Rheum with a View: Perspectives on Selections from the Literature

The Rheumatologist’s editor, David Pisetsky, MD, PhD, invited me to contribute regular commentaries about articles appearing in the literature. I accepted this opportunity with alacrity, delight, and enthusiasm.

The responsibility of identifying important articles in the literature and presenting these to colleagues is daunting and humbling. My own view of journal articles has changed over the years. As a fellow, I watched my mentor, Peter Schur, MD, (who is now the rheumatology editor for UpToDate), set out for the Countway Library, that magnificent facility at Harvard Medical School, for an afternoon each week. I was impressed by his methodological review of the clinical and scientific literature of rheumatology and immunology and how he listed every citation. I was grateful when allowed to copy his reference lists at the end of my fellowship, naively hoping that I might then possess the knowledge he accumulated. I too began to scan and collect the literature as he did, not then entirely appreciating the difference between knowledge and understanding, between information and wisdom. In some ways, the more I learned, the less I knew. Fundamental appreciations of rheumatic diseases remained (and still are) elusive.

Much published literature goes uncited (41% for biological sciences, 46% for medicine) and presumably unread. This suggests that a substantial proportion of scientific papers make negligible contributions to knowledge. Medical students also apparently read a small portion of assigned material. Second-year students, for example, were given approximately 11,161 pages of material, which could be mastered by reading an estimated 175 hours during their 168-hour week!

Rheumatology includes a good deal of material that is not particularly important—or that becomes less important over time. In 1988, James Fries, MD, surveyed rheumatologists to identify the greatest breakthroughs of the preceding 20 years. Although not cited in terms of specific references, 69 meaningful advances were presented in nine categories in about 2.5 pages of printed text, which is meager considering that our current major textbooks are thousands of pages.

My own view of the literature is considerably more critical than it was earlier in my career. I now read less extensively and more selectively, and no longer peruse some specialty journals. My criterion for an “important” contribution is an article that affects my understanding or practice of rheumatology, that influences my thinking or clinical behavior. I will share these with you here. I will comment on, not necessary “review,” literature selections, focusing on articles of potential interest to clinicians, affecting rheumatologic practice or thinking about rheumatology; perhaps more articles from sources other than major journals (that some readers might not have seen); and articles allowing me latitude to think more broadly about rheumatology, medicine, and, indeed, life.