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!