doctors' sloppy handwriting

[woodstockbirdybird]

Anybody know why doctors' handwriting is so illegible? I know this is a cliche, but it's one of those generalizations I've yet to find the exception to. I've asked a few of them myself, and was tols something about having to learn to write fast to take notes in med school, but this doesn't wash with me. I had to learn to eat fast in basic training in the army, but I don't continue to swallow chunks of meat whole. Any M.D.'s or families/acquaintances of M.D.'s out there who can give me some insight? Thanks.

[GuanoLad]

It's to help prevent layman patients from reading the prescriptions, or so I've always figured.

[curwin]

I think there was an entry about this question in one of the Imponderable books.

[Zenster]

It's called lack of professional attitude*. In the working world only slobs have illegible handwriting. I have had to repeat weeks of vacuum metallurgy experiments because someone left behind a scrawled lab journal.

* People have been given the wrong medication because of illegible handwriting.

[edwino]

I've done a lot of chart reading a writing. By and large doctor's writing isn't that bad. You get used to it. Especially with the recent spate of confused prescriptions (lots of new drug trade names sound the same), I think doctors are making an effort to get better.

To explain why doctor's writing is bad, you have to understand that they need to write a lot of stuff down for a history and physical exam. Even daily progress notes can go for pages in complicated patients. Add this to the fact that you have to talk while you write, that you are usually in a huge rush, and you are usually abbreviating every other word. I have written statements in charts that look like

Pt is 55 yo AAM c h/o CAD x 3 yrs, HTN x 3 yrs, (up arrow)chol x 3 yrs, MI c 3 c vessel CABG p 2 yrs, c/o 2d (up arrow)CP c exertion.

Any medical professional would know exactly what this means. When the layman sees something like

ECASA 65 mg PO qd qHS

it looks like gibberish. A medical professional knows it as "take a baby buffered aspirin every night before you go to bed."

[Carina42]

My SO is a doctor, & he has horrible handwriting, looks like sanskrit. But if he writes anything that's meant to be read by anyone other than himself, he prints so it's more legible.

Could be just habit. Alot of people have sort of illegible handwriting, and don't make an effort to be legible when writing something routine. I think my handwriting is pretty good, but sometimes I can't quite make out something I've written.

[TomH]

Doctors have to write an awful lot, often under pressure of time and while they are doing other things such as examining the patient and talking with colleagues. Add to that the fact that it is more difficult to decipher less-than-perfect handwriting if it contains a lot of unfamiliar terms and abbreviations, as edwino pointed out. It doesn't matter so much whether the average person can understand it, but whether other doctors, nurses, pahrmacists, etc. can.

It's called lack of professional attitude*. In the working world only slobs have illegible handwriting. I have had to repeat weeks of vacuum metallurgy experiments because someone left behind a scrawled lab journal.

If he was sepnding 80 hours a week in the lab without proper breaks (for meals or anything else), being called out in the middle of the night to work on the experiments with only a couple of hours' sleep, then he might have had some excuse for his bad handwriting.

[RainbowDragon]

I suggest to everyone that they speak to their doctor regarding the medication he prescribes for you, especially the name and dosage. Make sure to tell the pharmacist what your condition is (unless it is particularly embarrassing). Make sure you are leaving with the right medication. Read the information that comes with your medication to make sure it treats your condition.

Today many drugs sound similar and can easily be misread. I remember working for an insurance company and a pharmacist screwed up and gave mental medication to someone with a heart condition. Of course the pharmacist blames the physician’s poor handwriting.

If you find out you have been taking the wrong medication, DO NOT give the bottle to the pharmacist (they should have records of what they gave you). If the pharmacist gets the bottle, they will destroy it and make deny they gave you wrong medication. When you realize problems later, good luck suing the pharmacist without the bottle.

[Arjuna34]

Good tip about keeping the bottle, RainbowDragon. Everyone should look up their medication in a drug book (such as the PDR) to make sure it treats what they have. You can even look up medications online. People who want to go the extra mile will check interactions with other drugs, and the dosage

Arjuna34

[KarlGauss]

OK. Here's a real life example. What do you think it says? In a while, I will post another link with the answer and outcome!

[TomH]

I can't decipher the handwriting in the prescription linked above, but I do remember the case being reported in the BMJ.

