Here is the long awaited second part of Dr Chris Sanderson’s thoughts about #lettertome, where doctors write letters to PATIENTS instead of other doctors……

The idea of #lettertome goes further than sharing a copy of the standard doctors’ letter with the patient. Instead of writing about patients, maybe we could be writing to them. When we reconceptualise what we do in terms of patient-centered care, a letter can have very valuable functions:

• It explicitly addresses the patient’s role in their own care, as part of the team, and helps them to follow up their own part in the treatment plan
• It can restate and confirm the discussion that has been held with the patient, for them to use and refer back to – helping to overcome problems for patients of misunderstanding, mishearing, or simply missing much of what is said because they are overwhelmed
• Likewise, the GP and other clinicians can know exactly what has been communicated to the patient about their situation
• It can affirm the clinician’s care for the patient, and their plans to address the patient’s problems
• It can invite the patient to correct or update information that is being shared about them
• It conveys a fundamental message of respect, of collaboration, and of transparency in communication, and helps the patient to understand how the network of clinicians caring for them are working together in their care – who is doing what, and how they are staying in touch with each other to address the patient’s problems.

Following a pledge on ChangeDay Australia  http://changeday.com.au I have now changed the way I write my letters.  My letters are addressed to the patient, and cc-ed to all the other treating doctors. At the end of my consultation I tell the patient that they will receive a letter from me in the next few days, and that a copy will go to their other doctors, and I check that they are ok with that plan. No-one has said “no” yet…

I am gradually working out a template for doing these letters. I still include the same information that I used to include in my letters to other doctors, but now the language I use is as clear and simple as I can manage, and for the patient I put it into the context of what we talked about and decided when I met them. I tell them about the most important things I found when I examined them, and what that might mean. I list their medications, and describe the changes we have made, and attach their up to date medication list. I tell them if I am worried about them, and I express that concern in their letter. I express my hope that we can improve things for them, and I try to be specific about what it is I am trying to help them with.  I don’t say anything in the letter that we didn’t talk about when I saw them. I describe the followup plan, and list what I and other people need to do. And when things are improving, I gladly document that too.

The letters take no more or less time than my usual letters, and I write them on my computer as a word-processed document. I really quite enjoy writing these letters. However, my current system does require cut and pasting to get the letter onto the EMR and this is painful. I draft a letter to the GP on EMR which simply says something like “Please find attached a copy of the summary of my consultation with your patient X which I have sent to them.  If you have any concerns please contact me.”  (Or words to that effect.) Sometimes, if there is a specific request for the GP to follow through with something I will highlight it in the covering letter so it doesn’t get missed.  Then I cut and paste the patient’s letter onto the end of the GP letter in the EMR system.  As in many palliative care services, we have very little admin support and it is shared between many people and tasks. I am wary of asking for too much time from our endlessly patient admin officer, but these letters do need to be printed out onto letterhead and posted – which seems very retro in the age of paperless communication! However I am starting to wonder whether we should actually be asking all patients and their next of kin for their preferred email address as part of collecting our routine demographic and contact information, and checking whether they would like to receive emails from us. It’s the twenty first century after all, and many of my patients are more savvy than me!

Interestingly I havent had much feedback yet, so I am thinking about including a feedback form along with the letter and seeking comments (both from patients and from other doctors). I have no doubt that what I am doing can be improved and I would like to know if it is helpful, and also if there are problems with the practice that I had not anticipated.  I will keep you posted on how that goes!

If anyone is interested in joining the #lettertome campaign – just go for it. Post your pledge on the Change Day Australia website, and once you’ve been doing it for a while, let others know how you go. To me, working this way is truly the heart of palliative care – where we work with and for our patients, where we help people understand what is happening to them and why, and where we help them identify their choices and support them along the way as they make their own decisions. If I was the patient I would want no less.