Purpose & Content of a Cover Letter

Problem:

“Why does MDReview ask us to provide a cover letter with each case for external review? What should this letter contain? How do we write it in such a way as to not bias the reviewer?”

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Solution:

Simple or detailed, a cover letter is integral to effective external peer review. While MDReview learns a great deal about each case to make sure we recommend the best strategy and reviewer, we believe that a succinct written communication between our client organization and the reviewer is highly important. An appropriately written cover letter does not inject bias, but rather outlines the important issues to be addressed by the reviewer. Each case brings its own set of complexities and there can be no assurance that all key issues can be recognized and addressed by the reviewer. Even the best of reviewers can’t always see every nuance-especially given the highly complex cases we tend to see at MDReview. A well worded cover letter focuses the reviewer on the aspects of care most important to leadership. It is best that this letter comes directly from organizational leadership without having it filtered by anyone, including the MDReview team.

Some cover letters reflect the strategy that the less the reviewer knows, the better, or that there are no specific aspects of care that have been targeted for review. While this “less is more” approach is certainly defensible, there are also good reasons to outline specific areas of interest that have been identified. In a prior edition of ProblemSolved, I made the point that peer review is not a report, but a process. After submission of the final report, the reviewer can provide additional information or answer follow-up questions if the report fails to address all key concerns. However, a carefully worded cover letter not only ensures that identified issues are addressed in the final report, but also serves to reduce the likelihood of extending the time necessary to complete the peer review process. The more the reviewer knows up front about leadership’s questions, the higher the likelihood for the reviewer to address all the important aspects of the case in the written report without prolonging the process.

What makes for an effective cover letter? It is free of emotion. It does not state conclusions or leanings reached by anyone including the peer review committee or other clinicians. It asks specific questions or outlines areas of focus that are free of any bias.

And it provides no superfluous information that can give the reviewer any favorable or unfavorable perception of either the subject physician or the care provided. Including a brief overview of the case can be helpful, but the same standards apply.

Making the request “Please address the deficiencies related to management of complications that resulted from technical surgical errors” is full of bias. It shows that opinions have been formulated regarding both surgery and management of complications. A better formulation of the request would be “Please address the surgical complications as well as the subsequent management of those complications.” This focuses the reviewer on what leadership finds important without putting the reviewer in a position of having to agree or disagree with established opinions, in other words, without injecting unnecessary bias. Further, stating that the subject physician is known to be disruptive or is highly popular among his colleagues is information that is not only unnecessary, but can taint the reviewer’s thinking. Certainly, such statements can bring into question the validity of the review by anyone who is threatened by its findings.

An effective cover letter focuses the reviewer’s attention to aspects of the care as documented in the medical record without compromising the outcome of the review by injecting unnecessary bias. It is supportive of the highest integrity peer review while minimizing process delays.