1

How Dentists Read a Technique Article: A Qualitative Study

David W. Chambers, EdM, MBA, PhD; and Cindy Lyon, DDS

[This is an early draft intended for circulation among colleagues for comment. Areas known to need

attention are highlighted in red. At this stage, references are embedded in the text and shown in blue.

There is no abstract. The intended journal is JADA.]

Journals publish instructions for authors that prescribe standard structures, and the Vancouver

Convention of the World Association of Medical Editors is one example of efforts to achieve

consensus across publications. There is also advice from experts on how to read or write

effectively [Lozano JM, Ruiz JG. Reading a journal article. Indian J Pediatr 2000; 67(1): 55-62;

Piatti A, De Fiore L. How to read medical journals. From ad hoc perusal to proactive reading to

keep abreast of newly emerging evidence. Recent Prog Med 2008; 99(12): 590-8. Wagner JD,

Wagner SA. Keeping abreast of the medical/dental literature: a simplified approach. J Oral

Maxillofac Surg. 1992 50 (2), 163-8. Subramanyam R. Art of reading a journal article:

Methodically and effectively. J 2013, 17 (1), 65-70].

There is a small literature on the self-reported reading habits of health professionals (which

journals and how often?) [Barnard A, Kamien M. The reading habits of RACGP training program

doctors. Aust Fam Physician 1994, 23(9): 1753-6,8,60; Saint S, Christakis DA, et al. Journal

reading habits of internists. J Gen Intern Med 2000; 5(12): 881-4; Tenopir C, King DW, et al.

Journal reading patterns and preferences of pediatricians. 2007; J Med Libr Assoc 95(1): 56-53;

2

Zarshenas L, Danaei SM, Mazarei E, Najafi HZ, Shakour M. Study skills and habits in Shiraz dental

students; strengths and weaknesses. J Educ; Fujimoto, Yuka; Hagel, Pauline; Turner, Paul;

Kattiyapornpong, Uraiporn; Zutshi, Ambika. Helping university students to 'read' scholarly

journal articles: the benefits of a structured and collaborative approach. Journal of University

Teaching & Learning Practice. 2011, 8 (3), 1-12]. The most extensive literature in this area

concerns the identification and training of physiological processes that accompany reading of

passages of test, especially among those with reading difficulties [J Learn Disabil. 2015 Jul 30, e-

pub; Bergey BW, Deacon SH, Parrila RK. Metacognitive Reading and Study Strategies and

Academic Achievement of University Students with and Without a History of Reading.

Difficulties. Health Promot. 2014, 5 (3), 44, e-pub].

However, there are no empirical investigations of how dentists or other healthcare

professionals actually work their way through articles. There have been no studies of how

readers allocate their attention to segments in an article and how they use their own structure

and the structure of the article to navigate while reading under ad lib conditions. This paper

describes a qualitative study where clinical dentists were videotaped commenting on what they

were doing at various stages in reading a journal article describing a somewhat novel approach

to fabricating a provisional restoration. This is a first attempt to identify patterns and goals of

dentists when reading this type of literature.

Materials and Methods

3

This project was approved in the expedited category by the IRB at the University of the Pacific, #13-62.

The article used in this study was Terry DA. Developing a functional composite resin provisional in the

American Journal of Esthetic Dentistry, 2012; 1 (2): 56-66. The article presents a step-by-step

description of the fabrication of a resin provisional on the central maxillary incisors of a young patient

with optimal periodontal and occlusal conditions. In addition to the short abstract, short conclusion,

and 21 references, the main text of the article is 1,000 words in length. In addition to before and after

photographs, there were 28 color figures showing various steps in the procedure. The most unusual

feature of the procedure was injection of the flowable composite resin through a portal in a clear

silicone matrix placed over each tooth. Four individuals not participating the study were asked to read

the article without interruption and they did so in an average of 4 minutes and 42 seconds.

The sample consisted of 21 dentists, all of whom had at least 10 years’ experience with resin

provisionals. Their average age was 55.1. Eleven were part-time dental school faculty members and 2

full-time faculty members no longer practicing. Eight were currently in private practice.

