POST TRAUMATIC

By Martin Culshaw
Contact the author via Chris Johnstone by e-mail at christopher.johnstone@ntlworld.com

There is something going on in my office in-tray. Some dark, unexplainable, magical force. As if the correspondence lurking therein is able to multiply at will behind my back. For no matter how quickly and efficiently I attend to the mail (and anything purporting to be mail) in the rickety plastic-framed ducat by the window, there is always another bundle of stuff lying in wait for me when I return to it a minute later. Letters reproducing like rabbits? Perhaps it's time for a holiday…

I'm sure I am not alone. Despite the advent of electronic communication, most of us continue to find ourselves sifting through letters, journals, invitations, notifications, citations, complaints, results and reports in paper form. All this before we even get a chance to check our e-mail with countless attachments to be printed off. There is a seemingly endless supply of material correspondence winding its way to our offices- generally with the heading For Your Information - and so much to be checked, signed, copied, recorded and filed that one can feel more like Jonathan Pryce's character out of Terry Gilliam's Brazil rather than a physician.

Every day I receive (without asking) several promotional pamphlets from drug companies (to add to the ones that fall through my letterbox at home), telling me that further analysis of a milked-dry RCT reveals an exciting discovery in side effect profile compared to Brand X. Some are in pop-up form; others tell you how to claim your free gift. All are annoying.

Then there are the journals I've never subscribed to. Complete with cellophane, promotional inserts and more drug propaganda. Next I discover the invitations to far off conferences that have already taken place. Followed by the questionnaires- and reminders that I have still to return questionnaires. And buried under all of this might just be something relevant to my clinical practice. Or at least my pay slip? But seriously- add in any managerial, educational or research responsibilities and one's in-tray becomes a sea of paperwork beyond navigation.

In Psychiatry the situation is compounded by, for example, Care Programme Approach and Mental Health Act documentation. As a result, case-notes, even for those patients with a relatively short length of contact with the service, quickly become full to bursting- before proceeding to the Number 2 of 2 category and beyond.

The General Practice-Psychiatry interface is another victim. For instance, Psychiatry letters detailing first contacts with patients or those describing an admission to hospital can run to many pages. Too many pages. These letters, apparently specifically written with the communication of facts to the GP in mind, contain such relevant information as the patient being "casually dressed" when they presented to the hospital three months before. Rather than a helpful brief summary of progress in hospital and the situation at time of discharge, there is a tendency to go into minute detail about the patient's background. The most obvious conclusion to be drawn from this is that most of each letter remains unread and that the reader instead focuses on the first and last paragraphs which hopefully contain what they need to know about diagnosis, treatment and follow up plans. The material sandwiched in between exists as an unread testimony to the conscience of he or she who created all this prose during some sort of cathartic connection with a Dictaphone. As well as the burden on administration staff (and the small matter of rainforest destruction), the work of our medical secretaries to type out lengthy patient biographies is soul-destroying and surely not the best use of their time. I was guilty of composing such letters once and so now the one pearl of wisdom that I try to smuggle into my trainee's conscience is that the wheat/chaff ratio of this form of communication is of prime importance. Letter writing is a real skill.

However, some correspondence between health professionals clearly needs to be longer. Complex cases can not always be summarized without going into the whole story. Medico-legal reports are often utterly comprehensive since a show your working style can perhaps preclude a court citation for clarification. A typed, thorough account of a patient's life and mental health problems can be an extremely useful source of information for someone unfamiliar with the patient, doing research or having to compile a report. The danger though is that such letters come to replace hand-written entries in the notes. Eventually there will be every excuse for not writing legibly- it was going to appear in the letter anyway…

Keeping on top of all this paperwork requires an organizational ability that not all of us possess. Obsessional traits are a must if we wish to avoid this never-ending, Forth Bridge-painting task getting out of control. So the anal methods which I employ to try to manage all this mail include a ruthless and efficient triage system (the bin has a major role here) and the aim to empty the in-tray each time I'm there. It almost works. There is also the concept that reciprocity has a part to play: If I make my letters shorter and more to-the-point then those with whom I engage in correspondence will surely follow?

What can we conclude from all this? Perhaps that if a letter is to be long, it is because it absolutely needs to be long. If it is short it is because it has to be focused to communicate its ideas effectively. As such, we need to examine closely our reasons for writing what we write and for whom it is intended.

As Pascal once wrote:

"I have made this letter longer, because I have not had the time to make it shorter."

Other hoolet online articles by Martin Culshaw can be found at:
hoolet edition 47 - Post Traumatic
hoolet edition 30 - Back Seat Doctors
hoolet edition 28 - A Winter's Tale
hoolet edition 27 - Pleasure Principles

hoolet is the magazine of RCGP Scotland. It is supported intellectually, financially and emotionally by RCGP Scotland.

This issue maintained by Robert Hallam.