JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
care, bringing the patient back five times so that we can
complete our history taking, examination, investigation and
management plan. From the patients’ perspective it takes
no account of the amount of time a patient may spend
trying to get an appointment and waiting to be seen. The
net result of our 1948 view of the consultation is that we
have to keep seeing patients more regularly, creating a self-
perpetuating demand for appointments that are never quite
long enough. We seem to be fulfilling the negative comments
about general practice made by a social commentator in 1912
as ‘perfunctory work . . . of perfunctory men!’2 And all the
time the mandarins tell us that we need to be seeing
patients more quickly. You can’t reconcile continuity with
easy access—or, ultimately, patient satisfaction with short,
sharp, ineffective appointments.
So here’s an inconvenient truth. Why not introduce a
right for patients to have a minimum 15 minute
appointment with their GP? It should be a standard for
the NHS just as much as clean wards, reduced waiting times
for operations and free care at the point of delivery.
Reinforce it by stating that GPs should see a maximum of
28 patients a day and see what happens. It will reduce the
demand for appointments, improve satisfaction for both
patient and doctor, and allow doctors to deliver the more
advanced care that current knowledge requires—and so
reduce the demands on the secondary care services.
Try it and see. All we have to fear is another sixty years
of the same!
Competing interests None declared.
Aneez Esmail
E-mail: aneez.esmail@manchester.ac.uk
REFERENCE
1 Gray DP. The forty seven minute consultation. Br J Gen Pract
1998;48:1816–7
2 Allbutt C. The act and the future of medicine. Times 3 January 1912
Poor handwriting remains a significant
problem in medicine
In centuries past, doctors scribbled notes to keep a personal
record of the patient’s medical history. The notes were
generally seen only by the doctor. Today, doctors are no
longer one-man bands. With dozens of other professionals,
doctors are but one element of a large, multidisciplinary
health care team. A consequence of this expansion is that
illegible scrawls, hurriedly composed by rushed doctors, are
now presented to colleagues with no qualifications in
cryptology.
In a BMJ editorial in March 2000, Leape and Berwick
called handwritten medical notes a ‘dinosaur long overdue
Volume 99 December 2006
for extinction.’1 Six and a half years on, the dinosaur is alive
and well. In 2002, a report in this Journal revealed that 15%
of case histories were illegible.2 In 2005, three surgeons
audited the legibility of 40 randomly selected operative
notes from an orthopaedic ward in a large British hospital.3
Two nurses, two physiotherapists and two medical house
officers were asked to rate the legibility of the notes as
‘excellent’, ‘good’, ‘fair’, or ‘poor’. Only 24% were rated
‘excellent’ or ‘good’, and 37% were deemed ‘poor’.
For members of the health care team, deciphering the
notes can be a nuisance, sometimes requiring the assistance
of colleagues and, if a signature is present and legible, a
direct call to the author. Often, no name is left on the
form.4 The considerable time and frustration associated
with this detective work far outweighs the extra effort
needed to dot an ‘i’ or cross a ‘t’. Trying to save time by
writing quickly is thus a false economy.
From the patient’s perspective, illegible handwriting can
delay treatment and lead to unnecessary tests and
inappropriate doses which, in turn, can result in discomfort
and death. In 1999, an American cardiologist caused the
death of a 42-year-old patient when his prescription of 20
mg Isordil, an antianginal drug, was misread by the
pharmacist as 20 mg Plendil, an antihypertensive drug.5
Poor handwriting undoubtedly contributes to another
inconvenient truth: the high incidence of medical errors
in Britain, which is estimated to cause the deaths of up to
30 000 people each year.6
Illegible handwriting in medical records can have
adverse medico-legal implications. Stephens notes that
‘few admissions look more damaging in testimony than
physicians admitting they cannot read their own hand-
writing. Sloppy handwriting can be interpreted by the jury
as sloppy care’.7 In the Medical Defence Union’s Ten
Commandments of record keeping, ‘Thou shalt write
legibly’ comes top of the list.8 So, how best to fix this
problem? A sophisticated IT system to computerize patient
notes? Handwriting tests as part of hospital appointments?
