December 1997

DOI:10.1136/bmj.315.7123.1685 Authors: Ikechukwu Obialo Azuonye (Oxleas NHS Foundation Trust)

Introduction

A previously healthy woman began to hear hallucinatory voices telling her to have a brain scan for a tumour. The prediction was true; she was operated on and had an uneventful recovery.

No previous illnesses

Born in continental Europe in the mid-1940s the patient settled in Britain in the late 1960s. After a series of jobs, she got married, started a family, and settled down to a full time commitment as a housewife and mother. She rarely went to her general practitioner as she enjoyed good health and had never had any hospital treatment. Her children had also been in good health.

In the winter of 1984, as she was at home reading, she heard a distinct voice inside her head. The voice told her, “Please don't be afraid. I know it must be shocking for you to hear me speaking to you like this, but this is the easiest way I could think of. My friend and I used to work at the Children's Hospital, Great Ormond Street, and we would like to help you.”

AB had heard of the Children's Hospital, but did not know where it was and had never visited it. Her children were well, so she had no reason to worry about them. This made it all the more frightening for her, and the voice intervened again: “To help you see that we are sincere, we would like you to check out the following”—and the voice gave her three separate pieces of information, which she did not possess at the time. She checked them out, and they were true, but this did not help because she had already come to the conclusion that she had “gone mad.” In a state of panic, AB went to see her doctor, who referred her urgently to me.

I saw her at the psychiatric outpatients clinic, and diagnosed a functional hallucinatory psychosis. I offered general supportive counselling as well as medication with thioridazine. To her great relief, the voices inside her head disappeared after a couple of weeks of treatment, and she went off on holiday. While she was abroad, and still taking the thioridazine, the voices returned. They told her that they wanted her to return to England immediately as there was something wrong with her for which she should have immediate treatment. By this time, she was also having other beliefs of a delusional nature.

She returned to London and I saw her again at my outpatients clinic. By this time, the voices had given her an address to go to. Reluctantly, and just to reassure her that it was all in her mind, her husband took her by car to the address in question; it was the computerised tomography department of a large London hospital. As she arrived there, the voices told her to go in and ask to have a brain scan for two reasons—she had a tumour in her brain and her brain stem was inflamed. Because the voices had told her things in the past that had turned out to be true, AB believed them when they said that she had a tumour and was in a state of great distress when I saw her the next day.

Brain scan requested

In order to reassure her, I requested a brain scan, explaining in my letter that hallucinatory voices had told her that she had a brain tumour, that I had not, personally, found any physical signs suggestive of an intracranial space occupying lesion, and that the purpose of the scan was essentially to reassure the patient. The request was initially declined, on the grounds that there was no clinical justification for such an expensive investigation. It was also implied that I had gone a little overboard, believing what my patient's hallucinatory voices were telling her.

Eventually, after some negotiation, the scan was done in April. The initial findings led to a repeat scan, with enhancement, in May, revealing a left posterior frontal parafalcine mass, which extended through the falx to the right side. It had all the appearances of a meningioma.

The consultant neurosurgeon to whom I referred AB noted the absence of headache or any other focal neurological deficits related to this mass, and discussed, with AB and her husband, the pros and cons of immediate operation as against waiting for symptoms to appear. In the end, it was agreed to proceed with an immediate operation. AB's voices told her that they were fully in agreement with that decision.

These were the notes of the operation, carried out in May 1984: “A large left frontal bone flap extending across the midline was turned following a bifrontal skin flap incision. Meningioma about 2.5” by 1.5” in size arose from the falx and extended through to the right side. A small area of tumour appeared on the medial surface of the brain. The tumour was dissected out and removed completely along with its origins in the falx.”

AB later told me that when she recovered consciousness after the operation the voices told her, “We are pleased to have helped you. Goodbye.” There were no postoperative complications. The dosage of dexamethasone was halved every four days, and then it was stopped. She was on prophylactic anticonvulsants for six months. Antipsychotic medication was discontinued immediately after the operation, and there was no return of the hallucinatory voices or the delusions which she had expressed.

Discussion

AB telephoned me last Christmas to wish me and family a merry festive season, and to tell me that she had been completely well in the 12 years since the operation. It was this telephone call that brought this case to mind again.

It is well known that intracranial lesions can be associated with psychiatric symptomatology. But this is the first and only instance I have come across in which hallucinatory voices sought to reassure the patient of their genuine interest in her welfare, offered her a specific diagnosis (there were no clinical signs that would have alerted anyone to the tumour), directed her to the type of hospital best equipped to deal with her problem, expressed pleasure that she had at last received the treatment they desired for her, bid her farewell, and thereafter disappeared.

I presented her case at a conference later that year. AB attended and was closely questioned by several people about the various aspects of her experience. The audience was split down the middle. People who would be called X-philes today rejoiced that what had happened to her was a clear instance of telepathic communication from two well meaning people who had, psychically, found that AB had a tumour and sought to help her.

