Comparison of the Quality of Discharge Letters Written by Large Language Models and Junior Clinicians: Single-Blinded Study.

BACKGROUND: Discharge letters are a critical component in the continuity of care between specialists and primary care providers. However, these letters are time-consuming to write, underprioritized in comparison to direct clinical care, and are often tasked to junior doctors. Prior studies assessing the quality of discharge summaries written for inpatient hospital admissions show inadequacies in many domains. Large language models such as GPT have the ability to summarize large volumes of unstructured free text such as electronic medical records and have the potential to automate such tasks, providing time savings and consistency in quality. OBJECTIVE: The aim of this study was to assess the performance of GPT-4 in generating discharge letters written from urology specialist outpatient clinics to primary care providers and to compare their quality against letters written by junior clinicians. METHODS: Fictional electronic records were written by physicians simulating 5 common urology outpatient cases with long-term follow-up. Records comprised simulated consultation notes, referral letters and replies, and relevant discharge summaries from inpatient admissions. GPT-4 was tasked to write discharge letters for these cases with a specified target audience of primary care providers who would be continuing the patient's care. Prompts were written for safety, content, and style. Concurrently, junior clinicians were provided with the same case records and instructional prompts. GPT-4 output was assessed for instances of hallucination. A blinded panel of primary care physicians then evaluated the letters using a standardized questionnaire tool. RESULTS: GPT-4 outperformed human counterparts in information provision (mean 4.32, SD 0.95 vs 3.70, SD 1.27; P=.03) and had no instances of hallucination. There were no statistically significant differences in the mean clarity (4.16, SD 0.95 vs 3.68, SD 1.24; P=.12), collegiality (4.36, SD 1.00 vs 3.84, SD 1.22; P=.05), conciseness (3.60, SD 1.12 vs 3.64, SD 1.27; P=.71), follow-up recommendations (4.16, SD 1.03 vs 3.72, SD 1.13; P=.08), and overall satisfaction (3.96, SD 1.14 vs 3.62, SD 1.34; P=.36) between the letters generated by GPT-4 and humans, respectively. CONCLUSIONS: Discharge letters written by GPT-4 had equivalent quality to those written by junior clinicians, without any hallucinations. This study provides a proof of concept that large language models can be useful and safe tools in clinical documentation.

Letter Writing as a Clinical Tool in Grief Psychotherapy.

The benefits of expressive writing have been explored since at least the 1980s. The effect of expressive bereavement-related writing has been studied primarily in college students, yielding inconclusive results. Nonetheless, recent effective, integrated psychotherapy protocols, targeting complicated and prolonged grief, include writing assignments, typically in the form of letters. The present paper explores how and why letter writing might be effective and meaningful as a therapeutic tool in the context of grief psychotherapy. It describes how working with letters, addressed to the deceased, might help facilitate self-disclosure, promote exposure to what is avoided, confront unfinished business, encourage continuing bonds, and help achieve a coherent narrative around experiences with the loss. As a therapeutic tool, letter writing has the potential to be helpful to many bereaved people, as it is a simple, effective, and meaningful way to access and work with relevant clinical material in the context of psychotherapy.

Family Letter Writing in Terminal Cancer.

In this article, I examine relational dynamics within a family who exchange letters after the experience of terminal cancer. The collected letters of a terminally ill husband and father to his children are presented as documents for growth. The letters are explored as a meaning making narrative of a family affected by loss and uncharted territory. As a participant researcher, I composed a letter to my husband 2 years after his death using autoethnography as a method of inquiry. Our children also created letters for their father 2 years after his death. Intentional references are made to the transformative value of letters as narrations of reflections, anxieties, and paradigm shifts. The value of family letter writing within terminal cancer is offered as collaboration, connection despite death, and re/writing a future with a loving regard for shared stories.

Assessment of Current Genetic Counselor Practices in Post-Visit Written Communications to Patients.

Providing patients with post-visit written communication (PVWC) is a long-standing component of genetic counseling. However the depiction of this practice in today's clinical landscape is limited. To better describe this practice, we surveyed practicing clinical genetic counselors to ask if they send post-visit communications to patients and if so, what are the types, the average length, and the average time spent writing. They were also asked the perceived purpose of providing PVWC, if/how the practice has changed over time, and factors influencing the practice. Eighty three percent (233/280) of participants reported sending patients PVWC. Of those, 93% sent at least one communication written in patient-friendly language. The type of communication varied by specialty. Prenatal genetic counselors were less likely to send patient-specific letters and hybrid letters (defined as letters with content intended for both a physician and a patient) than those in cancer genetics (p = 0.010, p = 0.001, respectively) or pediatric genetics (p = 0.001, p = 0.004, respectively). Prenatal genetic counselors spent less time on average writing post-visit communications (19.0 min) relative to those in cancer and pediatric genetics (30.6 min, p = 0.027 and 37.7 min, p = 0.001, respectively). The most commonly cited purpose for sending PVWC was to provide patients a formal account of what happened during the appointment. These data suggest PWVC are still regularly sent to patients but the practice is variable and is influenced by numerous factors including specialty, years of experience, and time constraints.

