Prepare yourself for medicine in the post-apocalyptic world!The evolving interface with the medical literature.
They were once one of my most prized possessions, but now I can’t even give them away. Beginning in 1967 with the New England Journal of Medicine (NEJM), I began to bind my medical journals. The fact that the practice was begun for me by my late father-in-law only increased my emotional attachment to these physically and intellectually handsome books. As my career progressed, I added all the major general internal medicine and rheumatology journals to my collection. I was on the editorial board of two of these, wrote articles appearing in them, and reviewed countless articles submitted for publication by others. I carried these books from one institution to another for over 40 years until, following my active medical retirement, they ended up in a Stor-All facility. As I attempt to further downsize now because I no longer physically have room for them, I discover to my naive surprise and disappointment that no one else wants them. My current dilemma stems from the fact that I cannot bring myself to throw them away. Perhaps one of my readers can help me. Details about the collection can be found at the end of this article.
Access to the medical literature has changed.
As I wrestled the 30 heavy boxes of books from a $125/month Stor-All unit to my garage last summer; I had occasion to reflect on how I interfaced and used the medical literature over a career that encompassed an exploding volume of medical information; the rise of personal computers and devices; and digitalization of professional publication. How I looked for information and incorporated new knowledge into my research, teaching, and clinical endeavors evolved in the midst of these changes.
A weekly or monthly journal like the NEJM contains several original scientific articles, reviews of individual clinical topics, editorial comment, and a variety of other items thought to be useful to keep a physician current. Because my initial subscription to the “Journal” was a gift from the company that sold me my microscope, I began to read it regularly in college even before I started medical school. Despite being a “B” student at best as an undergraduate, I did very well academically in medical school and actually enjoyed it immensely. I have often speculated that allowing my curiosity to roam freely in the medical literature was of greater value to me than the high-pressure motivation faced by today’s medical students to prepare for the gauntlet of standardized tests necessary to advance from one year to the next or to graduate. As a medical educator, the only question from students that always disappointed me was: “Is this going to be on the boards!” In my opinion, “teaching to the test” robs medical students – indeed all students – of much of the pleasure if not the potential breadth of their education, but that is a topic for another article.
Always timely and on point.
Early-on, I was struck by the apparent coincidence that whenever I took up a journal issue I found something that addressed a topic I had recently been thinking about or that was relevant to one of the patients I was caring for at the time. That observation has never faded. Of course coincidence has nothing to do with it. Important and relevant information is always there – you just have to be ready to find it. In any event, when I advised even first-year medical students, I recommended that they subscribe to or otherwise follow a general medical journal of their choice such as the New England Journal of medicine, the Journal of the American Medical Association (JAMA), the Annals of Internal Medicine, or American Family Physician. These journals are available in medical libraries, but individual print subscriptions for students can be had for free or nearly so from the sponsoring medical publishers. The best way to learn from the medical literature is to get in the habit of doing so early.
How do you find what you want?
In those earliest years, most journal issues usually had something I could at least partially understand. The problem was that if you wanted more information about any specific topic you were generally up the creek. Except for a table of contents of that week’s or month’s issue, there was no such thing as a cumulative index. Only at the the end of the year or in the last issue of a series would a printed index for that volume be appended. This meant that a search of the medical literature involved looking up several indexing terms backwards one year or volume at a time in each different medical journal. You also had to be careful you were using the right indexing terms. In truth, major medical libraries had printed versions of an early Index Medicus, but these covered only a subset of all medical journals and still had to be addressed one year at a time. These were not available where I did most of my studying.
Of course, each individual article has its own references to earlier relevant articles at the end. Following these backwards from one paper to the next was how one could reconstruct the history of medicine. In the medical libraries of Columbia and the University of Pennsylvania, I used to be able trace a topic as far back as 150 years or more in Journals such as the the Lancet. In such searches to prepare for presentations or in writing papers, I rarely failed to discover major misunderstandings or misattributions that had been perpetuated uncorrected. Today, as libraries shed their printed volumes for lack of space or in favor of digital collections and coffee shops, I am not sure that my experience could be easily replicated.
Drinking from the fire hose.
During my clinical training we had weekly journal clubs where we took an hour to dissect one or two medical articles to learn how to evaluate them. How sound was the design? Did they collect relevant data? Was the statistical evaluation of their data appropriate? How well were the conclusions supported? For clinical studies, were the results generalizable to other groups of patients? I learned in these sessions that virtually no study can be considered perfect and that there are many studies of limited value in the medical literature. Even today, I often find myself taking more than an hour to read a single article. How to keep abreast of the medical literature, even for a narrow specialty, is a real problem. A commonly used phrase is that “it is like drinking water from a fire hose.” Neither can be done in a fully satisfying manner.
In response to the difficulty of keeping up, the importance of the abstract has grown. The ”abstract” is a summary of the article placed at its beginning. In my early experience and own practice, these would be written last and without the care given to the article itself. In these earlier times, abstracts sometimes functioned more as “teasers” and might even conclude with a sentence such as “the results will be discussed.” No longer. Abstracts today are highly structured short paragraphs divided into the same sections as the articles themselves: Background, Objective, Design, Patients, Measurements, Results, Limitations, and Conclusions. Contemporary abstracts are mini-articles of their own. Their evolution has responded to and perhaps was even driven by the rise of the machines and digital publication where the abstract functions essentially as a substitute for the article itself.
