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Keeping up is hard to do: The need for true grit

DII small banner By Warren R. Heymann, MD
Oct. 5, 2017

One of the daunting challenges in practicing dermatology (or any branch of medicine) is keeping abreast of advances in the literature to optimize patient care. As a clinician-educator, I have always had an interest in how we learn best. For full disclosure, I am a dermatologist, not a psychologist, nor a trained educator. The opinions I offer are from that perspective — other ideas from those with more expertise are welcome!

I recently sent a survey to subscribers of Dermatology Insights and Inquiries entitled “Keeping Current with Dermatology.” Out of 560 subscribers, 85 (15%) responded — thank you. From my understanding, that is a typical response to such a survey. The comments that follow questions are my opinions, not a statistical analysis. It is difficult to know what people think when 85% do not respond. Regardless, the survey is interesting, and worthy of thought and analysis.
I have rounded off the percentages to the nearest percent. My comments are italicized.

Q1. Please state your profession

1. Dermatologist 75 (88%)
2. Dermatology resident 7 (8%)
3. Physician (non-dermatologist) 3 (4%)
4. Mid-level provider (Nurse Practitioner, Physician Assistant) 0 (0%)
5. Other 0 (0%)

Because almost 90% of respondents are dermatologists, this is a relevant survey.

Q2. What is your age ?

1. 25 -34 years 22 (25%)
2. 35 – 44 years 34 (40%)
3. 45 – 54 years 6 (7%)
4. 55 – 64 years 13 (15%)
5. 65 – 74 years 7 (9%)
6. 75 years and older 2 (3%)

Two-thirds of the respondents are under age 44. A 44 year-old was born in 1973. Presumably from Generation X and subsequently (Y — “Millennial,” Z) will all be increasingly computer/internet savvy, and each group may look at the world somewhat differently.

Q3. How many hours a week do you devote to medical reading unrelated to specific patient problems?

1. 0 – 2 hours 45 (53%)
2. 2 – 4 hours 28 (33%)
3. 4 – 6 hours 5 (6%)
4. 6 – 8 hours 4 (5%)
5. More than 8 hours 3 (4%)

More than half of the respondents replied 0 to 2 hours. I wish I had asked a subset for that group — is it closer to zero or two hours?

Q4. How many hours a week do you devote to medical reading related to specific patient problems?

1. 0 – 2 hours 45 (53%)
2. 2 – 4 hours 33 (39%)
3. 4 – 6 hours 4 (5%)
4. 6 – 8 hours 2 (2%)
5. More than 8 hours 1 (1%)

If the majority are listing 0 – 2 hours per week, that means that no more than 17 minutes per day are devoted to medical reading.

Q5. Do you read general medical journals such as the New England Journal of Medicine or JAMA?

1. Never 13 (15%)
2. Rarely 45 (53%)
3. Usually 18 (21%)
4. Always 9 (11)

Two- thirds of dermatologists never or rarely look at classical general medical journals. Do dermatologists who read these journals have a broader sense of the patient’s health and illness?

Q6. Which of the following resources do you use most to stay current?

1. Peer-reviewed journals such as JAMA Dermatology and JAAD 68 (80%)
2. Proprietary publications such as Dermatology Times or the Dermatologist 1 (1%)
3. Alternative media such as Dialogues in Dermatology 3 (4%)
4. Internet dermatology Groups on Facebook 6 (7%)
5. Other 7 (8%)

The “other” responses were mostly electronic table of contents from different journals, or participation in journal clubs or other groups.

Despite the youthful respondents of this survey, the vast majority of dermatologists still use the core journals to stay current. I was surprised that only 1 person listed venues such as Dermatology Times – l know I peruse them to keep abreast of trends in the field.

Q7. What do you read when you review an article? (you may check more than one answer)

1. Introduction 51 (60%)
2. Abstract 75 (88%)
3. Methods 20 (24%)
4. Discussion 57 (67%)
5. Conclusion 63 (74%)

Given the volume of medical literature, it makes sense that most people review the abstract. The crux of validity, however, lies in the methodology of the study — the least looked at component of the manuscript.

Q8. How would you rate your knowledge of biostatistics to adequately evaluate current dermatological literature?

