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Matt Morgan: Patients’ notes should be addressed to them

BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2740 (Published 15 July 2020) Cite this as: BMJ 2020;370:m2740

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  1. Matt Morgan, intensive care consultant
  1. University Hospital of Wales
  1. mmorgan{at}bmj.com

    Follow Matt on Twitter: @dr_mattmorgan

Working in intensive care, I’m spared the pain (or joy) of writing clinic letters. In fact, most of the writing I do in my work is communication between healthcare professionals rather than directly with patients or their families. However, as with so many other things, covid-19 has changed this.

Relatives have often been unable to visit even critically ill loved ones during the covid-19 pandemic. As a result, the memories of tough conversations that I normally carry around with me have morphed from the distressed faces of family members into the rubber keys on my office phone. This collection of numbers is the first and last thing I see when breaking bad news. Then I document these tough conversations in writing, often starting with something like: “Today I spoke with this patient’s wife and told her that sadly her husband was critically ill. I told her that he was so sick he might die.

A BMJ Opinion piece published in 2018 argued that clinic letters should be written “to” patients, not “about” them.1 I think that the same should be true of our medical notes. When we put patients at the centre of all that we do—be it shared decision making or best interest decisions, or even simply holding their hand when families cannot do so—it seems odd that the perpetual record of that care should exclude them.

Instead, we should perhaps flip the narrative—or, rather, return to what such communication should be all about. I went back and rewrote that entry in the patient’s notes. It now reads: “Hi Davide, today I spoke to your wife, and I could hear your young daughter babbling in the background. I explained that you were critically ill, and I was worried that you were so sick you might die.

Subtle changes in language can be powerful. Although these changes may mean little in a biomedical or legal setting, I suspect that they could have an impact on numerous areas of medicine where we would least expect it. For example, patient diaries in some acute care settings may be helpful for patients and their families to read after their crisis is over. Such a diary is effectively a biography, where an autobiography is not possible—so, who better to address it to than the main protagonist without a voice?

The biography above had a happy ending,2 or at least a new beginning. A few weeks later I was able to write this: “I spoke with your wife again today. I was so pleased to tell her that you were better, you were off the life support machine, and your daughter will soon have her daddy back.

Footnotes

  • Patient consent obtained.

  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I have no competing interests.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine, research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination.

References