One of the trickier challenges for any diabetic eye screening programme is getting the wording right on the patient letters. Communicating the potential seriousness of diabetic retinopathy without terrifying the patient in the process is a balancing act that would challenge the skills of Charles Blondin, and when you add in the need to be clear and concise enough to earn a crystal mark, the feat becomes nigh on impossible.

Where I come from, Crystal Mark is the rough-looking bloke down the road who's addicted to methamphetamine, but in other parts of the country it's a highly prized award from the Plain English Campaign, which can be earned by any document with the clarity of a freshly fitted lens implant. The Derbyshire Diabetic Eye Screening Service won an even more prestigious award earlier this year, which was somewhat surprising as most of their letters begin with the words "Ey-up, duck", and they use the phrase "dunna wittle" in their R1 results.

But for the rest of us, finding the right words can be a constant struggle. A number of years ago, we started getting phone calls from patients who'd been told they had background retinopathy and were worried they were going blind. So we added a line to the results letter stating "This does not mean you are going blind". At which point we started getting calls from people who'd never even thought about losing their sight, and were suddenly terrified by the word 'blind'.

To this day, about 50% of newly diagnosed R1 patients tell me how reassured they were by the wording of our results letter. The other 50% tell me how panicked they were. The concept of Ironic Process Theory states that if you tell people not to think of an elephant, they automatically do. Except that in this case, half of them think of Dumbo, while the others think of the killer elephant attacks they've watched on YouTube.

To my mind, one of the main aims of patient letters should be the avoidance of telephone calls. Any letter which prompts either a question or a fear is going to result in a call to the office to have those questions answered and those fears allayed. An imperfect letter template could mean an entire admin team being tied up indefinitely. And yet getting it right seems extraordinarily difficult. When a patient moves into our area from another screening programme, they often bring their last results letter with them, and I'm constantly amazed by the variations in wording. A recent example informed the patient that whilst his eyes were clear of diabetic retinopathy, they'd noted an unspecified "non diabetes related issue" which might require treatment, and urged him to contact his GP. As far as the patient was concerned, it could have been anything from cancer to a brain tumour. It turned out to be a cataract.

Unfortunately, when it comes to clear communication, the national programme fares no better. The 'Guide to Diabetic Eye Screening' that we're all handing out to the patients, lists the concepts of 'bringing your glasses' and 'not driving after the appointment' under "hints and tips" rather than vital information. Which is a bit like putting the appointment time as a P.S..

And as for the national letter templates, they're an object lesson in the difficulty of getting it right. Logging on to the DESP extranet provides you with access to twenty-one standard letter templates, covering almost every eventuality bar alien invasion and tsunami, and yet still the perfect wording proves elusive. Take the R0M0 results letter. This is the one that all patients dream of getting, sent to those with no retinopathy, who have nothing to worry about and no problems to fear. It's the medical equivalent of a missive from the Reader's Digest prize draw manager. And here's how it breaks the good news:

You are at very little risk of sight-threatening diabetic retinopathy at this time.


Hurrah! A small risk of blindness! At the moment! It goes on...

Screening detects nearly all early signs of diabetic eye disease. However, very occasionally it can miss changes that could threaten your sight.


So we've probably missed something terrible. But we'll see you again in a year. Although whether you'll have enough vision left to see us is another matter.

That letter should fill people with happiness, relief and positivity, not fear, dread and paranoia. Unfortunately, the only people benefiting from that particular wording are the opticians with fundus cameras who can charge our worried R0M0 patients for an unneeded extra test.

Of course, the results letters are always going to be a minefield. But the appointment letters should be plain sailing. And plainly worded. Or so you might think. The standard DESP invitation letter template, which can be downloaded from the extranet, suggests using the following text:

The aim of diabetic eye screening is to detect any changes caused by diabetes that could damage your sight. You may be completely unaware of these changes but they are usually very treatable.


I like that wording a lot. The second sentence in particular sums up the most important, and most reassuring, aspect of screening: that if we find problems, we can treat them. It's something we need to repeat ad infinitum, in appointment letters, results letters and in clinics. It's the one fact that can stop patients worrying, and - despite its apparent obviousness - it's not widely enough known. This time last year, we added that text to our appointment letters, and it seems to have worked well.

Until now, that is.

I screened a Middle Eastern gentleman this week, whose knowledge of English was limited, but probably better than the average EDL member. Despite having to speak a little slower, we understood each other perfectly, and his affable nature meant that by the end of the appointment we were firm friends. I concluded by showing him the retinal photographs, talking him through what I could see, and reassuring him about the likely outcome, before standing up to show him to the door.

At which point he looked very confused. I repeated the information, briefly, in simpler words, but he still looked decidedly puzzled. So I asked him if he had any questions. His response succeeded only in transferring that look of confusion from his face to mine.

As unlikely as it may sound, he asked me why the appointment letter had told him to bring a change of clothes. I replied that it had merely asked him to bring a pair of glasses, but he was adamant that he'd been expecting to take all his clothes off, and wondered why I'd let him keep them on, suggesting that maybe I hadn't done my job properly. I politely argued my point again, and he responded by producing his letter and directing me to the section concerned.

It transpired that he'd taken the phrase "You may be completely unaware of these changes" to mean "You may need a complete change of underwear". He then held up a bag containing a pair of pants and a vest. And he wasn't even joking.

I'm not sure which is more surprising: the fact that he'd misinterpreted our letter so spectacularly, or the fact that he was quite happy to go along with it. Let's face it, if anyone has a good excuse for a DNA, it's the man who thinks the screening process involves getting naked, and may very well soil your underwear.

I can't wait to hear what he thinks of our results letter. He'll probably read 'background' as 'backside' and complain that I refused to look at his bottom.