I don’t write many letters these days.
Emails, I compose at an incredible rate, but pen to paper, no.
In correspondence with other doctors and patients I word-process although more often I use email. Short and to the point.
In a recent document shared at work, my eyes were opened.
All this is interesting as beforehand I had some inverse learning.
Not sure if that is the best term, it was something one of my trainees demonstrated to me, in other words I learned from someone I am training.
There is nothing wrong with this and day to day existence is composed of the adoption of information and knowledge from many sources.
On this occasion, I had been reviewing a letter the doctor had written.
It was a letter to the patient.
The patient’s doctor had been copied-in.
Within healthcare the most common mode of conveying information about patients is from doctor to doctor.
Those of you who have ever had a hospital appointment will be familiar with the sequence of events. Your GP writes something about you to the hospital doctor, the hospital doctor sees you in clinic (often calls you on the phone for an assessment) and writes a letter back to the GP with their conclusions, diagnosis and/or management plan.
Here is a short example:
///
Dear Dr Hyde,
Thank you for asking me to see Jemima P in my clinic. As described in your letter, she presents with episodic anomalous carotid dysfunction.
I could not find a cause for this although she reports drinking 30 units of alcohol a day and she smokes.
I have explained that her condition is incurable, and she will likely die in the next five years if she does not change her ways.
I have discharged her from clinic.
Yours sincerely,
Dr Jekyll
Honorary Professor of Carotid Dysfunction,
Department of Cardiology
Babylon University.
Babel.
///
No, this is not real, there is no such disorder and Jemima doesn’t exist, however this type of letter is commonplace.
Doctors frequently write as if they are living in the 1950’s. It is doctor as expert, patient as object. If they are lucky the letter will be copied to the patient, if not, the patient, Jemima, will have to wait for her GP to contact her to discuss the cigarettes and alcohol, or she might need ring the surgery to speak with reception to be told, ‘No, we haven’t received a letter yet.’
A inefficient and ineffective way to help people, to, ‘make people better’ as has always been my aspiration (if possible!).
I won’t critique the letter, suffice it to say, it contains jargon, it is talking about Jemima as if she is not a real person, it is cold, indifferent, and paternalistic. All things we have learned over the years are ineffective in… making people better.
Doing to a patient cf. doing with.
My trainee’s letter was something like this:
///
Dear Hieronymus,
It was a pleasure to meet you and your wife at home today.
We discussed some of your recent concerns and you described the way in which you become dizzy whenever you change your position from sitting to standing.
I measured your blood pressure and found that this drops from 145/70 when you are lying in bed to 80/40 when you are standing. When this happens the amount of blood reaching your brain is inadequate and you become dizzy. On one occasion you mentioned collapsing in the kitchen*.
Normally your blood pressure should rise a little when you move from sitting to standing, with you the opposite happens…
… Yours sincerely,
Dr Amanda Snippet
CC Dr Jordan River, The Practice, Rift Valley, Tinseltown.
///
Do you spot the difference?
This letter, which is in no way the letter my trainee wrote, but in a similar vein treats the patient as a person, an individual; she clarified when meeting him that he was OK to be called Hieronymus and not Mr Bosch, she conveyed the story (history) back to the patient, providing them with information that they can check or clarify for inaccuracies, ‘I didn’t pass-out in the kitchen, it was the living room’ for example. In this instance a trivial difference, in others, more significant. (We plan to amputate the right hand).
When doctors write letters they usually proof-read for accuracy and content. No one will proofread a letter better than a patient; they will find errors of fact that another might miss – the conversation is about them and their body after all.
And the letter also contains an explanation to the patient about their condition (and what will be done, etc) – this saves the patient ringing the GP and waiting, the letter is copied to the patient’s GP with specific instructions to, ‘Please continue the medicine I have started,’ for example.
This is person-centred care.
I have been banging the drum for over a decade. (Before that I didn’t have a name for what I was doing/promoting).
Taking the patient and regarding them as intelligent, autonomous entities, part of their medical condition, empowers, it involves them, stops them being a bystander to an active participant, it respects their insight and intelligence, it places the GP a little on the back-foot, it makes the letter writing more difficult as it is a significant change of the way of doing things.
And, why not?
Healthcare sort of works for most people most of the time.
When it goes wrong it can be a disaster.
This is a step towards inclusion.
Reading my trainee’s letter I was curious, ‘Writing to a patient, how odd!’ I thought.
Shortly after I received the document which you can find here.
It presents the argument for changing the way we communicate and correspond with patients.
It calls for better informed patients, a shift of the power-balance, away from ‘papa-says.’ It is an undoing of paternalism towards equality and inclusion.
Our patients are asking to be informed, it is our job not just to investigate, diagnose and treat but to engage and explain.
Today, how many doctors and other clinicians are writing letters to their patients and copying the GP?
The numbers are small.
We need to grow the movement.
Shift the balance.
Hasta la Victoria!
Many, many clinicians I know already practice person-centred medicine, this is not a criticism of them. The others (who likely don’t read this blog) know who they are. Beware! Change is coming.
*For more on this medical condition – postural hypotension, see here.
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