Learning to write letters: examination of student and letter factors.

Learning to write the letters of the alphabet is an important part of learning how to write conventionally. In this study, we investigated critical factors in the development of letter-writing skills using exploratory item response models to simultaneously account for variance in responses due to differences between students and between letters. Letter-writing skills were assessed in 415 preschool children aged 3 to 5 years. At the student level, we examined the contribution of letter-name knowledge, letter-sound knowledge, and phonological awareness to letter-writing skills. At the letter level, we examined seven intrinsic and extrinsic factors in understanding how preschool children learn to write alphabet letters: first letter of name, letters in name, letter order, textual frequency, number of strokes, symmetry, and letter type. Results indicated that variation in letter-writing skills was accounted for more by differences between students rather than by differences between letters, with most of the variability accounted for by letter-name knowledge and age. Although significant, the contribution of letter-sound knowledge and phonological awareness was relatively small. Student-level mechanisms underlying the acquisition of letter-writing skills are similar to the mechanisms underlying the learning of letter sounds. However, letter characteristics, which appear to play a major role in the learning of letter names and letter sounds, did not appear to influence learning how to write letters in a substantial way. The exception was if the letter was in the child's name.

Letters from Queer Elders: Transmitting Intergenerational Wisdom in LGBTQ+ Communities.

Intergenerational relationships have been established as a critical locus of psychosocial development, meeting needs of identity development for youth, generativity for elders, and connection and belonging for both. However, intergenerational relationships are both rare in the LGBTQ+ community and sorely needed as a buffer to the discrimination and harm that those within the community experience from systemic and structural oppression. Focusing on sexual identity, and employing a letter writing paradigm, we investigated the content of wisdom that LGB elders have to share with youth. In a descriptive, exploratory, mixed-methods, and pre-registered study, 94 adults ranging in age 50 to 79 years (M = 55.98; SD = 6.30) wrote letters to a fictional youth, Sam, as well as completed surveys of psychosocial development and well-being. Letters were content coded for themes, as well as for emotional tone and subjective perspective. The most common themes of wisdom shared included knowing and celebrating oneself, negotiating an oppressive society, and finding one's community. Those who wrote more emotionally positive letters scored higher on measures of wisdom and generativity, and lower on embitterment. Results are discussed in terms of the importance of cultivating opportunities for wisdom-sharing within LGBTQ+ communities to promote flourishing across the lifespan.

Dimensionality and Reliability of Letter Writing in 3- to 5-Year-Old Preschool Children.

The primary purpose of this study was to examine the dimensionality and reliability of letter writing skills in preschool children with the aim of determining whether a sequence existed in how children learn to write the letters of the alphabet. Additionally, we examined gender differences in the development of letter writing skills. 471 children aged 3 to 5 years old completed a letter writing task. Results from factor analyses indicated that letter writing represented a unidimensional skill. Similar to research findings that the development of letter-names and letter-sound knowledge varies in acquisition, our findings indicate that the ability to write some letters is acquired earlier than the ability to write other letters. Although there appears to be an approximate sequence for the easiest and most difficult letters, there appears to be a less clear sequence for letters in the middle stages of development. Overall, girls had higher letter writing scores compared to boys. Gender differences regarding difficulty writing specific letters was less conclusive; however, results indicated that when controlling for ability level, girls had a higher probability of writing a letter correctly than boys. Implications of these findings for the assessment and instruction of letter writing are discussed.

"Please, Mr. Postman:" Exploring the Use of Letter Writing to Address Loneliness.

PURPOSE: Informed by prior research and influenced by concerns that the COVID-19 pandemic heightened social isolation, this project examined the impact of a 12-month long letter writing project on levels of loneliness. METHOD: Through partnerships with local anti-poverty agencies, pen pals were paired between MSW students and community members who utilize services at these organizations. Participants completed the UCLA Loneliness Scale before and after the intervention. RESULTS: We found a mean decrease in loneliness at the end of the intervention. DISCUSSION: Letter writing was a successful way to attend to loneliness due to its accessibility to the participants. Our letter writing intervention is different in many ways from e-mail and texting. Participants noted that the waiting process between letter gave them time to think more deeply about their response as well as event to look forward to (e.g. getting mail). We found that the low-tech aspects of the project might have been helpful to some participants. CONCLUSION: Letter writing is an easily replicable, low-cost, low-tech activity for use by practitioners, which may be useful in a variety of social work settings to reduce loneliness.

