Letting patients see their referral letters may do more harm than good, argues Dr Sandra Winterton

I felt I had to respond to Dr PantingÍs article ïWhy patients should see clinical correspondence,Í Guidelines in Practice July 2003. While I agree with many of his comments, there are a number of points I would take issue with.

If we consider that a patient is at high risk of having a carcinoma, we have to mention this in the referral letter. Having a possible diagnosis of cancer hanging over you is stressful and could induce panic in many patients, which would continue until their hospital appointment and possibly beyond.

If the diagnosis is not cancer, patients will no doubt berate us for causing them unnecessary distress.

Even when you have told patients that there is a possibility of the diagnosis being cancer and explained why you are referring them, many are in denial because it is easier to deal with the situation that way. Having a copy of the GPÍs referral letter available to read may merely reinforce their anxieties.

Dr Panting suggests that any information omitted from the referral letter could be passed on by telephone. However, trying to contact hospital consultants or their secretaries can be very time consuming.

Dr Panting states that copying letters from specialists to GPs has been common in the private sector for some time. However, private specialists treat particular conditions and tend to see their patients infrequently, therefore they are less likely to build long-term relationships with them. I have known some of my patients for nearly 30 years and have an excellent relationship with them. I would hate this to be destroyed because of a comment in a referral letter.

It is often necessary to give background information to a consultant to ensure that the correct diagnosis or plan of action is made. This may include something the patient would not like to be reminded of, or may relate to relationships or problems with other members of their family.

I consider it essential to be completely honest in a referral letter and would hate to have to tell half-truths in case the whole truth might upset my patient. I have no intention of altering the way I write referral letters because the patient is to receive a copy. Whether it is always in the patientÍs best interest to read clinical correspondence is extremely doubtful.

Dr Sandra Winterton, GP,
Newcastle upon Tyne

Dr Gerard Panting replies:

Thank you for your comments. How individual doctors write their referral letters is a matter of personal style, and no doubt their knowledge of individual patients will influence exactly what they say in individual cases.

Having said that, there is no longer any place for paternalistic attitudes in medical practice. Only if disclosing information to a patient would be likely to cause serious harm to their mental or physical health could there be any legal justification for withholding that information from them. Worry does not come into that category and would certainly not be an excuse for keeping someone in the dark.

Patients whose doctors consider it necessary for them to be seen in the outpatient department within the two week limit for cancer referrals would doubtless realise that this is something that the doctor is taking seriously Æ with all the obvious implications. I doubt that a doctor being open with a patient is likely to cause any real harm.

While some patients will delight in berating their doctors for anything, I suspect that most will be grateful that the doctor acted promptly and I hope that no-one would seriously entertain grouses about efficiency and openness from the ungrateful few who do complain.

I frequently have to contact hospital consultants and know all about unanswered phones. The point here is that in those very few cases where there is a very sensitive message to convey, a phone call with the consultant concerned may be the most effective means of communication. This is not about being less than truthful but more likely about confidentiality and perhaps sensitivity.

If copying correspondence to patients becomes the norm, thought must inevitably be given to how the subject of that correspondence may react to it.

Dr Gerard Panting,
Communications and Policy Director,
Medical Protection Society

Guidelines in Practice, August 2003, Volume 6(8)
© 2003 MGP Ltd
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