Penmanship classes for medical staff, like those conducted
in some North American hospitals?9 After careful reflection,
we propose a less daunting and more economical solution
for the graphologically challenged: a New Year’s resolution
to write more legibly. This commitment must be made, of
course, in writing.
Competing interests None declared.
Guarantor Daniel Sokol.
Daniel K Sokol1 and Samantha Hettige2
1
Centre for Professional Ethics, Keele Hall, Keele University, Staffordshire
ST5 5BG, UK
E-mail: daniel.sokol@talk21.com
2
St George’s Hospital, Tooting, London, UK 645
 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
REFERENCES
1 Leape L, Berwick D. Safe health care: are we up to it? BMJ
2000;320:725–6
2 Rodriguez-Vera F, Marin Y, Sanchez A, Borrachero C, Pujol E. Illegible
handwriting in medical records. J R Soc Med 2002;95:545–6
3 Gakhar H, Sawant N, Pozo J. Audit of the legibility of operation notes.
In: Royal College of Surgeons of Edinburgh Audit Symposium 2005.
Edinburgh: RCS Ed, 2005
4 Thompson A, Jacob K, Fulton J. Anonymized dysgraphia. J R Soc Med
2003;96:51
5 Charatan F. Family compensated for death after illegible prescription.
BMJ 1999;319:1456
6 Medical errors ‘kill thousands’. BBC News Online. 2000. Available at
http://news.bbc.co.uk/1/hi/uk/682000.stm (accessed 14 October
2006)
7 Stephens E. Medical-legal liability in emergency medicine. 2005.
Available at http://www.emedicine.com/EMERG/topic945.htm
(accessed 14 October 2006)
8 Norwell N. The ten commandments of record keeping. JMDU
1997;13:8–9
9 ‘Handwriting challenged’ doctors to take penmanship class at
Cedars-Sinai Medical Center. 2000. Available at http://
www.sciencedaily.com/releases/2000/04/000426155803.htm
(accessed 14 October 2006)
Fear ever young: the terrorist death toll
in perspective
Why are people not afraid of driving? There are plenty of
people afraid of flying, and the terrorist attacks of 2001 can
only have exacerbated this phobia. Whenever you board a
plane you can see them: anxious passengers gripping their
boarding passes so hard they jam the automated counters at
the boarding gates. Where are the masses sweating and
shaking with fear as they climb into their cars?
Clearly fear is not always founded in facts. Every year
over one million people around the world die in road traffic
accidents, compared with about one thousand deaths from
plane crashes. The difference is that every fatal plane crash
makes the news whereas most car accidents remain
Figure 1 Relative magnitude of global deaths in 2001 from
selected causes. Data taken from the WHO World Health Report, 2002.
Total area of figure corresponds to global deaths in 2001. RTA, Road
646 traffic accidents, TB, Tuberculosis
Volume 99 December 2006
anonymous. In their safety briefings, flight attendants never
warn you that you are sixty times more likely to die driving
home from the airport than during the flight.1
This bias in reporting deaths also applies to terrorism.
One individual taken hostage and murdered by some
extremist group makes news headlines worldwide. If the
BBC World Service tried to report each AIDS death for one
year, the broadcast would take more than a year to
deliver—even without interruption and allowing just 10
seconds per death. If we considered tobacco-related deaths,
even two simultaneous news bulletins couldn’t keep up
with the death toll.
Everyone remembers where they were when those
planes crashed into the World Trade Center killing three
thousand innocent victims on 11 September 2001. It
changed human history. But how many people know that on
the same day five years ago, more than four thousand
children died of diarrhoea, three thousand people died in
car accidents, and eight thousand died of AIDS?2 In 2003
the collective annualized mortality burden from tobacco
was more than five thousand times that of terrorism.3
Furthermore, these deaths continued unabated on 12, 13
and 14 September, and every day since. The even greater
tragedy is that they were preventable. Despite the billions
being spent on ‘the war on terror’, are we any safer?
There is no question that terrorism is a global problem
that needs to be addressed. However, as Jeffrey Sachs
explains, ‘We need to keep September 11 in perspective,
especially because the ten thousand daily deaths (from
AIDS, TB, and malaria) are preventable.’4
Competing interests The author holds a pilot’s licence.
