BMJ  2003;327:E44-E45 (4 October), doi:10.1136/bmjusa.01060003 (published 5 September 2002)

BMJ USA: Letter

LETTERS RAPID RESPONSES FROM BMJ.COM

This article originally appeared in BMJ USA

A letter from Stanley Shere, published in the April 21 issue of the "BMJ," argued that it is dangerous when physicians dictate letters but then fail to read or sign them. As of May 19, 30 rapid responses had been posted on bmj.com in response to Shere's letter. Below we reproduce Shere's letter and a sampling of the rapid responses.—Editor

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Not reading and signing letters you have dictated is dangerous

This article originally appeared in BMJ USA

Editor—For some time I have been unhappy at the number of letters that I receive unsigned, usually from fellow consultants but more recently also from general practitioners. After the warm best wishes at the end of the letter they usually state "Dictated but sent unsigned to avoid delay"; as we both know, this is almost always totally untrue.

I know many consultants who virtually never sign their letters and, worryingly, never read them after dictating them. To add insult to injury, I recently saw a copy of a letter from a consultant to a general practitioner, unsigned and from the mistakes obviously unread, in which he had the cheek to encourage the general practitioner to send patients for assessment at the private hospital where he worked.

Last year I returned from having spent one month in the United States; there was an enormous amount of post awaiting my attention, much of it medical. The final trigger to my writing this letter was that of this large number of letters (mostly from fellow consultants but also from general practitioners), over half were unsigned and had that dishonest explanation in lieu of a signature. Several years ago I recall reading a letter in a newspaper from a medical colleague expressing concern about this matter, and he neatly and precisely gave his view—which I share—that the practice is both discourteous and dangerous.

The discourtesy is of course regrettable, but the dangerousness is of far greater importance—not least now, when the public image of doctors is so severely battered. I can certainly confirm the dangerousness of the practice but will give just two examples. One letter from a consultant physician ended with the warm greeting "with very best wishes, yours very sincerely," and referred to a patient and her family requiring my assessment concerning her "antihypertensive treatment" whereas in fact it should have said "antidepressive treatment." Another consultant's letter referred to a patient receiving chlorpromazine when in fact she was being treated with clomipramine; had he read the letter he would have seen this error.

This matter must be aired, and to have any impact I am sure that it requires a journal of the caliber of the BMJ for any useful impact to be made.

PS. I have just received an unsigned letter from a consultant informing me that he is treating the patient with clonazepam in a dose of 500 mg daily; I imagine that this dose would be lethal.

Woodley House, Nackington Road, Canterbury, Kent CT4 7AX, UK

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No excuse for sending unedited letters

In reply—I completely agree with Shere. If you send unread letters, you are doing it at your own peril.

I work 95% in one hospital and do two sessions a month in another. In the first hospital, every letter I dictate is typed and e-mailed to me. I read them, edit them, and sometimes rewrite an entire sentence or even a paragraph, and e-mail it back to the typist who will print it and send it for my signature on the same day.

The situation is slightly different in the other hospital. The letters are typed and e-mailed to me and I edit and e-mail them back. The letters are then printed and signed by a proxy, in order to avoid delay, which may be 2-4 weeks, if I were to sign it.

In this modern day of communications, there is no excuse for sending unedited letters.

Cleveland, Queensland, Australia sri_varman{at}health.qld.gov.au

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Sign a check, sign a letter!

In reply—To fail to check a letter sent out in your name is the act of a fool. The reason for checking a letter is to ensure that there are neither errors nor inaccuracies in the communication or the clinical information. It is the clinician's duty to ensure the completeness, accuracy, and veracity of the provided information. If the receiving clinician uses the information that has been provided and this information is inaccurate, then this clearly places the patient at significant risk, as outlined in Shere's letter. The excuses for not signing a letter, which Shere highlights, demonstrate poor professional attitudes and a dangerous risk-taking exercise. It would be more than embarrassing to declare that a document was inaccurate and unsigned if one's legal defense depended on that document. The theme raised by Shere also applies to internal communications and the completion of request forms. If a monetary check is invalid until it is proof-read, signed, and dated, then a clinical letter or communication should be viewed similarly. Sign a check, sign a letter!

