It was not long ago when it was possible for physicians to keep up with the medical literature. A conscientious physician who subscribed to the 3-4 leading journals in the field could manage to find the time to read through the titles of each monthly issue, and typically, read many of the abstracts.
“If a paper was particularly interesting, then you probably read through the main text,” says highly respected Milton Packer, MD, in MedPage Today.
He adds, “Those halcyon days are gone. There are now dozens of journals that publish research that is relevant to a specific practice, and many now publish weekly. The average physician does not receive a physical copy of a journal at their office or home, but instead, receives email notifications of new issues. Some dutifully click on the table of contents, but they spend less than 30 seconds perusing the titles. And they rarely click on an actual manuscript–before they go on to other emails.”
Packer continues, “In the past, physicians pretended to keep up with the medical literature. If they missed a recent relevant paper, they felt a bit guilty. Now, physicians do not even pretend. There is no guilt associated with “not keeping up.” Everyone has conceded that they can’t–and won’t–be current in their medical reading.”
How bad is it?
“Much worse that you think,” Packer asserts.
At a recent meeting of nearly 200 young physicians, Packer asked how many actually read an issue of any journal that was delivered to them, electronically or physically.
The answer: Zero.
Did they at least read the titles of the lead papers in the New England Journal of Medicine every week?
No one did.
Did they pick one journal in their field of interest and try to keep up?
Not a single hand went up.
Then I asked the most revealing question of all. When is the last time that you read any single paper on any topic from start to finish?
Shaken, Packer asked why no one was reading any papers. The answer was: “We don’t know how to read them. And most papers will subsequently get contradicted by another paper published somewhere else. So, it makes no sense to read any single paper.”
“If you think that these answers are unique to young physicians, think again,” Packer adds. He devotes all his energies to one highly focused field (heart failure), and typically reads dozens of papers each day. And yet, “It is impossible for me to keep up with every relevant paper. Instead, it is common for me to attend a meeting and hear about papers that I knew nothing about.”
To make matters worse, even impactful publications are not being read, Packer notes.
“Recently…, I posted an opinion piece about the CASTLE-AF trial, and many colleagues approached me at a national meeting to talk to me about the study. Most had really strong feelings about the study, one way or another. So, in each case, I asked whether the person had actually read the original CASTLE-AF paper. Of more than 40 people, many of them opinion leaders in the field, only two claimed that they did, but neither could tell me what the main findings of the study were,” said Packer.
Packer sums up this disturbing realization accordingly:
“Top-tier medical research is really hard, but in the past, the effort was worth it if you could have an impact on thinking or on clinical practice. Now much of the literature is replete with data and analyses that are satisfying to the authors but fall unnoticed as a tree in a deserted forest.”
I’ve had heart surgery, skin cancer procedures, surgery for inguinal hernia the size of a baseball, and other mostly routine treatments but am otherwise healthy and able to do whatever I like doing. But I’ve always wondered just how up-to-speed my doctors were when I arrived for a routine annual or semi-annual check-up.
My medical “team,” if you will, are university-based physicians, and I am blessed to be primarily in the care of clinicians who also have teaching responsibilities. They must come up with answers for their medical students, so reading journals in their field is a requirement of their “job.”
But what about the many other clinicians who are residents or attendings without teaching duties? I see them too. But if what Dr. Packer says is true, I’m just as likely, or even more likely, to be current on the consensus thinking about heart failure, melanoma, breast cancer and other conditions that either are included in my medical chart or are prevalent among my family and friends.
Case in point. Someone I will call Vic was recently diagnosed with metastatic gastric cancer, and the tumor had invaded other areas of his abdomen such that surgery was off the table. He was put on a regimen of standard chemotherapy for gastric cancer every other week. Vic was under the care of an oncologist at a highly regarded medical center who ordered a tissue report on his tumor from Caris Life Sciences, which specializes in molecular tumor profiling.
Vic entrusted me with the Caris report after his oncologist decided against adding immunotherapy to the chemo, which didn’t make sense to Vic. Since his particular gastric cancer had an especially poor prognosis, he was willing to assume the risks inherent in immunotherapy, which, like the chemo, had potential side effects, including death.
On page 1 of the report, under “Biomarker Highlights,” Vic’s tumor specimen tested “Positive for PD-L1.” This is the key biomarker for treatment options
Again, right there on page 1, under “Therapies with Potential Benefit,” pembrolizumab (Keytruda/Merck) is listed as the very first recommendation. Keytruda is–to date–the most successful cancer immunotherapy.
Now I may not be a genius (and many will attest to this), but I can read English. The way I read the tumor report, it was crystal clear that in Caris’s opinion–and they are the authority in this field–Keytruda was Vic’s most promising potential therapy.
On page 6 of the Caris report, there are two footnotes, #28 and #29, cited as references for the recommendation by Caris for Keytruda in Vic’s particular situation. Footnote #28 references the 2017 study, “KEYNOTE-059: Efficacy and safety of pembrolizumab (Keytruda) alone or in combination with chemotherapy in patients with advanced gastric or gastroesophageal cancer.” It is the most recent such study and the one upon which FDA approval last fall was based.
I read this study and here are its key conclusions vis-à-vis Vic:
1) In patients with Vic’s type of gastric cancer:
- a) Keytruda monotherapy “showed promising antitumor activity in patients whose disease had progressed after ≥2 prior lines of therapy and in previously untreated patients with PD-L1–positive tumors;” and
- b) Keytruda in combination with chemotherapy demonstrated promising antitumor activity in previously untreated patients.
2) Patients responded, “regardless of PD-L1 expression, but responses were higher in patients with PD-L1–positive tumors.”
Again, the loud recommendation of Keytruda by Caris wasn’t even mentioned in Vic’s treatment plan.
Put simply, Vic’s oncologist apparently hadn’t read the Caris tumor report recommending Keytruda. If he did and read the referenced study supporting the recommendation, Vic would have been placed on Keytruda immediately. When questioned about it, the oncologist simply said Vic was not a candidate for immunotherapy. Vic is now seeking another opinion.
Dr. Packer adds this discomforting closing comment about physicians, especially unnerving for us patients and observers in this modern age of scattershot news reporting.
“It is very hard to find someone who actually reads the main text of an individual paper these days. Yet, these papers fill our journals. And they are intended to provide information and enlightenment. But how can they, if no one reads them?” Packer concludes, “Some of my friends tell me that Twitter gets more traffic than medical journals. If that is true, we have truly entered an era of ‘evidence-free medicine.’”