Sessions were videotapes. The camera was positioned on the journal article to record the page being

attended to. The task for the participants was placed in context by the experiment says, “Imagine that

you are in your office and have some time. You find this article. What would you do?” Minimal

prompts were uses: “please proceed,” “tell me what you are looking at,” and “why did you turn back to

the front of the article?” Both the researcher’s and the participants’ comments were transcribed

verbatim. All participants reviewed the transcripts of their remarks within a few days of the recording

(two making minor word changes). Three participants also reviewed and approved the first-level coding.

4

The transcribed and coded dataset contained 30,000 words. A copy of the article and all the transcribed

comments by “readers” are available online at www.davidwchambers.com/in-pregress.

The customary approach to qualitative research was followed [Charmaz K. Constructing grounded

theory. Los Angeles, Sage, 2006; Glaser BG. Basics of grounded theory analysis. Mill Valley, CA: Sociology

Press, 1992; Glaser BG, Strauss AL. The discovery of grounded theory. Chicago: Aldine, 1967; Strauss A.

Corbin J. Basics of qualitative research. Newbury Park, CA: Sage, 1990] This procedure is most useful for

developing hypotheses rather than testing “yes/no” questions researchers have developed from the

literature or from previous research. The intent was to open a preliminary understanding of the

landmarks in clinicians’ approach to the technical literature.

At the first-level of coding participants’ sentences where converted into short phrases describing the

content of each thought or action. First-level coded phrases we sorted into categories in two additional

rounds of coding. Multiple rounds of coding were required because early approaches produced

idiosyncratic categories used by some participants but not by many others. Eventually a two-level

system was adopted. Four major categories (orientation, navigation, judgment, and distancing) were

identified. These were used by from 100% (navigation) to 75% (distancing) of respondents. A second

level of categorization within the major headings was also developed. For example, four types of

navigation emerged. Between 20% and 95% of participants used each of these more fine-grained

categories.

Seventeen additional subjects were recruited using the same inclusion criteria and questioned regarding

the entire issue of the journal in order to determine reactions to the target article from respondents

who were not specifically requested to read it.

5

In qualitative research, optimal sample size is not determined in advance by power analysis. Rather,

coding begins as data become available and data collection ends when the “concepts are saturated.” No

new coding categories were identified based on interviews with the final five respondents, so data

collection was terminated.

Results

Readers engaged in four activities to organize their approach to the article describing a clinical

procedure. These included orienting (identifying overall topic and style of the article); navigating

(pivoting from elements in the text to search for other material that may or may not follow in sequence

and may or may not be present in the article); judging (evaluating the value or applicability of parts of

the material); and distancing (identifying limitations in the article and reasons why the article should not

compel assent). Most readers used all four activities, and these on multiple occasions. Examples of

comments from readers representing these categories are shown in Table 1. The values reported in

Table 1 are proportions of readers noting each type of comment (in square brackets) and the average

number of such comments (in curly braces). All readers used the navigating and justifying categories at

least once. Only 5 percent skipped a general orienting activity, going straight to the detail. Eighty

percent of readers engaged in some form of distancing from the procedures or conclusions presented in

the paper.

Five transcripts were coded independently by the two authors. Agreement for the four major categories

of activities was above 90 percent in each case. Agreement for the 14 subcategories was above 70

percent.

6

[Determine whether the four main categories will be nouns, navigation, or gerunds, navigating.]

Each of the four major activities was coded at a more detailed level, as shown in Table 1. For example,

orientating could be recognized as taking place at the general level (as in a single-sentence global

characterization of the paper) or as refinement placing limits on the article (as its being a case report or

its having high esthetic content). A larger than typical number of comments is reported in Table 1 for

readers’ impression of the central point of the article. Among the 21 readers, there were at least 9

different interpretations of the main point the author was making.

