ERA Journal

Background

Doctors’ handwriting is the worst among health professionals [1]. Moreover, the illegibility of doctors’ handwriting is the cause of most medication errors [1-3]. In detail, the illegibility of doctors’ handwriting may affect the quality and safety of health care services causing harm to patients [4], lead to mal performance of nursing and other supporting staff members [3], and produce poor referral letters [1]. Furthermore, poor doctors’ handwriting is certainly unhelpful in legal transactions [5].

Medical fields are still dealing with written instructions

It is not yet too late to discuss medical, medicinal, and medication errors caused by doctors’ illegible handwriting according to [6], as there are more than 250,000 people die every year in the US due to medical errors which handwritten prescriptions are part of. Likewise, numerous studies investigated medical errors from the viewpoint of poor handwriting of prescriptions such as [2-,4,7,8].

Interestingly, Hsu et al. (2015) [9] reported the increasing dependence of clinical care on computerization claiming that studies have not addressed its adverse effect on physicians’ handwriting. They assessed the legibility, accuracy, and completeness of handwritten prescriptions taking advantage of a system crash at a large hospital. Their study found that none of the 1418 prescriptions had all necessary fields filled out where age and dosage details were frequently omitted. Other observations included a small frequency of illegibility and inaccuracies of drug name 11.4%, dose 13.6%, and strength 19.5%.

Literature Review

Lyons et al. [1] used computer technology in a Welsh health district to objectively compare and assess the handwriting of three groups: doctors, nurses and other medical professionals, and administrative staff. They collected a unified form filled by hand by the three mentioned groups, scanned it, analyzed it with computer software, and generated median legibility error scores for the participants. Ultimately, the study found that although doctors were asked to be as neat as possible, their handwriting was the worst among the other professions suggesting that the legibility of doctors’ handwriting is remarkably poor. Surprisingly, the study stated that the legibility of doctors’ handwriting was restricted to letters rather than numbers, suggesting that they might attach more importance to the legibility of doses.

Consequently, there is a general consensus on the doctors’ habit of illegibility. Therefore, individuals, groups, and institutions strive to help others attain self-awareness and synthesize their mind and body to function smoothly as one unit [10] and perform the sort of writing output that reaches excellent performance rates [2]. In that sense, the illegible handwriting of doctors is considered a finable offence in six American states [11]. Similarly, the court in India also directed doctors to write legibly [5]. [11] Went on thinking aloud and giving suggestions to enhance doctors’ handwriting by calling families, schools, and higher education institutions to pay more attention, take poor handwriting seriously, and pose penalties for careless handwriting.

[12] Nevertheless, thinks that the problem begins in the very early stages of the educational system, as although students’ handwriting tends to be poor or illegible, they are not making any efforts to be neat. Strikingly, [3] explores an inclination of literature that rejects a great deal of the intimidations of illegibility of doctors’ handwriting and proposes a considerable number of justifications. [13] For example, assumes that doctors’ handwriting has worsened after writing so much throughout their college years or in their very busy medical environment. [11] Similarly, state that doctors may plan to maintain the secrecy of their prescription contents, appear as not sure about the correct spelling of medicines, and leave it to nurses and pharmacists to decipher illegible words that seem to work as a mutual coding system between doctors and pharmacists.

[10] Names the hints that writers unintendedly leave behind to determine their characteristics and reveal their strengths and weaknesses “Beyond the conscious information contained in the written words, the handwriting also divulges information about you and how you felt unconsciously as you wrote.” [14], however, rejects all the attempts that were dominant less than a century ago to equate the mere analysis of handwriting with fortune telling, horoscopes, or pseudoscience. Instead, she calls for understanding handwriting analysis as an invaluable psychological tool that is supported by scientific evidence. Moreover, she states that handwriting analysis as a science dates back to Nero’s age when its first book ever was published in 1555 before it reaches its peak in the current century.