The X-phobes had a very different formulation. According to them, AB had been given the diagnosis of a brain tumour in her original country and wanted to be treated free under the NHS. Hence, they surmised, she had made up the convoluted tale about voices telling her this and that. But AB had lived in Britain for 15 years and was entitled to NHS treatment. Besides, she had been so relieved when the voices first disappeared on thioridazine that she had gone on holiday to celebrate the recovery of her sanity.

When I asked why, a student answered honestly: It was too long, and she kept losing track of what the paper was about. This was not a remedial class: These were students who had cleared the admissions process and written essays good enough to get them here. Yet a routine academic reading assignment had defeated them.

Every generation of professors has complained that their students cannot read. The lament is usually overblown, but data have caught up to anecdote, and what I am seeing in my classroom is no longer a hunch. There is a measurable, generational collapse in sustained reading and writing, and the academy is responding to it with improvisation and exhaustion rather than the structural overhaul it requires.

In February 2024, Adam Kotsko, who teaches in the Shimer Great Books School at North Central College, wrote in Slate that students who once handled 30 pages of reading per class meeting now seem “intimidated by anything over 10 pages and seem to walk away from readings of as little as 20 pages with no real understanding.” Crucially, he added that this is “not a matter of laziness on the part of the students” but of underlying skills they were never given a chance to build.

The Chronicle of Higher Education’s 2024 investigation found the same pattern across institutions as different as the Stevens Institute of Technology and Wellesley College, where the average SAT exceeds 1400. Nicholaus Gutierrez, an assistant professor at Wellesley, told The Chronicle that the baseline for what students consider a reasonable amount of work has dropped so noticeably that he has cut his readings accordingly; a 750-word essay now strikes many students as long. At Stevens, the science and technology studies associate professor Theresa MacPhail described following the mantra of “meet your students where they are” for so long that she has begun to feel “like a cruise director organizing games of shuffleboard.”

Worse, the national data tell the same story in colder language. On the 2011 National Assessment of Educational Progress (NAEP) writing assessment, which is the most recent comprehensive writing benchmark, only 24 percent of 12th graders reached the Proficient level, and just 3 percent reached Advanced; another 21 percent scored below Basic. The reading side of the ledger is worse, and getting worse fast: The 2024 NAEP results released in September 2025 show 12th-grade reading scores at the lowest level recorded since the assessment began in 1992. Thirty-two percent of 12th graders now score below NAEP Basic in reading, meaning that, in the assessment’s own language, they likely “cannot draw general conclusions based on concepts presented explicitly in a text.” And yet more than half of these same seniors reported being accepted to a four-year college. That last sentence is the whole problem in one line: We are admitting a cohort that cannot read at a college level and are pretending otherwise.

Why is this happening? One reason, of course, is smartphones.

I came into teaching as a skeptic of the anti-smartphone argument: I had a phone in my pocket throughout high school and college in the 2010s, and I read long books anyway. I now think I was wrong, because the neuroscience has caught up. In a 2017 paper, Adrian F. Ward and colleagues at the University of Texas at Austin’s McCombs School of Business showed that the mere presence of a participant’s smartphone — whether that be face down, powered off, untouched, or across the desk out of vision — measurably reduces available working memory and fluid intelligence on cognitive tests, with the largest effects on the most phone-dependent users. A 2022 study by Motoyasu Honma and colleagues at Japan’s Showa University used near-infrared spectroscopy to compare reading on a smartphone with reading the same passage on paper, and found that smartphone reading produced overactivity in the prefrontal cortex, suppressed sigh generation, and led to general lower comprehension scores; the authors argued that the sigh inhibition and prefrontal overload were causally linked to the comprehension decline.

So when a student tells me they “kept losing track” of a 20-page article, I have to acknowledge that they may be describing a measurable neurological condition. The neural pathways that support sustained attention are built by use, and they atrophy without it. Your body is a use-it-or-lose-it system, and the brain is no exception.

Another reason for the decline in student reading capability is increasing reliance on generative AI. In June 2025, Nataliya Kosmyna and colleagues at the MIT Media Lab released a preprint titled “Your Brain on ChatGPT.” They divided 54 participants into three groups writing SAT-style essays — one using ChatGPT, the second group using a search engine, the last group using nothing — and monitored brain activity with a 32-channel EEG. The ChatGPT group showed the lowest neural connectivity of the three, with up to 55 percent reduced connectivity compared with the brain-only group, and “consistently underperformed at neural, linguistic, and behavioral levels.” Eighty-three percent of LLM users could not quote a single line from essays they had written minutes earlier. When the LLM group was forced to write without AI in a follow-up session, their brain activity did not bounce back to baseline; the researchers coined the term “cognitive debt” for the lingering deficit.

