Unoffical Guide to Medicine Essay Competition – Medical Student Category Runner-up: Michael Smith

Well done to Michael on being a runner-up in the medical student category of our ‘Unofficial Guide to Medicine Essay Competition’ for his essay on “Can you read this? – Why do doctors have terrible handwriting? What sort of problems does this cause in the workplace? What measures can be put in place to reduce illegibility and error?”

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Hi, I’m Michael, I’m a first year medical student at the University of Warwick. In July 2016 I graduated with a B.Sc in Mathematics from Southampton, and I enjoyed education so much, that within 2 months I was back in full time lectures. Although there is quite a notable change from Mathematics to Medicine, and I can’t wait to see what the next 4 years have in store! (Although I feel that hoping there is some time off in there too, might be setting my hopes too high)

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Can you read this? – Why do doctors have terrible handwriting? What sort of problems does this cause in the workplace? What measures can be put in place to reduce illegibility and error?

Doctor’s handwriting is famously bad. But why is this a problem? In a world where the president of the USA is making policy statements in 140 characters, or less, in perfectly legible times new roman, a part of me can’t help but question why a doctor’s handwriting is being commented on. This is something that I will come back to later, but first I would like to explore the evidence behind the claim that doctor’s handwriting is illegible.
In 2005, Gakhar et. Al [1] found that 37% of notes written by doctors were deemed to be of poor legibility. Since the judgement was made subjectively, it is difficult to determine what exactly poor means, however the numbers are still startling. This appears to imply that the myth of Doctor’s having substandard handwriting is centred on truth. The importance of this however, is disputed. Whilst many sources proclaim that ‘Doctors’ handwriting is so poor it is putting the lives of hospital patients at risk’ [2], this claim is rarely based in evidence. In fact, there is very little evidence available on the impact of doctor’s handwriting on patients. In Kozak et. al [3] it is found that there was very little difference between the comprehension from handwritten to typed notes. This is a somewhat surprising finding, and the paper goes so far to claim that ‘physicians can communicate effectively on paper’. This statement, does not however seem to consider their own finding that written notes took 46% longer to read than typed notes. It may in fact be that doctor’s handwriting may not be illegible, but does serve to use up the precious time of healthcare staff.
When I was completing my degree in mathematics, I would often comment on the poor handwriting of my best friend (a medical student), and he would retort ‘yours will be just as bad once you’re a medical student’. I believe that this strikes at the heart of the problem. From day one of medical school, future doctors are rushed. Be it in lectures, where students are furiously scribbling down as much information as possible, or on the wards, where students are hurrying after consultants, who glide from one patient to the next, with the student attempting to write down every nugget of knowledge revealed by the consultants 40 years of experience. In all this hustle, something must give, and typically (and anecdotally) the handwriting of students will deteriorate throughout their time at medical school. This isn’t a problem to the student themselves, as the process is often slow, so the students adapt to reading their own writing. Furthermore, in many modern medical schools, there are no time-pressured, long answer exams. This means that their poor handwriting is not picked up by any members of staff, meaning the problem is not addressed.
The theme of time-pressure in healthcare is a common one. The two previous paragraphs provide and interesting juxtaposition. Firstly, we have the claim that poor handwriting is using up precious time, and then you have the counter claim that poor handwriting is a result of attempting to save time. Whilst it would be useful to have some statistics on exactly how much time it saves or costs to write in a quick but untidy manner, it is unfortunately not an entirely practical investigation to run, as the bias of those taking part is likely to affect the results, and it is difficult to measure the time taken to read and write without the subject being aware (and this is not even considering the ethical ambiguity of this practice). We can however consider the possible implications of lost time in each situation. I don’t feel it is too controversial to say that when a doctor is writing notes, it is rarely in an emergency. Although there is still time pressure, this pressure comes from the need to get through many patients, to ensure that everyone is seen. However, in an emergency setting, it is entirely believable that the notes would have to be read, and if time is being lost in this scenario, it has the potential to be more damaging. Although there is limited evidence to support the claim, it does not seem beyond the realms of possibility that poor handwriting from doctors could play a role in negative patient outcomes.
The obvious solution to this problem is to hire more doctors, and then all the doctors can spend twice as much time, writing perfectly eloquent notes in medieval calligraphy. Unfortunately, with the budget restraints currently placed on the NHS, hiring enough doctors to make this a possibility is simply not achievable (currently, even affording the calligraphy lessons for the existing doctors seems somewhat far fetched). I would however be interested in seeing the effect of including an increase in the handwritten work given to medical students, in which handwriting is judged and marked. This would provide motivation to medical students to pay attention to their handwriting, and allow medical schools to monitor the development of their students handwriting, providing evidence for the argument that medical students handwriting deteriorates throughout their studies. This would however, be an intervention which would not have a significant effect for several years, and the impact of the intervention would be difficult to measure.
Another potential intervention would be to computerise health records. This would remove handwriting issues; however, it must be considered how cost- and time effective it would be. To be time effective, there would have to be at least one computer available for each doctor and nurse, to avoid staff having to wait for the computer to become free to check notes urgently. This is clearly not a cost-effective strategy. Alternatively, there could be one computer to each patient. In the modern world, computers are becoming increasingly affordable, and a computer to each bed is not far from being an achievable target, however, the patient’s opinions must also be considered. So, I put the question to you; how comfortable would you be with the doctor stood by your bed side, tapping away on a keyboard, without you knowing what is being written about you? I know that the idea makes me somewhat uncomfortable, so we are still yet to find our perfect intervention.
In Glisson et. al [4], they found that a significant improvement was made in legibility of signatures, when the intervention group was given a name stamp and a standardized discussion on the importance of signature legibility (In the group of attending doctors, the legibility of signatures increased from 1.4% to 86%). This finding is staggering, especially when it is noted that there was such a notable change in the most senior doctors tested. This implies that, when provided with interventions which educate about the risks associated with a practice, senior doctors are likely to make notable changes to their practice, which is somewhat unexpected. I would therefore suggest that a similar trial is undertaken in the UK, with the following steps based on the intervention seen in [4]:

