Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Copying them in... the after-effects
- Sukhpal S Gill, Mithilesh Joshi (6 November 2008)
-
Letters as a record of clinic appointments or for Communication
- Tom Holdsworth (7 November 2008)
-
Write to the patient and send the copy to the GP
- Hugh C Rayner, Steve Smith (11 November 2008)
-
Copying letters to patients
- Judith H Harvey (11 November 2008)
-
Letters can injure your health, too.
- peter j mahaffey (12 November 2008)
-
Copying them in is not as simple as it seems
- Brian McKinstry, University of Edinburgh, 20 W Richmond Street, Edinburgh EH8 9DR (12 November 2008)
-
copy to GP, copy to patient....
- David G Samuel (12 November 2008)
-
Copying them in or copping out?
- John Main (14 November 2008)
-
Copying clinical letters to parents:See one-copy one !
- Sahana Rao, Peter Friend and David Tuthill (19 November 2008)
-
copy them in
- charles d shee (25 November 2008)
|
|
|||
|
Sukhpal S Gill, Final Year Medical Student School of Medicine, University of Birmingham, Birmingham B15 2TT, Mithilesh Joshi
Send response to journal:
|
Reading this article brought back memories of our recent elective in India, where it is common practice for patients to be fully responsible for their own medical records. Having stayed part of the time with relatives, we had the undue pressure of being set upon by them armed with their medical reports and investigation results seeking a second opinion from UK medical students. We were only too happy to iterate our medical school’s policy of not being able to give medical advice as students. However, it was interesting to explore how much they actually understood about what was in their medical records – surprisingly, very little. Although we partly agree with Richards that empowering patients with their own medical records is a worthwhile endeavour, our experience tells us that this is only the first step in achieving enhanced public health literacy.[1] In establishing a system of ‘copying them in’, one has to anticipate the added onus on doctors to better educate their patients about their medical records. Something which is rightly promoted and duly carried out by some dedicated healthcare professionals (e.g. patient.co.uk).[2] However, one must also anticipate the challenges that will be brought by the failure to adequately educate patients. The first of which will be addressing the increased workload as a result of dissatisfied patients seeking second, third or fourth opinions – which may just add to pre-existing confusion anyway. Indeed it will be interesting to see whether such a system leads to the need for a global consensus, on what constitutes an adequate minimal patient understanding of the contents of their medical records. REFERENCES: 1. Richards T. Copy them in. BMJ 2008;337:a2324 2. http://www.patient.co.uk/index.asp - accessed 05/11/2008 Competing interests: None declared |
|||
|
|
|||
|
Tom Holdsworth, SHO VTS Sheffield
Send response to journal:
|
I recently have had the experience of seeing a patient who had spent the previous few days in a state of high anxiety having been copied in to a letter from the cardiology clinic. The letter was a lengthy document covering recent investigations, examination findings on the day and the patients symtoms. This letter included highly technical information and made reference to a slightly abnormal incidental finding. The patient wanted to know why this had not been picked up before and why had nothing been done about it. A long consultation ensued reassuring a distressed and angry patient that this finding was of little consequence. My point is that this system does not work when letters are written as a record of the clinic appointment, which are then copied to GP and patient. Letters need to be fit for purpose - tell the GP what they need to know and likewise for the patient. Some other way of record keeping needs to be in place for the clinic (electronic?). Of course the problem with all this as usual is time. Competing interests: None declared |
|||
|
|
|||
|
Hugh C Rayner, Consultant in Renal Medicine and Medical Director - Medicine Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, Steve Smith
Send response to journal:
|
We welcome Tessa Richards' article about this fundamental issue. However, we suggest she does not go far enough. Adoption of the practice of copying letters to patients has been limited by concerns about consent, confidentiality, cost and causing anxiety. Our experience has been that these concerns are readily overcome if the letter is written to the patient rather than the GP. This has been our routine practice since 2005. Hardly any patients refuse the offer of a letter and many are grateful to hear they will receive one. We do not believe that formal consent is necessary as this is not the case for other professions, such as lawyers and bank managers, who write directly to clients. We have sought feedback from patients and GPs through questionnaires sent out with the letters. Their comments illustrate the benefits: “I appreciate the letter addressed to me – the patient.” “I can now understand the treatment I am having for my illness and happy to know that I am making some progress along the way.” Many patients are unable to recall the verbal information they receive during a consultation. “I for one will have forgotten half of what you have told me by the time I get home.” The letters provide useful continuity between clinicians. “Good to keep the letter, if you are under different consultants, you can just show them the letter instead of explaining every time.” “… can update people at work with my progress when they ask.” The patient is able to alert clinicians to typographical and factual errors which can then be corrected. “Wrong post code. 2 