If you had the power to change the system on how medicine is taught, to improve the learning experience and the outcomes in patient care - what would the three things you would change be?
Great article, doc. Your main point and examples can be applied to any profession. I’m not a real doctor (just a lowly PhD), so when I start thinking about a blog, article, or book, I do a fair amount of research constantly thinking about what my subject and theme should be. Gradually, I narrow it down to a title and first few sentences or paragraphs. This, then, guides my further research and narrowing, which can include some considerable editing. It becomes an iterative process until I really get going and eventually produce a finished product. (My younger colleagues would sometimes ask me how I could write a book. My answer, perhaps a little simplistic, was “If you can write an article, you can write a book. It’s just a series of papers, with edits and transitions to make it whole.)
I am not a medical professional, but I spent my career as a librarian/information professional. May I suggest that one way to keep up with some of the literature is through the NLM's National Center for Biotechnology Information (NCBI). You can set up searches for whatever diseases, conditions, techniques, etc. you want and you'll receive a daily list of links to new articles, previews of articles to be published, and more that are newly referenced in PubMed. I've found the lists to be very focused and very helpful to me as a patient who is interested in new research in a specific area.
The possibility for an active clinician to remain truly up to date is, paradoxically, undermined by an excess of clinical practice itself — a workload so overwhelming that it leaves physicians exhausted and with little time even to “read about” their own patients.
In real life, “School-Based Medicine” easily drifts into “Experience-Based Medicine,” characterized by a hypertrophy of judgment grounded mainly in accumulated personal experience, later nuanced by the lectures of “key opinion leaders” at medical congresses and the “professional” guidance of pharmaceutical representatives.
This troubling reality is sustained by the enormous pedagogical void present in nearly 93% of current medical curricula, which fail to train physicians to efficiently search for evidence, critically appraise it, synthesize it, and integrate it in response to a patient’s question — the only genuine way to remain continuously updated.
Random reading of medical journals is little more than a euphemism for this deficiency.
Serious question… Do you ever read literature provided to you by a patient? I am not a physician, but I did medical research for 23 years. Given that research was my “specialty,” I may have read more peer-reviewed journals articles than most practicing physicians, especially the younger ones. I’ve gotten pretty good at separating wheat from chaff, and I would never give my doctor a paper with a commercial agenda or from a questionable source.
And yet, in the few instances (which I can count on one hand) that I’ve given my doctor a printout of a clinical trial or statistical study, I get the feeling it’s going straight into the trash as soon as my 10 minutes is up. Not once has anyone mentioned at a subsequent visit the material I’d provided. Have I offended the “expert” by suggesting there may be something he may not know? Is he just too busy to read or scan something provided by a patient? Or am I mistaken? Perhaps he did actually read it and considered its contents, but dismissed its value or had forgotten about it by the next visit.
I definitely do, but not everything. The array of stuff I am given is broad. Something that applies to the specific patient's care, which is given to me in the office, I will always read. These days, many people share articles outside of clinic time, I can't keep up with these and generally ignore them.
As a physician, I am impressed when patients bring literature for me to read. I make a point to acknowledge their effort and initiative. I will always follow-up with them regarding my interpretation of the literature they shared. I can't say all physicians do this, but many of us will engage in discussion with patients around literature they provide. 😊
Firstly see if you can find who paid for the article. If it was the drug sponsor I usually discount it by about 30%. But good luck in searching for this because they try and hide it.
Never look at the RR. It’s the absolute risk reduction that is meaningful to your patients. If something is twice as good as nothing that worthwhile?
Skip the editorials. All they do is vomit back the
article. When’s the last time you gleaned any insight from an editorial. Rely on Sensible Medicine and others instead.
Most importantly always read the comments. In about 5 or 6 comments you’ll see a pearl no editorialist would see.
Skip JAMA. When’s the last time you saw anything meaningful in it? It’s all DEI, like the intros in NEJM. You like indoctrination? Better to read Pravda.
The point about cohort studies almost never changing practice is worth sitting with.
The hierarchy most clinicians operate by informally, RCTs change practice, observational studies inform priors breaks down in areas where RCTs are scarce or ethically impossible, which includes a significant share of what general practitioners actually encounter.
The other failure mode is the opposite: reading RCTs without tracking reversals, which means your practice updates positively but rarely updates downward.
I agree with all the above. In addition I find the editorial type articles that are included immediately following a study to be an efficient summary, as well as comparing outcomes, pointing out potential pitfalls and/or areas needing further study. They help put the article in context. Sometimes I will read them in place of the study itself.