1. Encourage doctors to write legibly.
2. Encourage doctors to clearly sign notes, so they can be contacted in cases of uncertainty.
3. Emphasize safety issues with illegible text.
4. If the text is illegible, make a clear note of the sections of the notes which are not understood, and request for them to be rewritten.

I believe that this intervention could be effective in improving handwriting among doctors, in a manner which is unlikely to consume a large amount of time for clinical staff.
Although doctor’s handwriting is usually decipherable, it can contribute to the loss of time, which can have notable consequences in emergency situations. Therefore, an intervention is necessary. The intervention laid out in this essay, whilst unlikely to rectify the problem entirely, may have a noteworthy impact on handwriting if employed on a large scale. It is also likely to be more time and cost-practical than many of the other potential interventions, however, the intervention should be trialled on a small scale initially, as there is no guarantee as to its effectiveness.
This is a field in which I feel a large amount of further investigation should take place in the future, as there is very little evidence currently available, for a topic which is often widely discussed in the media, and because of writing this essay, I have gained an interest in the topic, so I would be interested in researching in this area myself.

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Bibliography

1. Gakhar H, Pozo J, Sawant N (2005) Audit of the legibility of operation notes. Royal College of Surgeons of Edinburgh Audit Symposium
2. Hull L (2014) In: MailOnline. http://www.dailymail.co.uk/news/article-2629280/Doctors-handwriting-bad-putting-patients-risk-according-health-watchdog.html. Accessed 30 Jan 2017
3. Kozak EA, Dittus RS, Smith WR, Fitzgerald JF, Langfeld CD (1994) Deciphering the physician note. Journal of General Internal Medicine 9:52–54
4. Glisson JK, Morton ME, Bond AH, Griswold M (2011) Does an Education Intervention Improve Physician Signature Legibility? Pilot Study of a Prospective Chart Review. Perspectives in Health Information Management 8 (summer)