Not reading and signing letters you have dictated
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7310.448 (Published 25 August 2001) Cite this as: BMJ 2001;323:448All rapid responses
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From a GP's perspective, if I take the time to read a letter, I think
it is reasonable that the sender takes the time to check it for accuracy.
Some letters that I receive signed are by no means accurate, suggesting
that many letters go signed but unchecked, which I think is even worse
than unsigned and unchecked.
Letters from hospitals are an important means of ensuring good
medical care. If they are too time-consuming, perhaps they should be more
efficient. Many letters I receive reiterate my own referral letter at the
beginning. Many letters simply inform me that my patient visited the
outpatient clinic. Perhaps if fewer unneccessary letters were sent, and
if unneccessary waffle were omitted, there would be more time for checking
them. I would much rather receive fewer and pithier letters, and I would
be quite happy for them to consist of a short list of bullet points.
Competing interests: No competing interests
I type much faster than I write or dictate and its irritating that
many hospitals still assume that discharge letters and admission notes
must be handwritten.
Perhaps my diction lacks clarity and that's why the secretaries
mistype - but the positive side of checking my own reports is that I pick
up most of the funnies first. The best of mine was
"cholecystectomy and choledochogram uneventful, the brain was removed
on the third day."
The radiologists now use voice recognition software, to my sorrow I
no longer receive these reports as proof that the typists' mind was
elsewhere -
"There is a testicular shadow in the left lung"
(Lenticular shadow indicating fluid in the fissure, I was told when I
asked)
Nearly as surprising was a linear marking on the tibial cortex
"probably vascular and caused by the genital artery."
Competing interests: No competing interests
Everyone seems to have forgotten two important facts:
1) Protecting the patient's privacy. Yes, the patient DOES have a
right to privacy.
2) Most important, ACCURACY. Most letters, reports, notes that have
been dictated but not read are replete with errors. If a secretary
inadvertently omits a "not," she could be deleting a diagnosis of
carcinoma. Typed, unread histories tend to be garbled because the person
typing the report is neither the person who took the history nor, in many
cases, an individual who knows enough about medicine to realize that the
report does not make sense.
Physicians MUST read--and check--every written communication.
"Dictated but not read" is an insult to the referring physician and a
disservice to the worried patient.
Communication between medical colleagues and between doctors and
patients is at the heart of good medical practice. Any physician who
finds reading, checking, and signing letters too much trouble should go
into another line of work where accuracy is not so much the name of the
game.
And while we're talking about communication, verbal estimates have no
place in medicine. Only numerical estimates will tell the reader what he
or she needs to know.
Competing interests: No competing interests
Almost all your correspondents claim that letters cannot be signed
due to various pressures, or must be signed, because, well, lots of
reasons too. It has seemed to me that it is better at times to send an
unsigned letter when an early response is needed (it can always be checked
for accuracy later, if your typist can't understandyour dictation), but
preferable to read it first, when you might as well sign it: your
corrections will show you have paid attention to the content.
Some middle way might have been possible, but now I see that the GMC
has issued a C.o.P. (Counsel of Perfection, not Code of Practice) which
firmly plants responsibility for problems on those who don't sign. No more
timely reports, fewer patients seen, but no advice incorporated for
dealing with increased workload. At least they have the support of the
lawyers (who often seem to sign the name of the firm, not the individual).
There are ways round all this. Another 'rapid response' says type it
yourself; I suggest voice recognition programmes instead of dictation
machines, although the training sessions for the computer are quite
strenuous. We can look to technology to help out, but meanwhile a
judicious application of commonsense and tolerance might keep the
information flowing with reasonable accuracy, or at least as much as is
reasonably practicable, which should be the true test.
Gerald Freshwater
Occupational Physician,
Lerwick, Shetland Isles.
