Harris Matthew, Ferreira Ana, Morães Isabela, de Andrade Fernanda, de Souza Daise
Oxford University, Department of Public Health and Primary Health Care, Oxford, England.
Rev Panam Salud Publica. 2007 Feb-Mar;21(2-3):96-110. doi: 10.1590/s1020-49892007000200005.
To identify obstacles impeding the use of the reply letter by secondary level specialists in the municipality of Camaragibe, Pernambuco, Brazil, and to highlight possible solutions for improving communication at the interface between secondary level specialist care and primary care.
Conducted in 2003, this qualitative study used semistructured interviews with 10 randomly selected secondary level specialists. The following specialties were represented: neurology, obstetrics, gynecology, psychiatry, otolaryngology, and colposcopy. Interviews were semistructured, using an interview guide, based on the following seven categories: (1) profile of the specialist, (2) description of outpatient clinic services, (3) professional satisfaction, (4) assessment of the municipal health services, (5) assessment of the Family Health Program (Programa Saúde da Família), (6) description of the referral process, and (7) reply letter utilization.
Most of the specialists understood the importance of the reply letter and that this form of communication with the generalist would ensure continuity of care, avoid duplication of efforts or disorganized patient management, and would provide the generalist with the professional support required. However, the study found that most of the specialists do not routinely use the reply letter. In general, the specialists have their own criteria to reply or not to a referral, for example, whether the generalist "deserved" a reply, whether the patient will remain under their care, or whether the patient has a significant pathology. Reasons for low reply letter utilization rates among specialists were categorized into four broad themes: (1) workplace organization, (2) communication inhibition, (3) professional isolation, and (4) medical education.
Despite a general understanding of its importance, specialists in Camaragibe had difficulty adopting the reply letter as a form of communication at the interface between primary and secondary care levels. The reply letter can be effective in improving communication at the interface, but the broad cultural, historical, and organizational features of secondary level specialists need to be considered in order to improve reply letter utilization.
确定阻碍巴西伯南布哥州卡马拉吉贝市二级专科医生使用回复信的障碍，并强调改善二级专科护理与初级护理之间沟通界面的可能解决方案。
这项定性研究于2003年进行，对10名随机挑选的二级专科医生进行了半结构化访谈。涉及以下专科：神经科、产科、妇科、精神科、耳鼻喉科和阴道镜检查。访谈采用半结构化，使用访谈指南，基于以下七个类别：（1）专科医生简介，（2）门诊服务描述，（3）职业满意度，（4）对市卫生服务的评估，（5）对家庭健康计划（Programa Saúde da Família）的评估，（6）转诊过程描述，（7）回复信使用情况。
大多数专科医生理解回复信的重要性，并且这种与全科医生的沟通形式将确保护理的连续性，避免工作重复或患者管理混乱，并为全科医生提供所需的专业支持。然而，研究发现大多数专科医生并不经常使用回复信。一般来说，专科医生有自己决定是否回复转诊的标准，例如，全科医生是否“值得”回复、患者是否仍将由他们护理，或者患者是否患有重大疾病。专科医生回复信使用率低的原因分为四大主题：（1）工作场所组织，（2）沟通抑制，（3）职业孤立，（4）医学教育。
尽管普遍理解回复信的重要性，但卡马拉吉贝的专科医生在将回复信作为初级和二级护理层面之间沟通形式方面存在困难。回复信可以有效改善沟通界面，但为了提高回复信的使用率，需要考虑二级专科医生广泛的文化、历史和组织特征。
