Writing outpatient letters to patientsBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m24 (Published 27 January 2020) Cite this as: BMJ 2020;368:m24
- Hugh Rayner, consultant nephrologist1,
- Martha Hickey, professor of obstetrics and gynaecology2,
- Ian Logan, clinical lecturer in nephrology3,
- Nigel Mathers, emeritus professor of primary medical care4,
- Peter Rees, chair of Academy of Medical Royal Colleges patient lay committee5,
- Robina Shah, senior lecturer in medical education and director of the Doubleday Centre for Patient Experience6
- 1University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- 2The Royal Women’s Hospital and the University of Melbourne, Victoria, Australia
- 3Freeman Hospital, Newcastle upon Tyne, UK
- 4University of Sheffield, Sheffield, UK
- 5Academy of Medical Royal Colleges, London, UK
- 6University of Manchester, Manchester, UK
- Correspondence to H Rayner
What you need to know
Most patients and general practitioners prefer outpatient letters to be written directly to patients
Ask patients’ permission before sending them printed letters; written consent is needed for letters via email
Consider patients’ best interests and whether the content could be harmful before writing directly to them
In many countries (including the UK and Australia) it is still common practice for hospital doctors to write letters to patients’ general practitioners (GPs) following outpatient consultations, and for patients to receive copies of these letters. However, our experience suggests that hospital doctors who have changed their practice to include writing letters directly to patients have more patient centred consultations and experience smoother handovers with other members of their multidisciplinary teams.1 Writing letters to patients is also being used as an educational tool for improving medical students’ empathy and rapport with patients.23
A large proportion of patient complaints and litigation originate from poor communication.4 Correspondence that is delayed, not patient centred, and lacking information has been highlighted as a risk to patient safety.5 Writing prompt letters directly to patients can help reduce these risks.6
In this article, we offer practical advice on how to construct letters to be sent directly to patients, and suggest how these letters might encourage collaborative working centred on patients’ needs and wishes.
Evidence on this topic is limited but includes a small number of quality improvement studies looking at the impact of clinic doctors writing letters directly to patients or to the parents of paediatric patients, and these have consistently shown positive outcomes.
Four of us—Hugh Rayner, Nigel Mathers, Peter Rees, and Robina Shah—contributed to the 2018 guidelines on writing outpatient letters to patients for the Academy of Medical Royal Colleges (AoMRC) in the UK.7 These guidelines were based on our personal experience, consultation with clinicians and patients, and literature searches relevant mostly to UK clinicians.
The recommendations in this article are based, in part, on the AoMRC guidance, and also on findings from further extensive literature searches; they can be applied to all countries where care is provided in an office or outpatient setting.
How do letters affect patient autonomy?
The style, phraseology, and terminology of many letters addressed to health professionals means that some patients may not understand the whole letter.89 Our experience suggests that patients can also feel patronised by being written about rather than to, especially when they are described with adjectives such as “pleasant”10 (box 1).
Extract from a letter written to the GP and copied to the patient
Dear Dr Smith,
Re: Mr John Jones. Date of birth: 1st January 1950
It was a pleasure to see this pleasant 69 year old gentleman in the Cardiology Outpatient Clinic. He recently presented to you with increasing shortness of breath on exertion.
On discussion with Mr Jones about his symptoms, he continues to experience dyspnoea on exertion. This is particularly noticeable when climbing hills and stairs but is not associated with any chest tightness.
Mr Jones also gives a history of intermittent palpitations occurring once every couple of days but denies dizziness or blackouts. He previously had some peripheral oedema and symptoms suggestive of orthopnoea and PND, which improved with a course of furosemide.
Currently Mr Jones can undertake all his routine daily activities, albeit at a slightly slower pace than usual for him.
I suggested to Mr Jones that he takes furosemide 40 mg each morning on a prn basis for fluid retention.
141 words. Flesch Reading Ease score = 41.3
Revised version of the text, written to the patient and copied to the GP, incorporating the guidance from this article
Dear Mr Jones,
Re: Mr John Jones. Date of birth: 1st January 1950
It was a pleasure to meet you in the Cardiology Outpatient Clinic.
You recently saw your GP because you were more short of breath when climbing hills and stairs. You do not have tightness in the chest. You have palpitations once every couple of days. You have had no dizzy spells or blackouts.
The swelling in your legs and breathlessness when lying down at night improved with water tablets (furosemide). You can still do all your routine daily activities but at a slower pace than is usual for you.
If there is swelling of your ankles, I recommend that you take one 40 mg furosemide tablet each morning until the swelling has gone.
113 words. Flesch Reading Ease score = 71.2
Our experience is that patients feel more able to respond to and correct errors in letters written directly to them, and that GPs are saving consultation time by not having to explain the contents of letters that have been addressed to the GPs. Box 2 gives some examples of patient feedback on receiving letters directly.