In an attempt to analyze first-year medical students’ handwriting and label their types of errors, [15] assigned (N=134) medical students from Mahidol University’s four medical schools to write an English paragraph on medical ethics guided by three reading passages. For evaluating students’ work, they utilized a ten-criterion rubric. Interestingly, most students had errors with a high percentage of eight items out of the ten criteria. The ten criteria were as follows: inability to perform the assigned task because of not understanding the question, no introduction, no conclusion, no main ideas, no topic sentences, and no development of main ideas, no organization, errors in sentence usage and/or structure, no transitional words, and incoherence.

With findings such as that handwriting of doctors from different specializations looks similar, doctors should sidestep abbreviations to prevent confusion, and that pharmacists are considered the most likely to decipher prescriptions correctly; Cerio et al. [2] conducted a study to evaluate how legible doctors’ handwriting is, in the private and public hospitals of Quezon, Philippines. The study collected prescriptions and divided their contents as texts, medicine names, abbreviations, and numbers.

Correspondingly, Mandal et al. [8] went in the same direction of research investigating (N=120) private practitioners’ handwritten prescriptions for legibility and accuracy. In light of that, there were no spelling mistakes in medicine names and only 6.6% of the prescriptions were illegible or legible with effort. Ultimately, the study concluded from its survey that private practitioners have the habit of neither maintaining the standard nor ensuring the adequate quality of prescribing. They, however, orient themselves to the situation depending on two significant factors that confuse and affect prescription accuracy: omission of leading zero and use of archaic terms.

Likewise, (Albarrak et al., [4]) assessed and compared the completeness and legibility of (N=199) handwritten and (N=199) electronic prescriptions from different departments in King Khalid University Hospital, Riyadh, Saudi Arabia. The handwritten prescriptions were assessed by two pharmacists using a checklist made according to the design of the hospital. Findings of the study on prescription incompleteness and medication errors on both setups of prescription (handwritten and electronic) support that omitted or incomplete e-information and poor handwriting lead to numerous errors to be in agreement with previous studies such as (Brennan et al., [16] and (Barker et al., [17].

Similarly, Van Drempt et al. [7] assumed that the handwriting performance of healthy adults is influenced by factors that should be unveiled through a review of the literature up to 2010. Interestingly, they concluded that young adults write faster and more legibly compared to older ones, women’s writing is faster and more legible than men’s, and that nontraditional pen grips can consume an acceptable time to produce legible texts. Additionally, the study found that pen pressure varies across a page of text with a different speed, text size, words, and letters. Furthermore, mixed writing style and error corrections occurred in the samples.

Van Drempt et al. [7] emphasized the importance of assessment accuracy of handwriting performance as an essential factor in evaluating performance and outcomes and developing appropriate remedial programs. Nevertheless, they argued that research to update information about the advancements in the assessment and retaining programs or to guide practice is still limited and that there is not enough to know about unimpaired adults’ handwriting to suggest benchmarks for therapists.

Al-Johany et al. [18] as well conducted a study on 2nd-year dental students at the College of Dentistry of King Saud University (N = 71) using a three-part test: a handwritten answer to a question composed of four lines, drawing a picture, and preparing a plastic molar tooth from an amalgam. Interestingly, their results showed a significant correlation between the three parts of the test p<0.001.

It has referentially been found that junior doctors make more errors as compared to other prescribers according to Leape et al. [19] and later to Classen et al. [20]. This fact appears as a remarkable point to be considered in our study because it deals with a similar community - male and female second-year medical and dental students.

Objectives/Aims

The current study aims at addressing the following questions:

1. To what extent are medical and dental students aware of the errors caused by illegible handwriting?

2. What are the factors leading to illegible handwriting from the students’ point of view?

3. To what extent do medical and dental students agree to undergo handwriting training?

4. To what extent are medical and dental students aware of the contribution of illegible handwriting to errors in patient health care?

