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The Reading Habits of Medicine Clerks at One Medical School: Frequency, Usefulness, and Difficulties

Leff, Bruce MD; Harper, G Michael MD

doi: 10.1097/01.ACM.0000222273.90705.a6
Clinical Education

Purpose To describe the reading habits of medicine clerks, which previously have not been well described. Understanding issues related to student reading habits may provide insights and opportunities for medical educators to develop methods to improve clerks' clinical clerkship experiences and their information literacy skills.

Method The authors administered an 18-item survey tool to 120 students on their first inpatient internal medicine clerkships at the Johns Hopkins University School of Medicine in 2002–03. The questionnaire focused on issues related to what and how often they read during their basic medicine clerkship. Data were explored mainly with descriptive statistics.

Results One hundred twelve of 120 (93%) medicine clerks completed the survey. Clerks reported reading for an average of 10.8 (SD 5.6) hours per week (median ten hours per week, range one to 30 hours per week). The most commonly used and useful reading sources were UpToDate® and test preparation textbooks. Approximately 30% of students reported substantial problems in reading about their patients. Limited data suggest that reading habits and learning methods vary by year of medical school. Clerks are given disparate advice on appropriate reading sources to consult by attending physicians, resident physicians, and fellow students.

Conclusions Students spend significant amounts of time reading online sources during their medicine clerkship, especially UpToDate. Medical educators should become familiar with these sources and contribute to maximizing their effectiveness for students. Additional research focused on understanding how students build skills in information literacy and how educational programs can facilitate the development of those skills is needed.

Dr. Leff is associate professor of medicine, Department of Medicine, Johns Hopkins Bayview Medical Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

Dr. Harper is associate clinical professor of medicine, Department of Medicine, University of California, San Francisco, School of Medicine; and staff physician, San Francisco Veterans Administration Medical Center, San Francisco, California.

Correspondence should be directed to Dr. Leff, Johns Hopkins Care Center, John R. Burton Pavilion, Johns Hopkins Bayview Medical Center, 5505 Hopkins Bayview Circle, Baltimore, MD 21224; telephone: (410) 550-2654; fax: (410) 550-8701; e-mail: 〈〉.

When medical students arrive on the wards as clinical clerks, they are frequently exhorted by attending and resident physicians alike to “read medicine”: to read about their patients and about subject matter related to their clinical rotations. Acquiring knowledge through reading makes intuitive sense, yet there are few data to inform us how students go about this crucial task as they make the transition from classroom students to clinicians.

The reading habits of clinical clerks have not been well described.1 Limited evidence and anecdote suggest that they receive inconsistent advice on appropriate reading sources to consult and may have unrecognized problems in reading. Also, they may respond to a “hidden curriculum”2 that promotes reading habits that are not entirely consistent with clerkship learning objectives. In addition, as the Internet has become an increasingly common feature of medical education and practice, students rely increasingly on online sources3 that may not be appropriate to their educational needs. The issue of reading is important, as the ability to read about patients and patient care issues relates directly to several important medical competencies identified by the Accreditation Council for Graduate Medical Education, including patient care, medical knowledge, and practice-based learning and improvement. Understanding the reading habits of clinical clerks may help medical educators begin to develop an understanding of how students gather, assimilate, and use information to solve clinical problems, and ultimately develop an approach to using information in caring for patients. This, in turn, may facilitate the development of educational programs to maximize information literacy and better meet the learning needs of clinical clerks. In order to facilitate these goals, the aim of this study is to describe the reading habits of medicine clerks and issues related to their reading.

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All Johns Hopkins University School of Medicine students participate in a nine-week required clinical clerkship in internal medicine. At the clerkship orientation, clerks are advised by their clerkship director to use a basic medical textbook (print or online version) as a primary reading source, to read broadly, and to focus their reading on patient-related issues and on relevant topics for a basic medicine clerkship as outlined by curricula developed by the Clerkship Directors in Internal Medicine.4 The students are provided with a description of various techniques to approach the task of reading during their clerkship. They are advised to improve their medical knowledge and ability to provide quality patient care by focusing their reading on understanding the basic pathophysiology of disease, with the main goals of developing a differential diagnosis and interpreting clinical data to aid in the development of patient management plans. Students are also provided with a list of useful educational Websites and online resources.

At each of the clerkship sites, clerks have ready access to online medical resources, including online versions of medical textbooks such as Harrison's Textbook of Medicine or Cecil's Textbook of Medicine, PubMed®, UpToDate®, MD Consult®, Micromedex®, and others. In addition, at each of the clerkship sites there is a medical library available with ample print textbooks and journal resources.

