Abstract
I was doing a case-based discussion (CbD) with a third year GP trainee in my general practice surgery and part of the discussion was around a letter that he had written to a respiratory consultant for advice about a patient. I was struck that he had written quite a long letter that contained most of the clinical information, but was not very clear in terms of what was being asked of the consultant.
Here is a summary of the main learning points from the discussion:
Make sure the referral is to the right person Keep the letter concise Explain clearly at the start of the letter what question(s) you want asking and why or what action you are asking for Do not be afraid to share your clinical dilemma and possible ignorance in the letter Outline the patient’s ideas, concerns and expectations, especially of the referral Dictate the letter as close as possible to the consultation – at times this can be done with the patient present Ask colleagues if you can view their referrals Ask them to critique your referrals Ask the practice secretary for his/her opinion about your letters and those of your colleagues Think about what you like and do not like in a letter or email that you receive Avoid abbreviations
There is a lack of availability of clear guidance for referral writing, and at undergraduate and postgraduate level there is little formal training about this. Templates may help, but they can also hinder the effective use of referrals.
Make sure the referral is to the right person
Check that the referral is made to the appropriate specialist and/or individual to make it as efficient as possible and avoid delays for the referrer and the patient. You may wish to check with a colleague about this and the practice secretary can be invaluable in this process as well. This will also help reduce workload for practice staff and yourself, as incorrect referrals can take up a lot of administration time and effort.
Keep the letter concise
Sometimes less is more and communication can be aided by making correspondence professional and to the point. Ensure that appropriate relevant information is included in the letter including current medication and social history.
Explain clearly what question(s) you want answering
It is helpful for the person receiving the referral, and also good practice for the sender, to ensure that clear questions or requests are made and that clear logical clinical thought processes are followed. It can be as straightforward as stating what you and/or the patient want from the referral. Stating this at the start of the referral will aid the receiver to better understand the rest of the information sent.
Do not be afraid to share your clinical dilemma
Medicine is an art as well as a science and things are often not clear cut. Should you be unsure as to some aspects of the presentation it is perfectly acceptable to say so, but an explanation of your thinking can be helpful.
Outline the patient’s agenda
Remember to specify both your’s and the patient’s agenda so that the receiver knows what it is they need to address. It is helpful to clearly state the patient’s ideas, concerns and expectations of the referral.
Arrange the referral as soon as possible
Dictate or write the letter as close as possible to the consultation. At times this can be done with the patient present. It is good practice to make referrals in a timely manner. There will be occasions when you wish to discuss things with a colleague to ensure that you are doing the right thing for the patient. Try to avoid any unnecessary delays in referral. Patients appreciate being kept informed as to the progress of any referral. A good way to ensure good communication may be to dictate the referral letter with the patient present to ensure that you are conveying an accurate clinical picture.
Learn from others
Ask colleagues if you can view their letters and ask them to critique your referrals. Look at how your colleagues approach making a referral and see if there are any lessons you can learn. If your practice secretary types your letters her or she can give you feedback about the quality of the letters and even about your dictation style.
Think about what you like and do not like in a letter that you receive. Look at clinical letters that you have received and consider how you could improve upon their quality and/or learn from them.
Avoid abbreviations.
An area for errors in clinical practice is poor communication. Abbreviations can be a potential problem especially if their meaning is ambiguous at best or indecipherable at worst. Think about the person reading the referral, will that person understand any shorthand that is used?
Patient involvement and discussion
This approach to referral writing, in which patients are involved in the process of referral writing, was discussed with the practice patient participation group and individual patients. Patients thought being present at the time of referral helps patients regarding transparency about the details of the referral and additionally:
The timely writing of referrals is helpful for patients as the patient can see that the referral has actually been done if it is dictated in their presence Patients can input directly into the letter by adding additional information or correcting any areas of clinical information if necessary Patients can also add to the details regarding their agenda for the referral Transparency regarding the clinician’s agenda and thought processes in the referral can be a very powerful and useful aid to the doctor–patient relationship Some patients expressed surprise that a standard template was not used for all referrals. This is interesting as on most if not all standard template referral formats there is no area for explaining the agenda of the referring clinician or the patient, but the agenda is important to patients.