Legibility of doctors' handwriting is as good (or bad) as everyone else's

Doctors have a reputation for illegible handwriting. Is such notoriety deserved?

Methods

With approval of the Kansas University Human Subjects Committee, we recruited 10 right‐handed men and 10 right‐handed women with seven different occupations (accountant, attorney, automobile technician, builder, engineer, doctor and scientist). Participants wrote in cursive “The quick brown fox jumps over the lazy dog” in <17 s.

The number of malformed individual letters was judged by an investigator, blinded to participant characteristics.¹ Four blinded investigators independently rated the global legibility of the writing samples using a four‐point scale: poor, fair, good and excellent.² The power to detect a 25% difference was 0.8.

Results

No significant difference was seen in age, but there was difference in education (table 1). Intraobserver (κ 0.35) and interobserver (κ 0.23) agreements were good (p<0.001), as was correlation between the scoring methods (r −0.75; p<0.001).

Table 1 Participant characteristics and handwriting scores.

	Attorney	Builder	Scientist	Engineer	Doctor	Accountant	AutoTech	p Value
Sex (M/F)	10/10	10/10	10/10	10/10	10/10	10/10	10/10
Age* (years)	41 (10)	34 (7)	42 (7)	29 (6)	36 (10)	35 (12)	29 (9)	0.313
Education* (years)	20 (2)	13 (1)	22 (2)	17 (1)	22 (2)	17 (1)	14 (2)	<0.001
Poorly formed letters*	11.3 (5.0)	9.4 (6.2)	8.8 (3.2)	8.6 (7.9)	8.5 (5.2)	7.0 (6.7)	5.8 (3.9)	0.705
Median score (1–4; range)	2.0 (1.2–2.8)	2.0 (1.6–3.0)	2.1 (1.2–3.0)	2.3 (1.0–3.2)	2.4 (1.6–3.0)	2.6 (1.0–3.0)	2.6 (1.2–3.2)	0.076
Illegible (<2.0)	40%	30%	40%	35%	25%	15%	30%	0.619
Median score (1–4)
Male	2.0	2.0	2.1	1.8†	1.9†	2.3†	1.9†
Female	2.2	2.3	2.1	2.9	2.6	2.8	2.6
Pairwise p value	0.439	0.114	0.424	0.003	0.020	0.038	0.020	<0.001

AutoTech, automobile technician; M/F, male/female. *Data are presented as mean (standard deviation).

†Pairwise comparison, p<0.04.

Across occupations, no differences in legibility were observed with either scoring methods, even after adjustment for age and education. In all, 40% of the men's handwriting was illegible (score<2.0) compared with 20% of the women's (p = 0.057).

Comment

In a prospective study of 209 healthcare professionals, using a timed standard sentence and scoring for global legibility (1–4 scale), legibility of doctors' handwriting was not different from that of administrators.² In a comparison of 200 doctors and 500 community volunteers who wrote a standard sentence, doctors wrote more malformed individual letters.¹ A prospective study using computer scoring showed that doctors wrote poorly formed letters than other health professionals.³

Ours is the first study to compare the legibility of doctors' handwriting, with that of several other non‐healthcare occupations and to adjust for age, education and, most importantly, sex. Our study agrees with Berwick and Winikoff² that doctors' handwriting is no less legible than that of other occupations.

This lack of difference in handwriting legibility does not excuse doctors from responsibility for clarity and accuracy in their written communication. As handwriting illegibility correlates with prescription error rates and misinterpretation of orders,⁴ doctors should strive to have “better” handwriting than everyone else or embrace the computerisation of medical records and orders.