Unoffical Guide to Medicine Essay Competition – Medical Student Category Runner-up: Chai Chung Sien

Well done to Chai Chung Sien 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 work place? What measures can be put in place to reduce  illegibility and error?”

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Chai Chung Sien is currently a second year medical student in the University of Dundee. He is at present a student representative for the Dundee University Surgical Society (DUSS). He enjoys participating in activities both inside and outside the medical school and has helped out in a few events organized by the Dundee Malaysian Society (DUMAS). Chung Sien has a special interest in Human Factors and Surgery and is looking forward to do a project integrating the two. Apart from the academics, he especially enjoys listening to the oldies, reading fantasy novels and playing sports.

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

“You may not be able to read a doctor’s handwriting and prescription, but you’ll notice his bills are neatly typewritten.” – Earl Wilson. Doctors’ handwriting has been an ongoing joke for as far back as anyone could remember. They are notoriously known to write with strokes synonymous to chicken-scratches known only to a select few from their line of work. There are, however always two sides to a coin and the age-old question we need to ask is this: do doctors really have terrible handwriting?
A prospective study surprisingly showed that doctors actually do not fare better or worse when compared to non-doctors¹ contrary to popular belief. Nonetheless, the study did show that completing a writing task under time pressure led to a lower score in terms of handwriting for both groups involved in the study. In addition to that, another handwriting study showed that although there were statistically significant lower scores by the doctors as compared to nurses, a key thing to note was that a large proportion of the illegible words were in fact contributed by only a handful of doctors in the study². In light of this evidence, is it possible that this is in fact a living example of a few bad apples spoiling the whole barrel? Could it be that doctors are not actually plagued with bad handwriting but rather, the handwriting of the general population is just plainly bad?
On the other hand, there have been a fair share of studies that have suggested otherwise; that is, doctors do have worse handwriting in comparison to both the medical staff and the non- medical community^3-5. Taking into account the substantial workload and the unbelievable amount of paperwork that needs to be done, many have attributed this as the cause for their unique style of writing⁶. Despite the lack of evidence, it could be argued that their style of writing has been developed further up the line as an adaptive response to all the furious note taking they did while they were still medical students (it certainly feels that way for me).
Having said that, which side of the argument we stand behind does not change the fact that illegible handwriting has been identified as a hazard to the stakeholders involved in healthcare. Illegible handwriting in the medical community carries a much greater risk than that of other professions, in that not much harm would come as a result of not being able to read a business report as opposed to the medical notes of an acute care patient⁷. This should be taken very seriously as miscommunication within the medical community can very easily snowball into a disaster for the patients. For an instance, a retrospective chart review showed that written notes take 46% and 11% longer respectively to read and to answer questions regarding what was written⁸. Importantly, these results bring about two implications; firstly, more time is spent on deciphering what was written⁹ and secondly, information may not be transmitted as effectively and accurately. In other words, this means that more professional time will be wasted and that there is more room for misinterpretation.
Furthermore, misreading the name, dose and frequency of the drug is a very serious problem leading to potentially fatal events. In fact, there have been more than a few cases where death was unfortunately a result following the misinterpretation of the prescription made^10,11; one of which occurred due to an anti-anginal drug Isordil being swapped with a calcium channel blocker Plendil¹⁰. To illustrate the importance of legibility, a study conducted in a Swiss university hospital showed that 56% of the prescription orders were rated bad or below in terms of readability and that a high incidence of documentation errors found throughout the different stages of the prescribing process were associated with it¹².
Ideally, any discrepancies or illegible prescription should be and can be brought to the attention of the prescriber thereby curbing the potential disaster. However, this once again proves the point that the need to do so is simply a waste of professional time. Having said that, all will be good and well if the prescriber’s signature was legible which unfortunately, is not always the case^5,7,13. This makes things difficult for the healthcare team as this may lead to inaccurate documentation, potential legal issues and quite frankly frustration as they try to work out the prescriber’s identity. Both the Medical Defence Union and General Medical Council clearly advocates accurate and legible record keeping^14,15 . Therefore, it is safe to say that legible medical records have an important role in the medico-legal aspect too.
Illegible handwriting in healthcare is analogous to a time-bomb biding its time. Given the frequency of which drug-related errors occur, it is not an exaggeration but a fact, to say that errors pertaining to drugs represent the most common medical error killing tens of thousands and further harming millions as stated in a report by the US Institute of Medicine^16,17. In that very same report, it is stated that an additional 1.9 billion pounds of hospital spending was expended to treat injuries related to drug treatment. While bearing in mind that medication errors could arise from a multitude of system failures ranging from erroneous prescription and calculation to poor medical decision, it cannot be denied that illegible handwriting is one of them^12,17,18.
Having concluded that illegible handwriting is a potential risk and hazard, it is now important to consider what can be done about it. Instead of putting the blame on individuals with bad handwriting we should consider why the error occurs in the first place. In order to do so, a holistic systems approach, such as that provided by the SEIPS model¹⁹, could be used to identify key elements of the system that could be potentially improved on. At the level of the organization, we could look to education as a possible answer. In response to that, a pilot study was conducted in which handwriting courses were offered to doctors in an effort to improve their handwriting²⁰. Taking into account another study involving education intervention²¹, both studies showed promising results post-intervention with more legible documentation and signature. With the advent of modern technology, one could also look to employ the use of electronic health systems²². With this, handwriting could be kept to a minimum as records such as prescriptions or instructions are inputted via tablets or computers. In backing this, several studies conducted on computerized physician order entry (CPOE) and closed-loop electronic prescribing showed significant reduction as high as 84% in preventable potential adverse drug events(ADE) and 55% in non-intercepted serious medication errors^23-26 proving quite a compelling case as the way forward.
However good that sounds, this does come with its own set of problems such as the cost, problems with adapting to the new system and increased time spent on medication-related task²⁶. In addition to this, voice recognition may one day replace handwriting as the mode of documentation as one study explored the extent of its accuracy and the ethical implications it brings²⁷.With regards to absent or illegible signatures, the use of a name stamp may help improve compliance and adherence to the standard²⁸. Moreover, something simple such as writing or signing in print could help boost legibility^21,28. However unlikely, in a stressful environment where the workload is overwhelming , there may be a role for secretaries to play in recording patient notes and prescription as dictated by doctors⁷ or perhaps verbal orders taken by nurses in acute care scenarios²⁹.
The use of easily misunderstood abbreviations should be discouraged³⁰ given the similarities of the letters (e.g. ON,BD, QID or OD) and the multiple meanings it may possess³¹.In the same way, units like microgram should not be abbreviated but instead written in full in accordance to the BNF prescribing guidelines³². Every individual doctor has a responsibility in ensuring that the care patients receive are not in any way jeopardized. Having said that, an environment where doctors are able to safely call out on colleagues who are engaged in unsafe practice such as that of their handwriting should be cultivated. Lastly, at the individual level, task reflection and self- assessment is crucial in any stage of training and may help in ensuring that one’s handwriting standard does not fall beyond an unreadable level.
All things considered, handwriting still remains an important aspect of healthcare at least for now. Therefore, it is essential that it is kept to a safe standard where it would not bring about a cascade of errors. Before a joint effort can be instigated, a shift in mentality is first required; there is a need for more awareness and acknowledgement that this is indeed a real problem that shouldn’t just be brushed off and joked about. In conclusion, a collaboration at different levels of the healthcare system is required to tackle this problem and hopefully, one issue at a time, we can begin to mitigate the vast amount of preventable medication errors starting with handwriting. As for myself, I know what I will be practicing tonight.

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References

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