Methodology

Study Design and Settings

This is a cross-sectional study held at King Abdulaziz University in Jeddah, Saudi Arabia to investigate 2nd-year medical and dental students’ opinions regarding the importance of neat handwriting in the current healthcare settings. The study considers the ongoing development in computerization and automation of medical services and other factors that may negatively affect the features of students’ handwriting.

Survey

The survey used in the current study was specially developed by its authors in an online form to investigate the 2nd-year medical and dental students’ opinions about the characteristics of their handwriting. The items of the survey (22 items) varied between Likert scale items (14), Yes/No items (3), and MCQs (5).

The domains of the survey include the characteristics and demographic data of the sample, their willingness to receive handwriting remedial training, their perceptions regarding the factors contributing to handwriting illegibility, and their perceptions regarding the contribution of illegible handwriting to medical errors.

Ethics and consent

The study was approved by the Unit of Biomedical Ethics of the Faculty of Medicine, King Abdulaziz University, KSA (Reference No. 700-20). The study was also approved by the Research Ethics Committee, Faculty of Dentistry, King Abdulaziz University (Proposal No. 170-12-20). The purpose of the study was mentioned at the beginning of the survey.

Subjects

The samples of this study were collected after the 2nd-year male and female students got the hang of their medical studies at the medical and dental colleges of KAU during the academic years 2017/2018, 2018/2019, and 2019/2020. It is worth mentioning here that medical and dental students at KAU normally begin their medical studies with basic medical sciences after a complete preparatory year so far.

Inclusion criteria:

The participation in the questionnaire of this study was based on that the participant must be a 2nd-year medical or dental male or female student studying at the Faculty of Medicine or Dentistry of King Abdulaziz University during the academic years 2017/2018, 2018/2019, and 2019/2020.

Exclusion Criteria:

All survey questions were required, and no links were sent to individuals in disagreement with the inclusion criteria so there were no invalid responses received.

Sample Size

Snowball sampling - a non-probability sampling technique - was used to hire the most possible proportion of the medical and dental students’ population as a sample for the study. All the responses of the students who met the inclusive criteria were accepted to represent the three-batch population of the study.

Data Collection

This study used the website: https://app.surveyplanet.com/ as an online tool for the spreading of the questionnaires through common social media (WhatsApp, Telegram, etc.) as well as the preparation, collection, and export of the sample’s data. Another paper-based version of the survey was used to collect data from the students who do not prefer the electronic form. Data collectors were the leaders of each batch during the academic years 2017/2018, 2018/2019, and 2019/2020 for both medical and dental male and female students. It is to be mentioned here that participation in the present study was voluntary and no incentives were given to students to participate.

Data Analysis

The collected data was exported in Excel file format, prepared for statistical analysis using MS Excel, and analyzed using the IBM Statistical Packages of Social Sciences software (IBM SPSS Statistics v 22). The breakdown of population and sample data was done using Wondershare MindMaster software v 8.5.1. The statistical tests used for correlation examinations are specified in the Results section.

Results

Breakdown of Study Population and Sample

Figure 1 below illustrates the breakdown of our study population (N=1863) and sample (N=489). Our study population is composed of three 2nd-year medical and dental batches through the academic years 2017-2018, 2018-2019, and 2019-2022. As shown in (Figure 1), the respondents to the study survey made up 26.2% (N=489) distributed as 23.6% (N=153) of (N=649), 32.1% (N=220) of (N=686), and 22.0% (N=116) of (N=528) 2nd-year male and female medical and dental students in 2017-2018, 20182019, and 2019-2020, respectively.

Medical participants made up 62.6% (N=306) while dental participants formed 37.4% (N=183) of the total sample (N=489).

The gender characteristics of the study sample (N= 89) were summarized as 40.5% (N=198) male medical students, 22.1% (N=108) female medical students, 18.0% (N=88) male dental students, and 19.4% (N=95) female dental students.

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