Professional Documents
Culture Documents
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86 Practical Neurology
I have for some other professionals involved in the patient’s other clinics they are attending, and copy my
care, and often the patient too. Second, to correspondence to those clinics.
time copied most provide me with an essential summary of The evolution of electronic patient manage-
of my letters to what I thought at the time on the next occa- ment systems is improving communication but
sion I see the patient. Without my letters, I am few of us have the time in busy clinics to scroll
patients lost in the follow-up clinic, and spend valuable through pages of computer script searching
time going over old ground, rather than catch- for any other medical interactions that might
ing up with new information—this explains my have taken place since we last saw the patient.
frequent rage at lost medical records although The golden rule is to be over inclusive in to
the evolution of electronic storage has helped. whom you copy your letters—after all, the
Some suggest that clinical letters may also recipients need only (confidentially) bin them
serve as educational tools for patients and if they are not interested.
GPs—I am wary of this, as so often I am strug- Should you include the patient in your cor-
gling to educate myself, let alone someone respondence? In England and Wales, it is a
else. But if a letter is clear and precise, then legal requirement, albeit one that seems to be
any educational lessons should shine through. routinely ignored. While not a legal require-
Finally, a typed clinical letter also represents ment in Scotland, I have for some time copied
an important medicolegal document, and most of my letters to patients. There are some
hopefully might survive long after the hospi- difficult areas; the patient with symptoms sug-
tal notes have been destroyed, or your illegible gestive of early Parkinson’s disease or motor
scrawls have long since faded with time. neuron disease who you decide to watch, but
without sufficient certainty to make a diagno-
TO WHOM SHOULD YOU WRITE? sis for example. I used to think that copying
Simply, anyone that is relevant. Most impor- letters to patients suffering from functional
tantly, a hospital doctor should write to the symptoms was difficult but now realise that
person who referred the patient, most com- this is the perfect situation to include them
monly the GP. This might seem obvious but it in correspondence (even if they do continue
is a sad fact that some doctors omit the refer- to insist no one has taken their case seri-
ring doctor. In my experience this most often ously or explained to them the diagnosis!).
occurs when I refer a patient to a specialist Copying letters to patients certainly concen-
clinic. Here I do wish to be educated, and I trates one’s mind about what should, and
am interested to hear how the patient with should not, be included in a letter.1 There may
a brain tumour gets on in the long term, not be specific issues in areas such as psychiatry2
just after the first visit. If you run a specialist but increased openness between doctors and
clinic, remember to include the referrer, each patients can in general only be a good thing.
time you see the patient. I am equally aston- Do patients want to see their letters? This
ished to review patients who have suffered is simply too broad a question to be answered
complications of their neurological disease with a simple yes or no. Some do, a few do
which no one has thought I might be inter- not, and many are quite indifferent. It is clear
ested in. Orthopaedic surgeons pinning hips to me that many patients do not read the let-
of Parkinson’s disease patients are common ters I send them and often forget that I have
culprits here, and one memorable epilepsy sent copies to them. I have had very few com-
patient was surprised to discover that no one plaints, occasional corrections of fact (usually,
had told me of his near drowning experience, but not always, trivial) and many more posi-
and subsequent 3 months in an intensive care tive comments about copying letters. In my
unit, after falling into a canal after a seizure. own limited personal interactions with health
And all this had occurred in my own hospital services, including spinal surgery, I have never
(each department has its own medical records been copied into correspondence, but I should
rather than one universal set, which means it like to have been. For patients in whom you
is impossible to know without the patient tell- are proposing potentially complex changes to
ing you, and not unreasonably, many patients their treatment (eg, epilepsy or Parkinson’s),
assume that someone would have told us). I copying them in is only likely to enhance the
routinely ask patients at clinic visits which chances of the changes occurring correctly.
10.1136/jnnp.2011.242248
Davenport 87
Some doctors address their clinic letters system cannot cope with even simple format-
primarily to patients, copying in the GP and ting such as underlining, and a weird gremlin
other professionals.3 I have not adopted this turns quotation marks into open boxes. Nor
approach. In the UK, the system we operate did the system include a spell checker until
is that GPs refer to consultants for a con- very recently.