The prescription clearly says 20 mg. The maximum dose of the drug the pharmacist actually dispensed was, IIRC, 10 mg. The pharmacist should have realised that he was dispensing double the maximum dose of the drug and checked the prescription with the doctor. That is, after all, why we have pharmacists. Any idiot can put pills in a bottle but a pharmacist is supposed to know about dosages, interactions, etc. and check anything dodgy.

I'm not saying that the doctor wasn't at fault, but poor handwriting is rarely, if ever, sufficient to lead to a drug error.

[KarlGauss]

When I first saw the Rx in question, I wondered whether it said Zestril, Plendil, or Isordil. Each of these is a relatively common heart medicine, with similar a dosage range.

Well, here is the answer and the outcome.

Although the MD was clearly foolish, I agree with TomH that the pharmacist should bear some responsibility too.

[lucwarm]

getting back to the original question (why is doctors' handwriting illegible?) I think that the answer is power.
Doctors have a lot of status and power, and people with status and power don't have to make the effort to write legibly. It saves them a little effort (which is probably more than balanced by the effort of others trying to decipher their handwriting).

I like to think of myself as a pretty even-handed person, but if you compare my handwriting on (1) a note to my secretary to (2) a note to the senior guy, I have to admit that you'll see a difference.

I suppose this is another one of the petty tyrannies that we all suffer in a world of rampant inequality. Perhaps one day, computers will help solve such problems, but I digress.

P.S. Thanks for the good tips about checking the prescription, saving the bottle, etc. I'm surprised that prescriptions aren't logged.

[TomH]

Doctors have a lot of status and power, and people with status and power don't have to make the effort to write legibly.

Which is why judges, politicians, CEOs and all those other powerful people are notorious for having crappy handwriting, right? It's only the one group of people who can be sued, prosecuted and lose their livelihoods as a result of poor handwriting who choose to abuse their position in this way.

[lucwarm]

"Which is why judges, politicians, CEOs and all those other powerful people are notorious for having crappy handwriting, right?"

In the jurisdiction where I live, lawyers have to submit a proposed order along with motion papers. Of course, everything is carefully typed, proofread, etc. And what happens if the judge wants to modify the order before signing it? Nine times out of ten, he (or she) will scrawl a few changes down, make a few cross-outs, and sign it. Now that's power! (And yes, it's often barely legible)

It would be interesting to see how often doctors get in trouble for their poor penmanship. I bet that a lot of the time, the pharmacist or nurses or whoever was reading it get the blame for any mishaps.

[Una Persson]

My SO's handwriting on her prescriptions is so clear and perfectly nice you could read it from 10 feet away. Also:

1) it takes her a minute to write a script, and

2) I have even heard pharmacists comment on how they recognized her as the "one with the beautiful handwriting".

[Sue Duhnym]

Having worked in a couple of pharmacies and having a dad who is a PharmD, I know that MOST Pharmacists will NOT hesitate to call the physician on any ambiguity. In fact, I have never encountered one that didn't.

I can't tell you how many times I've pissed off customers by telling them that we're not filling their prescription until their doctor calls back. Usually it was for illegible handwriting but it was not unusual for the doctors to prescribe the wrong dosage, interacting drugs, or even something that the patient was allergic to.

I've seen eye drops prescribed for the wrong eye, ear drops for the wrong ear, chewable antibiotics for infants w/o teeth, and physicians who feed their patients prescription drug habits without remorse.

I've also encountered Doctors who call for prices on different drugs for their patients w/o insurance coverage, doctors with perfect handwriting and doctors who try to do the right thing only to have their patients undermine them.

I've seen forged prescriptions, stolen scrips, people who take half their dosages because they want to "save money" and people who take double their dosages because "two must be twice as good."

My point: There are bads seeds in every profession but there are just as many (and more) who take their professions seriously and try to do the right thing.

Be an educated consumer. It's your life (and health) and it's ultimately YOUR responsibility to make sure you're protected and well taken care of.

[/soapbox]

[jessicala]

Slight tangent: CNN had an article a few weeks ago about errors in prescriptions due to hard-to-read handwriting. According to the article, the Institute for Safe Medicine Practices wants to phase out handwritten prescriptions.

Here's the article: http://www.cnn.com/2000/HEALTH/10/04...andwriting.02/

[Zenster]

[rant]

If there is one item that is lacking more than anything, it is the educated patient or client.