In 2026, clinicians are more deficient in common sense than factual information. Reading the latest Elsevier, Wiley, Wolters, etc journals would contribute little to practical, useful, or actionable knowledge (Isn’t at least half of published research either wrong or outdated in a few years anyways)?
For 99% of practicing clinicians in the trenches, they’d be better off reading textbooks (yes, paper with no ads) to brush up their general knowledge, use AI tools like OpenEvidence, and read plenty of books on decision-making under uncertainty (ie Kahneman, Klein, Taleb, etc).
For many years, I developed CME content for industry for the rollout of new drugs, and even Big Pharma's paid-spokesmen "thought leaders" seemed to feel that docs, for better or worse, relied heavily on reps to educate them about new agents and classes of drugs. Thoughts?
Why, sir, do you question the rigorous impartiality of my masterpieces like the "leave-behind" card deck on "starting the conversation around [Condition X]? 😆
I advise trainees to figure out a knowledge management system early in their training and iteratively adapt it to their needs.
The imperfect system I've come to:
1. On the fly (e.g., UpToDate, OpenEvidence) - you need an answer right now and don't have time for a deeper dive, although this may prompt a deeper dive later.
2. Keep up with journals - I use Feedly to track RSS feeds of PubMed searches. I track numerous journals of interest this way and skim the headlines every morning. When I click a headline, it takes me to PubMed where I (usually) have institutional access to the full article.
3. Keep up with topics - I use RSS feeds of PubMed searches to track numerous topics (e.g., "advance directives," "assisted suicide OR MAID OR etc..."). I skim these headlines along with the journals.
The morning RSS review takes ~10 minutes. I don't read any papers right then unless I'm having a leisurely morning; I save anything interesting looking for later.
4. Figure out what you'll read - Like Dr. Cifu, I don't read every single article I find. I ask some questions. Is this an important journal for my field? Is the article of interest to me? If it's an older article, is it highly cited? Is it being discussed a great deal? Are patients asking about the topic? Are there any glaring problems in the abstract? Are there any glaring conflicts of interest which would turn me off entirely?
Once I read a paper, I don't read it start to finish. I usually skip the introduction if this is a topic I'm generally familiar with. I taste the discussion and conclusion, then I go on to digest the methods and results (focusing on figures, then turning to the text itself), and then I return to the discussion and conclusion to pull it all together. That's for a scientific paper. For an ethics or philosophy paper, I might read it more linearly because I need to follow the argument, but I may skim first to get a sense of where things go. By "skim" I mean I read the ~first sentence of each paragraph and try to find key words (novel, emphasized, and/or repeated words). I'll read the conclusion in closer detail to see if anything draws me in there. Even if the skim doesn't turn up anything, if this is a very important topic, I may return to read it more thoroughly.
5. Organize what you find - you need a reference management software even if you're not going to be writing a lot. This allows you to tag articles and find them easily in the future for reference, for talks, for teaching, for writing. I use Zotero, as it has tags and online access available within the VA firewall.
6. Targeted literature searches - you need to learn how to search the literature with a specific question. If you're at an academic center, librarians are great for helping with this. For most medical articles, PubMed is good, but if it's a much older article or outside science/medicine (I'm often searching in ethics and philosophy), you may need to use another database. A helpful technique to track a conversation in the literature is to either use PubMed or a tool like ResearchRabbit to discover what newer papers have cited the paper you're currently reading, and also review what papers your paper has cited. Bibliography hopping is a great way to learn and I've discovered a lot of good papers this way.
I forgot the latest component of my knowledge management system, particularly relevant for ethics and philosophy.
If I come across an excerpt or quote I find particularly compelling, I save it in an Obsidian-based zettelkasten: https://obsidian.md/ Within the Obsidian note, I include links to other relevant notes within my Obsidian database. Over time, this allows me to see novel connections between topics and ideas I may not have seen before, and also allows me to save quotes for future reference and use. Knowledge generation isn't in just knowing a bunch of stuff but in perceiving novel connections among the data you have.
Writing Doctoring Unpacked helps. I rarely write about a topic without learning something or more than something that is useful. Every now and again, I discover that a view I've had of something since residency was wrong.
Dr. Cifu,
If you had the power to change the system on how medicine is taught, to improve the learning experience and the outcomes in patient care - what would the three things you would change be?
