1. Clinic Letter Training & Current Practice A Regional Study in the light of Department of Health guidance Dr. Gita Modgil Dr. Anna Baverstock SpR Study Day Jan 2008

2. 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

4. Clinic Letters Fundamental process of referral Convey information from Dr to Dr Valuable reference source Evidence of informed consent process Medico legal record

5. 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

6. 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;89:1032-33 Clarkson JE, Merrick PL. Paediatricians reports to general practitioners: should parents receive copies? J Paediatr Child Health 1993 Dec;29(6):451-4

7. Views of doctors? Apprehension Concerns –Confidentiality & consent –Child protection/fabricated illness –Life limiting conditions –Generate complaints/further work

8. 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

9. Professional bodies General Medical Council –Good communication –Clinical Governance NSF Part 1– Information & Consent –Copy letters to parents MPS/MDU Framework of competences

10. 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?

11. Our study To determine current practice & training amongst Paediatric SpRs with regard to clinic letter writing Structured questionnaire All south-west core trainees

12. 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

13. Results - Feedback 32% no feedback at all 55% - consultants –Structure 42% - secretaries –Structure & Style 16% - parents –Content Mostly informal 86% found it helpful

14. 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

15. 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?

16. 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%

17. 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

18. 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

19. How can we improve? Awareness & understanding of DoH guidance essential Training in core years important Formal feedback to trainees

20. I wish people who have trouble communicating would just shut up. Tom Lehrer