Patient feedback on receiving personal letters
“I appreciate the letter being addressed to me”
“I now understand the treatment and I’m happy to know that I’m making some progress”
“I will have forgotten half of what you have told me by the time I get home”
“If you are under different consultants you can just show them the letter instead of explaining every time”
“I can update people at work with my progress when they ask”
“Wrong post code. Two medications need to be added to list”
“It would be useful to know the blood results. If my appointments are at 2 monthly intervals my knowledge of my current state is always two months out of date as I do not see the results until my next appointment.”
In the US, under requirements for the “meaningful use” of electronic health records, patients are often given an after-visit summary (AVS) at the end of an outpatient clinic visit.11 This was intended to empower patients and encourage self-management by helping them to understand their health, but AVS documents are often long, poorly laid out, and contain a lot of medical jargon. Clinicians and patients have attempted to improve the layout and readability of these documents, and to incorporate the type of plain language that is used in patient addressed letters; however, the inflexible architecture of electronic health records makes it difficult to implement these improvements.12
A small number of quality improvement studies in Australia,13 Ireland,14 and the UK151617 have reported increased patient and parent satisfaction, and found that most referring clinicians and GPs were supportive of the practice.
In one randomised controlled trial, personal letters were received more favourably than copies of standard letters addressed to the referring GPs even when notes addressed to the patients were attached thanking them for attending clinic—it found that 80% of patients were pleased or very pleased to receive the personal letters, and 81% found them to be useful or very useful.14
How do you write letters to patients?
Letters to patients need not be longer than those written to GPs (box 1). Keep sentences short, with one topic per paragraph. You can check the readability score with most word processing software. Box 1 shows a letter addressed to the GP having a Flesch Reading Ease score (derived from the lengths of words and sentences) of 41.3. The letter addressed to the patient has a Flesch Reading Ease score of 71.2.
Scores of 30-50: text generally understood by people with education higher than school level.
Scores of 60-70: text generally understood by people aged 13 years and above.20
Include the following information:
The reason for the visit
A summary of the history and relevant examination findings
A management plan
A list of medications
Answers to any questions asked by the patient or GP
Questions21 from patients that may be answered in a letter
Tests, such as blood tests or scans
What are the tests for?
How and when will I get the results?
Whom do I contact if I don’t get the results?
Are there other ways to treat my condition?
What do you recommend?
Are there any side effects or risks? If so, what are they?
How long will I need treatment for?
How will I know if the treatment is working?
How effective is this treatment?
What will happen if I don’t have any treatment?
Is there anything I should stop or avoid doing?
Is there anything I can do to help myself?
What happens next?
Do I need to come back and see you? If so, when?
Whom do I contact if things get worse?
Do you have any written information?
Where can I go for more information?
Is there a support group or any other source of help?
Begin with a familiar tone: “Dear Mr X, It was a pleasure to meet you …” (box 1).
Later, a more formal tone may be appropriate, for example: “This letter summarises the information we discussed about your heart condition.”
Use the first and second persons, and the active rather than the passive voice. Compare “I have referred you to a chest specialist” with “A referral to a chest specialist has been made.”
Non-committal language helps convey uncertainty, for example: “As I explained, the tremor and stiffness in your right arm suggest that you may have Parkinson’s disease.”
Consider incorporating standardised information about medical conditions in the letters, along with links to reputable information online, support groups, and patients’ electronic records if available. Include contact details for further support such as specialist nurses and therapists. Patient information leaflets can be posted with the letters.
Avoid small print; use at least 11 point. Ask patients with visual impairment if large print, eg, 16 point, would be useful.
Avoid labelling—for example, choose “you have diabetes” instead of “you are a diabetic.”
Avoid judgmental comments—for example, choose “you decided not to continue with this pregnancy” rather than “you wanted an abortion” (which may be perceived as being affected by the clinician’s own opinion).23
For children, young people, and people with learning disabilities, include language and information appropriate for their stage of development.24 Consider when the use of images and diagrams—eg, graphs of results and treatment pathway diagrams—might be useful.252627
Avoid commonly misinterpreted words28—for example, “chronic” can be interpreted as “really bad.”
Avoid jargon where it does not add value—for example, use “kidney” instead of “renal.”
Explain any use of jargon within the body of the letter, for example: “You have an irregular pulse. This is called atrial fibrillation.”
If medical jargon is needed to communicate information efficiently and precisely, consider including it in a diagnosis list or a section to the GP.
Avoid acronyms or spell them out at least once to avoid confusion.
Explain what each medication is for29 and their benefits and risks. Include clear instructions on how to take them (box 1). In the medication list, avoid Latin abbreviations for doses and schedules, and highlight changes with bold print, for example: “Furosemide—Increase to 80 mg twice a day to reduce ankle swelling.” Include a drug’s brand name if it might be more familiar to the patient.
