A glance at medical reading habits in Italy and England: is the writing on the wall?

Reading digital communication has not always been the boon it is considered to be by continuing medical education (CME) enthusiasts. The very first documented digital communication appeared in front of astonished onlookers during an orgy in King Belshazzar's royal palace in ancient Babylon (Figure 1). The Old Testament reports that a moving finger wrote a three-word message on a cloudy screen. None of those present could read or understand the foreboding missive:mene tekel peres*. Is it possible that the same linguistic incomprehension may prevent many doctors today from harvesting the fruits of digital communication for professional updating and clinical problem solving?Figure 1.: Rembrandt's (about 1635) Belshazzar's Feast. Reproduced with permission, © National Gallery, London.In fact, the close tie between language and technology may create a barrier, which is especially repellent for non-native speakers. In Italy, very few studies have faced the issue of how Italian doctors keep up to date. Tingali and his colleagues in Northern Italy found that 67% of respondents preferred to use textbooks in Italian and only 11% had subscriptions to professional journals. Only 10% claimed to use MEDLINE facilities [1,2]. To our knowledge, no one has assessed ability in English as a possible factor or obstacle in keeping up to date with the medical literature. In a small pilot survey of 98 practising anaesthetists in central Italy and 41 in the South Thames region of the UK (The Joint Winter Meeting of the Southern Society of Anaesthetists and South-East Thames Society of Anaesthetists, 11 February 2000; unpublished data) we found marked differences between the two groups in their journal reading habits, use of electronic media and perceptions of search expertise. The Italian group spent considerably less time reading medical literature (Figure 2). Part of the explanation may be the Italian group's access to both medical libraries and electronic media. In Italy the difficulties of using journals are often simply logistic. Thirty per cent of respondents had poor or no access and this was directly related to distance from Rome (Figure 3). The lack of efficient libraries and easy access to computing facilities means it takes a long time to track down the appropriate information because it is either not immediately at hand or too poorly organized for easy information retrieval.Figure 2.: Time per week spent reading medical literature.Figure 3.: Local access to medical information sources: distance to Rome.However, we found there was a correlation between perceived English language ability and time spent pursuing the medical literature. Only a quarter of those who reported they had no difficulty in reading papers in English said they spent less than half an hour per week keeping up to date compared with almost half of those who could only understand more structured text (such as abstracts, data presentation or case reports). Prestigious specialist medical journals in Italian have low distribution and do not have the breadth of the dozens of English journals available today. So, a paucity of good quality specialist medical information available in Italian may also be an important factor for non-native-English readers. Notoriously, foreign language readers often have a reading speed one half or two thirds that of the native speaker [3]. In the time consuming process of journal reading in English, this is undoubtedly an extra burden. In addition, those with poor English language skills are likely to have greater difficulty understanding more complex language, which may be found in discussion sections of scientific papers [4,5]. Trying to keep up to date may just be too difficult if a busy non-English speaking anaesthetist not only has no source of high quality medical information easily to hand but also has to struggle with a linguistic challenge. Encouraging reading in English on a regular basis may therefore be important. The difficulties encountered in the speculative domain of ‘discussion’ sections could be reduced by introducing ‘structured discussions’ [6] or simply by making clinically useful information more prominent in the graphic layout of journals [7]. Italy hovers on a national average of 8% Internet access and has lagged behind the rest of Europe in recent years. Nonetheless, 62% of Italian compared with only 45% of British respondents in our survey considered themselves to be ‘very competent’ or ‘competent’ in using electronic means to access information. Indeed, almost twice as many British anaesthetists, who generally have wider access to the Internet and electronic databases, claimed they were ‘incompetent’ or ‘not very competent’. This is all the more surprising as in as many as three of the hospitals in the Italian sample they had no access to the Internet or electronic databases at all. However, new technology, providing access to medical information, is being enthusiastically embraced by Italian doctors, who are used to a long-standing lack of efficient medical libraries in many hospitals. Personal access from home computers is growing. British doctors, on the other hand, have had access for many years to efficient traditional medical libraries and trained medical librarians and may not be so motivated to change their print-based reading habits. To date, the national health system in Italy has done little to provide incentives for doctors to maintain currency with medical information either by investing in informatic infrastructures or through CME programmes [1,8]. Currently, obligatory CME does not exist in Italy for medical practitioners, although they are foreseen in the near future. Although the principle of continuous professional training and compulsory yearly accreditation for public health workers was established for the first time in a parliamentary decree in 1999, it remains to be seen how the law will be modified or if and when it will come into force [9]. In countries like Italy, where institutional access to medical information is often difficult and where health care is more centrally managed, the use of the Internet is likely to exacerbate existing conflicts between patients' expectations and provision of health care [10]†. Journal reading is high up on the list of preferences for CME [12]. Skill in understanding English is a key to medical practitioner autonomy and maintenance of skills for non-native speakers. We have found indications of a low level of English language ability in our Italian sample. The risk for future CME programmes is that learner autonomy in the learner process may take a back seat to a centralized system, which ‘does not give credit to self-learning aimed solely at self improvement’ [13]. It may be hoped that improvement of language skills through accredited reading programme incentives will be contemplated in future CME training initiatives. While improving personal updating habits and skills is a common objective for all doctors, it behoves non-English speaking practitioners to maintain and refine skills in reading and medical informatic literacy. Keeping up with progress in medicine requires sophisticated linguistic skills. Native English speakers may take these for granted, but those who do not speak the de facto international language of medicine cannot. A latter day Daniel is unlikely to appear and so developing language skills must come before an improvement in regular medical reading habits. For some non-native-English-speaking doctors the writing may be on the wall!