medications to be added to list.” “From 2/9/05 my GP has changed the Pravastatin to Simvastatin.” The letter is a simple, timely way of passing on the results of tests taken during the consultation. “If my appointments are at 2 monthly intervals my knowledge of my current state is always 2 months old as I do not see results until my next appointment”.. Our practice has been welcomed by GP’s: “I asked all my partners their views on this ….. Excellent idea to send patients letters.” “Avoids misunderstandings between what they [patients] think they were told and what they were.” A common concern is how to retain important clinical information if the letter is written in layman’s terms. Our letters contain a diagnosis or problem list using standard medical terminology. This provides concise information to other doctors and allows patients to seek further advice from the internet and elsewhere about their diagnosis. The letter highlights important elements of the consultation including proposed investigations, changes in treatment and advice for action. Medical terms are accompanied by lay translations. There are no surprises – all the content of the letter should have been covered during discussions in the clinic. A current drugs list is always included, written in plain English rather than Latin abbreviations, for example “three times a day” instead of “t.d.s.”. Changes to drug treatment are highlighted in bold. Letters are always in English as the cost of professional translation is prohibitive. The letters are printed in large font if the patient is visually impaired. Hospital doctors have traditionally learned to write clinic letters by example. Universal adoption of writing letters to patients will only occur if training is incorporated in undergraduate and postgraduate education programmes. We devoted a departmental teaching session to translating examples of letters to GPs into letters to patients. The trainee doctors present often found this easier than the consultants. Writing letters to patients has greatly increased both patient satisfaction and our professional satisfaction with our outpatient service. Why don’t you give it a try? Competing interests: None declared |
|||
|
|
|||
|
Judith H Harvey, freelance GP London NW8 9QG
Send response to journal:
|
Having been involved in the past in promoting the copying of letters to patients, I am delighted to read Tessa Richards’ article. There are few other innovations that evoke almost 100% satisfaction from patients. But the first reaction of staff, whether they be doctors or secretaries, is concern that receiving copy letters will make patients more anxious. It doesn’t; it is lack of information that makes people anxious. As letters should be records of the patient’s consultation, there should be no surprises in them. But copying letters will not be adopted willingly if it is seen as yet another must-do; staff need to reflect on the benefits for their patients and to realise that it can actually save them work (fewer phone-calls, more informed patients — so easier and better decision-making), and to decide how it can be made to happen. As a GP I dictate referral letters during the consultation. Then both the patient and I know the letter is written, the information is correct, and that I have conveyed the patient’s concerns accurately. Patients without exception are pleased, even if their command of English means they do not understand every word I am dictating. Competing interests: None declared |
|||
|
|
|||
|
peter j mahaffey, consultant plastic & reconstructive surgeon bedford hospital mk42 9dj
Send response to journal:
|
Oh dear. Yet another slap on the wrist for clinicians from the BMJ, which does rather enjoy lecturing to, rather than supporting, its readers. If about two thirds of clinic letters are NOT being copied to patients, then wouldn't it be a good idea to first ask those authors for their reasons instead of criticising them & then airing the vocal opinions of the minority who do think its a good thing to actively transmit inter- professional correspondence to the patient? Writing to a colleague about a patient is not only about transmitting the facts. Its about nuances too, nuances which recognise that medicine is still, thank God, just about an art as well as a science. If I want to tell the GP that I found Mrs X to be anxious and possibly over-focussing on some symptom or other, then that is an opinion (not a fact) that I want my colleague to know.....so that he or she may better be able to formulate a plan to help her. But in today's politically correct climate, its highly likely that Mrs X would not only be upset to read that but might even complain about this sincere opinion. If we had all the time in the world for our consultations then it might be possible to talk the patient through those fears. But whilst giving lip service to "quality" in consultation, in reality the government actually requires us to 'pack 'em through' the clinics. Sadly, quality and reality don't fit in our present NHS. Personally I'm not in the slightest bit bothered about the patient seeing every single word of their file, but its a different matter pushing it under their noses. What for example does one do about those patients we meet all the time who simply dont want to know about their cancer diagnosis, and yet we need to tell the colleague who is managing their day to day health? In the nicest possible way, it really is the essence of armchair preaching for a journalist such as Tessa Richards to criticise those of us who disagree with her when she as remote from the hurly-burly of everyday clinical life as its possible to be.She should recall that not only in her own hands, but in those of active clinicians, the pen really is mightier than the sword. Competing interests: None declared |
