Writing letters to patients attending psychiatry clinicsBMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2857 (Published 04 December 2023) Cite this as: BMJ 2023;383:p2857
- Dave Martin, speciality trainee in General Adult Psychiatry, honorary research fellow12,
- Katharine Weetman, assistant professor in Clinical Communication, honorary research fellow34
Since around 2000, there has been a shift in UK medical and surgical culture and guidelines towards including patients in written correspondence about their care.1 UK guidelines and standards234 state that all clinical letters between physicians should be copied to the patient they concern, apart from exceptional circumstances such as the potential for patient harm or third party data breach.23 More recently, there has been a movement towards writing to patients directly5 and copying in the relevant physician, for example their GP. The aim is to avoid the detachment and patronage of third person letters sent to patients.567 Writing to patients can raise concerns regarding patient’s anxiety and understanding of letters, although evidence suggests that such views are largely unfounded.78 Evidence indicates that patients value receiving their letters and find them useful.91011 Furthermore, GPs find letters written to patients are more comprehensible and patient centred51213 and that the time spent explaining letters to patients is reduced by writing to patients in the first place.5
However, despite supporting evidence 14, 15 and guidelines,16our experience in psychiatry is that the practice of sharing letters with patients has not been taken up as readily as other specialties of medicine. Although there is limited evidence on the prevalence of patients receiving psychiatric clinic letters, it is, in our experience, very low. Sending copies of clinical letters to patients requires thought, particularly around the use of terminology, content, and tone.14 It is also not uncommon for a psychiatrist to hold a different view to the patient on the source of a problem. This may be viewed as a barrier, but it should not be a deterrent. Research shows that psychiatric patients, as much or more than other specialties,15 want copies of the letters written about them.17
The approach of one of the authors (DM), has been to write letters directly to patients, and copy in the patient’s GP. Such letters take the form of having a statement at the top of the letter to highlight pertinent information or requests for the GP to ensure important items are not missed. The letter is then carefully constructed so that it mirrors the content of the consultation, including: (1) the description of the problem(s) by patient in their own words; (2) the collaborative (or different perspectives) on the causes and effects; (3) any new realisations or ideas about how to address the problem(s); and (4) agreed or recommended next steps. Diagnoses are only included where already discussed, and either essential or agreed, with the patient. Following guidance, 5, 16 value judgements are avoided, and the preferences of the patient at the centre of the letter are considered before the inclusion of medical terminology. The response to this practice has been overwhelmingly positive with patients reporting that they have found the letters to be validating and useful. Some patients have recalled that they use the letter as a tool for hope and a reminder of feeling heard when experiencing suicidal ideation to help them navigate these thoughts. In terms of managing differences of opinion (e.g. source of auditory hallucination), both perspectives may be reflected in the letter, with clear differentiation between capturing the patient’s beliefs and representing the professional view; this does require sensitivity and balance, but it is possible to convey a clinical standpoint while not disregarding or diminishing a patient’s opinion or experience. In exceptional cases, writing a letter to a patient may not be in their best interests, such as if they are acutely distressed, or they may not want one. In such cases a confidential statement or letter could be sent to the GP only, but these situations are likely to be rare. Consideration of how a patient can access these withheld letters in the future is also important. Although some clinicians may be tempted to write two separate letters, to the GP and patient, this is often unnecessary and more time-consuming.
We believe that letters should be written to patients directly, and that the benefits of this outweigh the potential drawbacks. Some patients will prefer to receive letters that have been written to the GP, and of course this preference should be followed. We would encourage those who have not yet written to patients to try this and gather feedback on the effects. We would be interested to hear about these experiences. Although there is not one right way to draft a letter, in our experience, writing to patients may bring about benefits beyond the simple purpose of summarising a consultation.
Competing interests: none declared.
Provenance and peer review: not commissioned, not peer reviewed.