Students reported spending 61% of their reading time in patient-related reading, while 17% was for general reading in medicine and 22% was reading specifically for the USMLE medicine shelf examination with test preparation books.
Table 3 depicts problems that clerks described in their reading during the clerkship. Forty-four percent reported no problems in reading about their patients. The main problem related to reading during the clerkship was insufficient time to read medicine. Thirteen students (12%) reported that they did not know how to focus reading on their patients and 13 (12%) didn't know the best source to use. Only 5 students (5%) reported difficulty in finding sources appropriate to their learning level. However, 36 clerks (43%) felt there was a need for a textbook to be written specifically for the medicine clerk.
Apart from receiving advice during their clerkship orientation from the clerkship director, 72 students (64%) reported being given additional advice on what to read at some point during the clerkship. Table 4 describes the often conflicting advice students received regarding reading. Students reported receiving such advice from attending physicians, resident physicians, interns, and fellow students. Approximately one third of students were advised by attendings and residents to read journal articles. Forty-one students (37%) were advised by interns to use online sources. Students most commonly recommended to each other that they read test preparations textbooks.
We analyzed data by available demographic data and found no statistically significant differences in mean (SD) hours of reading per week by year in medical school: second-year, 12.6 (4.5); third-year, 11.0 (5.8); fourth-year 7.6 (3.7); p = .127. However, we identified a trend toward decreasing median hours of reading per week with students' advancing year in medical school: second-year, 12.0; third-year, 10.0; fourth-year, 8.5; p = 078. PhD status was not associated with a difference in mean or median hours of reading. Age was not associated with hours of reading in simple linear regression or in multiple linear regression when controlled for year in medical school and MD-PhD status. Third-year students (71% [68 students]) were more likely to use journal articles than second-year (57% [4 students]) or fourth-year students (30% [3 students]); p = .024. Among students who used lecture notes or conference handouts, second-year students (2.3 mean hours per week) reported using them more than third-year (0.9) or fourth-year students (0.8); p = .013. Among students who used test preparation books, second-year students (6.0 mean hours per week) used them more frequently than third-year (2.6) or fourth-year students (1.0); p = .003.
We found no differences in the reading sources used by the clerks and time they reported spending in an average week using those sources when we examined these data by MD-PhD status. There were no differences in ratings of usefulness of reading sources by year in medical school except that third-year students (79% [75 students]) were more likely to rate UpToDate extremely useful compared with second-year (50% [three students]) or fourth-year students (60% [six students]); p = .025. In addition, none of the second-year students rated online sources as the most useful, while 51 third-year students (54%) and four fourth-year students (40%) did so. Second-year students spent a smaller proportion of their time in patient-related reading (33.6% of time) than third-year (58.7%) or fourth-year students (64.5%); p = .011, with more time spent reading specifically for the USMLE shelf examination: second-year, 36.4% of their time; third-year, 21.2%; fourth-year, 24.0%; p = .094. However, given the small numbers of second- and fourth-year students, these analyses should be interpreted with caution.
To our knowledge, this is the first study to provide substantial data on the overall reading habits of medicine clerks. Our study suggests that medicine clerks spend substantial time reading medicine during their basic medicine clerkship and that the most often used and highly rated sources by the students were online sources, especially UpToDate. Test preparation textbooks were the most often used and highly rated print resource.
Previous study of medical reading habits has been limited. A study that focused on second-year medical students found that, despite having an assigned workload that exceeded the number of hours in a week, students read required texts for a mean of six hours per week, with a range of zero to 15 hours per week.6 Students did not purchase most “required” texts. The author noted that despite the fact that the curriculum was overloaded and focused on minutiae, students had the “good sense to reject the whole, taking only such parts as they find palatable.” A study of family practice residents7 showed that they read for an average of 3.7 hours per week, relying most on pocket manuals and least on original scientific research. Practicing internists8 read for an average of 4.4 hours per week, focusing on medical journals; and surgeons9 read for an average of 14 hours per month, relying most on journals. Internal medicine residents read for an average of 8.7 hours per week, of which half was spent reading about their patient cases.1 In that same study, 9 medical students were surveyed and were found to read for an average of 10.8 hours per week and relied solely on medical textbooks, this in the pre-Internet era. Students in our study reported reading, on average, exactly that amount of time.
