Why respecting a patient by writing to them, and not about them, is so important
At Picker, our mission is to promote person centred care. Positive therapeutic relationships between patients and care professionals are essential to this, and good, clear communication is an important part of building those relationships and providing high quality care.
Naturally, then, we welcome the Academy of Medical Royal Colleges’ publication of “Please, write to me”, a new document offering guidance on writing outpatient clinic letters to patients. Media reporting of the guidance has largely focussed on its recommendations to avoid medical jargon and use plain English, but the more fundamental recommendation is that doctors write to patients directly – rather than writing to their GP and sending the patient a copy.
Writing to patients, rather than merely copying them, is important because it prioritises communication between doctors and patients. It shows respect to patients and acknowledges the importance of their knowledge and understanding, which is vital if people are to take an active role and be involved in their own care and treatment. It is particularly encouraging that this guidance comes from the Academy of Medical Royal Colleges’: as BMJ Senior Editor Tessa Richards has commented, this represents medical professionals backing person centred communication.
The idea of sharing letters with patients is not new. The NHS Plan (2000) set out an aspiration that “Letters between clinicians about an individual patient’s care will be copied to the patient as of right”. The Department of Health issued guidance on this in 2003, encouraging doctors to consider patients when writing letters by avoiding jargon and plain English.
Between 2005 and 2013 these issues were tested in the NHS inpatient survey, which asked whether patients received copies of letters (2005-2013) and whether the letters were written in a way that they could understand (2009-2013). We found that the practice of copying letters increased, but with limited improvement in how understandable they were:
This is important because a badly written letter can be worse than no letter at all. Unclear or confusing letters can leave patients with new misconceptions or fears; at worst, these can influence people’s decisions or actions.
Writing understandable letters is not always easy. It is a skill, and like any skill it needs to be learned and practiced. Taking the time to learn and practice writing in plain English has wider benefits, though, as it appears to encourage a better overall approach to communicating with patients. In Germany, an excellent not-for-profit “Was hab’ ich?” (or “What do I have?”) offers a free ‘translation’ service where patients can submit their own medical reports and receive plain-English translations from volunteer junior doctors and medical students. A recent study by Bittner et al (2016) showed that medical students involved in this initiative were subsequently more effective in their communication skills in simulated consultations.
In some ways, talking about best practice in letter writing feels a little anachronistic – the NHS is aiming to be paperless by 2020, after all, so what future for letters to patients? The principle here transcends the medium: and the principle at stake is that communications should be prepared with the patient front-of-mind rather than as afterthought.
This should mean that information about care and treatment should be designed for patients first. Getting this right should mean that patients better understand their conditions and treatment, and should help improve clinical communication skills. Whether doctors of the future are writing letters, emails, or directly into shared records, the principle that this information is for patients should become the accepted norm and the assumed standard.