LOS ANGELES –– The class began with a gentle but humbling plea: "Pretend like you're in first grade."
For the next three hours, dozens of doctors who work at the prestigious Cedars-Sinai Medical Center here spent a grueling night last week confronting one of the most notorious problems in medicine: Horrible penmanship.
Shamed into attending by the hospital's chief of staff, fingered by nurses for having an undecipherable scrawl, they all trudged into an auditorium with paper and pencil--and their ringing cell phones--to hear two experts coddle and coach them to forget everything they know about handwriting and start from scratch.
Some came sheepish and left chuckling, but the session was hardly a joke.
"How we write something down for a patient can sometimes be a matter of life and death," said William Mandel, a cardiologist. "And we're realizing we could really use this kind of help."
Andrew Wachtel, a pulmonary specialist, had the same resolve.
"My kids think it's very funny that I'm stuck here tonight doing this," he said. "But most of us are trying to take this idea in the right spirit and give the lessons a chance. I admit it: I have terrible handwriting. It's just the result of how much we have to do."
Across the medical profession, there is growing concern that serious errors in both patient prescriptions and treatment are often rooted in the age-old habit of harried physicians scribbling off requests that pharmacists and nurses later have a difficult, if not impossible, time understanding.
Just six months ago, a Texas jury blamed a physician's illegible handwriting in the accidental death of a 42-year-old man who had a heart attack after receiving the wrong prescription. In a handwritten note, his doctor had prescribed 80 milligrams a day of "Isordil," a medication for heart pain. But a pharmacist misread the order as "Plendil," which is used to treat high blood pressure, and gave him the same dosage. The maximum recommended daily intake of that drug is 10 milligrams. The jury in the extraordinary case ordered the doctor to pay the victim's family several hundred thousand dollars.
A scathing report by the Institute of Medicine late last year also concluded that a range of medical errors that include written miscommunication between doctors and other providers in the nation's health care system may claim as many as 98,000 lives each year. The research group, which is part of the National Academy of Sciences, also urged hospitals and health maintenance organizations to take aggressive new steps to track and reduce the threat of human errors.
Since then, President Clinton has asked Congress to create regulations requiring hospitals to get to the root of medical errors and make them public.
"We still don't have good data on exactly what errors occur, or how frequently," said Dawn McGinley, a spokeswomen for the National Patient Safety Foundation. "But we think the handwriting of doctors can be a factor."
For the past decade, the American Medical Association has asked doctors to improve their penmanship or, if that endeavor proves to be hopeless, to print prescriptions and add the medical purpose of the orders to avoid confusion.
Some medical centers also are counting on help from emerging technologies. But the day when a doctor can recite a prescription to a computer that checks its spelling and even its dosage before relaying it to a pharmacist have not arrived yet--and will be costly. In the meantime, a few hospitals are resorting to other strategies.
The inaugural penmanship class this week at Cedars-Sinai had been in the works for months, after a staff survey this year revealed that poor handwriting was a major source of frustration to nurses and doctors alike.
Nurses spoke wearily of having to chase doctors for translations of patient charts, which delayed care. And doctors said they were tired of getting phone calls around the clock from pharmacists stumped by their written orders.
"There are so many drugs now that are so similar in spelling, and so many records that have to be kept with the way insurance has become," said Sheldon Kishineff, a pediatrician at Cedars-Sinai. "It's much easier for a mistake to be made."
Paul Hackmeyer, the hospital's chief of staff, decided to fight the problem at its source. First, to promote his concern, he offered free brunch at a luxurious hotel in Los Angeles to the first person at Cedars-Sinai to decipher a sample of a physician's illegible handwriting that he printed in the hospital newsletter. So far, no one has won the contest.
Relying on tips from nurses, he also made a list of several dozen doctors--young and old, male and female--known for having atrocious penmanship. He asked each one to attend a workshop he had arranged with two acclaimed handwriting specialists from Oregon. Then he braced for the worst.
Instead, the response was enthusiastic. One doctor even consented to having his photo and examples of his cryptic notations put on posters that Hackmeyer tacked to hospital bulletin boards. Hackmeyer also had to shift the session from a small conference room to the medical center's largest auditorium.
"At first I didn't think anyone would show," he said. "But only one of the doctors I called hung up on me. I've been using a tongue-in-cheek approach, but I'm also trying to make an important point. This is all about patient safety."
And so at the end of another long day last week, about 50 doctors still clad in white medical jackets or surgical scrubs gathered to hear Inga Dubay and Barbara Getty softly preach the virtues of what one of them called "handsome, clean, clear letters."
"I'm tickled to think you're brave enough to do this," Getty told them.
The two women, both longtime teachers of handwriting and calligraphy, have been giving similar presentations for more than a decade. Once a year in Portland, Ore., they host a free handwriting clinic that draws hundreds of people. But they said they had never spoken to such a large group of physicians.
Scorning the elaborate loops and curls of script, which they say has relegated America into a "please print" nation on forms, Getty and Dubay advocate a simpler, sloping handwriting style that resembles the box-and-stick letters that children use. It's called Italic, and it slowly won over the hospital crowd once it had meticulously practiced it for an hour.
Getty advised the doctors on how best to hold a pen. "Thou shalt not pinch," she said. She had the group copy the best-known full-alphabet sentence from bygone typing classes--"A quick brown fox jumps over the lazy dog"--letter by letter. At one point, she even persuaded nearly all of the doctors to raise their hands above their heads and slowly mimic how she drew the letter "x."
None of the doctors coaxed into coming to the workshop said their penmanship had ever contributed to a serious medical error. And for a while the presentation hardly seemed to captivate some of them.
"There's no way I can do any of this crap," one doctor grumbled as he rummaged through the salmon buffet that Hackmeyer shrewdly offered to help draw a big crowd. But, ever the medical students, they soon were posing intensely technical questions about the shape, size and stroke of properly written letters. "In the small case cursive k, how would you drop the loop?" one doctor asked Dubay.
Both instructors wandered the auditorium whispering over-the-shoulder encouragement to the doctors as they worked on their assignments. Progress, they said, would come only with weeks more of handwriting practice. "You've got to make a little plan for yourself," Getty told them.
Cedars-Sinai has no other penmanship classes scheduled--yet.
Hackmeyer wants to see if the first one makes any difference. Since he knows who attended the workshop, he is planning to examine samples of their writing in the months ahead. He also intends to track whether phone calls from pharmacists struggling to make sense of prescription requests from the hospital decrease.
"We believe we're raising the bar on this issue for other medical institutions," Hackmeyer said.
Near the end of the class, Kishineff sounded like a convert. "I think I've learned a lot from this," he said. "I try to be mindful and print everything, but this way might be easier and better for everyone, especially the patients. And I might stop getting calls from pharmacists in the middle of the night."