Great article, doc. Your main point and examples can be applied to any profession. I’m not a real doctor (just a lowly PhD), so when I start thinking about a blog, article, or book, I do a fair amount of research constantly thinking about what my subject and theme should be. Gradually, I narrow it down to a title and first few sentences or paragraphs. This, then, guides my further research and narrowing, which can include some considerable editing. It becomes an iterative process until I really get going and eventually produce a finished product. (My younger colleagues would sometimes ask me how I could write a book. My answer, perhaps a little simplistic, was “If you can write an article, you can write a book. It’s just a series of papers, with edits and transitions to make it whole.)
Um. Correction. “If you can write a paper, you can write a book.” Picky, but . . . Academics don’t usually write articles.
This is very helpful. Thank you!
I am not a medical professional, but I spent my career as a librarian/information professional. May I suggest that one way to keep up with some of the literature is through the NLM's National Center for Biotechnology Information (NCBI). You can set up searches for whatever diseases, conditions, techniques, etc. you want and you'll receive a daily list of links to new articles, previews of articles to be published, and more that are newly referenced in PubMed. I've found the lists to be very focused and very helpful to me as a patient who is interested in new research in a specific area.
Dr. Cifu,
The possibility for an active clinician to remain truly up to date is, paradoxically, undermined by an excess of clinical practice itself — a workload so overwhelming that it leaves physicians exhausted and with little time even to “read about” their own patients.
In real life, “School-Based Medicine” easily drifts into “Experience-Based Medicine,” characterized by a hypertrophy of judgment grounded mainly in accumulated personal experience, later nuanced by the lectures of “key opinion leaders” at medical congresses and the “professional” guidance of pharmaceutical representatives.
This troubling reality is sustained by the enormous pedagogical void present in nearly 93% of current medical curricula, which fail to train physicians to efficiently search for evidence, critically appraise it, synthesize it, and integrate it in response to a patient’s question — the only genuine way to remain continuously updated.
Random reading of medical journals is little more than a euphemism for this deficiency.
Serious question… Do you ever read literature provided to you by a patient? I am not a physician, but I did medical research for 23 years. Given that research was my “specialty,” I may have read more peer-reviewed journals articles than most practicing physicians, especially the younger ones. I’ve gotten pretty good at separating wheat from chaff, and I would never give my doctor a paper with a commercial agenda or from a questionable source.
And yet, in the few instances (which I can count on one hand) that I’ve given my doctor a printout of a clinical trial or statistical study, I get the feeling it’s going straight into the trash as soon as my 10 minutes is up. Not once has anyone mentioned at a subsequent visit the material I’d provided. Have I offended the “expert” by suggesting there may be something he may not know? Is he just too busy to read or scan something provided by a patient? Or am I mistaken? Perhaps he did actually read it and considered its contents, but dismissed its value or had forgotten about it by the next visit.
I definitely do, but not everything. The array of stuff I am given is broad. Something that applies to the specific patient's care, which is given to me in the office, I will always read. These days, many people share articles outside of clinic time, I can't keep up with these and generally ignore them.
As a physician, I am impressed when patients bring literature for me to read. I make a point to acknowledge their effort and initiative. I will always follow-up with them regarding my interpretation of the literature they shared. I can't say all physicians do this, but many of us will engage in discussion with patients around literature they provide. 😊
A few simple thoughts for modern times.
Firstly see if you can find who paid for the article. If it was the drug sponsor I usually discount it by about 30%. But good luck in searching for this because they try and hide it.
Never look at the RR. It’s the absolute risk reduction that is meaningful to your patients. If something is twice as good as nothing that worthwhile?
Skip the editorials. All they do is vomit back the
article. When’s the last time you gleaned any insight from an editorial. Rely on Sensible Medicine and others instead.
Most importantly always read the comments. In about 5 or 6 comments you’ll see a pearl no editorialist would see.
Skip JAMA. When’s the last time you saw anything meaningful in it? It’s all DEI, like the intros in NEJM. You like indoctrination? Better to read Pravda.
The point about cohort studies almost never changing practice is worth sitting with.
The hierarchy most clinicians operate by informally, RCTs change practice, observational studies inform priors breaks down in areas where RCTs are scarce or ethically impossible, which includes a significant share of what general practitioners actually encounter.
The other failure mode is the opposite: reading RCTs without tracking reversals, which means your practice updates positively but rarely updates downward.
