: October 2025 Copyright: ©2025 Gualdi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Martina Burlando, Via A. Pastore 10, 16132, Genova, Italy. ORCID ID: 0000-0002-4381-6718. Email: martina.burlando@unige.it 2 Original Article | Dermatol Pract Concept. 2025;15(4):5527 Introduction Italy has a universal public healthcare system covered by public funding, but citizens can choose to receive care from private practitioners. In 2023, 74% of total healthcare ex- penditure was covered by public funding, and only 23% was paid out of pocket [1]. Healthcare providers often receive gifts from their pa- tients, which is a common practice. Italians have a strong gift-giving tradition deeply rooted in their culture, dat- ing back to Roman times, when people exchanged luck- bringingbranches on January 1st as a wish for prosperity and abundance [2]. According to Italian law, public employees (including doctors) can receive gifts with a value up to €150. There is no specific rule concerning private practitioners, although all doctors have the ethical duty to refuse gifts or donations that could influence their professional decisions. Doctors usually perceive this practice as an excessive dis- play of gratitude on the part of patients for successful treat- ment or for the effort healthcare providers put into resolving a specific therapeutic or diagnostic difficulty. Could patient gift- ing be viewed as an indirect measure of patient satisfaction? To the best of our knowledge, while there are some pub- lished papers concerning the ethical aspects of gift giving by patients to doctorsfacility. The participants had an average of 17.7 years professional experience (range 1-37)). During the study period, 659 gifts were recorded, with 305 falling in the food category, 194 as beverages, 112 as personal items, and 48 as household gifts. It is worth noting that none of the gifts was job-related. Patients’ Characteristics From a study of 659 patients, it was found that 316 were females (52%) and 343 were males (48%). The average age of the patients was 57.5 years, with no notable differences between the sexes. Of the patients, 68% regularly visited the doctor who received the gift, usually once every 3–4 months, 26% visited occasionally (once every 6 months or more), and 7% had just one consultation with the doctor. As for the medical conditions that led to the consultations, 24.3% of patients had psoriasis, 14.3% had non-melanoma skin cancers, 13.2% had moles, 7.6% had melanoma, 5.3% visited for cosmetic reasons, 4.7% had atopic dermatitis, 4.6% had acne, 1.2% were scheduled for skin surgery, 0.6% had allergies, and 12.7% had other miscellaneous diseases.  Relationship Between Gifts and Dermatologists: the GRINCH Index The data provided pertains to the GRINCH index, which represents the mean ratio of gifts received to dermatolo- gists. The overall GRINCH value is 13.7, with a difference observed between males (14.3) and females (13.1). When analyzed according to different places of work, university dermatologists had a higher GRINCH index result (16.3) compared to that of general hospital dermatologists (13.1). Dermatologists working in public and private facilities had Introduction: Receiving gifts, especially during the Christmas festivities, is a common experience for healthcare providers. Gift-giving, being a spontaneous expression of gratitude, could enable the assessment of true patient satisfaction. Objective: In this study we used the Gifts Received durINg Christmas Holidays (GRINCH) as a po- tential index of patient satisfaction. Methods: GRINCH is an Italian national survey that started on 13 December 2022 and lasted until 6 January 2023. Fifty dermatologists, equally divided between males and females working in university hospitals, general hospitals, or private or public offices and covering almost all the Italian regions participated in data collection. The participants were asked to fill out a structured data sheet collect- ing the type and the estimated gift value, the demographic characteristics of the patient, and the type of condition that led the patient to seek medical attention. Results: A total of 659 gifts were recorded during the study period. The mean ratio of gifts/derma- tologist, GRINCH index, was 13.7. Notably, the Grinch index increased as the dermatologists’ ages increased in both sexes, and the same trend was confirmed by the data concerning the doctors’ number of years of professional activity. We observed a greater mean GRINCH value in male dermatologists compared to their female colleagues. Patients with chronic diseases were more prone to gifting; those affected by psoriasis, atopic dermatitis, or acne showed above-average GRINCH values. However, this finding seems unrelated to the dermatologist's field of expertise. Conclusion: Overall, these data strongly underline the importance of the doctor-patient relationship. A structured and prolonged mutual knowledge determines a trustful relationship that appears to be one of the fundamental bases of patient satisfaction. ABSTRACT Original Article | Dermatol Pract Concept. 