The Death of the Physician Letter

Melissa Walton-Shirley


November 02, 2015

"T he single biggest problem in communication is the illusion that it has taken place." — William H Whyte [1]

After asking the patient why she had come, then scouring six screens of enumerations and indentations, still neither one of us knew why she had been referred. The review of the six-page communication left me reassured that the patient wasn't feeling threatened or being beaten at home, is up to date on TB skin testing, and was instructed to get a pneumonia vaccine. From the medication list I guessed at least some of her maladies that proved by the end of her new-patient visit that my medical telepathy was still intact. I'm impressed she received a copy of the 2-week old progress note, but I have no idea why she would want it. It probably took 15 to 30 minutes to construct and proved nothing except that its author had become a fantastic scribe.

Although there are volumes written on the failures of doctor-to-patient communication and physician-to-physician communication in the inpatient setting, there are little objective data on the impact of the failure of communication in the outpatient world. Inpatients represent a fraction of the total population of patients; however, I have no doubt the cost of communication failure is in the billions in unnecessary testing, time off from work, and missed diagnoses. One of the prime objectives of the Affordable Care Act was to improve information sharing, but instead it has created enormous "information fatigue" by stuffing the patient record with useless fillers. It has caused the greatest interruption in physician-to-physician communication that the outpatient world has ever known.

In the old days (and in the day of better communication pre-EHR), I received letters like this:

Dear Melissa,

I've seen Ms Malinda for 15 years and her type 2 diabetes is finally under good control. I am concerned about her mom's history of heart attack that occurred at age 65. Malinda has already surpassed that age. She has really has no new complaints, no chest pain, and walks daily, but due to her risk-factor profile, I'm referring her for risk assessment.

By the way, I ordered and enclosed a lipid profile for your review. She should also try to avoid beta-blockers, as she suffers from moderate asthma. Please call if you have any questions.

Hope you find this information helpful,



Today, there is no time to be eloquent and little motivation to be informative. Just when we think we've done a great job of data entry (ignoring the ridiculous amount of time it stole from the patient), we hit the submit button only to turn the latest War and Peace of the day into a jumbled conundrum of useless information that only a coder could love. The QVC shopping-channel hawkers would be envious of how much time we are able to waste saying the same thing over and over.

Practitioners are being pulled in a million different directions. As a profession we are disheartened and battle-worn, but we must fight harder to not become what our government has mandated. We were savvy enough to get into medical school, survive the rigors of residency, then land a job, and we are savvy enough to find ways to overcome the obstacles placed between patient care and us.

The most effective way to lift the dark veil that is impeding physician-to-physician communication is to resurrect the physician letter. It doesn't have to be the Gettysburg address or elegant prose. It just needs to be a few lines that convey the essence of our concerns and some salient facts about the patient history. It literally takes about two minutes to let our referral base, our consultants, and our patients know that we are not going to stand for the failures of modern communication. These constraints have been put upon us without our permission. With better communication we can take our profession back to the day when the coordination of thoughts, ideas, and facts mattered, and when patients felt like they mattered, too.


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