- Ronan Lyons, consultanta,
- Christopher Payne, specialist registrar ()a,
- Michael McCabe, consultantb,
- Colin Fielder, consultantc
- aDepartment of Public Health, Iechyd Morgannwg Health, Swansea SA1 1LT
- bAccident and Emergency Department, Morriston Hospital NHS Trust, Swansea SA6 6NL
- cDepartment of Otolaryngology, Swansea NHS Trust, Singleton Hospital, Swansea SA2 8QA
- Correspondence to: Dr Payne
Concern has been expressed that poor legibility of doctors' handwriting may lead to prescription errors1 and problems with referral letters.2 Using computer technology to assess handwriting in an objective manner, we compared doctors' handwriting with that of administrative staff and other healthcare professionals in a Welsh health district.
Subjects, methods, and results
We contacted the staff in three main settings—the health authority headquarters, an accident and emergency department, and various departments in another hospital—and asked them to complete a form that contained boxes for the respondent's name, the 26 letters of the alphabet, and the digits 0-9. They were told that examples of handwriting were needed to test computer software for optical character recognition and were asked to write as neatly as possible. All 92 staff present in the three settings were asked to participate, and none refused. We analysed their responses with Teleform, a software package that allows handwritten replies on standard forms to be scanned and translated into text for computer analysis.3 Any unrecognised characters are highlighted, and an error score is generated.
For the analysis, the staff were divided into three groups: doctors, nurses plus other medical professions, and administrative staff. We collated the results with the SPSS statistical program. As the error scores were not normally distributed, we used median values when comparing each group and used the Kruskal-Wallis or Mann-Whitney U test to test any observed differences for significance. In order to control for possible confounding we examined the effects of sex, setting, and age separately.
The table shows the median legibility error score for each professional group. Numeric legibility was similar for all groups and not considered further. For letters there was a significant difference between the groups (P=0.006). The doctors had a higher median score compared with the other two groups individually (P=0.01 for nurses plus other medical professions, P=0.005 for administrative staff) or combined (P=0.001). Analysis of female respondents alone revealed a similar pattern, with the doctors having a higher median error score than the other two groups (P=0.032 for nurses plus other medical professions, P=0.09 for administrative staff, P=0.036 for the groups combined).
The doctors had a slightly higher median age (37.5 years) than did the other two groups (33.0 years and 31.5 years respectively), but this difference was not significant (P=0.78), nor was there any significant effect of age on legibility for all respondents or for doctors alone. The doctors in each of the three main settings—health authority headquarters, accident and emergency department, and departments in another hospital—had similar median error scores (7.0, 7.0, and 8.0 respectively, P=0.51).
This study suggests that doctors, even when asked to be as neat as possible, produce handwriting that is worse than that of other professions. This provides supportive evidence for the commonly held belief that the legibility of doctors' handwriting is unusually poor. A small prospective study in the United States reported no difference between the legibility of doctors' handwriting and that of other healthcare professionals,4 but this study used a subjective assessment of readability and the comparison group was confined to senior non-medical staff.
A surprising finding of our study is that the poor legibility was confined to letters of the alphabet rather than numbers. This may reflect the importance attached by doctors to the legibility of drug doses.
The software used in this study was not intended primarily to assess the quality of handwriting. However, it is possible that further development of handwriting recognition technology will lead to a clinical and epidemiological tool that would be particularly useful for monitoring change in individual performance over time.
Contributors: RL conceived and designed the study, designed the forms, and provided critical comment on the analysis and writing up. CP contributed to the study design, undertook data analysis, and wrote the article. MMcC and CF recruited participants, supervised data collection in the two hospital settings, and provided comments on the text.
Conflict of interest: None.