Students are graded on an honors, high-pass, pass, fail system based on their performance as described in evaluations by supervising resident and attending physicians using the reporter, interpreter, manager, educator (RIME) evaluation system.5 At the conclusion of the rotation, the students sit for the National Board of Medical Examiners subject examination in medicine (“shelf examination”). To pass the clerkship, students must demonstrate adequate clinical performance and achieve a minimal passing grade on the shelf examination. To achieve a final grade of “honors,” the clerk must demonstrate honors-level clinical performance by achieving a clinical rating of “educator” in the RIME framework, as well as achieving a threshold score on the shelf examination of approximately one standard deviation above the national mean United States Medical Licensing Examination (USMLE) medicine shelf examination score.

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Study population and setting

We conducted the study among 120 medicine clerks rotating through their first inpatient internal medicine clerkship at the Johns Hopkins University School of Medicine during the 2002–03 academic year. The medicine clerkship is a nine-week required clinical clerkship that students may take anytime between the last quarter of their second year and the first half of their fourth year of medical school. Most students take the clerkship during their third year of medical school. Students spend one half of the clerkship at the Johns Hopkins Hospital, an urban tertiary referral hospital, and one half of the rotation at one of two affiliated hospital sites: Johns Hopkins Bayview Medical Center, an urban-based academic hospital, or The Sinai Hospital of Baltimore, a community-based teaching hospital.

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Survey instrument and data collection

We created and administered to students an 18-item questionnaire that included short answer and five-point-scale questions. Question domains included students' demographic characteristics and reading habits during the clerkship, such as what sources they were reading, how useful they found them, the difficulties they encountered, and the guidance they received. We identified reading sources as either print or online. Print sources were basic medicine textbooks (e.g., Harrison's or Cecil's textbook of medicine), “essentials” textbooks (paperback versions of major medical texts), pocket-books (e.g., Washington Manual), journal articles, lecture or conference handouts, and test preparation books. Online sources were categorized as UpToDate, online versions of medical textbooks, online journal articles, Micromedex online, or other online sources. This taxonomy was developed on the basis of online resources available to students at Johns Hopkins and anecdotal evidence of the most popular online resources.

We piloted the questionnaire with a group of medical students prior to study initiation and changes were made based on their feedback. The questionnaire required approximately 10 to 12 minutes to complete. On the final day of students' medicine clerkship, the clerkship director or administrator described our study to the students. The clerkship director was never present when the questionnaire was administered. After completing the shelf examination, students had the option to complete the questionnaire in a completely anonymous fashion.

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Approval, consent, and funding source

The study was approved by the institutional review board of the Johns Hopkins University School of Medicine and by the dean for Student Affairs at the Johns Hopkins University School of Medicine. Oral informed consent was obtained from all study participants. This study was not funded.

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Statistical analysis

We first conducted exploratory data analyses and calculated means, medians, and ranges to describe the data. We then conducted an analysis of outcomes by students' year in medical school. We examined differences in means and median number of hours read using analysis of variance for continuous variables and chi-square or Fisher exact test for categorical variables. Differences in medians were compared using Wilcoxon rank-sum tests. In addition, we examined differences in outcomes by MD-PhD status using two-sided t tests to compare continuous variables and chi-square or Fisher exact test for categorical variables. Multiple linear regression was used to model hours of reading by covariates. Short answer items on the survey garnered few responses and did not contribute to our analysis. Statistical analyses were conducted with SAS, version 8.2 (SAS Institute, Inc., Cary, NC).

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One hundred twelve of 120 (93%) of students completed the questionnaire. Ninety-five (85%) were third-year medical students, ten (9%) were fourth-year students, and seven (6%) were second-year students. One-hundred nine students (97%) had completed another major clinical clerkship prior to the basic medicine clerkship. Eighty students (71%) used a handheld personal digital assistant device, and 86 students (77%) owned a basic medicine textbook.

Students reported reading medicine an average of 10.8 (SD 5.6) hours per week (median ten hours, range one to 30 hours per week). Table 1 depicts the reading sources used by the clerks and time they reported spending in an average week using those sources as well as a rating of the utility of each source. Students rated utility using a five-point scale where 1 = not at all useful and 5 = extremely useful. The most commonly used reading sources were UpToDate (107 students [96%]), online journal articles (91 students [81%]), and test preparation books (91 students [81%]). Sixty-one students (55%) used a medical textbook. The majority of students rated all of the reading sources they used as at least somewhat useful. UpToDate was rated as the most useful reading source, with 74 students (76%) rating it as extremely useful. Of all sources used by at least half the students, only UpToDate and test preparation textbooks were rated as extremely useful by at least half the students who used them. Table 2 depicts the source rated as the single most valuable by each student. Online sources were rated as the single most useful source for reading. The first nonhuman source consulted by medicine clerks to answer a medical question was an online source for 92 students (82%), followed by pocket books for nine students (8%) and basic medicine textbooks for six students (5%).

Table 1

Table 1

Table 2

Table 2

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.

Table 3

Table 3

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.

Table 4

Table 4

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.

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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.

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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).

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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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