Haunted by the unread.

Learning by osmosis is a total failure. My non-randomized, non-blinded trial (n = 1) entitled, “The acquisition of medical knowledge via proximity to copious medical literature,” has yielded decidedly negative results. As it turns out, you actually have to read the journals to learn anything from them. I sit in my office surrounded by reputable medical journals, often stacked on top of each other in pristine (mint) condition that would be the envy of every baseball card collector. Many titles boast multiple issues waiting to be read, a veritable cornucopia of evidence-based medicine awaiting an inquisitive mind and a critical eye. Somehow, collectively, they feel like an accusation I know I can’t refute. I know I should probably recycle some of them, even if they remain unread. Instead, I scan the covers and rearrange. Several interesting articles catch my eye, notable for their relevance to my current practice. I tidy up the stacks, admonishing myself for not reading more and vowing to devote time to whittling down the piles. But right now, my daughter wants to play dress up — she as a princess and me as the prince. In medical school, I distinctly remember the worry that I had not studied or learned enough. I remember feeling anxious as I waded through the first few exam questions: Would I remember all the parts of the Krebs cycle? Which one is the Schilling’s Test again? As the test progressed, my fears usually abated, and by the completion of the test, I no longer worried about my knowledge of anatomy/biochemistry/physiology — or whatever the subject of the exam had been. It was on to the next test — the next subject — in a repetitive cycle of educational stress testing. I recall that this changed during my internship. Not the anxiety about whether I had learned enough, but the forces driving that emotion. The test was no longer the end point; now I wanted more than anything to provide sound, evidence-based care to my patients. Their health was the only grade that mattered; with the stakes so high, I felt insecure about my medical knowledge. This insecurity was not lessened by my ever-present, severe sleep deprivation. Though I sometimes forgot where I parked my car after a call night, I recollect awe for those senior residents and attendings that rattled off names and details of studies from seemingly encyclopedic memories. I wondered: How do they know so much? How do they have the time to read? During that year, most of my mental calculus was applied to the logistics of doing laundry and getting groceries. I would occasionally open a journal, but it was more often that I woke with the words imprinted on the side of my face, rather than on my gray matter. As residency progressed, I learned more than I would have thought possible — with nearly all of the important lessons taking place at the bedside. I even learned a few of the studies, and managed to insert them whenever possible to perpetuate the myth of the well-read resident. Meanwhile, between articles I had printed out and subsequently abandoned and a myriad of journals that inexplicably began to arrive by mail, my apartment began to look like the office of Sir Osler, assuming he, too, had been a hoarder of “throw away” medical journals. Then, as now, I was reluctant to recycle these medical missives, as it seemed I was shirking my solemn responsibility to my patients. What if I have a patient with (insert disease here)? Should I give them (insert new therapy here) or stick with (insert old therapy here)? If I throw out this journal, I somehow felt, I’ll never know. I guess some habits are hard to break. Now that I am in practice, I realize that although the variety of journals has decreased significantly as I have become more selective, the stacks of unread literature remain a constant. The struggle to clean my office and recycle outdated journals is no less difficult — perhaps even more difficult, as each journal article seems to speak directly to my patient care or teaching activities. I suspect it will always be this way. I suspect the unread will always haunt me. I imagine that an estate sale after my death will involve hawking boxes of outdated medical literature to passersby seeking curios for friends in health care. Perhaps I will bequeath these stacks to my children in my will; no doubt their childhood memories have been shaped by the journals’ ubiquitous presence in our home. A tugging at my sleeve pulls me from my thoughts. I am reminded that I have a date with a princess. These articles will again have to wait. Leaving my office, I sigh as I take one last look at the stacks. Perhaps like all good clinical trials, my investigation of learning by osmosis bears repeating to ensure valid results. Or, perhaps I should submit the results of my study to one of these journals — even negative trials have value, after all. And, just maybe, some medical bibliophile will glimpse the study title on a journal’s cover while rearranging his or her own personal collection. Should this individual peruse the study and see that learning by osmosis is ineffective, perhaps he or she will be more proactive in reading the literature in a timely manner. However, I suspect this colleague will conclude, as I have, that more research in this area is needed.