In other threads I have often marveled at how medicine and law affect our lives more than just about any other branches of professional practice. Yet, people are consistently so blazingly ignorant in both areas as to astound me. Whenever I'm given a prescription I always inquire as to what specific action the drug will have. More often than not, it is my vetrinarian that I am talking to, but that's another matter. My vet knows the keen interest that I take in my animals and even reviews the x-rays with me.

I own a recent copy of the PDR and receive legal updates in my email. I try to stay abreast of current events in both professions. People who rely entirely upon someone else's judgement when their life or liberty hangs in the balance are asking for trouble.

[/rant]

[toadspittle]

Originally posted by TomH

Which is why judges, politicians, CEOs and all those other powerful people are notorious for having crappy handwriting, right? It's only the one group of people who can be sued, prosecuted and lose their livelihoods as a result of poor handwriting who choose to abuse their position in this way.

Frankly, except for schoolteachers and cartoonists, I can't think of any occupation other than doctors where lay people frequently see the person's handwriting. Almost everything is typed. Hence, docs get the bad rap, when handwriting is often bad in many occupations (and yes, I agree that power=the ability to not give a damn about how illegible one's handwriting is).

[woodstockbirdybird]

lucwarm and toadspittle, I imagine a combination of your answers is the best explanation to the question I originally posted. Nice to get the information on the patients' responsibility, though. This has turned out to be an interesting thread. Thanks, guys.

[Qadgop the Mercotan]

[quote]Originally posted by toadspittle
[b][quote]Originally posted by TomH
[b]

Doctors have a lot of status and power, and people with status and power don't have to make the effort to write legibly.

Man, where are docs accorded status and power? I wanna move there! After having spent the day arguing with an insurance company nurse about why the patient needs to be in the hospital instead of treated as an outpatient (she's 88, not breathing real well, and can't stand up for more than 15 seconds without getting dizzy, and oh yeah, she lives alone. But we'll treat her heart failure at home!) and getting screamed at by a patient for not giving her the narcotic pain pills she wants for her headaches (she's had all the appropriate tests to rule out organic disease, she gets headaches when she doesn't take narcotics, refuses detox for her dependency, it's illegal to prescribe narcotics to maintain an addiction!), etc. etc. etc.

Anyway, my handwriting is terrible, but I print all my prescriptions and instructions to patients to make sure they're legible. I don't know why my handwriting is bad, but previous posters points about how much we write, and under what circumstances, are pretty accurate.

[dwyr]

I think as many physicians have good handwriting as bad, but which gets noticed more? And it's true, when rushed handwriting deteriorates remarkably. I've made notes even I can't read later. But, when I call a doctor to clarify an order and he/she spends more time yelling at me for not understanding it than it would have taken to straighten it out I vote for lack of professionalism/power of status. I actually have had a doctor tell me, and I quote, "You should know what I mean." Pffft. Fortunately these kind seem to be the exception rather than the rule.
A final caveat-don't think that electronic ordering systems will solve all the problems. We have one and you would not BELIEVE the number of ways people can still screw up orders. As long as humans are on the planet can there ever be anything "fool" proof?

[festiva76]

As bad as it sounds, the unacecptable handwriting actually almost has a reason to it. I am a nurse, and have been for over two years. My signature, including my professional title, is nearly unreadable. With all the new, and almost daily Medicare regulations in place, I have to sign my name nearly 30 times per shift. After that many times, you tend to lose your perfect signature you normallly use. Blame the government...SPW

[edwino]

I had an attending who just signed "H" on the chart for his name. His handwriting was really no worse than usual, but he said that if a chart gets requisitioned by a lawyer, then the lawyer will usually sue everybody who's signature he can read for malpractice. This is a pretty poor reason, I suppose.

There is little excuse for having bad handwriting on prescriptions or charts in which the patient is being managed by a team. But, sacrifices need to be made for time. In clinics, I usually spend 5-10 minutes doing an exam for a daily note, and then 10-15 minutes writing. One month in clinics, my team was following 40 patients. I was writing 15-20 notes a day (ICU notes). Believe me, my handwriting got worse.

Most prescriptions usually are neatly written, at least during my clinics experience. Messy prescriptions are inexcusable, and that doctor from the previous link deserves a fine.

[lucwarm]

I know that this is straying from the OP, but

For what it's worth, I think "H" is making a mistake.

A persistent lawyer would subpoena enough records to figure out who "H" is.

