A Doctors’ Malady

A FEW YEARS AGO, Prakash Gadgil’s wife was found to be suffering from partial retinal detach­ment in her left eye, a fairly serious condition that can even lead to blindness. An eye drop was pre­scribed by an ophthalmologist along with other medicines. Later, Gadgil had only just squeezed a few drops, when she complained of a burning sensation in her eye.

“We had to take her back to the doctor, and ask why she was reacting this way,” says Gadgil, who runs FEQH (Forum for En­hancement of Quality in Healthcare), a non-profit organisation in Mumbai that works with the medical fraternity to improve the quality of healthcare. The doctor heard out the couple, consulted his prescription, and told them he had not prescribed the eye drop that Gadgil had administered.

After overcoming his initial surprise, he realised what had happened. The doctor had barely legible handwriting and the pharmacist whom Gadgil had handed over the prescription had successfully prised out the names of all the medicines listed, ex­cept one. What the pharmacist had interpreted as ‘cineraria’—a homoeopathic eye drop that is often prescribed for eye inflamma­tions—was in reality meant to just read ‘to continue medication’ of an already prescribed drop.

“The whole prescription was just very difficult to read. You could hardly make out the words,” Gadgil says. “In fact, the doc­tor took more than two minutes himself to read [the words ‘to continue medication’] what he had written.”

The Gadgils, of course, aren’t alone. The physician’s chicken scratch is a well-worn joke, but its pinch is probably felt most in countries like India, where doctors on an average see more patients in a single day than their counterparts in other countries probably do in a week, and continue to cling onto their pen and paper, even when there is the option of e-prescriptions.

An illegible prescription is more than just an irritant or incon­venience. This was brought to the fore recently, when the Orissa High Court directed the state government to ask all doctors in the state to fill their prescriptions and post-mortem reports in capital letters or in legible handwriting. “… the tendency of writing such zig zag handwriting, which cannot be read by any common man or by judicial officers, has become a fashion among the doctors of the state,” Justice SK Panigrahi said in his order passed last month. “Substantial number of doctors in the state resort to such hand­writing which cannot be read by any ordinary person.” The judge’s exasperation could perhaps be excused as he was presiding over a case where the petitioner, Rasananda Bhoi, a resident of Odisha, had lost his son to a snakebite, but the ex gratia payment due from the Odisha government for such incidents had not come through. The hurdle was the post-mortem report. The doctor had listed snakebite as a cause of death, but nobody could read it. Not even the judge. “… he has written something which is not legible and cannot be comprehended in ordinary course of reading unless the writer himself or handwriting expert is invited to examine such description,” the judge went on in his order.

This was not the first time a physician’s illegible scrawl had come up in the courts. Four years ago in the same court and under the same judge, a man seeking bail to go and take care of his ailing wife, had produced her medical records as evidence, including prescrip­tions with near-illegible handwriting. “…one issue which this court is constrained to articulate is that considerable time and frustration associated with detective work in so far as medical reports/doctors’ prescriptions are concerned. Such illegible scrawls composed by doctors creates unnecessary nuisance…” Justice Panigrahi had said in his order then. There have been several such cases elsewhere, too. An irked Lucknow bench of Allahabad High Court—after having had to summon doctors numerous times in different cases to explain their prescriptions and reports, and in some cases even fining some of them—had in 2018 stipulated that all handwritten documents by doctors like prescriptions and post-mortem reports, when sub­mitted in court, must come along with a computer-printed report.

What compounds the issue of a doctor’s poor penmanship is the nature of medical science today. In the past, only the attending doctor, a few nurses, and maybe a pharmacist had reason to read a patient’s medical record. Today, because modern medicine is a lot more complex, the size of a medical team that cares for a patient has expanded to include many more specialists, not to mention health insurance professionals who examine these notes for re­imbursement purposes.

More people today contribute to and read a patient’s medical record. So, every time someone scribbles to save time, many others end up wasting theirs trying to comprehend what has been written.