Hasantha Gunasekera
REFERENCES
1 National Safety Council. What are the odds of dying? Available at http://
www.nsc.org/lrs/statinfo/odds.htm (accessed 15 October 2006)
2 WHO. World Health Report, 2002. Available at http://www.who.int/
whr/2002/en/whr02_annex_en.pdf (accessed 15 October 2006)
3 Thomson G, Wilson N. Policy lessons from comparing mortality from
two global forces: international terrorism and tobacco. Global Health
2005;1:18
4 Sachs J. The End Of Poverty. How We Can Make It Happen In Our Lifetime.
London: Penguin, 2005:215
Too little compassion in health care?
I have been visiting one of England’s major teaching hospitals
a couple of times every week for most of this year. My father
in law is a ‘frequent flier’ with heart failure and various co-
morbidities. Seeing the NHS through the lens of his care is
sobering. The NHS’s addiction to structural change as a way
of sorting things out seems unlikely to shift his shoddy

aoroaa (MIAb IA) wltn tne onject or
establishing a national network of British
Airways travel clinics. Each clinic is able
to offer a full range of advice. There is
also a retail service for medical accessories
for the travellers. The clinics are directly
linked by computer to the London School
of Hygiene and Tropical Medicine and up
to the minute information is therefore
available concerning vaccinations and
health information in all parts of the
world.
Patients may obtain the address and
telephone number of the nearest clinic by
ringing 01-831 5333. Telephone advice is
not available and patients should make an
appointment at their nearest clinic.
CAMERON LOCKIE
Green Lane, Alveston
Stratford upon Avon CV37 7QD
References
1. Holden JD. General practitioners and vaccina-
tion for foreign travel. Journal of the Medical
Defence Union 1989; 5: 6-7.
2. Williams A, Lewis DJM. Malaria prophylaxis.
Br Med J 1987; 295: 1449-1452.
3. Campbell H. Imported malaria in the UK.
J R Coll Gen Pract 1987; 37: 70-72.
Palliative care: home or
hospice?
Sir,
In her editorial (January Journal, p.2)
Finlay looked at the emergence of
palliative medicine as a specialty and how
best the profession should prepare doctors
entering the field. She placed the emphasis
on experience in general practice, where
the hospice is seen to provide 'a bridge
between community and hospital'. I would
like to comment not on the training, but
on the general issues concerning the evolu-
tion of a specialty which should enable
multidisciplinary care in the community
to be led by the doctor who is in an ideal
situation to do so - the general
practitioner.
For too long death has been 'medicaliz-
ed' doctors having taken over what was
the job of clergymen in Victorian times,
thus largely protecting the public from
death. When caring for the dying we can
become engrossed in the science of symp-
tom control, neglecting the other essen-
tial factors necessary for good care, par-
ticularly communication. Failure here
reveals our inadequacy in the face of death
and without an open and honest approach
the patient is sent away from home where
he may prefer to be if he knew what was
wrong and what prognosis he had. Un-
necessary hospital admissions, which
drain hospital beds, could be avoided with
benefit to the patients and to their quali-
ty of life. It is the general practitioner who
Journal of the Royal College of General Practitioners, August 1989
usually Knows tne patient anti nls tamily
best and therefore is likely to have the best
rapport with them. He should use this to
his advantage, reversing the trend for
death to be hidden in hospitals, and help-
ing death to be once again a 'family
affair'
General practitioners should not be per-
turbed by the evolution of this new
specialty, but stimulated to fulfil their role
as family doctors from birth to death,
allowing their patients to die peacefully
and with dignity, without hospice care
unless it is required.
The aim of developing palliative care
then should be not so much to encourage
an increase in the number of hospices, as
to promote a specialty enabling communi-
ty care by the general practitioner at
home. The essence of the problem is not
so much the need for a specialist with a
place where he can care for the dying but
coordination of a multidisciplinary team2
with the general practitioner as leader.
It is important that the new specialty
aims to improve general practitioner care
for dying patients at home through
research and education, thus attempting
to avoid care in an institution. This does
not mean that there needs to be evidence
of certified experience for general practi-
tioners in the field or the gaining of yet
another diploma; but recognition that, as
Pugsley describes,3 there are many who
can advise the general practitioner in this
role, but none who can perform the task
better or with a greater insight into the pa-
tient and his family.
