Current issues of ACP Journal Club are published in Annals of Internal Medicine

Quality Improvement

Letters to patients improved patient satisfaction and recall in cancer care

ACP J Club. 1992 May-June;116:93. doi:10.7326/ACPJC-1992-116-3-093

Source Citation

Damian D, Tattersall MH. Letters to patients: improving communication in cancer care. Lancet. 1991 Oct 12;338:923-6.



To determine whether letters to patients outlining salient information from an oncology consultation influence their satisfaction with the consultation and recall of the information conveyed.


Randomized controlled trial.


General oncology outpatient clinic in Australia.


Those attending the clinic for a follow-up consultation that was to include discussion of treatment strategies, change in disease status, or intercurrent disorders were included. Patients attending for "check-ups" only (n = 38) or who did not speak English (n = 14) or who were considered too ill to be interviewed (n = 7) were excluded. The 48 eligible patients (age range 21 to 71 years) agreed to participate and were randomized after the consultation.


After each clinic visit the oncologist dictated letters including salient points of the consultation (i.e., treatment alternatives, test and clinical findings, referral arrangements, side effects, and prognosis) to the 24 patients randomized to receive the intervention. The medical student who attended the consultations completed unblinded, structured telephone interviews 3 to 19 days later with all 48 patients.

Main outcome measures

Patient satisfaction with the consultation was measured on 5-point scales for satisfaction with information about and explanation of the patient's condition, opportunities to ask questions, and the physician's honesty and willingness to discuss the patient's fears. The patients' recall of the consultation was measured similarly.

Main results

Overall, both groups of patients were well satisfied with their consultations. 13 patients who had received a letter were completely satisfied compared with 4 controls {95% CI for a difference of 38%, 13% to 62%}*. Patients who received a letter were more satisfied with the amount of information given and had a higher total satisfaction score than the controls (medians, 32.5 vs 30, P = 0.01). There was no difference between groups in the percent of items recalled (85% for the letter group vs 75% for the controls), but the intervention group had more information to recall than the control group (median 6 items [range 3 to 13] vs 5 items [range 4 to 9], respectively). 7 control patients recalled ≥ 1 item incorrectly compared with 2 patients who received a letter.


Letters to patients with cancer that gave the salient points of a consultation increased patient satisfaction and aided the patients' accurate recall of the consultation.

Source of funding: Not stated.

Address for article reprint: Professor M.H. Tattersall, Department of Cancer Medicine, Blackburn Building, University of Sydney, New South Wales, 2006, Australia.

*Numbers calculated from data in article.


This modest-sized randomized controlled trial has demonstrated that patients are more satisfied with oncology consultations and perhaps more correct in recall of information about care when visits are followed by letters. These findings are the more important because it has been found that patients perceive that they do not receive as much information as they want during the course of cancer treatment. This trial further suggests that letters perceived by patients to be conveying "bad news" produced more anxiety than "good news" letters, but increased satisfaction with care was apparent in both subgroups. Most referring physicians were supportive of this postconsultation letter strategy, although 21% of those physicians were either unsure of the letters' usefulness or concerned about the potential for misinterpretation of information and about possible distress to their patients.

The study would have been strengthened by using a blinded telephone interviewer. In future work, it would also be interesting to know how much of the information patients can acquire is actually available during study visits compared with the postvisit correspondence, how much time is committed to developing the postvisit letter, and whether patients (particularly the patients receiving "bad news") would have benefited further from an opportunity to ask questions about their letters. Clearly, these letters were not received casually. Each patient read his or her letter a mean of 2 to 3 times, and most patients (20 of 24) shared it with at least 1 other person.

This study suggests that practitioners might do well to send letters to patients and referring physicians after consultations. How much effort would be committed to such activities, whether this written addition to the consultant-patient dialogue needs to be followed by a telephone call to explore unresolved questions, and what the consequences of this correspondence are for longer term outcomes of care are all matters for productive speculation and future research.

Thomas Inui, MD, ScM
University of WashingtonSeattle, Washington, USA

Thomas Inui, MD, ScM
University of Washington
Seattle, Washington, USA