In 2005, a systematic review in the Annals of Internal Medicine made headlines when most studies found a correlation between increasing years in practice and decreasing quality of care. This article suggested that the longer physicians have been in practice, the less likely they were to adhere to updated clinical guidelines, leading to worse patient outcomes.1 This went against the long-held dogma in medicine: the greater the physician’s experience the better the patient care. This may be due to a shifting paradigm in our field where the scope of medical information is undergoing an exponential rate of advancement. A study in 2011 estimated that “the doubling time of medical knowledge in 1950 was 50 years; in 1980, 7 years; and in 2010, 3.5 years. In 2020 it is projected to be just 73 days.” This shocking statistic meant that “what was learned in the first 3 years of medical school will be just 6% of what is known at the end of the decade from 2010 to 2020.”2
In oncology, this knowledge explosion is palpable on a daily level, leaving physicians at a loss regarding how to stay ahead. For instance, during my attendings’ fellowship training, the management of lung cancer essentially incorporated a few chemotherapeutic drugs along with radiation. In 2020, the complexities of managing the different genomic mutations in patients with lung cancer has resulted in an explosion of therapies and various algorithmic pathways to tackle different molecular subtypes. This meant that a significant amount of knowledge my attendings acquired in training is now obsolete and they had to self-learn new advances to provide care for their patients with lung cancer. As I spend hours poring over journals and guidelines during my fellowship training, I wonder how much of it will remain relevant by the time I graduate.
Furthermore, as a trainee, your curriculum is carefully structured and mapped out from year to year. In a whirlwind of grand rounds, didactics, in-training exams, and daily patient rounds, you are constantly sponging information up and are challenged to learn more. Once you graduate, this constant stream of education is no longer at your disposal, leaving you at a loss to figure out alternate sources of learning. Additionally, with the hectic schedule of a trainee and later as a full-time attending, how can one remain current in such a rapidly evolving field with daily practice-changing articles?
Here are a few tips and strategies.
- Identify your learning style and focus on effective strategies for retention.
By now, you have spent more than a decade in medical school and residency honing your learning skills. You should have some idea regarding how you learn best. I, for one, can only retain information by correlating it to a patient. If I try to learn about breast cancer by reading about it from a textbook, I know that I will remember very little the next day. Personally, I can learn best if I see a patient in clinic, look up the relevant literature, and correlate the clinical decision-making to that encounter.
Recognize what works for you and what doesn’t so that your limited time is spent wisely. In general, evidence shows that simple reading is an inefficient use of time as adults usually retain information by active summarization and self-questioning.3
- Find an environment that is intellectually stimulating.
As you reflect on your career pathway, choose an environment that you find engaging. For some of us, we thrive as clinician-educators, stimulated by discussions with trainees on rounds, realizing that we need to step up our knowledge base. For others, daily patient interactions prompt them to keep up with the literature to ensure that they are providing the best care for their patients. Some may find that motivation in the thrill of researching a specific area and moving the field ahead in that regard. Pursuing your passion can truly foster joy in self-learning and ensure lifelong motivation.
- Tailor your learning towards your career path.
If you are a general community oncologist, you will need to know “something about everything.” You are on the front line of diagnosing patients and providing first-line treatment. In that case, an overview of management of diseases you will encounter is essential, especially the more prevalent ones. This is vastly different if you are a subspecialist in a tertiary academic center whose job is to provide third- or fourth-line therapies for patients who seek second opinions. An appropriate learning goal in the latter would be to focus on all the literature pertaining to that one specific area and a knowledge of relevant ongoing clinical trials.
- Subscribe to the right resources and let others curate the evidence for you.
An interesting study back in 2004 by Alper et al. estimated that it would take 627.5 hours per month to evaluate the 7,287 articles published monthly in high-quality primary care journals.4 Even two decades ago, it was impossible to stay abreast of the numerous articles published daily. This is why you need to subscribe to relevant high-impact journals and publications in your areas of practice—most have distilled summaries that provide an overview of the current literature. Some of my favorite resources include The ASCO Post, JAMA Oncology, and OncLive.
- Effectively utilize national and local educational meetings.
A national annual meeting like ASCO’s provides an excellent opportunity to hear the latest updates in the field. Sub-meetings, such as the Gastrointestinal Cancers Symposium, may be more relevant according to your areas of focus. Local meetings with highlights of practice-changing updates may be more appropriate for a busier general oncologist. Opportunities are available to stream conferences online later if you are unable to attend in person. (ASCO meeting presentations, for example, can be reviewed on ASCO Meeting Library.)
- Set aside time and learn on the go.
You must deliberately set time aside for learning, otherwise this will be neglected as time is spent on more pressing direct patient care or other administrative work obligations. Finding a long stretch of protected time is difficult, so you may need to get creative! Listening to a podcast, such as one from ASCO or JAMA, during your commute to work is one way to utilize time that is otherwise wasted. Try to dedicate 30 minutes before or after your workday for review of the journals you are subscribed to and to read up on a patient or two that you saw.
- Always remember our commitment to lifelong learning.
Medicine is a challenging, yet extremely rewarding, career. Ultimately, we chose this career to improve our patients’ lives and advance the field—both of which can be achieved only by our commitment to lifelong learning.
A Few Final Thoughts to Ponder
Realistically, a reform is required in our medical education and health care system if we expect physicians to be able to provide the appropriate up-to-date care that our patients deserve. An interesting article by Slawson and Shaughnessy raised the question of whether we should instead be teaching “information-management skills” to our trainees whereby they can “learn the techniques and skills to focus on finding, evaluating, and using information at the point of care”.5 This is imperative given that most of the knowledge they will learn at the start of their education will likely be obsolete by graduation.
Furthermore, an increasing amount of physician time is now spent on documentation, billing, and other administrative work that takes away from time that could be utilized for educational purposes. A study just published in Annals of Internal Medicine examined 100 million patient encounters and estimated that “physicians spent an average of 16 minutes and 14 seconds per encounter using EHRs, with chart review (33%), documentation (24%), and ordering (17%) functions accounting for most of the time.”6
In a health care system that now expects us to double- and triple-book patients to meet the “necessary” volume of encounters, we are spending most of our limited time on administrative tasks. Shouldn’t we instead build in time for the literature search and reading that is required to provide a patient with the complex oncology care they need?
- Choudhry NK, Fletcher RH, Soumerai SB. Systematic Review: The Relationship between Clinical Experience and Quality of Health Care. Ann Intern Med. 2005;142:260-73.
- Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 2011;122:48-58.
- Weinstein Y, McDermott KB, Roediger HL. A comparison of study strategies for passages: rereading, answering questions, and generating questions. J Exp Psychol Appl. 2010;16:308-16.
- Alper BS, Hand JA, Elliott SG, et al. How much effort is needed to keep up with the literature relevant for primary care? J Med Libr Assoc. 2004;92:429-37.
- Slawson DC, Shaughnessy AF. Teaching evidence-based medicine: should we be teaching information management instead? Acad Med. 2005;80:685-9.
- Overhage JM, McCallie D. Physician Time Spent Using the Electronic Health Record During Outpatient Encounters: A Descriptive Study. Ann Intern Med. 2020;172:169-74.