The hospice movement is of course
essential and to be highly commended. Its
main role should be advisory, for educa-
tion and research and to help in the
management of difficult cases.
RODGER C. CHARLTON
Criffel
Dalbury Lees
Derbyshire DE6 5BE
References
1. Bowling A. The hospitalisation of death:
should more people die at home? J Med
Ethics 1983; 9: 158-161.
2. Wilkes E. Terminal care: how can we do
better? J R Coll Physicians Lond 1986; 20:
216-218.
3. Pugsley R, Pardoe J. The specialist
contribution to the care of the terminally ill
patient: support or substitution? J R Coll
Gen Pract 1986; 36: 347-348.
GPs should not counsel
long-term
Sir,
As a general practitioner who is also a
trained counsellor, I was most interested
by Rowland and colleagues' discussion
paper (March Journal, p.1l8).
Letters
I nave recently leen reviewing my work
as a general practitioner in the context of
the doctor-patient relationship and the
client-counsellor relationship and have
concluded that it is both difficult and in-
appropriate for a general practitioner to
have a long-term counselling relationship
with a patient. Seeing someone for more
than one or two counselling sessions out-
side normal surgery hours fundamental-
ly alters the doctor-patient relationship
and it may not be possible for the patient
to allow the general practitioner
counsellor to continue in the general prac-
titioner role. This conclusion is supported
by Kelleher' who feels that the general
practitioner counsellor may overstep the
boundaries of the doctor-patient relation-
ship and confuse the patient.
My answer to the question 'Can general
practitioners counsel?' is in two parts.
First, counselling skills are an essential
tool in the repertoire of all general prac-
titioners for routine work and for short
term counselling interventions. These
skills need to be taught to doctors at all
levels in their training, particularly in the
light of the suggestion that 'prescribing
anxiolytic drugs (is) no more effective
than brief counselling by the general prac-
titioner in treating new episodes of minor
affective disorder'. Secondly, longer term
counselling is best undertaken with clear
personal boundaries in a confidential and
anonymous relationship by a 'secure
frame'1 counsellor who lives away from
the locality, is not involved in a long term
(often literally a lifetime) relationship with
the client and who does not allow the
counselling process to be compromised by
any other relationship.
S.H. COCKSEDGE
The Health Centre
Chapel-en-le-Frith
Derbyshire SK12 6LT
References
1. Kelleher D. The GP as counsellor: an
examination of counselling by general
practitioners. in: British Psychological
Society. Counselling psychology section
review (volume 4). 1989; 7-13.
2. Catalan J, Gath DH. Benzodiazepines in
general practice: time for a decision. Br Med
J 1985; 290: 1374-1376.
Importance of legible
prescriptions
Sir,
The serious consequences of negligently
writing medical prescriptions have been
re-emphasized by the court of appeal in
the recent case of Prendergast versus Sam
and Dee Limited and others. Dr Stuart
Miller had written a prescription for Mr
347

Prendergast, who was asthmatic with a
chest infection, prescribing three Ventolin
inhalers (salbutamol, Allen and Han-
burys), 250 Phyllocontin tablets
(aminophylline, Napp) and 21 Amoxil
tablets (amoxycillin, Bencard).
Mr Prendergast took the prescription
to the pharmacy of Sam and Dee Limited,
where it was dispensed by a pharmacist,
Mr Peter Kozary. Mr Kozary dispensed
the Phyllocontin and the inhalers correct-
ly, but instead of Amoxil he dispensed
Daonil (glibenclamide, Hoechst), a drug
used for diabetes to reduce the sugar con-
tent in the body. Mr Prendergast was not
a diabetic and as a result of taking a large
dosage of Daonil suffered permanent
brain damage.