So, why don’t doctors write more clearly? “Well, I don’t think any doctor does this on purpose,” says Dr RV Asokan, the president of the Indian Medical Association. He points to the large volume of patients that Indian doctors have to attend to as the primary reason. “We [the Indian Medical Association] always encourage doctors and ask them to write legibly. In fact, many doctors are also mov­ing to computerised prescriptions to resolve this issue,” he says. “But I don’t think anyone can ask us to write in capital letters. It might be desired, but I don’t think you can ask all doctors to do so. It is just difficult and not possible,” Asokan says, when asked about the Orissa High Court’s directive and the increasing demand for doctors to write in capital letters or in writing that is legible.  According to Asokan, such a rule would further burden the doctors.

(Photo: Ranadheer Bakkannagari)

In many hospitals, while the senior doctor might examine a patient, it usually falls on the medical student or the junior doctor to write out the report. Made to write multiple such reports in a day, perhaps it is no surprise that most of these reports get reduced to illegible scrawls.

And such a prescription can bedangerous. In the US, it is estimated that more than 7,000 people die annually because of medication-related errors caused by a doctor’s sloppy handwriting. Another study claims about 1.5 million Americans suffer from adverse reactions because of such errors. It is difficult to get an estimate of how much harm this causes in India, because very few studies have been conducted on this subject. One case, however, did get the spot­light, when the National Consumer Forum awarded `17.5 lakh in compensation to a couple whose child had died because of an error in a Noida nursing home in 1993. The child, a three-year-old girl, had been diagnosed with typhoid, and the paediatrician had written out a prescription that included an injection of Chloromycetin to be administered intravenously. The nurse had read the injection as chloroquine, and the child died a few days later.

Gadgil expects the number of people harmed from errors stem­ming from poorly written prescriptions to be huge, given the large number of prescriptions an Indian doctor writes daily. A few years ago, Gadgil had begun carrying out an informal survey to under­stand the scale of the issue. He had individuals associated with his NGO sit at around six of the busiest pharmacies in Chembur, a locality in Mumbai, for a day-and-a-half, and collect prescriptions that would be handed there. They would then call back the doc­tors whose numbers were listed on the prescriptions to check if the pharmacists had provided the right medicines. In all, out of the over 200 prescriptions they had collected, pharmacists had handed out the wrong medicines in 15 to 20 per cent of the cases. Out of these, 10 per cent were medicines that belonged to a brand different from the one prescribed by the doctor. “This isn’t permitted. In most cases, the person who gets the licence to run a pharmacy doesn’t even sit in it,” Gadgil says, pointing to how in many places, unqualified individuals were found to be managing pharmacies.

Gadgil often speaks out about this issue in medical conferences. To cut out these errors, since his non-profit FEQH works with a vast number of nursing homes, he has also developed a format in which notes about a patient can be filled out clearly. Over 200 nursing homes, he claims, are currently following the format. “Writing legibly isn’t difficult,” says Gadgil. “But I feel it’s an issue of habit and an attitude problem.”

Some other published surveys have also looked at the magni­tude of the issue. A 2011 study published in Australasian Medical Journal, which focused on a tertiary-level hospital in a rural area of Maharashtra, found 17.6 per cent of the prescriptions to have been written in illegible handwriting. Another study, which analysed the quality of prescriptions, both handwritten and computerised, in Anand in central Gujarat, found legibility to be a major issue. Dr Anuradha Joshi, the lead researcher who currently serves as creative medical educator and a professor of pharmacology at Parul Institute of Medical Sciences and Research in Vadodara, collected a total of 749 prescriptions (549 handwritten and 200 computerised), from three pharmacy stores in Anand over a pe­riod of nearly two years—2008 to 2010.

MANY OF THE prescriptions, especially the handwritten ones, when evaluated against the World Health Organiza­tion’s standards of prescription writing, were riddled with errors or incomplete details. When calculating each type of error in clinician and patient details, for instance, which included errors and omis­sions in the name, age, weight, or other such details of the patient, or that of qualification, registration number and similar details of the clinician, she found a total of 4,384 miscues in 549 handwritten prescriptions and 501errors in the 200 computerised prescriptions. In the category of drug item details, which encompasses informa­tion like generic and brand names of the drug, the dosage form and its unit, the process of how it is to be administered, and a few more details, she spotted a total number of 5,015 and 621 errors in hand­written and computerised prescriptions, respectively. When she checked the prescriptions for legibility, she found 24.41 per cent of the handwritten ones to illegible. “The issue of legibility was worse in prescriptions from rural areas,” Joshi adds, over the phone.

