Clare Hughes finds out why the Medical Defence Union sees doctors' illegible scrawls as a serious health hazard and suggests some practical tips for saving your patients from death by handwriting

An old saying goes that doctors go to school to learn how to write illegibly and pharmacists go to school to learn how to read what doctors write. But where is the evidence that our writing is so bad? The hypothesis that medics write in a code of self righteous chicken scratches has been tested in a number of studies.

How do doctors compare?

One study looked at the legibility of doctors' handwriting compared with that of other clinicians and healthcare executives and managers. Independent volunteers gave subjective ratings of legibility as either poor, fair, good, or excellent. They found that the poorest scores were associated with executives and men, but not specifically with doctors.¹ The researchers concluded, however, that just because they found doctors' handwriting to be average did not make it acceptable--they were worried that illegible handwriting can be an important clinical hazard.

Another study had conflicting results and supports the conventional wisdom that doctors' handwriting is worse than most. Researchers used computer analysis to compare doctors' handwriting with that of nurses and administrative staff. Even though they were all asked to write neatly, the doctors had significantly worse handwriting than the others.² Interestingly, the researchers found that poor legibility was confined to letters of the alphabet rather than numbers. This could indicate how important doctors think the legibility of drug dosages is. But it is not just dosages that need to be written clearly--badly scrawled drug names can become a matter of life or death if someone cannot read an illegible prescription.

The results of bad writing

An American cardiologist was fined $225 000 ($140 000; €200 000) in 1999 after scrawling a prescription that was misunderstood, resulting in the death of a patient. Ramachandra Kolluru wrote a prescription for Isordil, an antianginal drug, which was misread by the pharmacist as Plendil, an antihypertensive drug. The patient took twice the recommended daily dose of Plendil and died of a heart attack several days later.³

Drug errors are thought to cause at least 7000 deaths a year in the United States, a quarter of which stem from mix ups with the names of drugs. The US Food and Drug Administration recognises that bad handwriting leads to drug errors and now demands that drug names are tested by simulating the process of dispensing drugs using handwritten prescriptions.⁴

In recognition that bad handwriting can spell disaster for patients, the Medical Defence Union has as its first of 10 commandments of record keeping, "Thou shalt write legibly."⁵ Matthew Robson, clinical risk manager at the Medical Defence Union, says, "Patient records are not just for individual doctors, but are a way of communication with other doctors and healthcare professionals. If they can't be read then doctors are failing in their duty to communicate effectively." He suggests that poor handwriting is a casualty of the modern pace of life--medical students have to write quickly during lectures and doctors are always under pressures of time. As a result, handwriting is hastily written and poorly formed.

Can IT help

Information technology is playing an increasingly important part in medical practice, but it does not mean that proficient penmanship is a skill of the past. A portable computer system that recognises handwriting is set to become a regular part of the doctor's toolkit.

In most computer systems handwritten input is converted into text, whereas Tablet PCs leave the handwritten text as it is.⁶ This "digital ink" can be edited, searched, and sent as an email in the same way as word processed text. In the healthcare setting this input method is particularly useful because it allows doctors to illustrate clinical signs and symptoms as part of the electronic patient records.⁷ So, even digitalisation cannot save sloppy writers from having to smarten their script--not only do other people have to read their writing but the computer does too.

Lessons in handwriting

Scrawling doctors can now receive help to smarten up their handwriting. Kate Gladstone is a handwriting teacher who holds seminars to teach doctors how to improve their scribbles. She says, "Physicians' willingness to learn this skill has leapt markedly upwards in recent years. Death by handwriting cases have had a sobering effect on a profession that formerly affected a cheery, devil may care attitude towards a scrawl."

But can you teach an old doctor new tricks? Kate says, "I generally get good results. Only twice have I yet failed: in each case the doctor learned to write very well and very rapidly. But they preferred not to change because they regarded their personal expression, through an accustomed, if sloppy, penmanship, as far more important than whether anyone could read the writing or not." Kate suspects that slanted, looped, and hurriedly formed writing can lead to an unintelligible script.

In medicine, where the stakes are high, poorly formed handwriting can lead to unacceptable confusion and errors. An unreadable script can put the lives of patients at risk and quite frankly, despite the handwriting jokes, that is not amusing at all.

Dotting the i's and crossing the t's

A common handwriting misconception is that crossing the t's and dotting the i's after finishing the words is faster than doing it on the go. In fact, it is quickest to write the cross strokes or dots as you write each letter; lifting the pen at the end of the word, going back to the beginning and then back to the end is a "t bar time waster."

Dotting and crossing on the go keeps them in the right place rather than several letters ahead or behind, which increases legibility. T's cross stroke, when written at the time, easily joins most letters that follow and even if it does not, lifting the pen is easy.

Difficult down strokes

Nineteen letters contain down strokes--some, like a and u, are less obvious than others, like h and m. By keeping these down strokes parallel to each other the appearance and legibility of writing are improved.

Down strokes should go all the way down to the paper's guidelines before they begin turning or curving into the next upward stroke. Just following this tip will help most writers to increase their handwriting's legibility and speed.

Writing absolutely vertically is tiring and can slow down writing so it's best to write with a 5-15 degree slant. Generally, it is easier and quicker to read a right slanted manuscript than a left slanted one, so careful positioning of the paper can help.

Paper position

Repositioning the paper makes writing more comfortable and often improves a slant that is hard to read. Place the paper off centre, keeping it in front of the right shoulder for right handers and the left shoulder for left handers.

To get the all important 5º­15º angle the paper should be tilted so that its left and right edges are parallel with the forearm of the writing hand. Move the paper as needed to keep it in line with the non-writing hand.

Drop the loops

Loops in letters such as h and y account for a quarter of legibility problems. The letter f needs a top curve for clarity, so curve it a bit but not enough to form a loop.

Joined up writing

Letters should be joined up using straight lines--o must be joined to n using a horizontal straight line rather than a "smile," and a should be joined to n using a straight diagonal line.

If two letters cannot be joined without a curve, such as p to a and s to c, then not joining them at all is best. Avoiding joins that curve makes it easier to write faster because curved joins are the slowest and most difficult to write.

Lose the prettiness

Instead of spending time and effort making handwriting look ornate and pretty, concentrate on making it legible. Letters, including capitals, written in a flourished manner are difficult to write clearly at speed--make them plainer and less ambiguous. Rework just the letter that cause particular trouble and eliminate unnecessary ornaments to speed up writing and clarify the script.

This is an elaboration of an article that Clare wrote for Hospital Doctor.