Substituting Coffee Cake for Journal Articles: Another Unforeseen Consequence of IT

By  |  February 24, 2010 | 

Late February is the pits for interns – the novelty of being a real-live MD is long gone, and the rebirth of residency is too far beyond the horizon to see. The other day, my wonderful resident Anna brought aCoffee cake coffee cake to my ward team’s post-call rounds, partly to psych up the troops. This triggered a funny set of memories, memories of how residents showed their love for their interns and students during my training era, the 1980s.

We handed them journal articles!

For those of you whose academic mother’s milk is Google Scholar and UpToDate, let me tell you how this went, back in The Day.

After receiving our copies of the major journals in the mail (remember mail?), conscientious residents would tear out the full articles that were “keepers,” placing them in manila folders in the ugly steel filing cabinets we all owned. For other articles that were good but not classics, we found the page on which the journal helpfully printed index card-sized reproductions of the abstracts from that month’s issue, three to a page. And we’d carefully cut along the dotted lines, filing the cute little abstract-ettes in little recipe boxes, under tiny tabs that said things like “Wegener’s Granulomatosis” and “Prosthetic Valve Endocarditis.” And when we admitted a patient with Wegener’s, or TTP, or hypercalcemia (we hadn’t yet discovered C. diff or hypercoagulability), we’d find that little abstract and – if the article looked promising – haul off to the library to find and copy it.

The library in question wasn’t the imposing marble building across the street with the donor’s name above the front door – no, you never went there unless you were looking for a comfy seat for a nap or researching your big End of Residency talk. Instead, you went to the Housestaff Library, a ragtag collection of bound copies of major journals, the last few fraying editions of Harrison’s and Cecil, and any books edited by the department’s chair or key faculty. It was nobody’s job to keep this library organized and clean, and so it wasn’t. But that just made it all-the-more voila-ish when you finally found the perfect article!

[Sorry to interrupt, but I’ve got to tell you my funniest housestaff library story: During my time at San Francisco General Hospital, one ground floor room had a sign on the door that read, “Orthopedics Library.” What an odd place to put the library, I thought – most housestaff libraries were adjacent to their departmental administrative offices, and ortho’s was several floors up. One day, the door was cracked open and I peeked in. That was when I learned that the “Orthopedics Library” was actually a room with a bench press and free weights. Anyway, back to our tale…]

Now, with your hands on Fauci’s seminal “Spectrum of Vasculitis” article, it was off to the photocopy machine. Yes, residents spent vast amounts of their quality time photocopying articles for their interns and students. In 1984, one resident even wrote a letter to the New England Journal of Medicine called “Ripping and Filing Journal Articles,” taking the Journal to task for its habit of beginning an article on the back of the last page of the previous one (which meant the page needed to be photocopied if you wanted to tear both articles out of your personal copy of the journal). Fair point, but talk about a resident who needed to get a life.

[OK, that was me. But it was a New England Journal pub on my CV.]

In any case, now you had your single copy of an article – either pulled from your filing cabinet or copied from the journal. Before we young Gutenbergs made six more copies of the manuscript for our team, it was Branding Time. Since the purpose of handing the article to your students and interns was one part education and three parts showing them the love (and proving that you were doing a bang-up job), most residents, believe it or not, signed (or even stamped) the article with their name in the top right hand corner before xeroxing it. At Penn, two married residents, David and Essie Nash, were legendary photocopiers – their DAVID AND ESSIE NASH stamp graced hundreds of terrific articles coursing around the hospitals of Philadelphia like MRSA. David is now dean of Thomas Jefferson University’s School of Population Health, so this must have been good training for an academic career.

There’s more, believe it or not. When you received an article from your resident, the practice was to cross out the resident’s signature and place yours below hers – like a dog peeing on a tree to mark it. In fact, it wasn’t unusual to have 5 crossed out signatures in the upper right hand corner of a popular article. One time, as an intern trying to be precocious, I searched for an article relevant to a patient I had admitted the night before. I found the perfect article in my filing cabinet, photocopied it, and gave it to my teammates. “Have you seen this article,” I asked my resident, hoping he’d be impressed by my initiative. “Well, yes,” he smirked, and then he pointed to the top corner of the article, where his name (a big “X” through it) was at the top of the page, the first of seven crossed out signatures above my own. We all burst out laughing.

While all of this seems exceptionally juvenile now, this bizarre, narcissistic ritual was actually embedded in an important educational ecosystem. Interns were extraordinarily busy, and part of the resident’s core responsibility was to read, get smart, and teach her interns and students. (Most attendings were coming out of their research labs for a month of hospital medicine CME, and so few made meaningful contributions to the team’s education.) Finding the perfect article was one of the ways that we residents demonstrated that we were doing our jobs.

Today, as in so many other parts of our lives, the computer, with its magical access to the universe of on-line resources, has democratized the learning of clinical medicine. At UCSF, by the time morning rolls around, the students and interns have often already read the on-line UpToDate synopsis of the topic at hand, and may be as capable of teaching the resident (or attending) about it as visa versa.

While that’s got to be a good thing, it does challenge the apprenticeship model of residency education. I have no doubt that today’s residents can make meaningful contributions to their interns’ and students’ learning, but they’ll need to find ways to do this that go beyond being Hunter/Gatherers of key articles. It will involve thoughtfully synthesizing the literature or expert opinion and doing something far tougher than simply handing out a paper: teaching.

I have every confidence that our residents will adjust to this new ecosystem and take medical education to an even higher level. Although it’s always fun to invoke the Days of the Giants, truth be told, our system was often a sophisticated paper recycling plant rather than an educational Mecca. I hope my colleagues whose main focus is medical education are working on this – if so, or if you have fond or humorous recollections of your Ripping and Copying days, I’d love to hear from you.

Until then, bring on the coffee cake!


  1. Chip Crothers February 24, 2010 at 5:25 pm - Reply

    fun article as most of yours are. Here in the northeast we have an “a” on our library door even though the contents according to the unwashed are as you describe. Keep um coming.

  2. Es Nash MD February 25, 2010 at 3:06 am - Reply

    What a nice compliment—an homage to paper processes that are now obselete but we are flattered that they are remembered ! The file cabinets still exist but are now filled with files related to our 3 kids, our taxes and other such things.
    Someone should do a study about retention of information when read on paper vs online. Best wishes,
    Es Nash MD, Senior Medical Director, Population Health & Wellness, Independence Blue Cross

  3. Marly Holbrook July 27, 2010 at 4:06 pm - Reply

    nice point1

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About the Author:

Robert M. Wachter, MD is Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine. He has published 250 articles and 6 books in the fields of quality, safety, and health policy. He coined the term hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest growing specialty in the history of modern medicine. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. Together, the sites receive nearly one million unique visits each year. He received one of the 2004 John M. Eisenberg Awards, the nation’s top honor in patient safety and quality. He has been selected as one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine for the past eight years, the only academic physician to achieve this distinction; in 2015 he was #1 on the list. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.


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