sultation, and thus it seems appropriate that
the results of our consultation are addressed Structure
back to the referrer, although I think it right to Most clinical letters I have to read have no
include patients in the distribution. Proponents structure of any kind. Many are so short that
of addressing clinical letters to patients note structure is almost superfluous (ear, nose and
that it discourages medical jargon which is throat doctors, this means you). Others are
in some ways laudable, but also can poten- a prolonged stream of consciousness which
tially lead to rather ‘dumbed down’ letters. rambles on interminably before suddenly halt-
Medicine is technical at times, and while in ing at a seemingly random point (neurologists
favour of plain English, I would prefer to see can be guilty here). Neither version makes for
‘left L4/5 microdiscectomy’ listed in my let- an engaging or informative read. At the other
ter rather than ‘slipped disc operation’. Other extreme however, some letters contain simply
professions use their own technical language too many headings derived from a template,
in communication with clients, as anyone who making it very difficult to build up a coherent
has had interaction with lawyers or architects picture. The figure provides the simple three
will know, and it’s educational to find out what layer structure that I use (history, examination,
‘soffit’ or ‘inter alia’ actually mean. opinion). This might be customised for some
specialties (ie, surgical letters might include
WHAT SHOULD A CLINICAL operative procedures which are as important to
LETTER CONTAIN? surgeons as drugs are to us). My structure also
Letterhead provides an easy audit tool—if your examina-
The letterhead needs to be simple, uncluttered tion section is routinely longer than your his-
and contain the details of who you are, where tory section (surgeons take note), something
you have seen the patient (especially vital if is amiss. If your opinion section is routinely a
you work in more than one hospital) and how sentence (or less), or simply a précis of what
to contact you, including postal address, tele- you have already written, then reconsider.
phone and fax number (usually secretary) and
ideally email address. Including the names Diagnostic summary list
of the other 24 neurologists who work (to a I started to do this after working for a con-
greater or lesser extent) in your centre, along sultant who used this system; it seemed so
with their areas of expertise, qualifications and utterly obvious that I could not understand
secretaries, together with a colourful hospital why so few others used it. I still do not, and
logo is of no interest whatsoever to the reader, even within my own department, I am in a
and simply takes up space, but this practice is minority, although heartened to note that
remarkably common. The figure indicates my many of my younger colleagues have seen
own letterhead. the light. GPs will appreciate it (they are even
Computer generated letter templates asso- busier than you, and receive numerous letters
ciated with electronic patient management everyday, and do not have time to read every
systems are becoming increasingly common. word). It also makes life much easier when you
My own experience of these is poor. In my review the patient several months later. But
area, they produce almost identical looking the most important aspect is that it forces
letters from any of three hospitals, which you to commit to paper what you actually The diagnostic
means GPs frequently address queries to the think (see below). The diagnostic list is some- list is sometimes
wrong hospital. Almost half a page is taken times the most difficult aspect of the entire
up with demographic details and we are for- letter writing process, and it must be kept up
the most difficult
bidden (and technically unable) to customise to date on subsequent visits. If you take only aspect of the entire
them (which surely should be an advantage of one piece of advice from this article, let it be
such a system), so my colleagues’ names clut- this one, and I shall be satisfied. If you use it,
letter writing
ter up the right hand margin. Remarkably, the then the first item on the list should be the process
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88 Practical Neurology
Telephone: 0131 *** **** Fax: 0131 *** **** E-mail: rjd@skull.dcn.ed.ac.uk
Dear Doctor
Joe Bloggs (22.09.60). Alcorefuge, 13 Perfect Lane, PERFECT, PL98 1ZZ
History:
I met this 49 year old left handed unemployed man in my first seizure clinic at the Southern Infirmary today, following his referral from the emergency department
on 19.01.2010. He attended alone, and is single, with no children, and lives in a hostel for homeless people. He provided little history, and has little recollection of
the events of 30.10.09. I spoke to the manager of his refuge, who witnessed the episode. JB had just got up, and was sitting in the kitchen, when without warning
he made an “animal scream”, stiffened, and proceeded to convulse. The manager laid him on the floor, and estimated he was convulsing for about 4 minutes.
Afterwards, his breathing was heavy and snoring, and he did not waken until the paramedics arrived, at which point he became aggressive, and did not recognise
familiar faces.
This has probably never happened before, although his mother told him recently that he had some sort of seizure as a small child, perhaps a febrile convulsion, but
he was never put on medication. He has chronic alcoholism, and has failed rehabilitation a number of times previously. On this occasion, he had not had a drink for
about 48 hours.
His part history is uncertain. He has recently been referred to a psychiatrist (Dr Smith) for further assessment of his alcoholism and depression, and has taken
velafaxine for at least 2 years, and the dose has not been changed recently. He smokes “as many as I can”, and drinks “as much as I can”. He does not hold a driving
licence.
Examination:
His pulse was regular, and there were no neurological or hepatic dysfunction signs. Cognitive assessment not performed.
Opinion:
The story is consistent with a generalised seizure, and alcohol withdrawal is the most likely cause. His blood tests in the ED were normal except for a neutrophilia
of 15, and gamma GT of 478. His ECG was normal. I have organised an MR brain (his manager will ensure he attends for this). The key issue here is his alcoholism. I
would recommend oral thiamine and Vitamin B supplements, but no other treatment is required presently, and will leave the management of his alcohol to yourself
and Dr Smith. I will write with the scan result, but otherwise have not organised follow up. Please let me know if there are further problems.
Richard Davenport
Consultant Neurologist
10.1136/jnnp.2011.242248
Davenport 89
10.1136/jnnp.2011.242248