2025;15(4):5527 3 considerably lower values, at 12 and 11.4, respectively ( Figure 1 ). No significant difference was found based on the geographical location of the dermatologists’ practice. GRINCH value increased rapidly with the dermatolo- gist’s experience. Dermatologists with less than five years of experience had an average value of 4.3, while those with 5–10 years of experience showed a result of 12.5. The value increased to 14.6 for those with 11–20 years of experience and reached a peak of 24 for dermatologists with 21–30 years of work experience. For the group with over 30 years of work experience, the value decreased to 14.6, but this finding concerns only one dermatologist ( Figure 2 ). Additionally, the GRINCH index appears to be linked to the dermatologist’s age. Dermatologists under age 35 had lower values, with an average of 4.6, with males having 6.4 and fe- males 2.8. The value progressively increased with age, reach- ing the highest mean value of 21.5 for doctors aged 51–55. The average value then decreased, reaching 10 in the group age ˃60. Up to the age of 50, the male and the female trends overlapped, showing two different peaks: one for males in the 51–55 years age group (GRINCH 37) and the second for females in the 56–60 years group (GRINCH 43) (Figure 2). According to the dermatologist’s field of expertise, the GRINCH index showed three categories with high values: psoriasis (18.7), atopic dermatitis (17.5), and acne (16). The second group, including melanoma, NMSC, nevi, and surgery experts, presented average values slightly below the mean (12.2, 12, 12, and 11.8, respectively). Finally, the pedi- atric, aesthetic, and heterogeneous “ Other ” group showed even lower values (respectively 9, 10, and 8.5) ( Figure 3 ). The estimated value of gifts received by dermatologists suggests a relationship with the dermatologist’s age. Derma- tologists under age forty mainly received gifts included in the first class of estimated price. In the age interval from 40 to 54 years, the different classes of estimated prices were homo- geneous, while dermatologists over age 54 mainly received gifts included in the third and fourth price classes ( Figure 4 ). We also evaluated the gift flows between the patients’ dis- ease and the dermatologists’ primary expertise. The analysis shows a high correlation between psoriasis and aesthetics, with more than half (51.5% and 53.3%) of the gifts received by specialists in psoriasis or aesthetics coming from patients examined for psoriasis or aesthetic problems, respectively. This correlation decreased for experts in NMSC (34.2%), acne (17.9%), and melanoma (15.4%). Lower relations were found for experts in AD and surgery, with the latter receiving about half of the gifts (49.8%) from patients with melanoma or NMSC ( Figure 5 ). Figure 1 . Gifts/doctor, based on work type. Figure 3 . Gifts/doctor’s related expertise. Figure 2 . Gifts/doctor’s age trend. Figure 4 . Distribution of gifts according to dermatologist’s age and price range. 4 Original Article | Dermatol Pract Concept. 2025;15(4):5527 Our study was conducted in accordance with ethical models. The GRINCH index was derived from the sum of gifts received by all physicians, divided by the number of specialists. The average value was €13.7 and considered the cutoff. The GRINCH index increased with dermatol- ogists’ age in both sexes, reflecting the idea that more ex- perienced physicians are recognized and rewarded. There was also a gender difference, with male physicians having a higher GRINCH index than did females. Patients with chronic diseases were also more likely to give gifts, par- ticularly those with psoriasis, atopic dermatitis, or acne. The relationship between gift giving and chronic diseases did not appear to be related to the dermatologist’s field of expertise. Dermatologic surgeons received fewer gifts than did colleagues dealing with inflammatory chronic diseases, mostly from “historic” patients who had sev- eral dermatological consultations yearly. This could be due to the fact that chronic patients tend to establish a closer personal connection with their doctors, which makes gift giving a more common occurrence. Moreover, thanks to novel treatments such as biological therapies, patients with chronic inflammatory diseases can experi- ence life-changing improvement