There were four subcategories of navigating activities, and more than half of the readers used each of

these at least once. Skimming, the most popular navigation activity at 0.952, involved selective jumping

for recognized landmarks to the next, while assuming that the intervening material could be filled in

without surprise. Scanning always moved in forward in small segments. Hunting was another popular

form of hopping from landmark to landmark, used by 19 of the 21 readers. But hunting could involve

skipping from the introduction to the references and backward jumps. It was motivated by search for

presumed information – “I wanted to compare the before and after pictures.” Confirmation occurred

when a reader found what was being hunted for or reported that it could not be found. There were also

comments specifically about the photographs. Eleven of the 21 readers remarked that they were using

the progression of photos to guide their passage through the article.

There were also four subdivisions of the judging activity. Generally these comments involved readers

attempting to place the article in the context of their personal practice experience and to determine

whether anything in the technique could be adopted. The most common subcategory, selected at least

7

once by 19 of the 21 readers, expressed an interest in trying the procedure or more generally

recognition that it would be a valuable adjunct to their practices. Sometimes there was a more explicit

and detailed side-by-side comparison between the procedure in the article and what the reader was

familiar with – “this is like what I do, except I use different materials” or “I could not get patients to pay

for the extra time this would take.” Fourteen of the readers commented on the finished outcome being

very attractive, without in that comment making a comparison with their own practice. (Usually

comments on the outcome were followed with further comments making comparisons with the reader’s

practice.) Only four readers failed to remark on the excellent quality of the photography that

documented the case. These comments strongly emphasized that such beautiful photography could be

accepted as evidence the dental work was also of a high quality because anyone skilled and careful

enough to take such photographs would be skilled and careful in performing dental procedures.

Many readers placed some distance between themselves and the article, although there was no obvious

prompt to do so. An example used by more than half of the readers included comments that the article

did not answer all questions about the procedure and that it was not possible to generalize from the

case presented to other types of patients or to related procedures. There is no reason to make this

comment as it is a truism. More than half of the readers also noted that the case was ideal and thus the

procedure could not be used for all patients. About a third of readers raised questions about potential

conflicts of interest or excessive commercialism. Although there was a disclaimer and no unusual

pattern in identifying products by name, readers felt that even the potential for these factors would

excuse them from having to take the report at face value. A few readers noted that the paper was of

limited value because it was a case report and thus not high in the pyramid of best evidence. There was

an association between commenting that the article demonstrated an attractive result or that it

8

described a potentially useful technique and mentioning any of the four distancing postures (r = 0.451, p

= .04).

Figure 1 illustrates the fact that the four major activities were prominent at different points in working

with the article. The horizontal axis in this figure divides the number of comments for each reader

individually into quartiles based on temporal position. Q1 represents the first 25 percent of comment,

etc. The vertical axis is the number of comments. It is apparent that orienting activities were few and

most prominent when beginning to work with the article. Navigating activities were frequent at the

beginning, but tapered off sharply. The judging activities were present from the beginning and strongly

dominated toward the end. In fact, it was typical for readers to engage in general reflection at some

point, setting the article aside and reflecting on their own reflections. Distancing rose appreciably while

working through the material.

The video camera was positioned so that correlating its image with the verbal commentary made it

possible to identify what aspects of the article readers were attending to at any particular time. This

made it possible to reconstruct personal timelines for attending to segments of the article. These are

shown in Table 2. An “idealized” path through such a paper would involve sequentially working through

the overall appearance of the journal, then the abstract, followed by the introduction and text, the

photos and captions, a comparison between text and photos, the conclusion, and finally the reference.

In terms of the numbered code in Table 2, this sequences would be 0, 1, 2, 3, 3c, 4, 5.

None of the readers followed the “idealized” sequence. About half began with the introduction and half

started in the middle with the photos. Consulting references or the journal as a whole was relatively

9

rare and could occur at any point. There was substantial backtracking. Most time was spent with the

photographs.

It was implied in orienting participants that they should “do something” with the article to which their

attention had been drawn. This constitutes a limitation on the generalizability of the findings.