She did not look at how pharmacists worked around this is­sue, or if any guesswork was involved, since this was beyond the scope of her study. But she found, disturbingly, that many of the pharmacists dispensing medicines hadn’t studied beyond class seven or eight in school. “There is an urgent need for education on appropriate prescription writing and maybe inclusion of tu­torials on prescription writing in medical schools,” she says. “In my classes, I always push my students to write more, and to write clearly. That is very essential.”

Joshi’s study points to a drastic reduction in errors when doc­tors opted for e-prescriptions. “The benefits of doctors filling com­puterised prescriptions are very clear. But I understand this isn’t always feasible. You will need to be tech-savvy, need good internet connectivity, more manpower,” she says.

Most large hospitals in major metros have now entirely switched to e-prescriptions. Increasingly, many doctors in private clinics now also hand out such prescriptions. But this is just a drop in a large ocean, when one considers the many nursing homes, private clinics and hospitals across the country.

Dr Shantagiri Mallappa, a general practitioner in Bengaluru, con­tinues to write his prescriptions by hand. But he does so in capital letters. “I’ve always written it this way,” he says. “I feel it is my respon­sibility as a doctor to write in a way my patients can understand.”

Mallappa had always possessed a good handwriting, something that earned him praise even before he became a medical practi­tioner. He switched to writing in capital letters for greater clarity, he says, once he became a doctor. When he entered the medical profession, he realised however that he was a rare exception. He established the Karnataka State Doctors’ Handwriting Improve­ment Association 15 years ago, something which he still runs. Every six months or so, he ropes in handwriting improvement coaches to run day-long workshops for doctors from both allopathic and alternative forms of medicine. According to him, over 1,500 doctors have enrolled for these classes over the years.

“I know about the challenges doctors in India face, the work­load they have. But if you want to, you can write in capital letters. It is very possible,” he says, referring to how on an average he sees around 80 to 90 patients daily, and still finds no difficulty in writ­ing prescriptions in capital letters.

The burden of decoding the scrawls on a prescription primarily falls on two individuals —the patient and the pharmacist he takes his business to. In Nalgonda, a city in Telangana about a couple of hours from Hyderabad, a pharmacist named Chilukuri Para­mathma grew so tired of being handed prescriptions in almost illegible handwritings, that he began a decade-long campaign to fix the issue. “I had also read about the case where a three-year-old had died [in Noida] from a prescription error. It made me really sad because I know this is a big issue,” Paramathma says. He began writing to various government departments and officials, and even filed a PIL in the Andhra Pradesh High Court. This even­tually led to the Medical Council of India (MCI) issuing guidelines in 2014 that doctors must write their prescriptions only in capital letters. In 2016, the government also amended the Indian Medi­cal Council (Professional Conduct, Etiquette, and Ethics) Regula­tions, 2002, stating that “every physician should prescribe drugs with generic names legibly and preferably in capital letters and he/she shall ensure that there is a rational prescription and use of drugs.” Paramathma continues to push for more awareness. A few years ago, for instance, he distributed over 200 white coats that pharmacists wear among pharmacies in Nalgonda, with the phrase “Ask your doc- tor for prescription in capital letters” embroidered upon them.  Sometimes, a badly handwritten prescription will land up at his pharmacy and he will call up the doctor to confirm the name of the drug and to advise him to write in capital letters.

The issue, however, will at some point probably become a thing of the past. Optical Character Recognition (OCR), which is the tech­nology behind the electronic conversion of images with typed, handwritten or printed text into digital text, is known to be making progress in leaps and bounds, and many smartphones today can rec­ognise and even translate texts in photographs. Google announced at an event in Delhi in December last year that it is using artificial intelligence and machine learning to develop a tool that can help people identify medicines within handwritten prescriptions.

In Thane, a locality on the outskirts of Mumbai, the conversa­tions around such a technology is far from the minds of a doctor seated in a clinic today. A general practitioner for over 20 years, he moved to computerised prescriptions during the pandemic. “Some­times, some of my old patients find this a bit disorienting, and I feel they probably think the computer comes between me and them,” he says, referring to the look that appears on their faces as he fills in their details on the computer while they narrate their issues. “Even I found it a bit awkward in the beginning. But I will stop sometimes and tell them, it is a lot better this way.”

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