Clinic Letter Training & Current Practice

A Regional Study in the light of Department of Health guidance

Dr. Gita ModgilDr. Anna Baverstock

SpR Study Day Jan 2008

“ There are four ways, and only four ways, in which we have

contact with the world.

We are evaluated and classified by these four

contacts:

what we do, how we look, what we say and how we say it.”

Communication

Dale Carnegie 1888 - 1955

Clinic Letters

• Fundamental process of referral

• Convey information from Dr to Dr

• Valuable reference source

• Evidence of informed consent process

• Medico legal record

Department of Health

• Improve communication• Patient participation in care

• Good practice guidelines 2003• Copies of clinic letter

• From April 2004

• Department of Health, Policy & Guidance April 2003 Copying Letters to Patients: Good Practice Guidelines

What do families want?

• Department of Health pilot projects

• Parents & young people want copies

• Satisfaction improved• Empowers patient/parent

Bartle DG, Diskin L & Finlay F. Copies of letters to the family. Arch Dis Child 2004;89:1032-33Clarkson JE, Merrick PL. Paediatricians’ reports to general practitioners: should parents receive copies? J Paediatr Child Health 1993 Dec;29(6):451-4

Views of doctors?

• Apprehension

• Concerns– Confidentiality & consent– Child protection/fabricated illness– Life limiting conditions– Generate complaints/further work

Doctor to doctor

• Views of GPs & consultants – re content & standards

• Variation in desirable content & thoroughness of communication

• Communication is complex

Campbell B, Vanslembroek K et al. Views of doctors on clinical correspondence: questionnaire Survey and audit of content of letters. BMJ 2004;328:1060-61

Professional bodies

• General Medical Council– Good communication– Clinical Governance

• NSF Part 1– Information & Consent– Copy letters to parents

• MPS/MDU

• Framework of competences

Copying letters has arrived

• Expectation to copy letters

• Do we know what we are doing?

• Are we adequately trained?

• Do we know where to seek guidance?

Our study

• To determine current practice & training amongst Paediatric SpRs with regard to clinic letter writing

• Structured questionnaire

• All south-west core trainees

Results - Training

• 97% response rate (31/32)

• 3% SpRs - formal training• 42% SpRs – informal training• 16% had used SAIL assessment tool

• 90% would welcome training• Crossley JGM et al Sheffield Assessment Instrument for

Letters (SAIL) performance assessment using outpatient letters Medical Education 2001;35(12);1115

Results - Feedback

0

10

20

30

40

50

60Consu

ltants

Secre

tari

es

Pare

nts

SpRs

GPs

• 32% no feedback at all

• 55% - consultants– Structure

• 42% - secretaries– Structure & Style

• 16% - parents– Content

• Mostly informal

• 86% found it helpful

Results – Letter Style

• 71% - free text & problem list• 52%- paragraph headings

• RCT of effects of structuring letters

• Previous filed clinic letter influential

Melville C, Hands S & Jones P. Randomised trial of the effects of structuring clinic correspondence. Arch Dis Child 2002:86:374-5

Results – DoH guidance

• 58% SpRs aware of guidance– 30% not copying – why?

• 17% had received trust information

• Confusion around principles:– When not to copy letters?– Copying to young children?– Consent & confidentiality?– Third parties?

Results – Copying letters

• Only 52% currently copy letters

• 39% routinely ask parents• 6% document consent to copy

• writing separate letters 26% • using explanation paragraphs 13%

Results - Beliefs

• 90% SpRs believe copying letters will– enhance communication, – increase patient trust & concordance

• Only few believe it will lead to – increased confusion & financial costs– further workload to Drs & secretaries

Conclusions

• No formal training in written communication– When not to send copies?

• Half SpRs currently copying letters

• 90% agree with benefits of copying

• Current training gap

How can we improve?

• Awareness & understanding of DoH guidance essential

• Training in core years important

• Formal feedback to trainees

“ I wish people who have trouble communicating

would just shut up.”Tom Lehrer