UpToDate is the most read medical reference tool - how did Harrison's, Cecil's, etc. manage to lose that war?

This the summary of my Twitter discussion with an academic nephrologist (by the way, the founding editor of UpToDate is also a nephrologist):

@DrVes: UpToDate is likely the most read medical reference tool, at least in the U.S. - how did Harrison's, Cecil's, etc. manage to lose that war?

@kidney_boy (Joel Topf): Reasons for UpToDate winning: Harrison's had no search, and an editorial style that told you about disease but not how to treat it

@DrVes: Exactly. It's amazing that those publishing companies didn't realize that they shipped "malfunctioning" product for years, and never fixed it.

@kidney_boy (Joel Topf): Harrison's is the great preclinical prof teaching pathophysiology, UpToDate is the smart clinician teaching you how to care for the patient with EBM.

@DrVes: UpToDate now has sections on pathophysiology, some of them quite good, check T-cells types, for example. Unfortunately, a lot of medical students get their basic pathology knowledge from Wikipedia nowadays. Just go to the library section where medical students are and have a look at the monitor screens during study time.

@kidney_boy (Joel Topf): Remember Harrison's is the youngest of the medical texts, it won by having regional approach (headache rather than CNS) to organization.

@DrVes: Classic-style textbooks (e.g. Harrisson's) feel like "half-book" nowadays. The doctors in training often find themselves asking "Where is the second part with treatment, updates, etc.?"

Related reading:

Review of the much anticipated UpToDate iPhone app, arguably the most read medical reference tool. iMedicalApps.com.
Are You Dependent on UpToDate for Your Clinical Practice?
"With UpToDate, students and interns may be as capable of teaching the resident (or attending) as visa versa"
Study: UpToDate More Likely than PubMed to Answer Patient Care Questions
How Current Are Leading Evidence-Based Medical Textbooks? An Analytic Survey of 4 Online Textbooks (including UpToDate) http://buff.ly/X2kUKw

Comments from Google Plus:

Neil Mehta - Ves one of the most useful aspects of Harrison's is/was the approach to symptoms. This is the first 100 or so pages of Harrison's. Understanding this can be a huge help in becoming a good clinician. It is pretty dense reading but internal medicine residents can benefit from spending time on this. Agree UpToDate is a tremendous resource. One thing to remember about U2D is that sections can be written by one author and this does run a risk of bias creeping in (no different than textbooks) but readers should learn to look at other sources/primary literature when necessary.

Ves Dimov - Right. UpToDate is far from perfect but it is very time efficient. It provides quick actionable info within 5-10 minutes of conducting a search. The depth of the content is limited by the person who wrote that particular article, of course.

Robert Silge - Yes, but by and large the people writing that content are qualified to do so. It is to medical textbooks what Wikipedia is to general reference books. Updates faster, to the point, and has info on (almost) everything. Its depth may be lacking, but for clinical practice I doubt the benefits of reading through primary literature is worth the time spent doing it for most endeavors.

And frankly for your first foray into a field, as a med student for example, Wikipedia is a darned useful place to start.

Ves Dimov - And that's why UpToDate is most users' favorite resource. One of the few drawbacks is the price though, $495 per year.

Robert Silge - Wonder how many people pay for it out of pocket vs use an institutional login?

Gary Levin - Up to date is like rounding with your attending or professor with instantaneous gratification. Harrison belongs in the library or for a second year med student to learn the language.

Internal medicine residents spent little time reading, and prefer electronic resources, specifically UpToDate

This study from the Mayo Clinic assessed residents' reading habits and preferred educational resources at 5 internal medicine training programs via a survey.

78% of residents reported reading less than 7 hours a week.

81% of residents read in response to patient care encounters.

The preferred educational format was electronic, and UpToDate was the big winner among the surveyed group:

- 95% of residents cited UpToDate as the most effective resource for knowledge acquisition
- 89% of residents reported that UpToDate was their first choice for answering clinical questions

The study authors concluded that residents spent little time reading and sought knowledge primarily from electronic resources. Most residents read in the context of patient care.

The abstract does not mention anything about social media sources such as Wikipedia, blogs, and Twitter, but the residents encounter a lot of those through Google searches.

References:

A multi-institutional survey of internal medicine residents' learning habits. Edson RS, Beckman TJ, West CP, Aronowitz PB, Badgett RG, Feldstein DA, Henderson MC, Kolars JC, McDonald FS. Med Teach. 2010;32(9):773-5. Image source: UpToDate.