Our data suggest that students at different stages in their medical education approach the task of reading in different ways. As they advance through medical school, students appear to read less, move to reading journal and online sources, and focus proportionately more of their reading time on patient-related matters rather than on preparation for the USMLE shelf examination. However, these data need to be interpreted with caution given the relatively small number of second- and fourth-year students in the sample.
It is interesting that students use UpToDate to such a great extent. There are several hypotheses to account for this. In our experience, medical students are pragmatic and their reported reading habits suggest that they were following a method to maximize their efficiency and performance on the clerkship. Online, expert-based sources such as UpToDate—always available, and focused on providing answers to questions—may have been the most efficient means for students to obtain critical information. In addition, the heavy use of a source such as UpToDate, which provides succinct data on management and therapeutic issues, may be students' response to the focus on diagnosis and management of illness that occurs on clinical ward rounds. A recent study that monitored second-year medical students' use of UpToDate found that medical students rapidly adopted UpToDate to answer clinical questions.3 The substantial use of test preparation books probably reflects the pragmatism of students who must pass the USMLE medicine shelf exam in order to pass the clerkship. Although the use of a source such as UpToDate may not be especially useful in the development of information literacy skills needed in the later stages of a medical career, it is interesting that our data suggest a move toward journal reading among third-year students and reduced use of test preparation textbooks among third- and fourth-year students.
A majority of students reported problems with reading, the main one being a lack of time to read. This is consistent with previous studies of clerkships that suggest that students may benefit from having more time during the clerkship to read, as significant amounts of time are spent on activities of limited learning value, and that students would like to have more time to read.10,11 However, over 30% of the students we surveyed reported more substantive problems in reading about their patients, and this is an area for further descriptive investigation and possible educational intervention.
This study offers several potential lessons to medical educators. First, the increasing availability of online medical education resources can assist medical educators in improving their teaching efficiency by obviating the need to prepare detailed handouts or copy journal articles for students who can access easily such information online. Second, the disparate advice given to medical students by various colleagues suggests a need for medical educators to develop evidence-based advice to help students acquire the knowledge base required to become physicians. Finally, if medical textbooks are not yet obsolete, it is clear that online resources are here to stay until the next technologic revolution emerges. Educators should become familiar with these resources and contribute to maximizing their effectiveness for students.
The strengths of the current study include the high response rate to the questionnaire and the fact that it was conducted at an institution where students had continuous access to a variety of reading sources. In addition, to our knowledge, this is the first study to provide substantial data on the overall reading habits of medicine clerks in the Internet era.
The main limitations of the study are that although the data were collected anonymously, they are self-reported and may be subject to bias. Specifically, we have no method to determine whether students accurately reported the amount of time they spent reading. We lacked data to assess any possible relationships between reading habits and educational outcomes such as performance in the clerkship or on the USMLE medicine shelf examination. In addition, although we draw inferences, we lack a clear understanding of why clerks make the reading choices that they do. The study was conducted at a single medical school and its generalizability may be limited. However, perhaps the most important limitation is that the amount of time students spent reading or the sources they reported using or preferring are very crude measures of how students actually use information sources to augment their knowledge, solve clinical problems, and develop clinical judgment. Our data, however, do begin to shed some light on this process and point the way toward additional studies in this important area.
In conclusion, basic medicine clerks spend significant amounts of time reading during their medicine clerkship and, in the Internet era, rely on online sources, especially UpToDate. Our data suggest that students engage in reading strategies that maximize their efficiency and aspects of their assessed performance during the clerkship. It will be interesting to monitor the reading habits of medical students that came of age during the Internet era. Will they continue to rely on online sources such as UpToDate or will they make the leap to use primary data sources, such as journal articles? Recent cross-sectional data suggest they may not make this shift,12,13 and additional research on how students actually use materials to answer clinical questions is needed.
The authors wish to thank Dr. Patricia Thomas for review of and comments on the survey instrument and an earlier draft of the paper and for ongoing mentorship, Dr. Amy Knight for her review of and comments on an earlier draft of the paper, and Sharon Kuta for assistance with manuscript preparation.
Portions of this paper were presented at the annual meeting of the Clerkship Directors in Internal Medicine (CDIM), Savannah, Georgia, 2003.
Dr. Harper was supported by a grant by the Bureau of Health Professions (5 K01 HP 00015–05).
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.
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