Doctor or physician writing diagnosis and giving a medical prescription to female Patient

    Dumbing down doctors’ letters is not putting patients first

    13 September 2018

    As a doctor who places great emphasis on warm and open relationships with patients, I felt self-conscious and uncomfortable this week. The Academy of Royal Colleges have released controversial new guidance asking that doctors write to other doctors in layman’s terms, as patients are sometimes confused by the copies of the letters they receive. If we must insist on using the terms we have spent many years learning, we should write a separate copy to the patient. Have eight years of practise jaded me? Is a progressive, patient-centred approach slowly becoming fossilised into a rock of the old white-coated patriarchy? Or, do many patients not want to be patronised?

    This week’s advice coincided, almost to the day, with an NHS clinical commissioning group (CCG) in Leicestershire being forced to apologise for a user-friendly document in which they referred to gynaecology as ‘related to the female parts of the body used to make babies’, in a hilariously twee attempt to avoid jargon. Tellingly, a local patients’ right group were less amused, calling it ‘reductive, patronising and insulting’.

    Clearly patient communication is an uncharted minefield requiring careful judgement. Some people bristle at oversimplification or over-sensitisation, others want us to avoid all jargon. A paramedic colleague tells me how he recently had a lengthy consultation with a patient who didn’t know what his penis was, and consequently he spent twenty, presumably uncomfortable, minutes, discussing the pain in ‘your cock’. More recently, a young woman gently rebuked me for talking about her low white blood cells, telling me to just call it neutropenia. Every patient really is different.

    Outpatient clinic and discharge letters to GPs are often the only reliable thread to accurately view a patient’s medical history. It keeps all of the patient’s specialists and caregivers in the picture, and can literally be a lifesaver in A&E at 3am when the patient is too unwell to tell you their background. Patients, quite rightly, are copied in to keep them involved with their own care. Doctors and patients do talk in person during consultations, and this is the time that doctors can, and do, explain to the individual their medical condition and the way forward.

    Nor is universal dumbing down necessarily safe. Doctors will explain to patients with both water in their lung spaces, and pockets of fluid gathering around their lungs, that they have ‘fluid on the chest’. It is essential a that GP or another specialist knows whether their patient has pulmonary oedema or a pleural effusion, two very different problems. A ‘collapsed lung’ can mean just that, or can mean a pneumothorax – at 3am we need that information unequivocally, technically, in black and white, so that we can look after our patient safely. Technical jargon is, unfortunately, a necessary evil.

    I understand patients’ pain – reading an oncology or haematology specialist’s letter for a patient can feel like you are decrypting complex enemy submarine codes, self-consciously running chemotherapy regimes through like a modern day enigma machine. This usually can’t be avoided – you will struggle to find an oncologist who isn’t a passionate champion for their patient, and who doesn’t explain everything in the plainest terms to them. But I accept they will bamboozle me with their unavoidable coded potions, and sometimes, heavens forbid, I’ll need to look them up online. Patients can feel reassured that discomfort with jargon and TLAs (sorry, three-letter acronyms) is not for them to suffer alone.

    This all said, while technical precision itself mustn’t be lost, the vast majority of clinicians would support any movement to crush the penning of flamboyantly self-satisfied letters, better suited to a hammed-up university Shakespeare production than to a record of patient care. These outdated relics are still in occasional production, and growl to any patient unfortunate enough to read them that this is for us, not for you. Our patients may need to consult a medical dictionary, but we should ensure they don’t need to dip into the Oxford English dictionary.

    Healthcare today has to be patient-centred. We welcome our patients asking us questions and challenging our explanations, in a way that did not happen twenty years ago. It promotes discussion, irons out misunderstanding, and clarifies their personal wishes. While riding an immensely positive wave of patient-centricity, this particular suggestion comes at a time when even the basics of care and communication are being squeezed for want of resources. Aside from dreadful staffing and funding cuts, GP and hospital clinics run perpetually late due, in part, to a reluctance to skimp on the time needed to explain, rather than just administer, treatment.

    Sure, it would be great to send the usual letter, as well as a ‘diet’ copy for the patient. But that’s another letter to dictate in clinic, or write in A&E, before seeing the next patient. I’m not sure those delays would be popular or considered particularly patient-centred. Our NHS secretarial colleagues aren’t exactly sat idle in offices, balancing biros on their noses these days, either.

    Personal communication with patients must be clear and tailored to the individual. Being an advocate for my patients means open discussion with them, but also means thorough, detailed technical discussion with other professionals who care for them. Let us do away, for all our sakes, with rambling, outdated correspondence. But while patients shouldn’t be blinded with science, most don’t want their care dumbed down to crayon-scribbled collages.

    Contributed by Dr Sam Goodhand