>> UpToDate. UpToDate is essentially a concise online textbook for medical conditions. Medical students learn quickly to consult UpToDate for information on topics as varied as causes of hyponatremia (low sodium), manifestations of sickle cell crisis, or criteria for the MELD (model end-stage liver disease) score so that they (1) learn, (2) minimize the chances of looking like complete dolts during rounds, and (3) can expound at length in the “impression” and “plan” portions of their verbose notes. Interns and residents (and presumably attendings, too), continue to consult this useful resource on the fly for information as they evaluate and manage patients.
UpToDate is not a free resource. Word on the street is that within the past year, the company that manages UpToDate has increased their prices by 500%! Thus, any institution that would like to make UpToDate available to staff now must pay a fee that is over half a million dollars.
The folks at UpToDate know how much housestaff rely upon this program. Darn it.
A potential competitor is Dynamed, which prides itself on “superior evidence-based results”. I must confess that I’m impressed with the abundance of (very recent) citations Dynamed provides for different subjects [for things that are relatively uncommon, such as the efficacy of selective serotonin reuptake inhibitors (also known as SSRIs) in contrast to tricyclic antidepressants (TCAs)…]. Information is presented in a concise format, but allows the reader to consult the original articles with ease.
This is particularly striking because the other word on the street is that only 10% of UpToDate is evidence-based. I have no data to support that assertion; that’s just what the (reliable) rumor mill mutters. UpToDate could theoretically brainwash us all with heretical information that would absolutely impact patient care. (Not to say that some of us don’t already do that….)
A disadvantage of Dynamed is that one must already know something about the topic to make sense of the information. UpToDate is a textbook; thus, you can read general background information about progressive multifocal leukoencephalopathy (PML) before learning about appropriate management and treatment of this condition. On Dynamed, you better know what PML is or otherwise, the information doesn’t really make much sense.
>> Joe’s Goals. This is a great application to use for motivation. Joe’s Goals is a Web 2.0 tool that allows you to track your habits; in psychological literature, this behavior is known as “self-monitoring”. The very act of monitoring what you do (or do not do) can change behavior. For example, people who track how many cigarettes they smoke a day often suddenly realize just how often they are smoking, how many cigarettes they are smoking, and how much they are spending on that habit. This information, when blatantly recorded, forces people to become more aware of what they are doing and thus, may foster more rapid behavior change. Maybe. Benjamin Franklin was a proponent of self-monitoring. You could be just like him.
Amongst other things, I am currently tracking my academic reading. I like putting those green checks into the boxes to mark my progress. (And, for what it’s worth, learning theory posits that positive reinforcement—using the green check marks—is more effective in eliciting change than punishment—using the red stop signs. Empirical evidence suggests that the theory is accurate.)
>> Fortune cookies. A few weeks ago, a good friend purchased a magnet for me. The magnet reads
Some dream of fortunes
Others dream of cookies
She knows me well.
Today, the fortune inside my fortune cookie read
Your ideas will be totally acceptable.
What kind of fortune is that?
26 Jul 2007 |
It’s an ambivilent one, you fortunate cookie, you.
Comment by bill | 27 Jul 2007 @ 3:54am
What about eMedicine as an alternative to UpToDate? eMedicine is free (when you register). I’m only an MS2, so I don’t know how useful eMedicine would be to residents, but I certainly find it useful at my stage of training.
Comment by Brad | 27 Jul 2007 @ 5:46am
The Gestalt “paradoxical theory of change” is that the more you become aware of what “is,” the more you will change.
Comment by Don | 27 Jul 2007 @ 6:43am
Your ideas will be totally acceptable… in bed.
Comment by Terry | 27 Jul 2007 @ 7:09am
You don’t even want to know what UpToDate would charge us to add remote access…
Comment by Rachel | 27 Jul 2007 @ 2:15pm
I used MDConsult (which comes with the very useful FirstConsult) and AccessMedicine at my school, and have never once used UpToDate.
However, as a result, I don’t even know what UpToDate has to offer. Perhaps I’m still living in the dark ages.
Comment by Vitum Medicinus | 27 Jul 2007 @ 2:50pm
I used to teach and I try to run an evidence-based shop. It’s been about 2 years since I have looked at the various EBM products, but please indulge my opinions, for whatever they may be worth. There are lots of disclaimers because I realize the sources of my potential biases, but I stand by my opinions.
