This study explored the reliability and quality of letter-writing by medical students to the patients they saw during consultations as a teaching tool in family medicine. Both the patients and the experts gave high scores for the value and quality of the letters in terms of the description of the problem, adequacy of recommendations given, and courtesy and respect.
The patients, regardless of their age, gender, education level or place of living, gave higher scores than family medicine experts for all criteria – description of disease, recommendation and courtesy, most probably because that they valued the novel way of learning about their disease and recommendations for therapy and lifestyle change.
Family medicine experts were much stricter than patients in their evaluation of the content of the letters (adequacy and clarity of disease description and adequacy of recommendations), indicating that they focused on the transfer of medical facts. On the other hand, the highest scores and the smallest difference between the patients and experts were for courtesy and politeness, demonstrating that this aspect of patient-physician communication is the basic premise for interpersonal relationships in a family medicine office .
Both the patients and the experts seemed to like longer letters, as the length of the letter showed significant positive correlation with the given quality summary score.
The results of our study are limited by its cross-sectional design, lack of a control group, and absence of objective outcome, but the rating of the letters by experts and their agreement on the scores was consistent across two different student cohorts. Furthermore, the selection of the patients, which was made by the students and their tutors according to very general criteria provided by the researchers to the tutor, could have influenced the results because students and tutor may have chosen the patients they felt most confident to describe in a letter. As students had different tutors in urban and rural FM offices and we did not find differences in the quality of letters between these two sites, it is unlikely that students systematically chose more “convenient” patients for their letters. As the letters were a part of the course evaluation, it is more likely that they followed their tutors’ instructions and found most adequate patients for the task.
Within these limitations, our study indicates that the exercise of letter writing is a reliable education tool for family medicine course to develop competencies of students for communication with patients. Based on our first experience of writing letters to patients as a mandatory part of the family medicine course, we will continue to evaluate this educational intervention using more stringent methodological designs, and explore further how written communication would best supplement other learning tools in family medicine training .
The results of our study could also be interpreted as evidence for paternalistic views of family medicine practitioners, who prefer providing instruction and clinical competencies to communication with patients. The dominance of such paternalistic approach takes away the patient from the central role and from advantages of the “partnership in care” and “joint partnership” for increasing health care quality . The patient is a passive receiver of instructions, advice and information, with little respect for his or her feelings, opinions and priorities. Such traditional approach to family medicine should be replaced by the use of best available evidence coupled with the patient’s personal choice and values . However, such change can be best accomplished by radical reform of graduate medical education, with emphasis on empathy and communication skills . The reform can then bring about the development of different educational interventions for practical competencies, such as communication labs which help students to understand their future role as physicians and their relationship with patients, to develop self-confidence and prepare them for the first contact with patients [19, 20]. The curricular reforms are directed to increasing practical work, problem solving, early contact with patients and greater bonding of students with their mentors [20, 21]. The relationship between the student and the teacher should mirror patient-physician relationship: it should have the characteristics of mutual respect and build the process of shared decision-making, with the aim of promoting cooperation rather than competition .
Direct evidence for the value of written communication with the patients comes from the study of Roberts and Partridge (2006) , which compared the satisfaction of patients and family medicine practitioners in receiving letters from outpatient consultants written specifically for the physician or for the patient. While patients appreciated both types of letters, they found significantly more terms they did not understand in the letters written to physicians than to patients. The letters written specifically for patients were also significantly shorter and easier to read.
In contrast to the study of Roberts and Partridge , where patients underlined more terms they could not understand, family medicine experts in our study underlined three times more problematic phrases than patients. While patients were mostly concerned with phrases they thought were not clear for a lay reader, the experts were equally concerned with correct professional terminology and correctness of information as they were with the adaptation of the style for the lay reader. Together with the value ratings of the letters, our results show that patients appreciated the letters as a benefit of their visit to the family medicine office. This was a general experience, as it was not influenced by the characteristics of the patients, including age, gender, education and employment. The type of family practice (urban vs. rural) also did not influence the evaluation of letters, although the consultations in rural offices were significantly longer than in urban offices and this was also significantly associated with higher patient enablement. Our qualitative analysis of patients’ reaction to letters  showed that some patients were initially anxious about getting a letter from their consultation in a family medicine office, as they are used to often getting bad news from specialists’ consultations of discharge letters from hospitals. However, after the experience, their responses were mostly positive and optimistic, not only from the point of view of information received (“I understood everything in the letter and now I know about my disease better than before.”) but a personal satisfaction and hope (“I periodically go back to read the letter again, and it helps me.”, “I found the letter very comforting and reassuring.”) . We are currently working on a separated qualitative analysis of students’ evaluation of the letter-writing exercise to explore their satisfaction with the learning outcomes, interactions with the faculty and professionalism.