Maybe it’s my Catholic upbringing.
Or maybe it’s a manifestation of my ongoing imposter syndrome, but I seem to always home in on articles that are critical of some practice or procedure which has been part of my repertoire for years causing instant anxiety and guilt.
Most recently my well-developed sense of guilt was heightened by a specialist’s blog on the online version of the New England Journal of Medicine. Professor Paul Cox, from the Harvard Medical School was bemoaning the inclusion of descriptors such as ‘pleasant’ and ‘lovely’ in referral letters from GPs to specialists.
He makes a number of points about the inclusion of such subjective opinions in this sort of correspondence. He suggests this is done to hopefully get better treatment for patients we prefer and he questions what it implies about the people we don’t call pleasant or lovely.
In addition, he says “doesn’t this ‘lovely’ imply something demeaning and patronising about the label? Of course it does.
“While no doubt there are some people who are more likable than others — and that this may influence what it’s like to care for them — I’d prefer we keep these subjective views to ourselves”, he concludes.
Oh dear. By now you will have no doubt guessed I am forever including similar adjectives and subjective observations in my referral letters.
Worst still, I have always felt I have been helping the specialist rather than hindering them – giving them a heads up as it were. Making them privy to an opinion usually developed over the course of many visits over many years which I thought they might appreciate given that they will be expected to dispense expert advice for that particular patient with that particular condition within minutes of their very first meeting.
Many other subjective observations would be expected to be included in a good referral letter – anxious, pale, emotionally labile or flat affect can be entirely opinion but are worthwhile features to describe. Is it so wrong to describe the nature of your interaction with this patient?
I know it is a code of sorts. Just like I write “poor historian” for a patient who gets confused or “patient requests referral” when the referral is more at the patient’s instigation than my own, but it is a way of communicating a sense of the whole patient rather than just transferring responsibility of patient A with condition B to specialist C.
And as much as it does, in all honesty, reflect a fondness for the patient it also says, in not so many words, this patient is not neurotic, a Munchausen’s, aggressive or even one of those patients who you will never please or cure no matter what you do (aka heartsink patient).
As for what it means if I don’t describe a patient as lovely, I didn’t realise it meant anything at all. Isn’t it just the default position for the majority of patients, including those who the GP may not know as well? Is anyone really comparing and contrasting referral letters?
So, is Professor Cox right or is he being unduly “curmudgeonly and negative” (his words not mine)? Certainly from the dozens of comments posted on his blog, he certainly has his supporters.
One of the more articulate, convincing comments was supportive of his stance against describing patients as pleasant, lovely or even delightful.
“I think it is misguided to facilitate a bias that we should strive to avoid. We are charged with really wanting to do well for every patient. It is our calling,” said the commenter, which is pretty hard to argue against, even if it does sound a little sanctimonious.
It is worthwhile remembering this is a US blog and as far as I can discern most of the comments came from US doctors, so there was strong flavour of medicolegal risk and protecting against future litigation.
And let’s face it, this is a bit of an indulgence when there are so many other areas of clinical practice that are far more worthy of our attention – melanoma detection, meningitis protection, measles prevention to name a few.
But Professor Cox has given me, at least, food for thought.
After all these years, maybe it is time to rethink my descriptors of some more favoured patients even if I honestly believe that my elderly patient with newly-developed paroxysmal atrial fibrillation is a “delightful 91-year-old lady”.
To be fair, I’m sure the cardiologist will work that out within minutes of meeting her anyway.