This is the first neurophysiological evidence that early reliance on LLMs measurably alters the brain’s engagement with writing tasks, and it is consistent with what those of us in front of classrooms are watching happen in real time. When I assign analysis, I am not trying to extract a polished product; I am trying to put the student’s mind through resistance in order to make it stronger. Offloading the struggle to a chatbot does not “free students up for higher-order work.” It deprives them of building the strength to do any substantial cognitive work at all.

There is a final factor that is contributing to this decline in reading skills, and that is that the students arriving in my classroom today are the first cohort to have experienced Common Core-influenced reading instruction across the entirety of their K–12 schooling. Whatever the standards’ original intent, the on-the-ground implementation in many districts replaced sustained reading with the practice of pulling “evidence” from disconnected short passages, the same format used on the standardized tests that increasingly determine school funding. The education scholar Natalie Wexler, among others, has documented this pivot in detail: Students drilled on “finding the main idea” in two-paragraph excerpts never build the stamina or background knowledge that longform reading requires. The pandemic then added fuel to a fire that was already burning. NAEP scores for 13-year-olds dropped sharply in 2022 and have not recovered. A 2023 EdWeek survey found that 24 percent of secondary-school administrators described pandemic learning loss in English and language arts as “severe or very severe.”

In July 2025, the journalist Mary Harrington argued in The New York Times that “thinking is becoming a luxury good.” The ability to read deeply and reason at length is fragmenting along class lines as ultra-processed digital media replaces text in everyday life, much as ultra-processed food has replaced cooking. Her longer treatment of the subject in First Things makes the more provocative case that we are witnessing the end of print culture itself, and with it the end of the cognitive substrate on which modern liberal democracy was built.

I see this stratification in the classroom and on the page every week. My students from districts that protected sustained reading through small class sizes, strict phone policies, and faculty who refused to teach to the test all arrive with their attention relatively intact. My students from districts that surrendered to devices and standardized testing arrive cognitively winded. A democracy that requires a literate electorate is now training one fraction of that electorate out of literacy while marketing to the other a “deep work” lifestyle as a luxury good. The students who cannot read a 20-page article today are the voters who will not be able to read a bill, or the jurors who cannot follow a closing argument, tomorrow.

I do what I can in my own classroom to address the problems. I break 20-page articles into two halves and assign the first half with explicit analytical tasks. I require exploratory writing before formal drafts. I model (visibly, on the board) how to track an argument across pages or distinguish a source’s claim from my own analysis. I make structured peer review explicit, because the workshop format I used to take for granted now collapses into “this is good” and “maybe add more details” the moment I step back.

But I want to be plain about the limits of what an individual instructor can do, and all of these solutions have costs. Scaffolding a 20-page article into halves compromises the integrity of the argument I am asking students to engage, just as modeling note-taking in a credit-bearing rhetoric course is using a college slot to teach a middle-school skill. None of the syllabi I teach are designed to deliver this type of cognitive rehabilitation, and pretending otherwise has produced credential inflation. We cannot keep conferring degrees on students who cannot do what the degree is supposed to certify.

I’m afraid I don’t have answers. I do, however, have some questions that may point us in the right direction. If higher education is going to respond to the reading crisis as a structural problem rather than a private burden carried by composition instructors and adjuncts, it has to stop avoiding the following questions: If a majority of incoming students cannot read at a level the curriculum requires, are we admitting students we cannot serve, or offering a curriculum we cannot provide?

Why are first-year writing and reading-intensive general-education courses still the most adjunctified, lowest-paid, highest-load corner of the university, at the precise moment when their work has become the most important work the institution does? What is the responsible institutional response for AI usage: Is it a syllabus statement, or a sequencing principle that requires students to demonstrate the cognitive work themselves before AI assistance is permitted?

Why are most college classrooms still phone-permissive by default? K–12 districts from Florida to California are now banning phones bell to bell; higher education has somehow lagged behind the public schools. Universities benefit from a pipeline they did not build and refuse to repair. What would it mean for a university system to invest seriously in the reading instruction happening in the high schools that feed it, rather than treating remediation as something to be quietly outsourced to first-year composition instructors?

The thing I am no longer willing to do is pretend this is a temporary adjustment period, or that “students will adapt.” They will not adapt on their own. The conditions that produced this collapse are still in place: the phones, the algorithmic feeds, the test-prep excerpts, staffing models that load the reading-intensive work onto the most precarious faculty, and now the chatbots that finish students’ sentences before they’ve even begun to think of them. If we want literate citizens, we will have to rebuild the conditions for literacy deliberately, against the grain of every incentive currently pointed the other way. I know the academy has the will to do that. It also has the obligation."

— Tyler Jagt, 1 June 2026, "My Students Can’t Read"

Standing in his laboratory, Harvard professor Sean Eddy gazes at a row of vacant work stations. More than a year ago, this lab was filled with over a dozen researchers. On a given day they might be working independently on analyzing genomic sequencing or gathered around the group table, drinking coffee and helping each other troubleshoot questions about genomic data from different species.

Now, after his funding was terminated under the Trump administration, the computer screens are gone and the room is silent. He's one of the last people left.