Seventeen new subjects were recruited and asked to comment in a general way regarding how they

would spend their time with the journal issue (not the article) handed to them. (One claimed only to do

online searches). All but one respondent began with the table of contents. All 16 read through the titles

of the articles; 3 looked for familiar names among the authors. All 16 also thumbed through the journal

from start to finish, looking at each article. Tables and photos were the items most commonly focused

on. One or two abstracts were read. On average, subjects indicated an interest in reading just under 2

of the five articles, the one drawing the most attention being the article used in this study. Where

comments were offered about which articles attracted attention, the dominant standard was topics the

reader was already familiar with, especially because that was an area of interest in practice. Two

respondents mentioned that it was good to see “evidence-based dentistry,” which they defined (when

asked) as procedures they used being mentioned in peer-reviewed publications. Although the journal is

peer reviewed, that point was not apparent or verified by those commenting on it.

Discussion

This is a first attempt, using qualitative research methods, to understand how dentists structure their

“reading” of the clinical technique literature. Twenty-one dentists with private practice experience

fabricating provisional restorations on upper anteriors were videotapes while working through an article

documenting this technique and commenting on it.

10

It is apparent that readers actively engage with the professional literature – they personalize it. Even for

such a straightforward technique paper, there was wide variation in readers’ understanding of the

purpose of the paper and what they might expect to gain from reading it. Among the 21 participants

who read some of the article, at least 9 distinct sets of expectations were generated as to why the article

should be considered.

Readers also customized their navigation through the article. They created personalized structures upon

which to frame their understanding. It is rare that they proceeded in a linear (page-to-page) format or

used the conventional “introduction, material and methods, results, and conclusion” required for such

literature. The dominant organizing principles in this case appear to be personal relevance in practice

and the visual pattern created by the photographs. Because this was a technique article, readers also

use the well-known technical sequence as an organizing principle. The frequent jumping ahead and

backtracking appear to stem from readers needing to verify that their template for the flow of the

article (technique) was matching at each point the standardized structure for such literature. Most

attention was focused on possible differences between these two patterns.

The explosion of online journals has arguably increased adherence to the formal format of publication

while expanding the range of tightly niched topic publications. This has led in turn to the growth of

computer-aided searching and systematic reviews that offer one filter (formal structure and scientific

rigor) and the bundling of scientific offerings under publishers that sell bundles of services to libraries. .

It is likely that the interactivity of digital communication will also produce an alternative to the formal

literature where practitioners can customize a structure for new knowledge that more closely matches

11

their personal needs. [This paragraph may be too much in-your-face for Michael Glick. Some references

are needed.]

In addition to the structure provided by the technique being described, readers organized their

approach to the article through a personal lens of potential value in practice. The one reader who

stopped half-way through the abstract said he only does Ceric and thus the article would only have

theoretical interest to him. The 17 individuals in the separate sample who were asked to look at the

journal as a whole, made similar comments. Readers stayed with the article longer when the question

of potential personal value remained open.

There was no priming in the instructions and the experimenter was careful not to suggest that it would

be appropriate to judge or evaluate the article in any way. Participants were instructed to “do whatever

you would naturally do with such an article in your office.” The fact that judgmental comments about

both the technique and the article were so dominant should be investigated further. It is reasonable

that good reading is critical and that dentists would engage in judging the value of what they read –

even to the point of stopping reading at any point where value is judged to fall below a personal

threshold.

On the other hand, the distancing activity was unexpected. In many cases this went beyond judging the

applicability of the material for personal use. Distancing increased at the same time attention was

focused on the practical value of the technique in practice. Distancing was significantly more prevalent

when the article was judged to describe an effective outcome or a useful technique. Readers were not

looking for reasons to avoid the technique; they were preserving their ultimate authority to make the

decision. It is as though readers were saying “I may or may not agree with the literature, but I want the

12

freedom not to have to be told how to practice.” This effect has been reported in the literature

[Albarracín D, Mitchell AL. The role of defensive confidence in preference for proattitudinal information:

How believing that one is strong can sometimes be a defensive weakness. Person Soc Psych Bul 2004;

30(12): 1565-84; Frey D. Recent research on selective exposure to information. Adv Exper Soc Psych

1986; 19: 41-80; Chambers DW. Bayesian updating. Forthcoming].

