Doctors record, discuss and conclude in writing. Therefore, medical students need to practise their writing skills and be tested on their ability to write professionally.
Photo: Einar Nilsen
All doctors write. Few write academic articles, but nearly all write patient records, referrals, test requisitions, case histories and medical certificates (1). Doctors produce a large amount of written material, irrespective of whether they write by hand (which is rare these days), on a keyboard, with a Dictaphone or use speech recognition systems. Since many patients are treated by many doctors in multiple departments and various parts of the health services, the written material must be readable, complete, concise and relevant. Clinical decisions and good collaboration depend on doctors writing good patient notes, letters and referrals.
Thus, a large part of a doctor’s life is spent writing. But is the quality assurance of the doctors’ patient notes, referrals and case histories adequate? Doctors are trained in communicating better with their patients, but they are not trained in writing better (2), and many doctors complete their medical training with only a minimum of writing skills practice. We also know that many referrals from GPs are unclear, incomplete and rather verbose (3), that a considerable proportion of hospital doctors’ reports after discharge are inadequate (4) or too long, rambling and tarnished by poor language (5), and that the dialogue between doctors in different parts of the health services concerning shared patients may be suboptimal (6). Laboratory doctors may complain about the absence of relevant clinical information on test requisitions, and case histories may be full of internal jargon, in-house terminology and cryptic abbreviations. Such issues make medical assessments more time-consuming, difficult and more uncertain than necessary. Patient treatment will be poorer, and the risk of errors increases.
Most medical students have performed well in school, and their ability to write in Norwegian (and English) is generally more than adequate. However, writing patient records, referrals and academic articles as a doctor is quite different from writing school essays and similar texts. The change of format, genre and context entails other and far higher requirements for precision and clarity. During their studies, most students appreciate all types of feedback that their medical teachers can give them, including with regard to patient records and written submissions, but some students may have an exaggerated faith in their own writing skills (7).
New curricula are now being introduced in all medical schools in Norway. The time allocated to a mandatory student thesis will increase somewhat compared to previous curricula. In Oslo, work on the student thesis must result in a 25 – 30-page manuscript, which will be assessed by an external examiner and receive a pass or fail grade (8). In addition, the students must write laboratory reports, training course reports and reflective memos, as well as patient notes at the university hospital and during their practical training periods (Jan Frich, personal communication). In recording patient notes, i.e. recording of the patient history and clinical examination, the medical teachers will review the findings and approve the written patient record. Similar writing skills training is included in the new curricula in Bergen, Trondheim and Tromsø.
Many will claim that the extent of this writing skills practice will still be insufficient for an academic study programme such as medicine. It is therefore essential to make use of all available opportunities for writing practice. Writing skills practice must be prioritised by the students, the medical teachers and the programme coordinators. The same applies to practice in oral presentations, such as summarising patient interviews and clinical evaluations on diagnosis and treatment.
Digital written exams, largely based on multiple-choice questions, have been introduced or are being introduced in all medical schools in Norway, in Oslo soon with grades from A to E. In such exams, the students should also be tested – and be graded on a scale – on their ability to express themselves in writing. Reliability concerns can be satisfied in several ways. After all, what is most important: that the students are good at ticking the most correct alternative among 4 – 5 options, or that they are able to write a sensible answer to an assignment with no pre-defined response categories? Patients rarely come into the doctor’s surgery with four alternative diagnoses or courses of action written on their forehead – medical reality is much more complicated than that.
Writing well is different from and much more than mastering grammar, adhering to rules of the comma and avoiding typos. Good writing means choosing the right words and stringing them together to convey the message to the reader in the way the author intends (9, 10). Medical students need to learn how to report clinical observations and describe medical assessments in writing and speech in a structured and systematic way. Good writing depends on clarity of thought. For, as a wise person once said: it is only when you start writing to reach out to others that you understand your own thoughts (10). Therefore, students need to practise their writing skills and be tested on them. Welcome to a new academic year!