Randomised trial of the effects of structuring clinic correspondence

Abstract

We performed a randomised controlled crossover trial of clinic letters. Structured letters were compared with conventional letters containing problem lists. There were 32 participants; 25 preferred the structured letter. Median rating and items identified were higher for the structured letter. Structured clinical correspondence with paragraph headings is strongly preferred and increases comprehension. E ffective correspondence is essential given the volume of mail reaching general practitioners (GPs) and the need for timely and accurate communication on complex cases. Past advice on clinical correspondence has been based on common sense, particularly "keep it short". 1 Previous studies have examined GPs' preference on letter structure. UK studies in paediatrics have established that GPs like problem lists 2 and some degree of structure. 3 Structure in letters was also preferred in other studies.4 5 The consistent overall message is: structure the letter, and tailor content to your audience.In a local questionnaire study of GPs we found they were action orientated, wanting rapid information on diagnosis, management, any actions for them, and patient/carer information. They were strategic readers, spending a median of 30 seconds on each correspondence item, concentrating on the first and last paragraphs. They expressed concern about "missing" important information hidden among a mass of irrelevant detail. Using these findings, we developed a proforma letter with problem list and subheadings. We hypothesised that this would improve letter comprehension compared with the traditional format. METHODSWe designed two letters of similar length by adapting the contents of anonymised clinic letters. Each contained all relevant information, and was in Times Roman 12 point with single line spacing. Each letter was prepared in two formats: unstructured with problem list (conventional) and structured. Participants were randomised by concealed number to read the structured letter either first or second.Participants read their first letter, noting the reading time in seconds. Next, we asked them to identify eight specific items of information using a checklist, as a measure of letter comprehension. They repeated the process for the second letter. They then rated each letter on a five point modified Likert scale (very poor, poor, average, good, excellent). Finally, they were asked which letter they preferred.The format was piloted using 10 participants (seven GPs and three paramedical specialists). Using these results we estimated that 22 participants would be required to achieve 80% power with a two sided significance level of 5%. Subsequently, with the agreement of local GP tutors, the study took place at the start of scheduled postgraduate GP education sessions. Non-GP principals were excluded from participation. Verbal consent was obtained from each participant.The main outcome measures were the number of items correctly identified, the letter rating, letter preference, and the reading time. We analysed results using SPSS 9.0...

The preference of general practitioners for structured outpatient clinic letters

“…This finding confirms the results of surveys in other specialties. [1][2][3][4] This study also highlights how little time GPs typically spend reading letters.…”

Effective communication betweenENTand primary care – a survey of outpatient correspondence

“…GPs usually have seven and a half minute per consultation, leaving little time to extrapolate key information from a secondary care letter, yet most consultation letters contain minimal structure . Current research suggests that GPs generally prefer structured outpatient clinic letters . This current evidence does not, however, address the quality of structuring required nor does it succeed in evaluating its efficiency and efficacy with regard to management of the patient.…”

“…As the drive to improve communication efficiency between secondary and primary care takes shape, most hospitals have resulted to direct electronic communication with general practitioners hence most outpatient clinic letters are forwarded to GP electronically. This contributes to the significant amount of data being received contemporaneously by GPs . With the multiple time pressures and constraints on primary care, it is estimated that over 80% of GPs spend <1 min reading outpatient clinic letters .…”

“…This contributes to the significant amount of data being received contemporaneously by GPs . With the multiple time pressures and constraints on primary care, it is estimated that over 80% of GPs spend <1 min reading outpatient clinic letters . GPs usually have seven and a half minute per consultation, leaving little time to extrapolate key information from a secondary care letter, yet most consultation letters contain minimal structure .…”

Clinic letter training and current practice among paediatric specialist registrars

“…Studies looking at clinical correspondence between general practitioners and consultants illustrate marked variation in desirable content and thoroughness of communication between these groups 4. Structured correspondence is strongly preferred and increases comprehension 5. The previously filed letter is highly influential and common practice is to refer to this letter, especially for new SpRs.…”