|||
|
|
|||
|
Brian McKinstry, Reader Primary Care Research Division of Community Health Sciences: General Practcie Section, University of Edinburgh, 20 W Richmond Street, Edinburgh EH8 9DR
Send response to journal:
|
Sir, At first sight, Tessa Richards’ suggestion that we should copy patients into all correspondence may seem like a good idea.(1) However, there are many drawbacks that have to be considered. She advocates this on the grounds of improving health literacy. However, a significant minority of people in the UK have general literacy problems (2) and are unlikely to benefit from such an intervention. Indeed the intervention is likely to increase health inequalities. As currently written many letters from hospital are difficult for patients to understand. I and my colleagues have found ourselves in the situation of explaining to alarmed and bewildered patients who have received copies of their correspondence the meaning of phrases and abbreviations such as “…the benefits of IOL* may be limited because of the presence of incurable dry AMD*”. It is not difficult to see why patients who often have several chronic conditions may erroneously interpret such information in the worst possible way or even as a terminal prognosis. It is important therefore that letters should be comprehensible to patients (and also to doctors -translation below!) Some patients will not want confidential details of their medical history entrusted to the postal service, or even to be potentially viewed by other members of their family. Patients would have to be informed about the potential for data loss once the letter leaves the NHS and should be asked to give consent. It cannot be routine. This of course will add to the length of any consultation. Our practice sends and receives several hundred letters and investigation results every day. If we assume a conservative estimate of £0.5 ($0.75, €0.6) per item for copying patients into correspondence how will this be resourced? Hospitals and practices will have stop some services they are currently providing to resource this. How will we know if the intervention is cost effective? Access to an electronic record (for the computer literate) would reduce the cost of this, but this of course has its own drawbacks.(3) I would make a plea that before we rush headlong into providing the service that Tessa Richards suggests that we think it through, plan it properly to maximise its benefits to all patients and importantly decide if the potential overall benefit is worth the cost. Brian McKinstry * IOL = Intra-ocular lens replacement, AMD = Age-related macular degeneration 1. Richards T. Border Crossing: Copy them in BMJ 2008;337:a2324 2. DfES. The skills for life survey. National Needs and Impact Survey of Literacy, Numeracy and ICT Skills. (2003). Stationery Office: London 3. McKinstry B, Vulnerable people have most to lose from online access BMJ 2007; 334: 599 Competing interests: None declared |
|||
|
|
|||
|
David G Samuel, F1 doctor - General and Breast Surgery Prince Charles Hospital, Merthyr Tydfil. CF47 9TD
Send response to journal:
|
I am fortunate to be a junior doctor working for a consultant who looks to involve his patients in every aspect of their care. Patients are informed of their diagnosis and their illness is explained to them at the earliest opportunity. Working with a Breast surgery team explaining and breaking bad news is an every day practice in dealing with Breast cancer patients and patients need comfort, support and information about what lies ahead. I was born with a congenital deformity which came as a total shock to my parents at the time of my birth. Both are educated people with first class honours degrees and are able to understand, retain and repeat information – crucial aspects of informed consent and decision making. Yet, minutes after my birth, when it was obvious that my leg was unusual by the crowd of nurses and doctors, they were told rather patronisingly that the “baby doctor” (Paediatrician) will be here shortly to talk to them and that “baby is fine” but we need to check him again?! My parents were annoyed and the situation was made worse when my father was asked to lie to mother about my disability, and on refusing to do so was then asked to “break bad news”. I think the scenario reflects how far we have come in communication skills but also how damaging lack of understanding and interaction between clinician and patient can be. While some patients would prefer not to know the intricate details of their condition the majority do or appreciate the opportunity to ask questions and to be kept informed. My team make it a part of normal patient care and practice to copy all dictated clinic letters to both the GP AND patient. I have been taught that you should never say or write something you would not want a patient to read. In an era of freedom of information surely the days of making comments about the patient – often derogatory are long gone. I only hope that I remember what I have learned from my first few months as a doctor in terms of the benefits of open and honest communication with patients, and maintaining these practices throughout my career. Copying letters and correspondence to patients should be as common practice as consenting a patient before a procedure. Not a luxury or an optional extra but a fundamental part of patient care. Competing interests: None declared |
|||
|
|
|||
|
John Main, Consultant Nephrologist James Cook University Hospital, Middlesbrough, TS 4 3BW
Send response to journal:
|