in their condition, which generally results in feelings of gratitude towards the pre- scribing doctor, thus making gift giving more likely. Private dermatologists received fewer gifts, possibly due to the commercial nature of their relationship with patients. Italy has a universal public healthcare system covered by public funding, and patients who choose to receive treatment in a private practice mostly pay out of pocket. As a conse- quence, they may not be as prone to showing appreciation through gift giving. Discussion Healthcare managers must evaluate patient satisfaction and determine the factors that influence it as patient satisfaction can impact healthcare institutions’ finan- cial success. However, assessing patient satisfaction can be complex and challenging. There is an ongoing debate about how to define patient satisfaction and to create a comprehensive conceptual model. One of the main chal- lenges is the spontaneity of patients’ responses. When pa- tients complete questionnaires after a visit, their answers may be influenced by expectations and beliefs rather than by their experience [9,10]. To measure patient satisfaction with a doctor’s care, we decided to use gifts as a potential indicator of satisfac- tion, as gifts are a concrete and spontaneous manifestation of satisfaction. The heterogeneity of dermatology spe- cialists’ work and the Christmas period provided an op- portunity to evaluate the use of gifts to measure patient satisfaction. However, accepting gifts from patients raises ethical concerns [11,12]. While gifts are usually well- intentioned, they can create ethical uncertainty in health- care. The national, regional, and hospital Code of Conduct guidance and guidelines regulate gift giving to healthcare professionals to ensure their integrity is not compromised and that they are not placed in a conflict-of-interest situ- ation. In our study, the gifts received were of small mone- tary value, well below the threshold of €150, in compliance with Italian law. Moreover, all the involved dermatologists adhered to a strict behavioral guideline according to which gifts had to be spontaneous and must not interfere with medical decisions. Figure 5 . Gift flows according to patients’ disease and dermatologist’s field of expertise. Original Article | Dermatol Pract Concept. 2025;15(4):5527 5 5. Williams B, Wilkinson G. Patient satisfaction in mental health care. Evaluating an evaluative method.  Br J Psychiatry. 1995;166(5):559-562. DOI:10.1192/bjp.166.5.559. 6. Larsen DL, Attkisson CC, Hargreaves WA, Nguyen TD. As- sessment of client/patient satisfaction: development of a general scale.  Eval Program Plann. 1979;2(3):197-207. DOI:10.1016/0149-7189(79)90094-6. PMID: 10245370. 7. Locker D, Dunt D. Theoretical and methodological issues in so- ciological studies of consumer satisfaction with medical care.  Soc Sci Med (1967). 1978;12(4A):283-292. PMID: 675282. 8. Ng JHY, Luk BHK. Patient satisfaction: Concept analysis in the healthcare context. Patient Educ Couns. 2019;102(4):790-796. doi:10.1016/j.pec.2018.11.013 9. Ferreira PL, Raposo V, Tavares AI. Primary health care patient satisfaction: Explanatory factors and geographic characteris- tics.  Int J Qual Health Care. 2020;32(2):93-98. DOI:10.1093 /intqhc/mzz134. PMID: 32047931 10. Zolkefli Y. Healthcare Dilemma Towards Gift Giving by Pa- tients.  Malays J Med Sci. 2021;28(5):137-141. DOI:10.21315 /mjms2021.28.5.14. PMID: 35115896. 11. Lyckholm LJ. Should physicians accept gifts from pa- tients?.JAMA .1998;280(22):1944-1946.DOI:10.1001 /jama.280.22.1944. Conclusions These data strongly emphasize the importance of the doctor-patient relationship built on mutual understanding and prolonged interactions. Such a relationship fosters trust, a fundamental basis for patient satisfaction. In Italy, this sat- isfaction is often expressed through a “pensiero,” a small gift or gesture of gratitude. References 1. 7° Rapporto GIMBE sul Servizio Sanitario Nazionale. https:// salviamo-ssn.it/var/contenuti/7_Rapporto_GIMBE_SSN.pdf. Ac- cessed on May 2025.Coffee N. Gift and Gain: How Money Trans- formed Ancient Rome. Classical Culture and Society. New York: Oxford University Press. 2017. xiv, 296. ISBN 9780190496432. 2. Crawford MJ, Kessel AS. Not listening to patients—the use and misuse of patient satisfaction studies.  Int J Soc Psychi- atry.1999;45(1):1-6.DOI:10.1177/002076409904500101. PMID: 10443244 3. McAuliffe E, MacLachlan M. Clinicians’ Resistance to Con- sumer Satisfaction Surveys: What They Never Tell You. J. Manag. Med. 1992;6(3):47-51. 4. Merrill Carlsmith J., Aronson E. “Some hedonic consequences of the confirmation and disconfirmation of expectances. J Abnorm Soc Psychol.1963;66(2):151.