Digital medical literature here to stay.
Make no mistake, the availability of accessing the medical literature digitally over the internet in a library, at home, or for that matter on the wards has been a wonderful advance. My first experience with a digitized medical literature database was in the early 1990s with the availability of the Index Medicus of the National Library of Medicine on proprietary CD-ROMs. I could effortlessly look up my choice of key words and print out dozens of references to articles appearing in several hundred different journals. For example, I could retrieve virtually everything written in a given year in major medical journals about The Gout. The best part, was that the results returned included more than just the name of the journal, authors, and dates, but also the actual abstract of the article. I became a “sniffer” of the medical literature instead of a leisurely gourmand. For many situations, I was willing to exchange breadth for depth. One could gain a useful sense of what physicians and scientists around the world were thinking and to know where best to look for further details. Of course, the disks were always 4 to 6 months behind.
Help is available – some more reliable than others.
In our current era of data-driven, evidence-based medical practice [Surprise! It was and is not now always so], we individual practitioners receive valuable help from organizations like the Cochrane Database of Systematic Reviews that use standardized methods of evaluating the quality and applicability of clinical information. We have the benefit of “meta-analyses” that combine smaller studies of limited power into larger assemblies that can be more convincing. Thoughtful reviews or updates on given topics are still being written. There has been an emphasis on making the medical literature more useful to the practicing physician and to help sort out the best studies from weaker ones. Still, in my opinion, the content of major clinical journals overly reflects the powerful influence of the pharmaceutical industry and not just in the ads. I miss the “patient-series” article that described the natural history of an illness followed by a single physician or group. I miss (and have never forgotten) the kind of article by Professor William Bean, who for 36 years measured the growth rate of his own finger and toe nails. I suspect that article would have a hard time finding a home today. It seems to me that there is much more emphasis today on drug therapy than there is on the pathophysiology and natural history of illness. Of course both approaches are necessary because treatment is best based on knowledge of the cause of the illness.
Not without limitations or shortcomings.
The switch to a digital medical literature is not without its own concerns. The older medical literature has not been digitized at all and most medical libraries are physically unable to house the bulk of these old books. Furthermore, just because the material is in digital form does not necessarily make it more available to the public – even for research that has been funded by public money! Access is still restricted. Most of it is not free. While public databases such as PubMed can be searched without cost and one can often retrieve a useful abstract, the complete article is likely to require a separate purchase on the website of the publisher. I had an easier time of it in a comprehensive medical library.
Can digital knowledge get lost?
I recently returned from a trip to Italy where I visited the library of the oldest secular university in the world in Bologna. I confess to feeling a profound sense of reverence in the presence of the old medical books in the library museum. These were physical proxies of my professional ancestors. However, as I looked around the room, I noticed, as I did in the famous monastery library of Melk, that there was no evidence of any sprinklers or fire protection system. I was told in Melk, and I suspect it was the case in Bologna, that there was more fear of water damage from a sprinkler malfunction than of fire. Despite the best efforts of Google, these books have not been scanned and digitized. The fact is that books can burn or get flooded. The library of Alexandria burned, and even in my lifetime, irreplaceable collections that have not been digitized have disappeared in smoke. Even worse, books and libraries have been burned intentionally for philosophical, religious, or political reasons. What portion of our collective wisdom had been lost to us? I do not know, but it is clear that knowledge is as mortal as we are and can be lost or become unavailable for centuries. We don’t call it the dark ages for nothing.
Does the fact that printed materials can be digitized imply that their content becomes immortal? It would be nice to think so, but all of us know or have heard of people who have lost their entire collection of digital photographs for one reason or another. Formats of digital material change. I can no longer access much of my own personal research data or papers written on computers or with software that no longer exists. In my opinion is is foolish to assume that our digital libraries are any more immortal than we ourselves or our books. We need both digital and physical means of information preservation. So it is that I offer my collection of bound medical journals to someone who will take care of them as a hedge against the possibility of the post-apocalyptic world of Mad Max, the Terminator, or the Matrix.
To help preserve the work of innumerable contributors to medical knowledge, I offer these volumes at no cost to a suitable caretaker who will give them a good home. My preference is for a non-profit educational or service entity that is willing to arrange to pick them up. I can help within Louisville. Below is a list is what I have. Your help or suggestions gratefully welcome,
My name is Peter, and I am trying not to be a hoarder.
New England Journal of Medicine: 1969 – 2001, V. 281 – 345
Annals of Internal Medicine: 1971 – 2001, V. 74 – 135
American Journal of Medicine:1971 – 2001, V. 1971 – 2001
Archives of Internal Medicine: 1971- 1978
Arthritis & Rheumatism: 1972 – 2001, V. 15 – 44
Journal of Rheumatology: 1982 – 2001, V. 9 – 28
Annals of Rheumatic Disease: 1980 – 2001, V. 39 – 60
Seminars in Arthritis & Rheumatology (unbound): 1977 – 2005, V.4 – 35
I haven’t decided what to do with these monthly series of books, each a textbook of its own:
Medical Clinics of North America:
Rheumatology Clinics of North America: