Trying to bridge the gap

MEDICAL MATTERS: "Illness is what the patient has on their way
to see the doctor and disease is what they
have on the way home" - Anon

Consultations in medicine are often referred to as being either patient-centred or doctor-centred. The ideal interaction is a judicious mix of both, where the patient is given enough time and space to tell his story before the doctor intervenes with some clarifying questions of his own.

But sometimes the biomedical model of disease dominates, with the doctor intervening early in the consultation with a series of closed questions concerning the duration and severity of symptoms.

These and other questions often invite a yes or no answer rather than allowing the patient to expand on his story and what he thinks might be the problem.

Longer consultation times may be needed to facilitate a patient-centred agenda. Consultations of 20 minutes and more have been shown to contain more dialogue initiated by patients with a chronic illness. But research has also shown that if a doctor allows a patient to proceed uninterrupted, the full story lasts, on average, just 28 seconds.

A powerful image of the ideal consultation and one that will help to integrate a scientific approach with the patient story is that of a bridge.

"Doctors travel back and forth across the bridge, taking the patient's story of illness to be informed by medicine's abstract knowledge and then to be interpreted and returned to the patient as a prescriptive diagnosis retold in the form of a case history," Dr A H James has said of the bridging concept.

Researchers in Cork and Limerick have just published a study in Clinical Medicine which shows the benefits of a novel way of strengthening this bridge between doctors and patients.

Dr Mary Cahill, a consultant haematologist at the Mid-Western Regional Hospital, Limerick, randomised 150 new patients referred to an outpatient clinic to either receive a personal letter from her summarising the consultation or a brief note thanking them for attending.

Working with Marie O'Reilly and Prof Ivan Perry of the Department of Epidemiology and Public Health at University College Cork, she then assessed patients for their recall of and satisfaction with the consultation.

Patients were assessed for recall at their second outpatient appointment about 10-12 weeks after the first visit by an independent observer.

Patient satisfaction was also assessed among those who had received personal letters. And the patients' doctors were asked for their attitude to the idea by means of a questionnaire.

Rather than receive a standard doctor-to- doctor letter after their patient attended the clinic, the referring doctor received a copy of the personal letter to the patient. These letters were modified in style and language to suit a non-medical reader. They included details of the problems discussed and the decisions made during the consultation. A diagnosis and arrangements for follow-up were also specified.

Although no statistically significant impact of sending letters directly to patients was found in terms of their recall of the consultation, there was a trend towards higher recall of key items.

But in terms of the bridging concept between doctor and patient, those who had received a personal letter expressed high satisfaction rates. Some 81 per cent found the summary letter to be either very useful or useful. And while 83 per cent of patients were very satisfied with the accuracy of information provided in the personal letter, 10 per cent identified inaccuracies.

Four patients reported the summary letter had upset them and a further two noted it had worried them. Yet all six of these patients said they were pleased to have received the letter.

These are important findings. If 10 per cent of letters contain inaccuracies, then sending a personal letter to the patient allows this to be corrected on the next visit.

And, if a minority of patients are upset or worried, again the letter will hopefully prompt a discussion about the patient's concerns.

These are vital bridging functions in the doctor-patient relationship and, in my view, are a key reason why the idea of doctors writing to patients should be promoted.

What did the referring doctors think? A substantial 92 per cent rated the personal letter as a very useful or useful method of doctor-patient communication.

Noting the 2000 NHS plan in Britain made a commitment to give patients the right to see copies of doctors' letters about them, the authors say: "Indeed, it may be argued that patients have a right to see relevant correspondence in a form accessible to them.

"We anticipate that written communication between clinicians and patients, including personal and generic material, will assume increasing importance over the next decade," the authors conclude.

Let's hope they are right and that time and resources are made available by the Health Service Executive to allow this to happen.

Dr Muiris Houston is pleased to hear from readers but regrets he cannot answer individual medical queries.