References: GMC News, August 2001, and Rapid Response "Type It
Yourself", e-BMJ, Aug, 2001
Competing interests: No competing interests
The Editor,
I read the article and resposnes to not signing dictated letters. As
i write this letter to you now i can only imagine 10 years ago when email
was not a part of our everyday life as it is today. Now i'm imagining 10
years in the future, clinics may still be the same size but the NHS may be
so technologically advanced that our clinic summaries will go directly to
the relevant teams via email and the internet.
Will we be signing those email letters?
All clinicians are allegedly very busy people and we must have faith
in our support staff to reproduce our dictations precisely. Though every
effort should be made to sign our dictated letters there will be instances
when unsigned letters arrive to GPs. This is not a reflection of
disrespect but of the system overwhelming the practicing clinician.
I look forward to the day when our dictations can be transcribed
directly to our computers and then dispatched to our colleagues by the
click of a button....signature included of course.
Competing interests: No competing interests
For the last three years I have been typing my own letters and
operation reports.
With appropriate templates and spell checks, this is fast and accurate,
does not require proof-reading, and though I do sign almost all
personally, the office manager can sign pp should I be away.
Currently I am in the process of networking with my major referral base
with secure e-mail to speed up still further the transmission of
information.
Typing skills, although undoubtedly slower than a professional typist are
easily attained, and the time saved by not having to proof read, and re-
submit corrections - spelling, content and syntax - far outweigh the lack
of typing speed
Competing interests: No competing interests
Not signing letters is hazardous for Paediatricians
Editor,
I agree with Shere(1) that not reading and signing the letters you
have dictated can be dangerous. I am also interested by the correspondence
that this letter has generated(2) and I have several points to add to the
debate from my perspective as a paediatrician.
1. Following Wright (3), I feel that the letter has two main
purposes. Firstly, to inform the recipients of the diagnosis and
management of the case. Secondly, to be an accurate record in the child's
case notes. Considering the latter, it is particularly important that the
information is correct for the purposes of future contacts with the child.
These contacts can be with doctors who have not met the child before or
with doctors who are less experienced than the author of the original
letter. If a mistake occurrs in the dictation or typing of a letter
without correction, the mistake can be replicated in subsequent
consultations and this can inadvertently lead to a change in management
with drastic consequences.
2. Many of the drugs that are prescribed by paediatricians are not
licensed for use in children and are used in doses that may be difficult
to check in the standard formularies such as the British National
Formulary. This inevitably leads to an unease on the part of General
Practitioners who are sometimes reluctant to take responsibility for
unfamiliar prescriptions. GPs need to be secure in the knowledge that the
letter on which they base their prescription is accurate.
3. In the Community setting it is my experience that the letter has a
wide circulation between all professionals involved in the care of the
child including representatives of health, education and social services.
A copy is also sent to the parents of the child. It will do little for
their confidence to receive an unsigned letter riddled with inaccuracies.
4. I agree with Jones(4) that we are all busy and that the
administrative pressure on doctors continues to grow. However, if we do
not have enough time to ensure accuracy in our communication, then we do
not have enough time. This should be recognised and efforts must be made
to rectify the problem.(5) If we are to communicate quickly and
efficiently in the 21st century, then we should embrace and utilise
electronic technology and include a suitable device to clarify that the
information contained in the letter has been validated by the author.
The 'letter' is central to communication. Paediatricians must take
responsibility for their dictation. We must say what we mean and mean
what we say.
Ieuan Davies
SpR Paediatrics
University Hospital of Wales,
Cardiff
CF4 4XN
y.tarw@virgin.net
1. Shere S. Not reading and signing letters you have dictated is
dangerous. BMJ 2001;322:922.
2. Letters. Not reading and signing letters you have dictated. BMJ
2001;323:448-449.
3. Wright J . Further dangers of clinic letters. bmj.com 200;322.
4. Jones M. Not signing letters means that they get sent out quickly. BMJ
2001;323:448.
5. Nottingham J. Time for signing letters is surely issue for trusts'
management. BMJ 2001;323:448.
Competing interests: No competing interests