Do patients wish to 'listen in' when doctors dictate letters to colleagues?

OBJECTIVES: To evaluate the effects on clinical outcome of dictating correspondence in front of patients and sending them copies of letters.
DESIGN: Observational study of the practices of two consultants, one of whom (RDS) routinely dictated letters in front of his patients and almost always sent them a copy while the other (AM) did neither. Questionnaires were completed anonymously by patients at the end of their consultation.
SETTING: Neurology department of a teaching hospital. PARTICIPANTS: Patients attending neurology outpatient clinics.
RESULTS: Seventy-two percent and 62% of the two consultants' patients were audited, and the demographic features of the two groups were similar. Eighty-six percent and 25% of RDS's and AM's patients, respectively, said that they wished to be present during dictation (p < 0.001). Within AM's group, those who had had some experience of the practice (with other consultants) were more likely to express a desire to be present during dictation (p = 0.023). Ninety-two percent and 77% of RDS's and AM's patients, respectively, felt that having a copy of their letter would be 'very useful' or 'useful' (p < 0.001). The perceived usefulness of receiving a copy letter and the desire to be present during dictation were associated for the total group and for RDS's patients. The two groups of patients were asked to express their degree of understanding at the end of the consultation, and 81% and 93% of RDS's and AM's patients, respectively, thought that their understanding was 'excellent' or 'good'. No trends emerged with regard to patients' preferences (to be present or absent during dictation and to receive or not receive a copy of their letter) and their level of understanding.
CONCLUSIONS: Patients appear to like being present when their letters are dictated, and appreciate receiving copies of these, but their overall understanding is seemingly independent of these variables. The success of the clinical consultation is probably influenced by numerous factors, and the elevation of patients' presence during dictation of correspondence and receipt of copy letters above all others seems unjustified.

Introduction

The NHS plan in the UK made a commitment to give patients the right to receive copies of letters about their treatment and care,[1] and the Department of Health asked all Trusts to implement this policy from 1 April 2004. The ‘evidence base’ for justifying this guidance is not robust, although small scale studies have been undertaken in various disciplines to evaluate its acceptability and utility, including in psychiatry,[2-4] general practice,[5] urology,[6] otolaryngology[7] and diabetology.[8] The ‘outcomes’ in these surveys have for the most part been positive, and have supported the activity. The practice of dictating the letter to the specialist or general practitioner at the end of the consultation has been scrutinized less well. Also, when attempts have been made to analyse this more critically, for example in the study by Lloyd in which he randomized families at his paediatric outpatient consultations to being present during dictation or not, there has been no difference in outcome (patient satisfaction in this case).[9] Notwithstanding the relative paucity of evidence to justify the practice of copying letters to patients, influential figures within the NHS have encouraged it, claiming for example that it ‘goes to the heart of putting the relationship between patients and doctors on a more equal footing’ (Harry Cayton, the Department of Health's Director of patient experience and public involvement).

The practice clearly has advantages which are self-evident. It has the capacity to increase trust and openness between professionals and patients. Patients are likely to be better informed, and compliance with treatment(s) by patients should increase. Overall, the process should enhance the patient's understanding of the specific clinical problem and should promote better health generally. Clearer communications between the patient and his doctor are likely to result, and the doctor–patient relationship will have been enhanced. The advantages of doing the dictation in front of the patient are identical, but additionally may prove reassuring for the patient. The accuracy of the data collected during consultations is likely to increase, and consequently fewer errors are likely to accumulate in patient records.

The processes are not without pitfalls, and these include potentially the risks to confidentiality (information regarding a third person needing to be divulged, or simply the copied letter getting into the wrong hands). The patient himself might not wish to be present when his letter is dictated, and may not wish to see or hold copies of letters pertaining to their health. There is a possibility too of information ‘overload’, where too much technical information may confuse and baffle the patient. Finally, if adopted widely, the postage and stationery costs are likely to be considerable.

There are little data on the topic in the neurological literature, although opinion leaders have described their anecdotal experience with it.[10,11] The current work was an attempt to quantify patients' opinions about both practices in the context of an audit. The study was undertaken in a neurology department of a teaching hospital.

Method

The outpatient consultations of two consultant neurologists were analysed. The first (RDS) dictated almost all his letters in front of the patient, and almost invariably sent copies of letters to them. Exceptions to this practice were cases in which potentially life-threatening illnesses were suspected or being investigated, such as brain tumour or motor neurone disease. The second consultant (AM) did not dictate letters in the patient's presence, but did send some copied letters to her patients, especially those with chronic headache. In the study, the patient was asked to complete a questionnaire at the end of the consultation, but in view of the different consultant practices slightly different versions were used in the two populations (Figures 1 and 2). In an earlier audit carried out in October 2007, very similar rates of patient satisfaction were reported by the patients of both consultants at the end of their consultations (unpublished observation). The collected data were scanned and presented in an Excel spreadsheet. Statistical analysis was carried out using SPSS for Windows.

