The rhetoric of patient voice: reported talk with patients in referral and consultation letters.

Referral and consultation letters are written to enable the exchange of patient information and facilitate the trajectory of patients through the healthcare system. Yet, these letters, written about yet apart from patients, also sustain and constrain professional relationships and influence attitudes towards patients. We analysed 35 optometry referral letters and 35 corresponding ophthalmology consultation letters for reported 'patient voice' coded as 'experience' or 'agenda' and we interviewed 15 letter writers (eight optometry students, six optometrists, and one community ophthalmologist). There were 80 instances of reported 'patient voice' in 35 letters. The majority (68%) of the instances occurred in referral letters, likely due to differences in both 'letter function' and 'professional stance.' Reported 'patient voice' occurred predominantly as 'experience' (81%) rather than 'agenda' instances. Letters writers focused on their readers' needs, thus a biomedical voice dominated the letters and instances of reported 'patient voice' were recontextualized for the professional audience. While reporting 'patient voice' was not the norm in these letters, its inclusion appeared to accomplish specific work: to persuade reader action, to question patient credibility, and to highlight patient agency. These letter strategies reflect professional attitudes about patients and their care.