I’m all in favour of health literate patients and spend a lot of time informing them of what we’re doing and why – indeed I see my role as helping them understand what is happening to them and giving them their options so they can then choose what they want (including no treatment or tests). But I don’t copy my letters to them, for the following reasons. The purposes of clinic letters are to a) communicate with GPs, and b) keep a legible record in the notes of what is happening and what might happen in this case. It is written in medical speak and it is fantasy to suggest that letters written like that will ever be meaningful, without further explanation, for most patients. So if I use those letters as a way of informing patients, I will need two letters –one for them, and one for the notes. If , on the other hand, I want my patients to know what is happening to them, that takes more than a letter. A motivated doctor who spends time in the clinic explaining things, showing results and x-rays etc, may well inform patients better than one who simply copies patients into all correspondence. And of course most of the research showing it works will be done by enthusiasts who both set out to be informative in clinic and copy letters. I would be happy for patients to read their notes as they wait to see me – at least then they can easily and quickly ask about things they don’t understand. Some departments in our hospital do automatically copy letters, and sometimes I am asked to translate these when patients come to my clinic. And of course, no-one should have a test done without also being told how they will be informed of the result (and many of our Renal patients can go on the net to see their important blood tests). In the era of target driven medicine, it is easy to imagine us being forced to demonstrate that patients are copied in to correspondence, as a surrogate measure of patient centred care. Like many easily countable targets, this one would be a simplistic cop out that tells us nothing about what we really want to know. So, all in favour of the end, just disagree about one of the means. John Main Consultant nephrologist Competing interests: None declared |
|||
|
|
|||
|
Sahana Rao, ST3,Paediatrics Birmingham Childrens Hospital, B4 6NH, Peter Friend and David Tuthill
Send response to journal:
|
We read with interest Tessa Richard’s article “Copy them in” (1). Since 2004 the Department of Health (DoH) has recommended that all patients should receive a copy of clinical letters following attendance at outpatient clinics after obtaining consent (2). Previous studies have demonstrated improved parental satisfaction and compliance following this advice (3,4). We have explored the current practice amongst paediatricians in Cardiff and sought factors influencing its implementation and also assessed the level of awareness amongst junior paediatricians of the DoH advice. It was conducted in person and enquired about: the frequency of copying letters to parents; consent; and asked the clinician’s views on the benefits and disadvantages of forwarding copy letters. All the consultants and specialist registrars (SpRs) in general and speciality paediatrics were eligible. 30 questionnaires were completed from a workforce of 56 doctors; 15/38 consultants and 15/18 SpRs. 73% of the Specialist Registrars were unaware of DOH guidelines and none of them had received any formal training on written communication with parents/patients Practice Yes No Sometimes Routinely copy letters 10 20 Copied letters only in special circumstances 14 16 If copied wrote separate letter to parents 7 18 5 Awareness for need of consent 6 24 Obtained consent in special circumstances 6 24 Influencing factors Believed it improved communication 23 4 3 Believed it Improved parental satisfaction 21 3 6 Believed it Improved compliance 15 6 9 Increased workload 14 12 4 Increased parental anxiety 14 10 6 Potential for breech of confidentiality 15 9 6 Few paediatricians routinely copy their letters to parents despite the proven benefits, DoH advice and them believing it improves communication! Hardly any ever take consent for this in routine practice, not unreasonably in our opinion. We believe that routine copying of GP letters to families provides clear and prompt written communication of medical advice and medication doses to parents. The workload is minimal and we have never experienced any patients who have reported increased anxiety. Perhaps the old medical advice of see one-do one should be amended to see one-copy one! References: 1. Richards T, Copy them in, BMJ 2008;337:a2324 2. Department of Health Guidelines, Copying clinic letters to patients. Good practice guidelines (2004) 3. Bartle G, Diskin L, Finlay F. Copies of clinic letters to the family. Arch Dis Child 2004;89:1032-1033 4. O'Driscoll BR, Koch J, Paschalides C. Copying letters to patients: Most patients want copies of letters from outpatient clinics and find them useful. Br Med J 2003;327:451 Competing interests: None declared |
|||
|
|
|||
|
charles d shee, chest physician queen Mary's Hospital, Sidcup,Kent,DA14 6LJ
Send response to journal:
|
With regard to the correspondence about copying letters to patients, generally it seems that those doctors who are sceptical are those who have not actually tried it, whereas those who send copies routinely are enthusiastic.I had initial reservations, but for four years have sent copies of letters to patients,including letters to GPs and tertiary referrals.Asking patients if they would like copies adds minimal time to a consultation, and very few decline (some ask for a close relative to receive the letter instead).The informal feedback from patients has been uniformly favourable, and they say it makes them feel more involved in their management. None of my consultant colleagues who has tried copying letters to patients has subsequently stopped because of the theoretical problems and most,like me,have become converts to the practice. Try it and see! Competing interests: None declared |
|||