How to Subscribe to "What's New" Specialty Page of UpToDate? No Feed, No Problem for Google Reader

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. These selections are changed with each major release of UpToDate, in March, July and November. See these updates by clicking on the specialty you are interested in.

The page does not provide RSS feed for the different specialties. One solution is to copy/paste the URL address of each subspecialty page you are interested in the Google Reader "Add a subscription" field (top left corner). Google Reader will automatically create a RSS feed from this "feedless" page.



References:
UTD Contents: What's New

Are You Dependent on UpToDate for Your Clinical Practice?
5 Tips to Stay Up-to-Date with Medical Literature
Image source: UpToDate.

What's new in infectious diseases from UpToDate

- Brain MRI may be useful in patients with endocarditis. In one study including 53 patients, early use of cerebral MRI led to the reclassification from possible to definite IE in 30% of cases.

Figure 1. TEE shows AV Endocarditis in a patient with IVDA. There is a large vegetation on the aortic valve with 2-3+ AI (click to enlarge the image). Source: Double Hit – Right and Left-Sided Endocarditis in a Heroin Abuser.

- Cotrimoxazole prophylaxis was associated with a 50 percent reduction in deaths in patients starting antiretroviral therapy with CD4 counts lower than 200 cells.

- Universal influenza immunization: In 2010, the CDC expanded the recommendation for influenza vaccination to include all individuals 6 months of age and older. Previous guidelines recommended influenza vaccination for individuals over age 50 and for those at increased risk of influenza complications and close contacts of such individuals.

How to Subscribe to "What's New" Specialty Page of UpToDate? No Feed, No Problem for Google Reader

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page.

The page does not provide RSS feed for the different specialties. One solution is to copy/paste the URL address of each subspecialty page you are interested in the Google Reader "Add a subscription" field (top left corner). Google Reader will automatically create a RSS feed from this "feedless" page.

References:
What's new in infectious diseases. UpToDate, 2010.

UTD Contents: What's New

Are You Dependent on UpToDate for Your Clinical Practice?
5 Tips to Stay Up-to-Date with Medical Literature

What's new in pulmonary, critical care, and sleep medicine from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in hematology:

Asthma

When evaluating patients for occupational asthma, sputum eosinophil counts at 7 and 24 hours after specific inhalation challenge have a greater sensitivity and positive predictive value than exhaled nitric oxide (eNO).

Critical care

Proton pump inhibitors (PPIs) may be slightly more effective than histamine-2 (H2) blockers at preventing gastrointestinal (GI) bleeding in critically ill patients. However, the difference is small if real.

Idiopathic pulmonary fibrosis

Sildenafil, tyrosine kinase inhibitor imatinib, and pirfenidone, an anti-fibrotic agent, were each no more effective than placebo for treatment of idiopathic pulmonary fibrosis.

Pleural effusion

Using ultrasonography to identify a site for diagnostic thoracentesis is associated with significantly lower risk of pneumothorax, than using the physical exam for site selection.

Pulmonary embolism

PE is frequently asymptomatic. Among 5233 patients with a DVT, 32 percent had asymptomatic PE.

References:
What's new in pulmonary, critical care, and sleep medicine. UpToDate.

What's new in rheumatology from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in rheumatology:

Lower dose colchicine for treatment of acute gout

A lower dose colchicine may have similar efficacy and fewer side effects than a traditional, higher dose regimen for patients with acute gouty arthritis. Colchicine given as 1.2 mg followed by one additional dose of 0.6 mg an hour later (total dose 1.8 mg) worked similarly to 1.2 mg followed by 0.6 mg every hour for up to six hours.

Nocturnal leg cramps

Quinine is no longer recommended due to the potential for serious side effects, drug interactions, and only modest benefit. Calcium channel blockers and vitamin B complex have limited effect.

Anti-CCP antibody testing in RA

Testing for anti-citrullinated peptide/protein antibodies (ACPA) has become common in the evaluation of patients for rheumatoid arthritis (RA). Second generation anti-cyclic citrullinated peptide (anti-CCP) antibodies had the highest utility, with higher specificity and similar sensitivity to rheumatoid factor (RF). Both RF and anti-CCP testing should be performed in patients suspected of having RA. Should I order an anti-CCP antibody test to diagnose rheumatoid arthritis?  http://goo.gl/L3abc - Yes. Cost of RF is $43, anti-CCP $102

Golimumab for RA

Golimumab, a neutralizing human anti-tumor necrosis factor alpha monoclonal antibody, is administered subcutaneously once monthly for the treatment of rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis.

