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Letters to patients: sending the right message

BMJ 2002; 324 doi: (Published 16 March 2002) Cite this as: BMJ 2002;324:685
  1. Philip E M Smith (SmithPE{at}, consultant neurologist
  1. Welsh Epilepsy Unit, University Hospital of Wales, Cardiff

    Ihad described her in my letter as “enmeshed with her mother,” although I had kept this opinion to myself during the consultation. It was a trivial and unnecessary remark, which added nothing to the diagnosis or management plan. Her general practitioner, embarrassed for me, refused her mother's request for a copy of the letter. Eventually, of course, she obtained one and was understandably annoyed by the attempted cover up. My throwaway line had damaged my relationship with the patient, but more importantly had strained the trust between her GP and the family. I resolved then that my clinic letters would report the consultation solely, would include only narrative and comments openly discussed, and would be copied to the patient.

    There is no room for the jokes and smart remarks that used to entertain us

    Copying medical correspondence to patients is increasingly practised and the inquiry report into children's heart surgery at the Bristol Royal Infirmary recommends it ( The advantages go far beyond a display of greater openness. Letters can aid understanding, provide information, empower patients, and thereby improve adherence to treatment regimens. Away from the distraction and anxiety of the hospital patients can read and re-read about their diagnoses and management plans, the names of medications or of personnel, and lifestyle advice. It can be therapeutic to know that the doctor has listened and understood. Also, doctors who know that their patients will receive a written record of the consultation are likely to have more open and honest conversations with them, and to write clearer and more accurate letters.

    Initially I selected patients to receive a clinic letter, preferring some not to have written evidence of my diagnostic and prognostic speculations until matters were more definite. Limiting the letter content to a report of the consultation, however, almost always avoided this problem. All my patients now receive a copy letter unless there are particular reasons to withhold one. I could envisage sending an additional covering note to the referring doctor to allow speculation on conditions not discussed at a first consultation—for example, suspected motor neurone disease—but so far this has not seemed necessary. By far the most difficult letters concern those where diagnostic uncertainty is coloured by prominent psychological features. Even here, a written explanation of the nature and mechanism of psychological and non-organic symptoms, copied to the patient, often seems more helpful than skirting around the issues in clinic, only to address them in a letter to the general practitioner.

    A copied medical letter clearly differs from a specially worded one designed for a patient, and clinicians might worry that technical terms could be misinterpreted, frightening, or confusing to patients. Yet even doctors accept incomprehensible language in correspondence from other professionals without becoming unduly alarmed. I annually resist the urge to examine the minutiae of my accountant's tax submission, even though this contains important personal information.

    Overall the response from patients who received letters has been overwhelmingly favourable. Perhaps the most enthusiastic feedback was: “Brilliant: I didn't take in technical terms at first but went through it with the family and enjoyed finding out what each bit meant.” Another anxious woman in whom I diagnosed mild Parkinson's disease had initially felt unable to explain her situation to anyone, and it was three months before she summoned the courage to show my letter to her daughter. Far from the expected hysterical reaction, she received sympathy and support.

    The only real complaint was from someone whom I had described as “this 44 year old right handed ceramic tiler …” Like the patient described in a recent BMJ filler (BMJ 2002;324:19), his objection prompted an overdue change in my routine opening sentence. I also now double check drug doses and patient addresses, and use fewer abbreviations. I am sometimes unsure to whom to address letters concerning young teenagers, people with mental illness, and those with learning disabilities or dementia, and accept that there are confidentiality issues in copying such letters to a third party.

    It should now be the exception to write letters that we would not wish patients to read. Clearly there is no room for the jokes and smart remarks that used occasionally to entertain us, or even for the patronising value judgments (“this pleasant gentleman”) that once were common. General practitioners already frequently share our letters with patients and may be surprised that they are so seldom written with this in mind. We can embrace our patients' increasing demand for access to notes and letters as a major opportunity to improve our communication with them. And in the unlikely event of my writing again that someone is “enmeshed,” you can be sure that it will have been discussed with the patient first in the clinic.

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