A Brief Self-Compassionate Letter-Writing Intervention for Individuals with High Shame.

Objectives: Over the last decade, the mental health of undergraduate students has been of increasing concern and the prevalence of psychological disorders among this population has reached an unprecedented high. Compassion-based interventions have been used to treat shame and self-criticism, both of which are common experiences among undergraduate students and transdiagnostic vulnerability factors for an array of psychological disorders. This randomized controlled study examined the utility of a brief online self-compassionate letter-writing intervention for undergraduate students with high shame. Method: Participants were 68 undergraduates who scored in the upper quartile on shame. Individuals were randomly assigned to a 16-day self-compassionate letter-writing intervention (n = 29) or a waitlist control group (n = 39). Participants completed baseline, post-assessment, and one-month follow-up measures. Results: Participants who practiced self-compassionate letter writing evidenced medium-to-large reductions in global shame, external shame, self-criticism, and general anxiety at post-assessment, and gains were sustained at follow-up. Additionally, there were trend-level effects for increases in self-compassion and decreases in depression for those who participated in the intervention. Conclusions: This study examined the efficacy of self-compassionate letter-writing as a stand-alone intervention for undergraduate students with high shame. This brief, easily accessible, and self-administered practice may be beneficial for a host of internalizing symptoms in this population and may support university counseling centers as they navigate high demand for mental health services.

Barrett's Power Theory: Re-Conceptualizing the Pediatric Organ Donation Experience With Letter Writing.

Pediatric organ donation is often a time of reported turbulence and isolation for both families involved. Communication through letter writing is a way for those families to connect and heal, if they choose to participate. Barrett's Power as Knowing in Participation in Change Theory, with its accompanying health patterning, is applicable to this experience by facilitating awareness, choices, freedom to act intentionally, and involvement in the change process related to the pediatric organ donation process. Two families' experiences connected through organ donation and letter writing, as conceptualized through the lens of Barrett's Power Theory, supported future use of patterning of knowing participation in change for families.

The effects of providing peer feedback on learners' genre awareness in English as a foreign language business letter writing.

Despite the important role of the genre awareness in facilitating the effective communication in the global business context and the need to teach and practice writing for various social purposes, there was scant classroom-based research on effects of providing peer feedback on EFL learners' genre awareness in business writing for fulfilling the particular communicative purpose. This study examined whether student reviewers could improve their genre awareness in business letter writing by providing peer feedback to other students' writings at varying levels. Sixty business English majors, taking the business writing course for 1 year under the tutelage of the same instructor, participated in the current study. They were randomly assigned to the experimental group who reviewed the students' drafts at different levels (high, medium and low) and gave written comments and the control group who received no treatment but did self-revision. Both groups followed the genre-specific evaluation criteria during peer feedback and self-revision. Repeated-measures ANOVA on the two groups' writing performances at different timepoints (pretest, immediate posttest, transfer posttest and delayed transfer posttest) demonstrated that the participants in the experimental group had better performance than those in the control group at the transfer posttest as well as the delayed transfer posttest. Moreover, providing weakness comments on both the low-quality and the medium-quality drafts had significant effects on their own writing quality at the subsequent tests, whereas providing strength feedback on the high-quality drafts had statistically significant impacts on their own writing quality at the immediate posttest and the delayed transfer posttest. However, multiple linear regression analyses demonstrated that only offering weakness comments to the medium-quality drafts could effectively predict the reviewers' overall writing quality in the immediate posttest, the transfer posttest, and the delayed transfer posttest. Tentative research and pedagogical implications of the findings were discussed.

Dear Breath: using story structure to understand the value of letter writing for those living with breathlessness - a qualitative study.

Background: Despite the prevalence of dyspnoea (the pathological term for breathlessness) amongst the general population and the diagnostic importance of dyspnoea for respiratory illness, public awareness of dyspnoea is poor with an estimated two million people with undiagnosed Chronic Obstructive Pulmonary Disorder in the UK. We explore whether therapeutic letter writing is a valuable arts health approach for those living with breathlessness. Methods: Eighty (80) participants took part in 10 workshops held in community-based settings. The overall approach was qualitative. We analysed the data thematically. Results: Informed by theories of story structure, our analysis explores letters written to the breath in terms of there being a protagonist, antagonist, a process of recognition and reconciliation. Conclusions: Writing a letter to the breath facilitates new ways of relating to breathlessness. Letters create a personal narrative and workshops create a public story. Further research should explore whether therapeutic letter writing can support communication about breathlessness with clinicians.

