Posted in Administration, Uncategorized

Writing a referral letter

This topic came up in conversation at the practice recently. Disclaimer – I am not the world’s best letter writer, and English was not my favourite topic at school!

This post is perhaps more an opener to think about how you are currently constructing your referrals, and how you can improve on this. Some people take the mail merge literally, and mail merge their last consultation, whereas some people like to write a life story of their patient. I must admit, I have been guilty of both of these in the past.

The most important point when considering referral letters is what are you asking the person on the end of the referral for. This should be the very first sentence of the referral. For example, if you think someone needs surgery then that’s what the referrer needs to know. Plus, you might wish to explain why you think the patient needs the procedure. An example might be “I would be grateful if you would see this 48 year old woman, who has been suffering recurrent episodes of cholecystitis, for consideration of a cholecystectomy”. Thus, the reader knows exactly what you’re thinking, and hopefully what the patient is expecting.

Leading on to the second point – make sure the referral reflects the conversation you had with the patient. If you’ve told the patient you’re referring them for one reason, and the letter makes it sound like it’s for something totally different, it is going to lead to a difficult consultation between the patient and whoever they have been referred to. So keep the story consistent. For example, if there are strict criteria in your area for knee replacements, and you know the patient doesn’t meet them, it is not helpful to tell them you are referring them for this. In reality, you are referring them to a specialist since you’ve exhausted the options, and you need to see if there’s anything available in secondary care that they can try whilst they don’t meet the threshold for replacement. It works in the opposite direction too – why are you referring someone with a hernia to a surgeon, if they don’t want to have surgery? You need to be clear what your patient’s agenda is, and clarify to them what your agenda is when referring.

The above is by far the most important part of writing a referral. The rest is just details, and, in some ways, is shaped by the referral processes local to you. Examples locally are the virtual gastroenterology and neurology clinics. They have been set up to manage the demand for these services locally. The process is simple – you refer to the clinic, they read the letters, they may provide some advice and not see the patient, they may book patients in for investigations first prior to review, or they might see the patient in clinic initially. As such, giving a good history is essential to them making the right decisions. So thats what you need to do. Go back to the days of having to present patients on the post-take ward round, or back in medical school, and present your patient. For example if there is pain – describe the pain. You need to describe the associated symptoms, and the duration of them. You need to include any relevant medical history or medication history. You don’t need to talk about their broken toenail back in 1984! Think about what you’d like to know if you could give patients forms to describe their symptoms in advance of your appointment. Imagine how much easier the consultation may be if you had a nice outline of everything before you saw the patient. (Remember we do have a rough outline as we at least have their medical history, current medications, etc. in front of us)

You don’t want to bore the reader, and you don’t want them to be digging through your letter to make sense of why a patient is being referred. This is why mail merge letters from the relevant consultation are not the most helpful. Your consultation notes are just that – your consultation notes – not you discussing the case with someone else. We often use abbreviations and incomplete sentences, and flit from one part of the history to another. Read the last consultation in the next patient’s notes you open and see if you feel that you know exactly what the writer was thinking, and whether it was an easy read! The other factor here, is a lot of surgeries undertake referral audits, and/or review referrals before they leave the building, which is another reason to make clear why you are making a referral and whether it lives up to peer scrutiny.

Another reason for writing a concise, clear referral is because it helps you. Writing or dictating the referral may prompt you to undertake some further investigation, or ask a few further questions prior to sending the referral off. I like to write my referral as soon as I have wound up the consultation, where possible, as all of the information is fresh in my mind, and I just find it a lot quicker.

Remember I said you don’t need to tell the patient’s life story? You really don’t! I know this because I have, once or twice, received a response thanking me for my ‘comprehensive’ history. Which I am pretty certain means they stopped reading it halfway through! Just give the relevant points!

I hope this is of use when you write your next referral!

Posted in ARCP, eportfolio, ESR, MRCGP

Reflective learning

This entry has come about through a chat with one of our trainee’s. He felt that it was difficult to get to grips with reflection. He told me that he got to know about Gibbs (1988) reflective cycle, and that this had improved his ability to reflect. I also recalled this was the model my sister was encouraged to use during her midwifery degree.

So I went back to my theory from my Postgraduate Certificate of Medical Education, did a bit more reading, and thought I’d share the salient features. Having looked through numerous theories of learning and reflection I do agree that Gibbs’ method fits the GP e-portfolio learning log well.

It’s important to note that reflection is a very personal experience. It can give an insight to your personality, and can reveal how you are feeling at a point in time. It’s useful to be open when writing a reflection, and feeling comfortable that whoever reads your entries will treat this information as confidential, and be supportive and developmental in their feedback. Though, it is sometimes easy to fall into doing a lot of description, and sharing of feelings, but less about how this has impacted upon your learning, and any changes you might make. Hence, why having some models to frame your reflection upon can help.

One of the earliest theorists to consider reflective learning was Dewey. His thoughts were that reflection was potentially very useful when making sense of situations that we may have found difficult. To learn from it required a description of the event and questioning ourselves to analyse why it occurred in that way, and considering ways to change the outcome of the event. (Dewey, 1933)

One of the most common theorists to come up in discussion of reflection is Kolb. His learning cycle (1984):Kolb learning cycle

It’s a very simple model. But what I don’t like about it is that one of the stages is to ‘reflect’ and I find that it doesn’t help with structuring the reflection. Instead, I would use this model in association with another model, that discusses the reflection in greater depth.

So we come to Gibbs Reflective cycle (1988).

Gibbs reflective cycle

Gibbs’ model of learning is what we call iterative – learning through repetition. The aims of his model are to:

  • Challenge assumptions
  • Explore different ways of doing things
  • Promote self-improvement
  • Link practice with theory
  • Thinking about the positive as well as the negative

I’m going to give an example of a reflection using this structure

Description – I saw a man in his 30’s who presented with haematospermia. It had happened on 2 occasions. As soon as he told me what the problem was I realised I knew nothing about the topic.

Feelings – I felt myself getting stressed because I didn’t know what I was going to do. I really had no idea whether this was something to be concerned about or not. I think, looking back, I must have looked disinterested because my mind was wandering trying to think what I was going to do, whilst he was still telling me about the problem.

Evaluation – Actually, I don’t know if he noticed just how stressed I was, as I managed to keep calm on the outside which was good. I explained a need to check some guidelines so I could quickly look on GP notebook to work out what to do! He seemed satisfied with the consultation, though I was quite worried that I’d missed something else during the time I wasn’t fully listening.

Analysis – I think my worry that I knew absolutely nothing about the topic hindered my ability to listen to the patient, and thus my consultation skills were not up to scratch. If I had been able to keep calm, and think ‘I can look this up’ earlier on, it would have facilitated a better consultation.

Conclusion – I could have been completely open with the man and said I wasn’t sure and needed to have a look/ask a colleague. I could have done this during the consultation or afterwards and followed this up with a call. I also think that I need to separate my concern about a lack of knowledge from the consultation structure. It hampered the consultation, and added extra stress.

Action plan – I will read up on haematospermia more thoroughly, and this might lead on to other men’s health topics I have less knowledge about. I will also try and role play some consultations where I really don’t know the answer, and try to focus on what I can do. I can also try out different ways to signpost that I need to look up some information.

References:

  • Dewey, J. (1933)¬†How We Think. A restatement of the relation of reflective thinking to the educative process¬†(Revised edn.), Boston: D. C. Heath.
  • Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall.
  • Gibbs G (1988) Learning by Doing:¬†A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.