I agree with all the above. In addition I find the editorial type articles that are included immediately following a study to be an efficient summary, as well as comparing outcomes, pointing out potential pitfalls and/or areas needing further study. They help put the article in context. Sometimes I will read them in place of the study itself.
Excellent advice. That penultimate sentence is so true about learning from an actual patient.
In 2026, clinicians are more deficient in common sense than factual information. Reading the latest Elsevier, Wiley, Wolters, etc journals would contribute little to practical, useful, or actionable knowledge (Isn’t at least half of published research either wrong or outdated in a few years anyways)?
For 99% of practicing clinicians in the trenches, they’d be better off reading textbooks (yes, paper with no ads) to brush up their general knowledge, use AI tools like OpenEvidence, and read plenty of books on decision-making under uncertainty (ie Kahneman, Klein, Taleb, etc).
For many years, I developed CME content for industry for the rollout of new drugs, and even Big Pharma's paid-spokesmen "thought leaders" seemed to feel that docs, for better or worse, relied heavily on reps to educate them about new agents and classes of drugs. Thoughts?
This is true, but scary. "Thought leaders" and pharma reps (often one and the same) do not give reliable information.
Why, sir, do you question the rigorous impartiality of my masterpieces like the "leave-behind" card deck on "starting the conversation around [Condition X]? 😆
I advise trainees to figure out a knowledge management system early in their training and iteratively adapt it to their needs.
The imperfect system I've come to:
1. On the fly (e.g., UpToDate, OpenEvidence) - you need an answer right now and don't have time for a deeper dive, although this may prompt a deeper dive later.
2. Keep up with journals - I use Feedly to track RSS feeds of PubMed searches. I track numerous journals of interest this way and skim the headlines every morning. When I click a headline, it takes me to PubMed where I (usually) have institutional access to the full article.
3. Keep up with topics - I use RSS feeds of PubMed searches to track numerous topics (e.g., "advance directives," "assisted suicide OR MAID OR etc..."). I skim these headlines along with the journals.
The morning RSS review takes ~10 minutes. I don't read any papers right then unless I'm having a leisurely morning; I save anything interesting looking for later.
4. Figure out what you'll read - Like Dr. Cifu, I don't read every single article I find. I ask some questions. Is this an important journal for my field? Is the article of interest to me? If it's an older article, is it highly cited? Is it being discussed a great deal? Are patients asking about the topic? Are there any glaring problems in the abstract? Are there any glaring conflicts of interest which would turn me off entirely?
Once I read a paper, I don't read it start to finish. I usually skip the introduction if this is a topic I'm generally familiar with. I taste the discussion and conclusion, then I go on to digest the methods and results (focusing on figures, then turning to the text itself), and then I return to the discussion and conclusion to pull it all together. That's for a scientific paper. For an ethics or philosophy paper, I might read it more linearly because I need to follow the argument, but I may skim first to get a sense of where things go. By "skim" I mean I read the ~first sentence of each paragraph and try to find key words (novel, emphasized, and/or repeated words). I'll read the conclusion in closer detail to see if anything draws me in there. Even if the skim doesn't turn up anything, if this is a very important topic, I may return to read it more thoroughly.
5. Organize what you find - you need a reference management software even if you're not going to be writing a lot. This allows you to tag articles and find them easily in the future for reference, for talks, for teaching, for writing. I use Zotero, as it has tags and online access available within the VA firewall.
6. Targeted literature searches - you need to learn how to search the literature with a specific question. If you're at an academic center, librarians are great for helping with this. For most medical articles, PubMed is good, but if it's a much older article or outside science/medicine (I'm often searching in ethics and philosophy), you may need to use another database. A helpful technique to track a conversation in the literature is to either use PubMed or a tool like ResearchRabbit to discover what newer papers have cited the paper you're currently reading, and also review what papers your paper has cited. Bibliography hopping is a great way to learn and I've discovered a lot of good papers this way.
I forgot the latest component of my knowledge management system, particularly relevant for ethics and philosophy.
If I come across an excerpt or quote I find particularly compelling, I save it in an Obsidian-based zettelkasten: https://obsidian.md/ Within the Obsidian note, I include links to other relevant notes within my Obsidian database. Over time, this allows me to see novel connections between topics and ideas I may not have seen before, and also allows me to save quotes for future reference and use. Knowledge generation isn't in just knowing a bunch of stuff but in perceiving novel connections among the data you have.
Writing Doctoring Unpacked helps. I rarely write about a topic without learning something or more than something that is useful. Every now and again, I discover that a view I've had of something since residency was wrong.