for all the responses and ideas everone... I'm getting it does seem to make a difference on the circumstance... I notice a difference in my docs offices staff and the "climate" - some staffs are very loyal and have no turnover - others super high turnover and when you see that - usually mean not getting motivation they need to continue in the jobs...

The review I'm going thru I received very short notice (on purpose) - and I've had to contact every doc I have - and I've made sure to thank every person verbally that handled my records and got them to me so quickly..... and they know I appreciate it.... and I dont want to seem to try to influence the doc statements in any way (they are separate forms that have to be filled out only by doc) so its a tight line..... and right now I'm being very careful to not do anything like that.... going forward though will think of maybe little occasional "treat" and t-u note to doc when someone does go above and beyond.....

As for hospital situations - I've had frends show up to visit me in the hospital with food for the whole staff (their idea) and it was gobbled up asap.... but thats a different type atmosphere and in my case anyway, was well received (I'm sure the docs never knew about it)......

Sounds to me therefore like the circunstances really can dictate the gratitutdes extended....