Letter to my patient #1: Introduction

In March 2020 the COVID pandemic reduced our pain clinic to a skeleton service. Consultant anaesthetists were sent back to operating theatres or intensive care units, physiotherapists and nurses to the wards. I found myself covering an emergency-only service, taking phone calls from patients who were struggling with their pain, or having problems with their medication. Outside of a structured clinic setting, these calls had an informal feel. So when the call ended it felt strange to write a formal letter to the patient’s GP, as would be usual practice in a clinic setting. These brief consultations seemed instead to lend themselves to direct communication between clinician and patient: 

Dear X, it was good to speak to you by phone this morning; this is what you were concerned about, this is what we discussed, this is what we agreed. Sending a copy of this letter to the patient’s GP meant prescriptions could then be initiated or existing medication titrated as usual. 

I began writing all my clinical letters in this way, addressed directly to the patient and copied to their GP. The more I did so the harder it was to imagine going back to the traditional model of writing letters to GPs about the patient as a third party, letters that the patient concerned would never see. As a pain service, we promote self-management strategies to cope better with a complex long-term condition, so why not empower patients to self-manage by sending them bespoke information about their condition, and the agreed treatment plan, from the outset?  If we agree to medication changes, surely it makes sense to send a summary of these changes directly to the people who will be making these changes? Of course these details are always explained carefully in the clinic, but we know that we all find it hard to  retain all that we are told in any medical appointment. Sending a written summary takes the pressure off patients or their accompanying relatives to remember what can be a confusing jumble of information, passed on in a stressful environment. After years stuck unthinkingly in the traditional model of medical communication, this new way of working felt like a revelation. 

As it turns out, I am not the first clinician to have had this experience. In fact, as I was later to find out, I am a few years behind the curve. In 2018, The Academy of Medical Royal Colleges published guidance (‘Please write to me – writing outpatient letters to patients’) encouraging all doctors to write directly to patients after all outpatient consultations. They cite the General Medical Council’s ‘good medical practice’ guidelines – “you must give patients the information they want or need in a way they can understand”. Understanding is key, and it presents two distinct problems when it comes to letters to patients from the pain clinic. Firstly, there is the question of presenting complex information in a way that is easy for most people to read. Readability is a fascinating topic, but one to which I had not previously given much thought (you have probably already reached that conclusion yourself). I have had to discipline myself to constructing shorter sentences with fewer clauses and a simpler vocabulary, which turns out to require a lot more effort than my default verbosity.  

The bigger issue, though, is with understanding of the condition of chronic pain itself. The UK Faculty of Pain Medicine recognised this in their Core Standards for Pain Services document in 2021:  “The difficulty in understanding the nature of persistent pain and accepting its very persistence is a significant problem, with about 50% of the population attending pain clinics in England still as puzzled 12 months into treatment as at the start.” How best to communicate difficult and complex concepts about a condition (and some of the treatments for that condition) that we don’t fully understand ourselves? 

This is the question that I hope to address in future issues of Pain Matters, in a regular column. In the meantime, I would love to hear from readers about their experience of communication from the pain clinic (or any other clinics), good or bad. If you have received a letter from a clinician, has it been helpful in any way? What could make it better? What do you wish had been covered? 

Lars Williams

You can write to Lars Williams c/o Pain Matters, email: editorial@painconcern.org.uk.