Adventures in Ethics and Science

I have, of late, received a number of emails asking advice on matters somewhere in the territory between ethics, etiquette, and effective communication with members of the tribe of science. While I’m no Ann Landers (as has been noted before), I’ll do my best to answer these questions on the blog when I can, largely so my very insightful commentariat can chime in and make the resulting advice better than what I could generate on my own.

Today we have a question from a reader struggling with the question of how to address one letter to two doctors. He writes:

Hi Dr Free-Ride,

I’m not sure if this is a topic that falls within your normal scope of
interests but whatever advice you can provide would be appreciated.

For personal (ie non-academic) reasons I have to address a letter to two
medical specialists who work in separate but related areas. They are
co-operating to a greater or lesser extent in investigating a family
health problem as well as taking individual approaches according to
their specialities.

Each is attached to a different hospital and each is head of their
department. However, one has the title Associate Professor whilst the
other has the title Professor. The A/Professor is a female and the
Professor is male. Based on the first letter of their surnames lets say
that we have A/Prof L. and Prof M.

A/Prof L. is, apparently, doing more (maybe most) of the work at the
moment but she is not very communicative (ie. despite far too many
attempts at contact we have heard nothing from her) whilst Prof M. is
quite active in the matter also and maintains at least some contact.

The problem, obviously, is the address and the salutation.

One solution seems to be that I should send the same letter individually
addressed to each of them with an indication (cc: otherdoctor) that the
other person has received a copy. I’ve got some fuzzy thoughts as to why
I don’t like that solution but I’m having difficulty in writing down
those thoughts.

I could address the letter in strict alphabetical but that seems to
“promote” A/Prof L. and it would seem natural to write the salutation as
“Dear Madam and Sir, …” which adds to that appearance. I did consider
“Dear Doctors, …” but that seems to be ignoring their professional
titles which I think is not a good idea.

Of course, I could reverse the address and therefore, as I see it, obey
the academic hierarchy but as each are heads of department in their own
right I’m not sure that my understanding of the hierarchy is correct.
I’m also concerned that A/Prof L. would read this as not respecting her.

So, I’m rather confuzzled at the moment.

If you are able to un-confuzzle me I’d be very grateful!

I know that you sometimes use received emails as blog material and you
are very welcome to use this email if it is useful to you.

Thanks for your time.

Ivan.

I’ll admit that my first thought was to go for the same letter addressed two ways, with the doctor to whom a particular copy of the letter is sent as the addressee and the other doctor (who gets the other version of the letter) cc’d. Like Ivan, though, I decided that I don’t like that solution. First off, going this way introduces the practical risk of mixing up letters and envelopes, leaving each of the doctors in question receiving a letter on which he or she is cc’d but not the primary recipient. This would, of course, be the opposite of what was intended, and could potentially leave each of the doctors feeling less directly involved and responsible as far as the query in the letter, and perhaps even as far as the family medical situation more generally.

Indeed, even if you got the right letter in the right envelope, I think this addressing strategy tends to reinforce the idea that the two doctors are interacting with the family medical situation separately, rather than in collaboration. I take it that one important reason to write to them about this situation together is to help them actually collaborate in dealing with the situation, and with the interested family members (including Ivan writing the letter to them).

So, the easy answer having been shot down, I think the important question to ask is what is the best way to construct this letter to get these two doctors communicating effectively with each other and with the sender?

Especially in the case of Associate Professor L., who is presumed to be working hard on the case but who has so far not been in contact with the family about how this work is progressing, the hope is that the letter will result in communication — that she will update the family on what she has learned so far, what work is still in progress, what sort of timeline she imagines for having enough information with which to make some reasonable decisions about the health situation, etc. The letter needs to communicate to her that the family needs her updates — not because they don’t believe she’s working on the case, but because this information will be more comforting and useful to the family in getting through the situation than will continued radio silence.

Professor M. has maintained some contact with the family (although perhaps not providing as frequent updates as the family would like). The letter needs to leave Professor M. inclined to keeping the family in the loop as he works on the case.

Potentially, the letter can also put Dr. L. and Dr. M. in better communication with each other on this family health problem. Although they work in different areas and at different institutions, they may find this professional collaboration on this particular case productive. They may be able to share relevant articles or case reports they turn up in their own literature searches, or possibly fruitful ideas that the other has better expertise to evaluate. Indeed, collaboration on this particular case could lay the groundwork for future productive collaboration between the two doctors and the departments they head.

Plus, if Dr. M. is in regular contact with Dr. L. about this case on which they are both working, there’s a chance he can communicate to the family about what he knows of Dr. L’s current progress. It’s possible that Dr. M. is just more comfortable communicating with the family (or with patient families in general) than Dr. L. is, making him a more reliable conduit of information. This is not to say that Dr. L. shouldn’t be working on communication skills or has no duty to keep the family up to date on her progress. However, training one’s doctors in such skills and duties can be tiring work. Pragmatically, having a reliable way to get the information (via Dr. M.) is better than getting no information at all.

Where does this leave us as far as addressing the letter?

I’m not entirely sure the recipient address and the salutation are sufficient to communicate what needs to be communicated (with respect to the family’s desire to be kept in the loop with regular updates from both doctors, and the family’s hope that the doctors will collaborate with each other to find the best approach to the family health problem in question). There may need to be some explicit communication of this in the body of the letter itself.

