How letters can spell a better level of treatment

MEDICAL MATTERS: Have you ever wondered what a doctor writes about you, the patient? Look at any chart or electronic record and it will probably contain several letters: a referral from your GP to a consultant; his reply; or even a discharge summary following your stay in hospital.

And it is not just letters either. Every time you are seen in a GP's surgery or hospital out-patients department your story, as interpreted by the doctor, is written down. When you are an in-patient, notes about your progress are written up several times a day by different doctors and nurses.

Since the introduction of the Data Protection Act, patients are entitled to see their electronic records. The Freedom of Information Act gives a formal mechanism whereby public sector patients can see their clinical notes, including letters.

It's fair to say that this has encouraged doctors to be more careful about what they write. Judgmental terms - previously added unthinkingly - no longer appear.

During my training, I occasionally came across terms, such as "little old lady" (sometimes abbreviated to "LOL") in the notes. Often they were adverbs or adjectives that made one wince.

Terms such as "overly dependent", "dysfunctional" or "unkempt", while representing honest medical opinion, are not terms anyone would relish when used about them or their families.

In fairness, you were as likely to see "this pleasant 71-year old" or "this stoic gentleman" as you were to see terms which could be negatively construed.

In any event, they are no more, although the practice of using abbreviations has increased in medicine. But that is for another column.

What led me to write about the topic were some observations in the medical journals over the past year in which doctors have espoused sending copies of letters to patients as a matter of routine. The inquiry report into the Bristol Royal Infirmary heart surgery scandal recommended that copying medical correspondence to patients become routine medical practice.

The advantages are obvious: a patient can read and reread a letter away from the distraction and anxiety of the hospital. Letters can aid understanding, provide information and empower patients. They can even improve adherence to the treatment prescribed.

Most importantly, they give the patient an insight into the level of understanding of the problem by their doctor. And should there be any major misunderstanding, it is a chance for the patient to contact the doctor and remedy the situation.

There are potential problems with just copying what is essentially a doctor-to-doctor letter. Technical terms might frighten or confuse a patient. They could be misinterpreted, thus adding to, rather than avoiding, confusion.

What about copying letters to young teenagers, people with mental illness or those with dementia or learning difficulties? Despite the problems, should they not be treated the same as everyone else?

A separately worded letter to patients is another option. Although time-consuming for the doctor, it would be ideal for the patient. Medical terms could be explained, advice and treatment expanded upon and follow-up arrangements clarified.

But what about the next step? Why shouldn't patients write to doctors? After all, the patient is the centre of healthcare and should have an opportunity to contribute to the exchange of information.

The system might work like this. The GP writes a referral letter to the hospital consultant and gives a copy to the patient. After the outpatient appointment, the specialist writes to the GP and the patient. The patient then replies to the consultant about his experience of the illness and its management, with a copy of the letter going to the GP. The consultant will then respond to some of the points in the patient's letter.

Apart from improving communication between doctors and patients, such a system could reduce the number of follow-up appointments in hospitals, many of which ensure that a patient is tolerating treatment and to check for problems. A feedback letter might also be appropriate after a period as an in-patient.

A system of triangular communication would not suit every patient and all clinical situations. Indeed, if it were carried out on a large scale the cost and time implications would be considerable. But even on a small scale, it offers the potential to empower patients and improve the level of care.

For anyone interested in the idea, I suggest you discuss it with your GP and consultant first.

A template for a feedback letter from a patient might include the following: your name, address and date of attendance or operation; a paragraph of appreciation, mentioning specific positive aspects of your experience as a patient; a paragraph about some things that might be improved; a positive ending and an invitation to reply.

•E-mail Dr Muiris Houston, Medical Correspondent, at mhouston@irish-times.ie or leave a message at 01-6707711 ext 8511. He regrets he cannot reply to individual medical problems.