The article selected places limitations on the generalizability of this study. A highly visual article was

chosen to make data capture easier. It should not be expected that dentists will read other literatures,

such as lab studies, epidemiology, systematic reviews, or basic science, the same way. Research using

other publication formats should be attempted. But it was clear from this study that dentists are keenly

focused on visual information. Not only were the photos used to structure reading for many

participants and most time was spent with the photos, readers also assign supererogatory value to the

visual images are managed. Beautiful pictures were taken as, to a certain extent, signaling beautiful

dentistry.

13

Figure 1. Use of four reading activities at various points when dentists “read” through a case report

article. [noun or gerund?]

Q1 Q2 Q3 Q40

10

20

30

40

50

60

70

80

90

100

Orientation Navigation Judgment Distance

14

Table 1. Categories of activities used to organize their approach to the article by readers of a clinical

technique article.

O Orientation: what is topic, structure of article? [0.952] {4.1}

k One-sentence summary, central topic, what is it about? (may be reframed) [.810]

Okay, this is about making a mock-up.

This will be some technique, so I want to see how much it is like what I do.

This case was about restoring a worn and chipped anterior teeth with composite resin materials as a

prelude to some other final restorative treatment.

He’s trying to convince us to clear up any esthetic or functional issue before doing the final restoration.

This is one of those hot shots on the circuit showing off his best cases.

It’s all about patient understanding and motivation . . .

This is about bonding . . . pretty run of the mill.

The novel point here seems to be injection through the clear matrix.

He’s going to show the steps in fabricating a temporary.

q Qualifications, elaboration of topic, restrictions (“case report,” “how-to”) [0.905]

He’s trying to build this case from the point of view of guidance.

Novel injection technique unique here is the injection through the silicone.

N Navigating, using structure in article [1.000] {9.7}

s Skimming, taking in overall structure for guidance, orienting, elements [0.952]

I’m just reading through the captions related to the pictures before I’m actually reading the text. [0.952]

Well, I am just looking at all the pictures first. Just trying to get the scope of what they are trying to show.

15

h Hunting, looking for information presumed to be present but not when and where needed

(jumps backward or forward) [0.905]

I’m correlating the narrative and the pictures.

I’m check references for familiar names; just looking at the references to see if there’s anybody I know.

I’m just doing a little comparison. I’m going back to the kind of before and after.

c Confirming, finding information sought (or abandoning search) [0.857]

Well, I wanted to see whether he did want he said he wanted to do.

Okay, here is what it is. They’re developing a functional provisional.

So that’s the first thing I look for, and these pictures I’m looking at confirm what I’ve read.

i Illustrations (photos) guide story line, clear detail, document case accurately [0.524]

So, photographic evidence of a procedure . . . basically its evidence about the procedure from start to finish.

You do other things and that’s all nice, but the photographic illustrations provide

much more insight.

J Judging, evaluating, comparing, use of standard external to article [1.000] {14.2}

t Technique worth knowing, useful to do this, new approach, might try (or not), benefit to

reader [0.952]

Those things are useful if you want to get a quick instructional tip.

It’s something that I do and I used to do a lot of this kind of esthetics and this looks like an article that would

there is potential value here.

I would try this out, definitely.

16

f Finished product well done in this case, nice result materially, patient satisfied (or not),

benefit to patient [0.667]

It’s going to give good esthetics, but also it’s going to have both esthetics and occlusion as well.

Looking at these photos he’s going to get really good esthetics. You know, it’s a pretty nice result.

So I’m looking at the high quality and the skill of the outcome, and was there really a significant

outcome? And I’d say there was.

Well let me just say right now that the provisionals are so fantastic that I can’t see what more can be done.

To see something being done that you do yourself at a flawless level of accomplishment. And that’s quite

rewarding to see.

d Documentation complete, photos suggest general quality and care of author [0.810]

The photography is magnificent.