In the high court, Mr Justice Auld in-
dicated that a doctor owed a duty of care
to a patient to write a prescription clear-
ly and with sufficient legibility to allow
for possible mistakes by a busy phar-
macist who might be distracted. Having
established that in his opinion the word
Amoxil on the prescription could have
been read as Daonil, Dr Miller had been
in breach of his duty to write clearly and
had been negligent. Such liability could
not be excused by the argument that there
had been sufficient information on the
prescription to put Mr Kozary on his
guard. Dr Miller's negligence had con-
tributed to the negligence of Mr Kozary,
although the greater proportion of the
responsibility (75%) lay with Mr Kozary.
On appeal, counsel for Dr Miller
argued that the word on the prescription
standing on its own could reasonably have
been read incorrectly. However, various
other aspects of the prescription should
have allerted Mr Kozary to the fact that
something was wrong. The strength
prescribed was appropriate for Amoxil
but not for Daonil; the prescription was
for Amoxil to be taken three times a day
while Daonil was usually taken once a
day; the prescription was for only seven
days' treatment which was unlikely for
Daonil; Ventolin and Phyllocontin were
well known treatments for asthma and it
would have been unusual to have diabetes
and asthma treatments on one prescrip-
tion and finally, all prescriptions of drugs
for diabetes were free under the National
Health Service but Mr Prendergast did
not claim free treatment for the drug. All
of these factors should have raised doubt
in the mind of Mr Kozary and as a result
he should have contacted Dr Miller.
Therefore, the chain of causation from Dr
Miller's bad handwriting to the eventual
injury was broken.
Lord Justice Dillon rejected this argu-
ment in the court of appeal. First, it was
no defence to Dr Miller to rely on the
348
already established negligence of Mr
Kozary when he himself had been in
breach of his own duty of care to write
clearly and had been negligent. Second-
ly, those other factors were not enough to
make it beyond reasonable foreseeability
that Daonil would be prescribed.
Therefore, the chain of causation had not
been broken.
The implications of this decision are
that doctors are under a legal duty of care
to write clearly, that is with sufficient
legibility to allow for mistakes by others.
When illegible handwriting results in a
breach of that duty causing personal in-
jury, then the courts will be prepared to
punish the careless by awarding sufficient
damages. Liability does not end when the
prescription leaves the doctor's surgery,
even if the doctor has been grossly
negligent. It may also extend into and be
a cause of the negligence of others.
KENNETH MULLAN
Department of Public Administration
and Legal Studies
University of Ulster
Jordanstown
Northern Ireland
The community pharmacist
Sir,
The recent exchanges in the Journal on the
subject of dispensing and the role of
pharmacists in primary care has been
illuminating as much for what was not
said as for what was.
Rural practice is being given an ex-
tremely hard time by pharmacy and phar-
macy is being given an almost equally
hard time by government. While there are
honourable exceptions, the predominant
motivation for the pharmacy is money, in
exactly the same way as for any other retail
shopkeeper. The rural practitioner is not
so saintly as to be wholly unmoved by
money but something which non-
dispensing doctors may not realize is the
huge satisfaction that is to be gained from
being able to do the whole job of health
care provision oneself. The patient has
much to gain from dispensing by the doc-
tor, and is acutely aware of it, as may be
witnessed by the number of letters that
our MP received when this practice was
threatened, over 700. The sadness of the
fraught atmosphere over dispensing is that
patients, if given a free choice, would pro-
bably opt to have both a dispensing doc-
tor and a local pharmacist. For the mo-
ment at least this is not likely to come
about and, in consequence, everyone loses.
The paper by Taylor and Harding (May
Journal, p.209) is riven with inconsisten-
Juraal of the Royal College of Generl Practitioners, August 1989
Letters
cies and non sequiturs. The sharing of
responsibility in the 1982 case cited ap-
pears not to have profited the victim. With
respect to another case, I venture to sug-
gest that most doctors would not dispense
250 mg of Daonil (Hoechst) tds. A com-
puter would not let such items through.
Compliance with prescribed treatment
is hindered by the physically remote
dispensing process which is imposed on
the majority of clients. Why else would
such an enormous proportion of prescrip-
tions written fail to be dispensed?