Figure 1

Questionnaire used for RDS's patients

Figure 2

Questionnaire used for AM's patients

Results

The demographic data on the patients who were questioned from the practices of the two consultants are shown in Table 1, and the age distributions are shown in Figure 3. The periods of study were 3 and 1.5 months for RDS and AM, respectively. The 263 subjects represented 72% of RDS's patients seen during the period of study, and the 126 subjects of AM's represented 62% of her total patients. The demographic features were similar, and the age distributions were not statistically different.

Table 1

Demographic data for patients in study. FU = follow-up; N/K = not known

Consultant	Period of study	Number questioned/total seen	Patient type			Sex
			New	FU	N/K	M	F	N/K
RDS	21 July 2008–31 October 2008	263/362	85	169	9	119	138	6
AM	11 September 2008–29 October 2008	126/202*	74	49	3	59	62	5

*Patients seen at a weekly specialist movement disorders clinic were not questioned

Figure 3

Age distributions of patients in study

In AM's case, a further analysis of her patient population was undertaken to see what experience they had had previously of doctors dictating letters in their presence (Table 2). The majority had never experienced this (63%).

Table 2

Previous experience of ‘listening in’ in AM's patients

Frequency	n	%
Always	11	9
Often	6	5
Sometimes	12	10
Hardly ever	15	12
Never	79	63
Not known	3	2

When asked whether they wished to be present during dictation (Table 3), 86% of RDS's patients said ‘yes’ compared to only 25% of AM's patients. However, in AM's group, 50% of respondents were ‘unsure’. The differences in responses were tested using Chi-square and were found to be significant (p <0.001). We attempted to see whether the responses of AM's patients were influenced by their prior experience of sitting in on dictation. Those who gave definite answers of ‘yes’ and ‘no’ in her group were analysed according to whether they had had previous exposure to the practice (always, often, sometimes versus hardly ever, never) (Table 4). There did seem to be a trend for more subjects with previous experience of being present during dictation to say ‘yes’ (p = 0.023).

Table 3

Patients expressing desire to be present during dictation (%)

	RDS	AM
Yes	86	25
No	7	23
Unsure	6	50
Not known	2	2

χ2 = 147.272; df = 2; p <0.001

Table 4

Breakdown of preferences (to be present during dictation) in AM's patients, according to previous experience

Opinion	n	Experience?
Yes	32	11 (34%) Exp.
		20 (62%) Inexp.
No	29	4 (14%) Exp.
		25 (86%) Inexp.

χ2 = 17.772; df = 8; p = 0.023

When asked whether they wished to have a copy of the letter, the answers of the two groups also varied (Table 5). Among RDS's patients 73% thought it ‘very useful’, 19% ‘useful; and 3% ‘no difference’; the respective percentages in AM's group were 52%, 25% and 13% (p <0.001).

Table 5

Patients' preferences to hold copy of letter (%)

	RDS	AM
Very useful	73	52
Useful	19	25
No difference	3	13
Unhelpful	0	0
Very unhelpful	3	4
Unsure	1	4
Not known	1	2

χ2 = 25.243; df = 4; p <0.001

The perceived usefulness of receiving a copy of the letter and the subjects' desire to be present during dictation were associated for the total group (p <0.001) and RDS's patients (p <0.001), but not AM's patients (p = 0.190) (data not shown).

The degree of understanding expressed by the patients at the end of their consultations were dichotomized (‘excellent’, ‘good’, ‘little’, ‘no’) to aid analysis. It should be noted that the grading of outcome in the two questionnaires varied (they were specified for RDS's patients and a spectrum of responses from 1 [no understanding] to 5 [complete understanding] made available to AM's). More of AM's patients thought they had an ‘excellent’ or ‘good’ understanding (93%) than RDS's (81%) (p <0.001, with responses to category 3 in AM's patients being excluded from the analysis to enable alignment).

Finally, when investigating whether patients' wishes (to be present during dictation of letters or receive copies of letters) correlated with their understanding, no clear trends emerged, with equally large proportions of patients of both consultants stating that they had excellent/good understanding in both groups (i.e. wanting or not wanting to be present during dictation, and wishing or not wishing to have a copy of the letter) (Tables 6 and 7). Taken together these data suggested that patients' desire to be present during dictation and their wish to hold a copy of the doctor's letter were independent of their overall knowledge and understanding.