Dr. H's tactics would be used to demolish his credibility at trial:

"Now Dr. H, is it your normal practice to conceal your identity, or did you feel some special need to do it in this case?"

Objection! (sustained. Please refrain from argumentative questions counsel.)

"Dr. H, were you aware that by signing your name only as 'H,' it would make it more difficult to ascertain your identity?"

"And what was your purpose in doing this Dr. H?"

"And was this your regular practice, Dr. H?"

"And were you aware that this was against (some hospital regulation), Dr. H?"

"But you did it anyway, didn't you?"


etc. etc. etc.

[DoctorJ]

In my experience, surgeons are the worst offenders when it comes to chicken scratching. To understand this, you must understand the mindset of the surgeon--everything done outside the OR is done in a hellbent rush. (Not universally true, but close enough.)

Another important thing is that chart writing is usually redundant--the doctor will almost always be dictating the note as well. As such, the note is more for the doctor's benefit than anything else. Still, it's tough when you're trying to read another team member's note on an inpatient, or when it's a prescription.

Edwino is right--part of it is time, and part of it is the bizarre language that we use. I can't tell you how many times a day I write something like:
WD, WN 58 yo M, AOx3, NAD
HEENT: PERRL, EOMI, CN II-XII GI
CV: RRR, no M/R/G
Chest: CTA/P B, no CVAT
Abd: Soft, NT, ND, +BS.
Ext: no C/C/E.

To the layman, it's total gibberish whether scratched out or typed out. The physician sees it and says, basically, "He's OK."

Dr. J

[Yeah]

Interesting discussion but I'd like to know if there exists any objective evidence that the handwriting of practicing physicians is any better or worse than the handwriting of practicing lawyers, stockbrokers, bankers, parliamentarians, physicists, diplomats, pilots, army officers, automobile sales persons, flight attendants, etc. (after adjusting for age and sex).

[MsRobyn]

Originally posted by Zenster
[rant]

If there is one item that is lacking more than anything, it is the educated patient or client.

In other threads I have often marveled at how medicine and law affect our lives more than just about any other branches of professional practice. Yet, people are consistently so blazingly ignorant in both areas as to astound me. Whenever I'm given a prescription I always inquire as to what specific action the drug will have. More often than not, it is my vetrinarian that I am talking to, but that's another matter. My vet knows the keen interest that I take in my animals and even reviews the x-rays with me.

I own a recent copy of the PDR and receive legal updates in my email. I try to stay abreast of current events in both professions. People who rely entirely upon someone else's judgement when their life or liberty hangs in the balance are asking for trouble.

[/rant]

For the most part, I agree with you, Zenster.

I take issue with laymen second-guessing physicians using references that are not intended for laymen. I can't tell you how many people who have ended up in the hospital because they misunderstood a reference manual that was too technical for them. Not everyone understands that kind of technical language.

That said, there are many references designed for the average patient. The Internet is a wealth of information on medications, as is your friendly neighborhood pharmacist.

Finally, I work at a VA medical center that trains med and nursing students, interns, and residents. My job is to read orders and enter them into the computer. If I can't read an order, have questions as to the dosage, route, frequency, etc., or if something is left out, I ALWAYS ask the doctor or pharmacist to clarify.

And everyone should do the same. When you receive a prescription, even if it's for something you've taken for a long time, verify the name, dosage, route, and frequency with your doctor after he writes the prescription. If there are any changes, ask him why. Then, when you get the prescription filled, learn the color and shape of the pill or capsule, and ask questions. The best piece of advice my pharmacist-father ever gave me was not to let questions go until they've been answered to MY satisfaction. It's MY body and MY health.

Robin

[red_dragon60]

Another WAG would be that the pharmacist might, after seeing the doctor's handwriting for a while, be able to pick out the slight nuances after staring at t for a while. This may help stop forgers. Maybe it works, but my guess is that docs do not so this intentionally.