Breaking bad news
For some results, a telephone call may be more appropriate than a letter30 but ideally, aim to explain potentially upsetting results face to face.
If a letter is the only way, include an interpretation of the results, the proposed next steps, and a way for the patient and GP to contact you, such as an office phone number or email address.
When arranging tests, it is good practice to ask patients how they would like to receive their results before they leave the consultation room.
Conveying clinical information in letters
Include all the clinical information required by the patient and the GP.1 You may wish to add a section with information directed specifically to the GP at the bottom of the letter (consider including only information that requires action here rather than specialist detail that can be found in hospital records, especially if these are accessible from primary care).3132
Additional letters may be needed when referring patients to other hospital specialties. In these cases, provide copies to patients and GPs for their reference.
When is consent required?
It is good practice to ask patients how they prefer to receive correspondence from you and to ask patients’ permission before sending anything out to them.33
In the UK, children under 16 can be written to directly with their permission if the doctor judges that they fully understand what is involved.34 Otherwise, hospital doctors typically write to their parents or guardians.
Guidelines about electronic communication between patients and clinicians primarily focus on technical and administrative issues.35 Technological advances are addressing some of the security concerns but current recommendations from NHS England are to gain written consent before sending letters to patients by email, as most internet email accounts are not considered secure.36 We recommend that clinicians seek confirmation of local IT arrangements and guidance about emailing patients from their employers.
Sending printed letters by post may seem outdated in the internet age. However, many people do not have access to email or the internet, and a paper letter may receive more attention than an email.37
For adults who lack the capacity to give consent, hospital doctors may consider writing directly to GPs and, when it is in patients’ best interests, copies of these letters can be sent to patients’ representatives.
When would you consider writing only to the GP?
Letters written only to GPs may be needed if sharing the content with patients could be harmful. Examples include letters relating to safeguarding concerns, litigation, or dishonesty, or where there is disagreement between patient and clinician. In the UK,38 Australia,31 and the USA32 information may be shared without consent in some circumstances if the sharing of information is in the best interests of a child or vulnerable adult. In these cases, record who has been given the information and for what reason.
Is effective letter writing part of my professional development?
Discussing your experience and inviting feedback from clinician colleagues and patients can improve your letters39 and provide material for your professional development portfolio. Consider using the change in practice as a quality improvement activity and an opportunity to report back on your experience and learning.
Education into practice
How could you include feedback from patients and colleagues about your letters in your appraisal portfolio?
How might you encourage your colleagues to write directly to patients?
Do you feel more comfortable addressing letters to patients or to fellow health professionals? For what reasons?
How patients were involved in the creation of this article
The comments in box 2 show the main themes of the responses from 218 patients during a six month pilot to introduce writing outpatient letters to patients in HR’s department. These comments about the value of letters to patients and patient safety formed the basis of what we included in the article.
Authors Peter Rees and Robina Shah are patients and chair patient representatives, Peter Rees for the Academy of Medical Royal Colleges and Robina Shah for the Royal College of General Practitioners. When creating the article, they brought perspectives that validate patients’ lived experiences and that are closely aligned to the NHS constitution.
We also considered comments from patient representatives from a number of Royal Colleges and Faculties.
Sources and selection criteria
This article is based on recent guidelines from the Academy of Medical Royal Colleges (AoMRC) in the UK: “Please, write to me.”7
The AoMRC guidelines were coordinated by the UK Royal College of GPs and developed by a team of 20 clinicians and patient representatives. The process started in February 2017. Four of the six authors of this paper were part of this team (HR, NM, PR, RS). HR led the writing of the guidelines, producing the first draft, and included in subsequent versions extensive written suggestions and comments made by the rest of the team during a series of teleconferences. The guidelines were edited for clarity by Lee Monks of the Plain English Campaign, and were reviewed and commented on by the AoMRC patient advisory group and the AoMRC Council. The process by which the guidelines were written was a Delphi process. A systematic review of the literature was not undertaken for the writing of the AoMRC guidelines.
In preparing this article for The BMJ we incorporated feedback received following the publication of the AoMRC guidance. We also conducted PubMed literature searches using a variety of search terms such as “writing,” “outpatients,” “letter” and “correspondence,” and scanned more than 2000 search results. We found more general relevant material about writing to patients irrespective of setting, including educational tools for teachers of medical students. We also found useful material relating to outpatient care in Australia, the Republic of Ireland, and the US.
Contributorship statement and guarantor: HR wrote the first draft of the manuscript. He has written all his outpatient letters directly to patients since 2005.
MH, IL, NM, PR, RS critically revised the manuscript for important intellectual content. All authors commented on and revised subsequent drafts and approved the final version of the manuscript.
Competing interests We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Transparency HR is guarantor for the manuscript and affirms that the manuscript is an honest, accurate, and transparent account of the material being reported, and that no important aspects of the subject have been omitted.
Provenance and peer review Commissioned; externally peer reviewed.