Dear readers,

We are honoured to bring you a guest post, in fact two, and indeed we hope more, from the fabulous Dr Chris Sanderson, palliative care physician.  I have to say that I was so inspired by this idea, by putting patients at the centre of our communication, where they should be, that I totally stole this idea for my own Change Day pledge.

Below is part one of her description of her pledge for Change Day, #lettertome.

#lettertome : A twitter campaign to improve how we share information with patients.

Social media is such a wonderful space for spreading ideas – and sometimes the simplest ideas may convey a world of significance. Recently on twitter, there was a conversation between various doctors and patient advocates about how we speak to and about our patients, and the subject of doctors’ letters was raised. Thus was born a new hashtag, a pledge for Change Day Australia, and potentially a new way of doing things.

I want to take the opportunity of my first blog for Palliverse to consider the topic of doctors’ letters and the complicated place they hold. For me, writing letters has always been the bane of my professional life – as I can’t dictate for nuts, I have fairly high standards for my letters (I like to think!) and because, (if I think about it honestly), I feel that it is the place that my clinical skills, such as they are, are on display to my colleagues. The entirely primitive state of the IT in the public sector where I work makes this even more challenging and time-consuming than it already is.

More generally, medical letters fulfill a number of roles, including as a:

• Summary of a clinical assessment for future reference
• Tool for communication with, and feedback to, other clinicians
• Legal document

More subtle functions may also be present– for example the positive reinforcement of referral relationships between GPs and consultants, which are important in private practice.

However at a fundamental level the letter between doctors, similarly to the conversations that doctors sometimes have amongst themselves, may communicate not just a clinical summary but a whole lot more. For instance when we describe “the difficult historian” , the patient who “failed treatment”, “the non-compliant patient” – these are some of the phrases that we may use to convey coded messages amongst ourselves about what we have found difficult in dealing with this particular person and their circumstances, and our judgements on them. The things that are included or excluded convey so much – about the letter writer, mostly. (Although to be fair, the daunting throughput in many outpatient clinics may limit the capacity of clinicians to address more than one symptom or problem in an appointment, and their letters no doubt reflect this.)

However it is sometimes a little shocking to try reading a standard medical letter through the eyes of a patient. One of the twitter correspondents who has been supporting #lettertome was very distressed by a comment in a medical letter about her own case, which read (sic) “I also found endometriotic deposits under both diaphragms!” She felt that the use of an exclamation mark conveyed a sense of “glee” in her doctors about what they had found. This style of communication did not convey any sense to her that she was cared for as a person – quite the reverse.

I remember as a student being told that the test for what we write about patients in the casenotes is that we would be comfortable to own up to it in a coroner’s court, or see it published on the front page of the Sydney Morning Herald: this was called “the daylight test”. For our letters, the equivalent test is perhaps whether we would be comfortable to let the patient read what we have written about them.

The concept of giving patients a copy of their own medical letter has been around for a while. In the NHS Plan of 2000 it was decided that patients should be given a copy of their own letter, “as of right”. There is some useful guidance available online on how this should be done, discussion of issues related to consent, and what the limits of the practice should be. (Wirral Community NHS Trust, 2012) I have no idea how widespread the practice now is in the UK – probably not common at all, based on the twitter discussion, but there is a small amount of literature that evaluates it in various settings (Pothier, Nakivell, & Hall, 2007; Roberts & Partridge, 2006). Both of these articles are available as free full text for those who are interested.

My next post will describe #lettertome – a new way of approaching doctors’ letters.

References:

Pothier, D. D., Nakivell, P., & Hall, C. E. (2007). What do patients think about being copied into their GP letters? Ann R Coll Surg Engl, 89(7), 718-721. doi: 10.1308/003588407X205413

Roberts, N. J., & Partridge, M. R. (2006). How useful are post consultation letters to patients? BMC Med, 4, 2. doi: 10.1186/1741-7015-4-2

Wirral Community NHS Trust. (2012). Protocol for copying letters to patients: NHS

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