Well first of all they’re very nice pictures. They’re well photographed. They’re well composed.

The photography I’m looking at is very high quality so it lends to the idea that everything you’re seeing is

high quality and his expertise and skill in esthetics dentistry is high quality.

Good pictures. There’re really pretty. The value of good pictures is that they can tell more than the words.

p Personal comparison to own practice (positive or negative) [0.810]

That’s what I’m looking for to see if it would apply in my office.

Because I am comparing author’s instruments to own, comparing that to what I use in my practice.

This is the kind of dentistry that I’ve done quite a bit of. It’s something I’m interested in.

D Distancing, limiting [.800] {5.6}

e Extending claims beyond what article justifies, overgeneralization, limits not acknowledged

[0.550]

17

I have some questions here about the strength. . . .

It doesn’t describe the drawbacks . . . I really want information about indications and of where this

technique fits into the bigger picture.

There’s a little discussion of when to use this, but it’s really general. It doesn’t give me any more resolution

but it is too general than before I read it.

Right now I’m just kinda picking it apart. ’m pretty skeptical about the longevity of the restoration.

Oh, it’s staged to be highly perfect. Too perfect.

m Potential marketing, commercial contamination, coi or emphasis on product naming [.250]

They’re giving a lot of detail about the brands. That comes across as a little sales-pitchey.

Generally I will look on the inside of the journal to see whether there is any commercial support for an

article.

I wonder if there’s some support for the author from that company.

r Not a scientific study, research standards not observed [0.350]

And it’s a case report and so it’s not a peer-reviewed article.

I just don’t know whether this is actually refereed or not.

It’s a case report; it’s not a study.

u Not practical, too much for most patients [.600]

This would involve a big consult

There’s nothing at all in here about the health costs of doing this kind of work.

We can make this look really nice, but it’s not going to hold up for more than ten or fifteen years, and then

we’ll have to replace it.

If I’d just a general dentist, making a living in my office, I would probably I would have to charge so much to

do this my patients could never afford to have the work done.

18

NB: Values in [square brackets} are the proportion of respondents selecting this activity or subactivity at

least once while reading the article. Values in {curly braces} are the average number of times the

categories were used.

19

Table 2. Attention flow through various segments when “reading” a clinical technique article.

0 = Journal overall, outside article

1 = Abstract

2 = Introduction and text

3 = Photos, captions, and text on first encounter and going straight on

3r = backtracking in photos, captions, and text

3c = correlating and comparing among photos, captions, and text

4 = Conclusion

5 = References, acknowledgments

1, 3a, 3c, r, 2, 3a, 3b, 3r, 4, 5, 0

1, 2, 4, 3, 3r, 3r, 3c, 4, 3c, 3r, 3r, 5, 0

1, 2, 3, 1, 3, 3r, 5, 0, 3, 3r, 5, 1, 3, 3c, 3r, 1, 2, 0

1, 3, 2, 3r, 3c, 3r, 4, 5

3, 1, 2, 3, 3r, 3c, 3r, 3c, 3r, 4, 5

3, 3r, 2, 3, 3r, 3r, 3c, 4, 3r, 0

3, 2, 3, 3r, 3c, 3c, 3, 3c, 3r, 3r, 3r

3, 5, 4, 3, 3r, 3r, 2, 3r, 5, 3r, 3c, 3r

1, 3, 3r, 3c, 3r, 3c

3, 3c, 3r, 5, 3r, 3c

3, 3c, 3r, 3c

1, 3

1, 2, 3, 3c, 3r, 3r

1, 2, 3, 1, 3, 3r, 5, 0, 3, 3r, 5, 1, 3, 3c, 3r, 1, 2, 0

3

1, 3, 5, 3r, 2, 3c, 3c, 3c, 3r, 3c, 1

20

3, 3r, 4, 3r, 1, 3, 3r

3, 1, 2, 3, 3c, 4, 3r, 3r

3, 1, 4, 1, 2, 3c, 3r, 3c, 4, 3r

3, 1, 2, 3, 3c, 3r, 4