Improving doctors' letters

Patient care hinges in part on adequate and timely information exchange between treating doctors. Referral and reply letters are common means by which doctors exchange information pertinent to patient care. Ensuring that letters meet the needs of letter recipients saves time for clinicians and patients, reduces unnecessary repetition of diagnostic investigations, and helps to avoid patient dissatisfaction and loss of confidence in medical practitioners. Much clinician time is spent writing or dictating letters to other doctors, but the extent to which these letters contain the information needed by letter recipients is uncertain. Pringle1 described the referral letter as "the most underexploited method to influence consultant attitudes" and the reply letter "the most neglected route of GP education". Few studies have investigated the information content of doctors' letters, and/or the information preferences of doctors receiving letters.

Theodore Dalrymple, in his Spectator column "If symptoms persist", reported a letter interchange between a general practitioner and an emergency department as follows:

While this exchange may not be typical, it highlights the opportunity for enhancing doctors' diagnostic and letter-writing skills.

Discharge letters after hospital admission have been reported to be deficient in several content areas and in their timeliness and legibility.2,3,4,5 It has been observed that letters from specialists to referring doctors are commonly written as much for the dictating doctor's records as for the benefit of the letter recipient's.6 In some institutions, a typed letter to the referring doctor is the only hard-copy record of the consultation. This duality of purpose compromises optimal communication between specialists and referring doctors.

Studies of referral letters have consistently reported that specialists are dissatisfied with their quality and content. The concerns most often expressed are the frequent absence of an explanation for referral, medical history, clinical findings, test results and details of prior treatment. A summary of studies that have carried out information audits of referral letters or investigated specialists' information preferences is presented in Box 1.

One of these studies investigated the quality of referral letters in the cancer care setting, which is our particular area of interest. A limited audit was made of 103 consecutive new patients seen by one radiation oncologist in Sydney.9 Of the 80 referral letters available, 95% reported the diagnosis, but only 56% provided a history of the current illness. Less than half the letters described the clinical findings or included information on medical history, social history, current medications or allergies. The author concluded that relevant and important information was not communicated in referral letters.

Several authors have reported the use of form letters to enhance information content and communication in referrals from GPs to hospital and medical specialists.11,12,13,14,15 Form letters are generally shorter but contain more information than non-form letters.13 Couper and Henbest reported an improvement in the quality of referral letters after the introduction of a form letter, but the quality of reply letters did not improve.14 Dupont reviewed the information content of 600 referral letters to a dermatology outpatient clinic and proposed that a preferred form letter should be sent to GPs by the hospital department with the kind of information required.15

A summary of reports of the information content of specialists' letters to referring doctors is shown in Box 2. Attempts to improve the quality of correspondence from medical specialists to referring doctors have included the promotion of problem lists in letters11 and the use of a structured letter containing both a problem list and a list of management proposals.12 In a study of letters relating to patients attending an open-access chest-pain clinic, GPs preferred structured, computer-generated letters to unstructured, dictated letters.17 Computer-generated discharge documents for patients after surgical admissions are also preferred by GPs.18

There have been few studies of specialists' letters in the cancer care setting. Bado and Williams5 noted that GPs preferred letters from hospital specialists to include technical topics (eg, diagnosis, results of investigation, treatment details) more than social topics. More than 80% of GPs wanted information on prognosis and what the patient had been told, yet less than 20% of letters contained this information. Tattersall et al16 identified eight items rated as essential information by a majority of letter recipients: diagnosis, clinical findings, test results, further tests, treatment options and recommendations, prognosis, likely benefits of treatment, and possible side effects. On the other hand, fewer than half of doctors receiving letters regarded details of medical history, drug or social history as essential, yet many letters contained these details.

McConnell et al19 reported a staged investigation of letters from oncologists to referring doctors. In semi-structured interviews with seven oncologists, 10 surgeons and 11 GPs, they sought views on what information was needed in reply letters after an oncologist consultation. They identified 32 discrete categories of preferred information and compiled a list of common problems encountered in doctor-to-doctor communication. Based on these data, the investigators developed questionnaires for referring specialists and GPs and conducted a survey of a large group of referring GPs and specialists. Factor analysis of the resulting data resolved the 32 items into five categories of information: history/background, psychosocial concerns, examination and investigation findings, future management/expected outcomes, and treatment/management plan. Letters gathered from a large group of oncologists were then studied for their information content and compared with the preferences of the referring doctors. Letters commonly contained details on results of examination and investigations (items most often wanted by surgeons) but "rarely mentioned" details desired by referring doctors concerning the treatment plan, future management/expected outcomes, and any psychosocial concerns. A content template for letters from oncologists was proposed.

We used the results of McConnell et al19 to develop a training course for oncologists in communicating with referring doctors after a new patient consultation. We also sought the views of the Royal Australian College of General Practitioners concerning the preferred content and format of letters from medical specialists, and prepared a letter prompt sheet (Box 3) that was presented during the training program. For a summary of our program and results, see Box 4.

Our study demonstrates that attending a letter-writing training course significantly improved the content of oncologists' letters after subsequent new patient consultations and increased the satisfaction of letter recipients in several areas.

Several years ago, Prasher21 suggested that the specialist medical Colleges explore the possibility of developing a standard letter for all specialists replying to GPs. The Royal Australasian College of Physicians recently encouraged contributions to its newsletter, Fellowship Affairs, concerning medical record keeping and the format of correspondence, but no template has been recommended.22 Specialist medical societies, the Colleges and/or hospital departments could usefully provide guidance to referring doctors on the preferred information and format of referral letters.

There are clear advantages of having a structured format for referral and reply letters, including the use of headings to allow the reader to easily identify the information desired.

Conducting a letter-writing training program is an expensive intervention. It is yet to be established whether use of a letter content and format prompt card with no accompanying training will promote improved written communication between doctors.