Barriers, Challenges, and Decision-Making in the Letter Writing Process for Gender Transition.

This article addresses the challenges that clinicians face in writing letters of support for transgender and gender-diverse clients. It addresses common but challenging clinical representations to help the reader understand the nuances associated with writing letters. Three cases are presented. The first addresses systemic challenges, the second addresses management of care, and the third addresses co-occurring mental health concerns. Recommendations for practice are provided based on the experiences included within the 3 case examples.

'I Haue Ben Crised and Besy': Illness and Resilience in the Fifteenth-Century Stonor Letters.

The modern and medieval meanings of words reporting ill health often bear little resemblance to one another. This article compares the use of 'diseased' and 'sick' in the fifteenth-century Stonor family letters. It examines the word 'crased', which implies physical ill health most directly, but also suggests emotional, psychological, or spiritual distress in female family members especially. The article then turns to the practical implications of poor health, asking how and why it affected the day-to-day concerns of the Stonors and their associates. It uncovers compelling evidence for resilience in the face of many and competing calls of duty. Finally, the article presents unique palaeographical evidence for the impact of illness, where a correspondent is so 'seke' that he can scarcely hold his pen.

The contributions of vocabulary and letter writing automaticity to word reading and spelling for kindergartners.

In the present study we examined the relation between alphabet knowledge fluency (letter names and sounds) and letter writing automaticity, and unique relations of letter writing automaticity and semantic knowledge (i.e., vocabulary) to word reading and spelling over and above code-related skills such as phonological awareness and alphabet knowledge. These questions were addressed using data from 242 English-speaking kindergartners and employing structural equation modeling. Results showed letter writing automaticity was moderately related to and a separate construct from alphabet knowledge fluency, and marginally (p = .06) related to spelling after accounting for phonological awareness, alphabet knowledge fluency, and vocabulary. Furthermore, vocabulary was positively and uniquely related to word reading and spelling after accounting for phonological awareness, alphabet knowledge fluency, and letter writing automaticity.

Letra e escrita na obra de Jacques Lacan / Letter and writing in the work of Jacques Lacan / La letra y la escritura en la obra de Jacques Lacan / La lettre et l'écriture dans l'œuvre de Jacques Lacan

Os autores apresentam a letra na obra do psicanalista francês Jacques Lacan como conceito que trata de uma leitura e de uma escrita do inconsciente. Para tanto, faremos uma apresentação do conceito no seminário 9 L'identification (Lacan, 1961-1962), particularmente nas lições de 6/12/1961, 13/12/1961, 20/12/1961 e 10/1/1962. Com base na relação entre traço e letra, signo e significante esperamos demonstrar uma diferença no entendimento do conceito comparativamente ao texto L'instance de la lettre, de 1957, quando letra surge pela primeira vez formalizada na obra do autor e voltada principalmente para a leitura do inconsciente

The authors focus on the notion of letter in the work of the French psychoanalyst Jacques Lacan. In other words, letter would refer to both a reading and a writing of the unconscious. Therefore, we shall present this concept as described in the Seminar 9, L'identification (Lacan, 1961-1962), particularly in the lectures on December, 6th, 13th, and 20th, 1961, and on January, 10th, 1962. Our purpose is to demonstrate a different way of understanding this concept, by starting from the relation between trace and letter, sign and signifier. As such, our way is different than the one of The instance of the letter, originally delivered in 1957, in which letter was first formalized in Lacan's work and was especially focused on the reading of the unconscious

Los autores enfocan la noción de letra en la obra del psicoanalista francés Jacques Lacan como un concepto que se refiere a una lectura y una escritura del inconsciente. Presentan este concepto, descrito en el seminario 9, L'identification (Lacan, 1961-1962), particularmente, en las lecciones de 6/12/1961, 13/12/1961, 20/12/1961 y 10/1/1962. A partir de la relación entre trazo y letra, signo y significante proponen una comprensión diferente del concepto de letra tal como fue formulado por primera vez en la obra de Lacan, en el texto de 1957 L'instance de la lettre, en el que este término se refiere principalmente a la lectura del inconsciente

Notre article s'occupera de la lettre chez le psychanalyste Jacques Lacan, comme un concept qui traite d'une lecture et d'une écriture de l'inconscient. Nous ferons une présentation du concept dans le séminaire 9, L'identification (Lacan, 1961-1962), en particulier les leçons de 6/12/1961, 13/12/1961, 20/12/1961 et 10/1/1962. À partir du rapport entre le trait et la lettre, le signe et le signifiant, on espère démontrer une différence dans la compréhension du concept vis-à-vis du texte L'instance de la lettre de 1957, où la lettre apparait pour la première fois formalisée et dirigée principalement à la lecture de l'inconscient