[festiva76]

In response to everyone griping about sloppy medical handwriting, I think it has nearly everything to do with the fact that so much has to be written, not a "power" issue. I have been a nurse for two and a half years, and I have had alot of first-hand experience with illegible handwriting. I work in a long-term care facility, and have had to call doctor's offices more than once to ask what the heck was written. Frustrating? You betcha. Dangerous? Very. With all the new regulations in Medicare nowadays, I have to chart alot. My handwriting has suffered greatly as of late. My signature has become illegible, although I do make a concerted effort to make everything else readable. My point is this: when you have to sign your name 40 times a day, it starts to look like chicken scratch after a while. I realize, however, that my professional license is on the line, and DHEC can take that from me if it looks bad enough. In any case, time constraints or not, MD's had better start watching that issue. It's gonna take just a case or two more of negligence before some licenses start getting pulled. I worked long and hard for that piece of paper that lets me put a title behind my name, and doctor's have to work a heck of a lot harder for theirs. The really sad issue is that it is the nurse who gives the med who will be charged with involuntary manslaughter in the case of a misread order. Wise up docs, before anyone else gets killed.

[Dr_Paprika]

I know of no cases where doctors have deliberately tried to make the prescriptions illegible which would open them up to far more legal trouble than it would save. If anything is readable on the script, it should be the doctor's name since the physician really does depend on the pharmacist to address the occasional error, scrawl or smear.
As for the messiness, just a simple matter of i)time and ii)the fact many patients are on tremendous numbers of medications; polypharmacy is a real problem for old people with diabetes, joint pain and failing hearts and kidneys -- a very sizable population. I have seen people discharged on 25 medications. When you are already an hour behind and have four patients waiting in the emergency room and have to write out a prescription for 25 medications, see how much time you take. That being said, most docs I know have scripts that a pharmacist would be able to read easily. The code makes things more difficult for the layman, sure, but would be easy to learn if you wanted and is just done for the sake of brevity and tradition. If you think this answer is a sleazy cover-up, perhaps you could take Haldol 5mg PO qhs mitte 2 weeks and think about this whole thing again.

[festiva76]

Also, I agree with the statement that surgeons are the worst. My first nursing job was for an orthopedic surgeon. He is considered one of the best orthopods in the state of SC, but boy does his handwriting suck. After working for him for almost a year, he flipped out one day when I asked what he wrote on a chart. He basically told me that if I couldn't read his writing to find another job. Well, that, combined with other professional clashes, led to my resignation.

[lucwarm]

Quote:

"He basically told me that if I couldn't read his writing to find another job. Well, that, combined with other professional clashes, led to my resignation."

I'm glad you got out of an unpleasant situation.

Sorry to harp on the "power" issue, but I would interpret the above exchange as a person using (abusing?) his power.
Do you think that this doctor would cop this kind of attitude with a member of the board of directors at the hospital where he primarily works?

Assuming that the medical board exams have handwritten portions, it would be interesting to look at a year's completed exams. I bet the handwritting is very good.

As I mentioned in a previous post, I dream of a day when nobody will have to endure the petty tyrranies we all suffer every day.

[festiva76]

The surgeon to whom I am referring is a highly respected physician at our local medical center, who has practiced for nearlt 20 years. He is known around the hospital for throwing temper tantrums. He once broke scrub in surgery and threw his pager across the OR because a colleage was paging him during a difficult back surgery. He then proceeded to stomp the pager until it broke into many pieces. He has a very short fuse. He once burst into the examination room at the office while I was interviewing a new patient to obtain an H & P and told me "You're taking too damn long with these people." He then turned around and walked out. I was left in the room, highly embarrassed. After apologizing profusely and finishing the interview, the doc and I shared a few words about that issue. Yes, I am glad I am out of that place.

[handy]

Because they write in latin, not english, right?

I know a teacher said to my son that he would be a doctor when he gets older. Why he asked? Because she can't read his handwriting.

[Qadgop the Mercotan]

Originally posted by handy

Because they write in latin, not english, right?

I'd hardly call it latin, just a few latin-derived abbreviations. for example:

Amoxicillin 250 mg #30
i po tid x 10d

i here means one, ii is 2, iii 3, you get the idea
po means per ora(?) or "by mouth"
tid means tri(3), i here means "times", and d is deum

it's all shorthand

[Qadgop the Mercotan]

sorry, d is dium, or day

[TomH]

"p.o." is per oram.

"t.i.d." is ter in die (three times a day)

I do think that the continuing use of Latin-derived abbreviations is questionable now that so few people are familiar with Latin. It just creates another, unnecessary potential source of error.

[CnoteChris]

Just so you know-

I saw on a blurb yesterday that CBS Evening News, With Dan-Tanna-Rather, is having a story covering this exact topic on tonights broadcast.