As far addressing both recipients with proper honorifics and recognizing both for their expertise and accomplishments (as heads of their respective departments), I think it would work to address the letter:

Herfirstname L-lastname, M.D., Associate Professor and Head of [Her department], Her Institution

Hisfirstname M-lastname, M.D., Professor and Head of [His department], His Institution

To my mind, this recognizes the (slight) difference in academic ranks, but doesn’t make a gigantic deal out of it, emphasizing instead their positions as department heads — and the special disciplinary expertise from those different departments that each of them is drawing upon to work on this case.

Alphabetical order seems as fair as anything else, and having the less-communicative Dr. L. listed first may gently put her on notice that the family needs a bit more from her (at least in terms of communication) than she has given so far.

As far as the salutation, my first preference would be:

Dear Dr. L. and Dr. M.

especially since medical types seem most comfortable being addressed as “Doctor” (and somewhat discomfited by holders of mere Ph.D.s who introduce themselves as “Doctor”). But, it would also be appropriate to use the salutation:

Dear Prof. L. and Prof. M.

I have never, ever seen “Dear Assistant Professor X” or “Dear Associate Professor Y” as a salutation. The convention seems to be to identify the precise professorial rank in the address block, then address any flavor of professor as “Prof.” in the salutation. Because this is conventional, neither Dr. L. nor Dr. M. should be jarred by it.

I hope this helps Ivan with the problem of addressing the letter — although I’m probably adding at least a paragraph to the body of the letter to explicitly address the collaboration and communication Ivan is hoping not to undermine with the address and salutation.

Commenters who have other suggestions here (especially if they think the advice I’m offering is wrong) should share them in the comments.

Comments

  1. #1 D. C. Sessions
    February 1, 2010

    Channeling PalMD: “Where is the primary care physician in all of this?” Not directly on-point, but still important. One of the roles of a good GP/FP/Internist is to do exactly this kind of coordination (or so I’m informed.)


    dcs, who is trying to help his mother change primary caregivers for this very reason.

  2. #2 ecologist
    February 1, 2010

    Good grief! This is an issue?

    My take on it? Address the letter by the information needed to get it delivered properly. Professorial rank and departmental headships are irrelevant. Hence:

    Herfirstname L-lastname, M.D.
    Department of [Her department]
    Her Institution

    Hisfirstname M-lastname, M.D.
    Department of [His department]
    His Institution

    Salutations on the letter exactly as you described:

    Dear Dr. L. and Dr. M.

    I agree completely that the issue to be communicated needs to be stated clearly and explicitly. Trying to have it inferred by means of subtleties of salutation will fail.

  3. #3 Ivan
    February 1, 2010

    Hi Janet,

    Many thanks for your quick response! Your mind-reading mechanism is working superbly – you have managed to articulate just about every thought that I had about this letter!

    The letter is to serve a couple of purposes one of which, as you said, is to remind Prof L. that an occasional update would be appreciated (more than nothing at all in nearly three years would be good!). The other main reason for the letter is to provide a more detailed medical history of the family than either doctor currently have (this is due to some more-recently diagnosed “issues” (through the PCP) which seem to link back to previously thought-to-be unrelated issues).

    So, yes, it is essential that the two doctors understand that they are working together as well as working with my family.

    Janet, I’m glad that you feel that an explicit mention in the body of the letter (suitably subtle) regarding lack of contact would be appropriate. Thanks!

    It’s unfortunate but I also think that gender is an issue in my thinking regarding addressing. It seems to be that the correct thing to do is automatically give preference to the female but I’m not willing to do that. I’d prefer to address the letter correctly (as much as possible) regardless of gender so that whoever should be correctly addressed first will be. As I said, regardless of other issues, my thoughts were that I should try to respect the “hierarchy”.

    So my gender related thoughts were that it is possible that the better-credentialled male could be upset at being addressed second (for professional as well as gender based reasons) even though I feel, like you Janet, that the letter should be addressed firstly to Prof L. I’d like to think that professionals are above this sort of thing but I rather think not!

    @DCS: The PCP is a very good doctor in our opinion but no matter how good his skills even he can’t make people communicate if they choose not to. We understand that the PCP has sent several letters as well as personally making ‘phone calls to each of the departments. He, apparently, is getting the same response as us!

    The “condition” appears to be some rare genetic disorder (part of which is positive for malignant hyperthermia and muscle wasting which seem to be linked in this case) so we are dealing with a geneticist (*presumably* for diagnostics, this is Prof L.) and a neuro-muscular researcher (who, we think, is waiting to find out who in the family is affected and to what extent). We have been told that they are each recognised (as are their departments) as one of the leaders (if not the best) in research in these areas in the country. Obviously, this is well outside of the scope of knowledge of a PCP.

    So I’m not convinced that changing the PCP would achieve anything in this case and I’m not certain that we even have the option of changing specialists. My understanding is that all research in this field is ultimately channelled through the departments of these two professors.

    Good luck with your mother DCS, it has taken us long time to find a PCP that we really trust and can work with! Our PCP has recently been diagnosed with Chronic Fatigue Syndrome so we will probably have to start our search (again, sighs) in the next year or so.

    Ivan.