1. Poor 34 (40%)
2. Fair 35 (41%)
3. Good 14 (16%)
4. Excellent 2 (2%)

Think about this — if 80% of dermatologists, who are at the top of their medical school class, think their ability in biostatistics is no better than fair, how is the rest of medicine doing? Without an understanding of increasingly sophisticated biostatistics, how can the reader adequately assess the quality of the manuscript?

Q9. What is your greatest barrier preventing you from maximizing your medical reading?

1. Time constraints 69 (81%)
2. Accessibility to the literature 9 (11%)
3. Comprehension of the literature 1 (1%)
4. Relevance to practice 4 (5%)
5. Other (please specify) 2 (2%)

The “other” responses were 1) the mass of available medical literature and the inability to select wisely; and 2) the medical literature is only a part of what is important to read and learn.

We live hectic lives, both personally and professionally, so the fact that 80% put time constraints at the top of the list is no surprise. What amazes me is the fact that 80% of respondents struggle with biostatistical analysis, yet only 1% think they have difficulty comprehending the literature.

Q10. Please comment with your ideas about how physicians should keep current with advances in dermatology

Thirty-seven respondents offered comments — for the sake of brevity, there were common themes. I will start with a quote from a respondent; Ah for the “good old days” when one really felt that one had a pretty good grasp of the entire field!” Time crunch tops the list. There are far too many demands at work (EMR, administrative dictates, etc.) that leave little or no time to read. Most people advocate a multipronged approach — journal clubs, grand rounds, meetings, and Internet groups. There were even a couple of kudos for DI&I — thank you!

What conclusions can be reached by this exercise? Firstly, acknowledging that keeping up with medical dermatological literature is a problem. I believe that it is integrally related to another prevalent issue — burnout.

Practicing medicine is stressful, and the cornerstone of practice is knowledge. If a physician thinks that they may not be current in their database, their level of anxiety is likely to increase. As Bartels states: “With medical knowledge growing constantly, it has become necessary to possess a high level of information literacy to be able to keep up with the literature. Furthermore, as patients can now search for information on the Internet, clinicians must be able to respond to this type of information in a professional way when needed.” His approach, based on peer-reviewed literature is appropriate: 1) Define your problem; 2) Create a search strategy; 3) Choose bibliographic databases; 4) Search; 5) Select suitable references from those that have been retrieved; 6) Assess whether the search was satisfactory; 7) Redesign the search strategy and/or choose other databases/search tools; 8) Repeat steps 2- 6, if necessary. (1)

What Bartels does not address, however, is the greatest impediment to keeping current – the lack of time to do what is necessary for physicians to feel reasonably comfortable that they are up-to-date (or at least not hopelessly behind). When I had this feeling as a premedical student at NYU trying to keep up with the workload, my mother gave me a Yiddish answer —“Warren, what you need is sitzfleisch”. This is actually a German word that translates to “sitting flesh” (i.e., sitting on your derriere) describing what is necessary to endure or persist in any given endeavor.

The current buzzword for such persistence is “grit.” Sharkey et al determined that higher levels of grit related to greater health care management skills, and higher mental and physical health-related quality of life scores in adolescents and young adults. (2)

I conclude with my opinions: 1) Take a deep breath — you’ll always be behind, but you can stay current; 2) Be engaged in multiple learning venues — learn from your colleagues and teach them as well. Everyone will be better off; 3) Be disciplined by grit (or sitzfleisch, if your prefer) — if you can put Game of Thrones on your must-watch schedule, you can also figure out how to carve out a couple of uninterrupted hours each week to delve into medical literature relevant to your practice. Paradoxically, you will be working harder, but it will also invigorate you, making burnout far less likely!

1. Bartels EM. How to keep up with medical literature. Best Pract Res Clin Rheumatol 2009; 281-90.
2. Sharkey CM, et al. The role of grit in college student health care management skills and health-related quality of life. J Pediatr Psychol 2017 Apr 8 [Epub ahead of print]

All content found on Dermatology World Insights and Inquiries, including: text, images, video, audio, or other formats, were created for informational purposes only. The content represents the opinions of the authors and should not be interpreted as the official AAD position on any topic addressed. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

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