Much depends on which definition of EBM you use; mine is the strictest and most severe version of critical assessment. You know, the one that says that 90% of what physicians do is not EBM. Although there is always evidence, it may not be the direct and ideal evidence of outcome that one should have if we operated with mechanical certainty. There is always a role for inference in medicine, but the discipline of EBM suggests that inference can be and often has produced erroneous conclusions in the past.
This is very important because so much practice today is driven by people who say they are being evidence-based but are not. Miliman, for example, always cites “evidence” but their approach appears to me to reflect the best way to make a lot of money by misusing the concept!!!
With this strict definition of EBM, e-medicine is a very useful source of information for the medical student. I would like to think physicians could do betetr, but given the reality of clinical practice today, I think it is one of the best sources of fast accurate information. I am noticing that wikipedia has become a terrific source of similar information and in time will probably represent a significant competitive threat to e-medicine. Smart move to sell the company, guys.
Up-to-Date is wonderfully complete in its reporting of the studies and supporting evidence but does not adopt a particularly critical eye. (We used it at our residency). Their major advantage is that they are unmatched in being up-to-date (sorry) and complete.
In my opinion, a review journal that presents all the evidence, but then is equally up-front about the level of evidence supporting the information is American Family Physician (I’m biased, I wrote for them…)
Dynamed is both very complete and very critical (I am biased, they invited me to write for them some years ago.) However the level of skill and time investment required to understand the information is, in my opinion, far beyond the capacity of the majority of harried practitioners. I also know they have been working hard to make it a top-notch commercial success, including many upgrades that I have not seen. I used them almost exclusively when I was preparing lectures back in the day.
Info-Retriever is something I have used in the past… (multiple disclaimers this time: I know the guys who started it, one has been an editor for me in the past, I have taken their course). It is an excellent resource for the physician who cares to develop critical assessment skills. Probably doesn’t answer quick questions for the doc who doesn’t care how he gets the info. Major advantage is that it is point-of-care (i.e. handheld) platform.
Several large publishers have put together handheld products, but my experience, although positive, is that it is like having a Merck in your pocket. Somehow I never bothered reloading the one I had on my handheld (slowed things down too much) and I still use my 5-Minute Clinical Consult from 2001 for THAT kind of reference. Then again, I tend to use Google maps on my smartphone more often than ePocrates! Somehow reading a textbook in clinic on my handheld is not helpful to me, when I have an internet-enabled computer in every room.
One of the ideas that the InfoPOEMS/InfoRetriever guys use reminds us that there is really a different effort required for different kinds of reference information. Sometimes I need to know the dose to treat H.Pylori (use ePocrates), sometimes I want to look for different recipes (Up-to-Date) and sometimes I want to see if there is any evidence to support H. Pylori eradication in recent immigrants from endemic countries (there isn’t, you need a real critical assessment tool AND you need the skills). Each question is answered differently.
Comment by Dr. Dino | 29 Jul 2007 @ 10:54am
[…] Intueri points out UpToDate’s extraordinary pricing and makes some comparisons to DynaMed. […]
Pingback by davidrothman.net » Blog Archive » Questions about UpToDate | 2 Aug 2007 @ 3:59pm
Word on the street of “price increases by 500%” must have come from a rep. Not true at all. Make sure to check out the “authors” section of a resource also. Since you mentioned Dynamed, it happens to be almost all written by AAFP physicians, even residents. The rep didn’t mention that! Nothing against family docs, but they aren’t specialists. I’ll gladly pay for Uptodate.
Comment by Don | 8 Aug 2007 @ 2:23pm
[…] To add to my collection of silly fortunes in fortune cookies (”Your ideas will be totally acceptable“), here’s the fortune I received from the dim sum restaurant: You will reach high levels of intelligence. […]
Pingback by intueri: to contemplate | 19 Aug 2007 @ 2:53pm
[…] Sul blog Intueri to contemplate si fa il punto sui prezzi (quasi esagerati) di UpToDate in comparazione con DynaMed. […]
Pingback by UpToDate « Medicina in Biblioteca | 21 Aug 2007 @ 3:31am
i have http://www.clinicalevidence.com which does the job for me over uptodate, much shorter info that you can really use at the point of care, rather than sifting through pages and pages from uptodate (sometimes over 20 pages for 1 topic). I just dont have the time to read all that when I just want a quick answer at the point of care. bmj clinical evidence does this for me.
Comment by goran | 18 Mar 2008 @ 9:34am