Table 6

Level of understanding in those wishing to be present/not present during dictation

	RDS		AM
Present	n = 225	Exc/good 77%	n = 32	Exc/good 84%
		Little/no 20%		Little/no 15%
Not present	n = 19	Exc/good 95%	n = 29	Exc/good 93%
		Little/no 5%		Little/no 7%

Table 7

Level of understanding in those wishing/not wishing to hold a copy of their clinic letter

	RDS		AM
Very useful/useful	n = 242	Exc/good 78%	n = 97	Exc/good 86%
		Little/no 19%		Little/no 13%
No diff/very unhelpful	n = 16	Exc/good 81%	n = 22	Exc/good 95%
		Little/no 19%		Little/no 5%

Discussion

This paper has attempted to investigate neurology outpatients' opinions on whether or not they wish to be present when their clinic letter is dictated, and whether they would prefer to have a copy of this letter for themselves in due course. We have done this by auditing patients' views by questionnaire, at the end of their consultations with two consultant neurologists. A high proportion of patients from both consultants' practices were audited. The demographic data on the two populations studied were similar, but there was a higher proportion of ‘new’ patients in AM's group. As the study was an observational, ‘real life’ one, the individual practices of the two consultants were not altered during it. While RDS tended to avoid dictating letters containing some types of bad news following consultations, this scenario did not arise during the three months of study. With experience and appropriate candour, the situations where the contents of a letter to a colleague cannot be shared fully with the patient are few and far between.

The questionnaires were anonymized for analysis and were filled unsupervised, but nevertheless there may have been pressure on patients to respond ‘favourably’. As both consultants worked in the same hospital and clinic areas, it is unlikely that there would have been a systematic bias in the responses received for one consultant. The evaluation of how much understanding patients had of their condition after the consultation (our surrogate for ‘outcome’) was not objective, and based purely on the patient's own perception. Additionally, it may not have captured the entire patient experience. Factors other than understanding (for example, confidence and happiness) may have been more influenced by being present during dictation. However, in an earlier audit, very similar levels of satisfaction with the consultation were expressed by the patients of the two consultants. The outcome in this case was chosen as a simple measure of what should be the most tangible benefit from listening in. Indeed, one may have expected those with an excellent/good understanding at the end of the consultation to be less interested in having a copy of their clinic letter, a trend that was not seen for either consultant.

Our results suggest that patients who have been present during the dictation of their clinic letters appear to like the practice. Even in the case of AM's patients (who were not present during dictation), those who had had some experience of it previously expressed a desire to be present. Between 92% and 77% of patients thought that having a copy of their clinic letter would be ‘very useful’ or ‘useful’. There was a significant difference between the two consultants, perhaps reflecting the patients' experiences and their expectations (13% of AM's patients thought it would make ‘no difference’ as opposed to only 3% of RDS's). Clearly patients differ in their profiles, and in the group as a whole there was an association between those wishing to be present during dictation and those who thought having a copy of the clinic letter would be useful. Does the observation that this trend was present in RDS's patients but not in AM's suggest that patient engagement is already being influenced by what has taken place at the consultation?

Crucially, however, the study failed to show any associations between patients' levels of understanding and their desire to be present during dictation or receive a copy of the clinic letter. This was the case for both consultants, and implies that these variables are independent of one another.

The current observations add an element of complexity to the debate on what constitutes ‘best practice’ at the outpatient consultation. While patients might feel happier being present when their letters are dictated and like receiving copies of correspondence relating to them between professionals, their understanding is influenced (probably) by other means too. In the current study, the level of understanding expressed by the patients of the consultant who did not dictate in their presence or routinely send out copy letters was greater, bearing in mind that the outcome scales were not strictly comparable. It might be argued that utilizing consultation time for dictation actually detracts from the time available for discussion, and the greater ‘understanding’ expressed by AM's patients is a reflection of this. However, it is not known whether this difference persists (or even reverses) after a delay of a few weeks or months, a question that could be answered in a follow-up study.

The clinical consultation is a complicated interaction, with an array of tasks being carried out sometimes simultaneously. Consequently there are likely to be a number of factors that contribute to making it successful. While improving communications by dictating letters to other professionals in front of patients and sending them copies appears to be the ‘right thing’ to do and is appreciated by patients, to raise them above all the other acts one carries out during consultations seems unjustified. Indeed the current evidence would suggest that one could be equally (if not more) effective by omitting these. It seems that there are many different means of skinning this particular rabbit, and it is perhaps down to the individual clinician to work out through training and experience what works best for him/her.

DECLARATIONS

Competing interests

None declared

Funding

None

Ethical approval

Not applicable

Guarantor

RDS

Contributorship

All authors contributed equally

Acknowledgements

The proformas were developed and piloted by three work experience students: Haroon Miah, Anurag Sharma and Winnie Ihuoma. Jean Wallace in the audit department collated data and carried out some of the analysis. Andrew Thompson provided data on clinic attendance. We are grateful to our excellent clinic nurses (who contribute to the success of clinical encounters too) for handing out the outcome forms. Finally, we are grateful to our patients and their carers for their time, patience and contribution

Reviewer

Eric Scott Sills