Taylor and Harding are on much firmer
ground when they speak of 'a ready source
of drug information' and of pharmacists
being well placed to deal with minor
ailments. With respect to the latter, how
much better placed they would be if they
were able to sell more truly effective items
and how much better served the public
would be if pharmacy were not cocoon-
ed by resale price maintenance. However,
to state in the journal serving the leading
edge of primary care physicians of the UK
that 'Pharmacists are the only health pro-
fessionals to whom there is quick and easy
access without a prior appointment and
who are willing and able to advise patients
on minor health complaints as well as on
health education' seems recklessly
undiplomatic.
Professor Salkind (letters, May Journal,
p.214) takes an academic's oblique view of
the issue and as a consequence falls pain-
fully astride his own conclusions. Minor
ilness can often be managed without the
intervention of general practitioners and
even more often by no treatment at all.
'Improving the quality of personal con-
tact with patients' is what dispensing by
doctors is really all about; that is real
'lateral thinking'
Balon, Evans and Green (letters May
Journal, p.215) also take a tumble in their
contribution. I strongly dispute the con-
tention that retail pharmacies are com-
monly open for the hours described. In
our own case, when threatened by a phar-
macist opening in the village, we
calculated that given the opening hours
at his other premises there would be a loss
of pharmaceutical provision to the public
approaching 75%. Doctors fulfil the func-
tion of managing minor illness for 24
hours a day, 365 days per year, even bear-
ing the responsibility for it when the ac-
tual work is done by deputies. By contrast
pharmacists are only too ready to allow
doctors to dispense for many hours every
night, at weekends and bank holidays.
Where is the commitment to patient care
in unsocial hours?
There is no question whatever that
pharmacy has a cornerstone role in
primary care but that role is not dispens-
 In the Public Eye
News and Features
Compensation awarded for death after
illegible prescription
Fred Charatan, Florida

A Texas jury has attributed the death of a 42 days later. The overall quality of care given by
year old patient to an illegible prescription Dr Kolluru was not at issue, the jury heard;
and has ordered the doctor who wrote it to his illegible prescription was the sole reason
pay $225,000 compensation to the patient’s for the judgment.
family. The total judgment of $450,000 in- The case again raises the issue of the leg-
cluded an equal award against the dispensing ibility of doctors’ handwriting. Mr Bucking-
pharmacist. ham pointed out: “Many doctors are having
The doctor, cardiologist Dr Ramachandra to stop and think, ‘That prescription I wrote
Kolluru, wrote a prescription for 20 mg Is- illegibly this morning may result in an ad-
ordil (isosorbide dinitrate) for angina, every verse verdict.’ ”
six hours. But, because of the illegibility of the Three policies issued over the past 7 years
prescription, argued Kent Buckingham, law- by the American Medical Association have
yer for the family of the patient, Ramon urged doctors to “improve the legibility of
Vasquez, the pharmacist dispensed the same handwritten orders for medications” and to
dosage of Plendil (felodipine), a calcium review all orders for accuracy and legibility
channel blocker used in the treatment of hy- after writing them. Doctors with poor hand-
pertension, for which the maximum daily writing are advised to use direct, computer-
dose is only 10 mg. A day after taking what ised order entry systems or at least to print or
equalled a 16% overdose of felodipine, Mr type medication orders. Dr Kolluru’s lawyer,
Vasquez had a heart attack and died several Max Wright, said after the trial: “This jury
clearly questioned why in the electronic age
. . . we’re still using this antiquated system
based on a three and a half by five inch piece
of paper.”
A trustee of the American Medical Asso-
ciation, Donald Palmisaro, noted that reduc-
ing all sources of medication errors is a top
priority of the National Patient Safety Foun-
dation at the association. In addition, the US
Adopted Names Council, housed in the as-
sociation, aims to reduce such errors by help-
ing drug manufacturers to avoid drug names
The illegible prescription that look or sound alike.

.............................................................................................................................................................................

US board of education advises against drugs

for behavioral problems
Fred Charatan, Florida

A US board of education has passed a reso- The resolution passed by Colorado Board
lution urging teachers to use discipline and of Education carries no legal weight but
instruction to overcome problem behavior in sounds a warning on the growing use of
the classroom, rather than encouraging par- drugs such as Ritalin (methylphenidate hy-
ents to seek drug treatment for their children. drochloride) to deal with disruptive behavior

80 wjm Volume 172 February 2000