Friday, August 05, 2005

How and why do doctors read?

It occurs to me that the ways we read medical literature fall into at least two categories. First there’s the type of reading we do to practice evidence based medicine (EBM). That type of reading focuses on the clinical question at hand as it applies to a particular patient. We often use the PICO acronym to help us formulate the question. (In a Population with my patient’s attributes, what is the effect of the Intervention in question versus a Comparison group with respect to Outcomes?). Such a question forms the basis for a search that will retrieve relevant articles. This highly focused and specific type of reading has been variously termed question driven reading, problem based reading and foreground question reading, and often relies on POEMs. It is often done “at the point of care”, e.g. the physician’s office, the exam room or the hospital ward. The reading material might consist of abstracts of randomized controlled trials, a systematic review, or topic summaries from a filtered source such as Bandolier, DARE, TRIP, or Up to Date. This is a relatively new type of reading, not possible before the availability of the Internet and the vast repository of searchable medical databases.

Another type of reading is the more traditional type which, although often patient based, is not as focused. It is sometimes referred to as
background question reading. I have recently heard the somewhat derogatory term “reading for the heck of it” to describe this type of reading. Such reading often draws on DOE (disease oriented evidence). It is more likely to take place at home, and the topic might be related to a patient you saw that day, or that week. The source could be a textbook or a narrative review. It would have a broader scope than the former type of reading, and might encompass the clinical features, epidemiology and pathophysiology of a disease.

So why do I make a fuss about this? Well, it seems there’s a ground swell of opinion these days against background reading.
This article encourages students to do problem based searching of filtered resources, but not to bother with standard medical journals! This tutorial on EBM warns the reader that DOE is worthless if not dangerous. I’m reading more and more opinions of this sort, many taking aim against narrative reviews, textbooks, experts and the practice of reading about pathophysiology. The purveyors are purportedly doing this to advance the cause of EBM. I would argue that this reflects a narrow view of EBM. The classic paper by Sackett, et. al., which many recognize as a defining article on EBM, clearly points out that expertise and judgment (which I believe derive from background reading) are important components of the process.

I believe both types of reading are essential. Without foreground reading we can’t bring the best and most current evidence to bear on the individual patient’s problem. Without background reading we lack depth of understanding, and can never cultivate the expertise and judgment so essential to the rational and prudent application of evidence.

Now excuse me while I go read a chapter from Harrison’s.


jamesgaulte said...

students who believe they only need to read pre-digested,edited summaries and guidelines related to particular clinical issues as they arise are as naive as students who once believed everything their profs told them.To not read more broadly will lead to docs that are woefully undereduated and unthinking.

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