Whiston Hospital, Prescot, Merseyside L35 5DR, UK jeff.mcilwain{at}gwise.sthkh-tr.nwest.nhs.uk

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Letters need not be signed

In reply—I gave up signing my clinic letters seven years ago and began ending them with "dictated but not signed by . . . ." I therefore disagree with Shere. I did so because I visit peripheral clinics every other week. Initially my letters were typed by secretaries at these clinics and sent back to my base hospital for signing. However, it was usually more than a week after the clinic before the letters went into the post, and I felt this delay was unacceptable. I am fortunate to have excellent secretaries whom I can entrust with the task of typing, and I have full confidence in them.

Moreover, more than 100 patients are seen in my clinics each week. If I spent half a minute reading and signing each letter, that would be about an hour a week—time which, in my opinion, could be better spent. I encourage my trainees to dictate but not sign as well.

I do not think GPs are being discourteous in sending such letters as they are busy people too. Nor do I think I am being discourteous to the GPs in sending them such letters, and I've never had any complaints on the matter. Frequently I see typing errors such as patients complaining of severe "lover back pain," but I have not encountered anything dangerous occurring as a consequence within my own specialty.

Ysbyty Gwynedd, Bangor, UK mel.jones{at}btinternet.com

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Signing unread letters is more dangerous

In reply—I agree with Shere. If the letter is sent without the author reading it, then say so but cut out the mushy drivel of the excuse.

But worse, and one of my pet hates, is the shower of letters and similar documents coming toward me that have been signed, but clearly not read. Surely this is more dangerous to the signer. Perhaps the unsigned letter is a way of avoiding being held responsible for the mistakes that doctors are not going to find and correct?

Exeter, UK midgley{at}mednetics.org

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Return the letters marked "opened but not read"

In reply—Shere is right to highlight the danger of letters that are "dictated but not signed." However, the impact of airing the issue in the BMJ may be less than he hopes. I made precisely the same point in the BMJ 10 years ago,¹ but the practice has continued unabated. An interesting suggestion was that offending letters should be returned marked "opened but not read."²

International Atomic Energy Agency, Vienna, Austria j.doherty{at}iaea.org

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I can't read and sign 200 x-ray reports a day

In reply—As a radiologist, much of my dictated output is not in the form of letters, but as radiological reports, sometimes as many as 200 a day. Checking and personally signing all of these is, of course, impractical. One has to trust the secretarial staff to transcribe one's dictation accurately, and the clinicians to make contact if the sense of the report has become garbled beyond recognition. Nevertheless I am sure that mistakes occur from time to time.

Rotherham District General Hospital, UK tom{at}powell1935.freeserve.co.uk

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Use secure web-based systems

In reply—In Sweden the issue of signing your report has recently attracted some attention in a case where a cancer result was missed and the treatment delayed when the doctor was on vacation and had not signed his report.

For several years it has been mandatory to sign your reports at most hospitals. In my case, being a consultant doctor at different physical locations, it meant earlier that it could take several weeks before I was back in the same hospital and able to sign, which is too long in most cases.

I have solved the problem by using a web-based system, which allows me to do all the signing on the Internet. My secretary gets my voice file through the Internet and then types it. I can then read and sign it, and then send the referral back to the referring doctor—all through a web interface.

I assume there are some different systems, but the one I have come across, which works well, is made by MDinTouch International Inc (www.mdintouch.com).

Helsingborg, Rehabklinik, Sweden pal.lindstrom{at}priomed.com

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Not signing letters keeps my stress levels in check

In reply—Yes, a signed letter is more courteous than an unsigned one. But I hope that the GPs in my area realize that an unsigned letter was dictated with just as much courtesy, that my stress levels are kept in check, and that it will arrive more quickly. I would postulate that what GPs really do not like are long, rambling, and unstructured letters in which it is difficult to pick out essential information like diagnosis, treatment, and the date of the next appointment.

Five years ago, when I started adding "Please accept unsigned to avoid delay" to my letters, there was some economy of the truth, as Shere would have suspected. However, "Please accept unsigned to avoid delay and because the prospect of unnecessarily signing 2000 or 3000 letters a year fills me with nausea and will bring on my early departure from the NHS" would not have struck the right tone.

Peterborough District Hospital PE3 6DA, UK timothy.rimmer{at}talk21.com

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A secretarial misconception

Editor—In reply—I take care to sign my letters before they are sent out. I dictated a detailed letter on a patient whom I saw in a recent Child Development Clinic, including information on birth history. On my receipt of the letter for signing, I was surprised to learn that the patient had been born by "normal virginal delivery." Wasn't the last one of those about 2001 years ago?

Ealing Hospital, Southall, Middlesex UB1 3HW, UK don.urquhart{at}usa.net

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