Rituximab for primary Sjogren's syndrome

Rituximab, which is used for the treatment of B cell lymphomas, rheumatoid arthritis, and other autoimmune and lymphoproliferative disorders, is a chimeric monoclonal antibody directed against the B cell antigen CD20. One course of rituximab treatment resulted in significant improvement in patients with Sjogren's syndrome (SS).

References:
What's new in rheumatology. UpToDate.

What's new in endocrinology from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in endocrinology:

Osteoporosis

Denosumab (Prolia)

Denosumab is a fully human monoclonal antibody that specifically targets a ligand known as RANKL (that binds to a receptor known as RANK) which is a key mediator of osteoclast formation, function, and survival. Denosumab was approved for the treatment of postmenopausal women with osteoporosis at high risk for fracture (history of osteoporotic fracture, multiple risk factors for fracture) or patients who have failed or are intolerant of other available osteoporosis therapies. Denosumab inhibits the formation, function, and survival of osteoclasts. It decreases bone resorption, increases bone mineral density (BMD), and reduces the risk of fracture.

Teriparatide (Forteo)

Teriparatide (parathyroid hormone) did not accelerate fracture healing in postmenopausal women with distal radial fractures.

Transdermal teriparatide patch worked as well as teriparatide injection in postmenopausal women with osteoporosis.

Orlistat (Xenical, Alli) in obesity

Severe liver injury has been reported rarely with the use of orlistat (13 reports). Over the ten year period of the review, an estimated 40 million people worldwide used orlistat.

References:
What's new in endocrinology and diabetes mellitus. UpToDate.

Image source: Flickr, Creative Commons license.

What's new in obstetrics and gynecology from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in obstetrics and gynecology:

Obstetrics

Influenza vaccination with inactivated vaccine is recommended for pregnant women, regardless of the stage of pregnancy. The 2010-2011 influenza vaccine is trivalent and includes antigens from both the 2009 pandemic H1N1 influenza virus and seasonal influenza viruses.

Use of acetaminophen during pregnancy was associated with a reduction in neural tube defects, as well as cleft lip/palate and gastroschisis. These data support the safety of acetaminophen for relief of fever and pain.

Gynecology

Like CA 125, human epididymal secretory protein E4 (HE4) is a promising biomarker for ovarian cancer. In contrast to CA 125, HE4 levels do not appear to be elevated in women with endometriosis, and thus can be useful to rule out ovarian cancer in patients with endometriosis and a pelvic mass suspected to be an endometrioma.

Sterilization does not impact sexual function. Sexual function appears to be unchanged or improved in women following tubal sterilization.

Botulinum toxin may be useful for overactive bladder syndrome (onabotulinumtoxinA, Botox®). Detrusor injection of botulinum toxin (BoNT) had a transient effect. The average time between injections was 8 to 12 months.

References:
What's new in obstetrics and gynecology. UpToDate.

Image source: Wikipedia, GNU Free Documentation License.

What's new in gastroenterology and hepatology from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in gastroenterology and hepatology:

Hepatitis C virus (HCV) infection

Peginterferon alfa-2a was superior to peginterferon alfa-2b with regard to virologic response rates in patients with chronic hepatitis C virus infection, genotypes 1, 2, 3, or 4. Patients being treated for chronic hepatitis C virus infection should receive peginterferon alfa-2a rather than peginterferon alfa-2b.

72 weeks of therapy with peginterferon alfa-2a plus ribavirin in patients with HCV genotype 1 or 4 was not better than 48 weeks.

Chronic use of proton pump inhibitors (PPIs)

Chronic use of proton pump inhibitors (PPIs) may lead to an increased risk of fractures. FDA recommends that healthcare professionals who prescribe proton pump inhibitors should consider whether a lower dose or shorter duration of therapy would adequately treat the patient's condition.

Ulcerative colitis

Once daily dosing of delayed-release mesalamine (Asacol 400 mg tablets) 1.6 to 2.4 g/day was as effective as twice daily dosing for maintenance of clinical remission in patients with ulcerative colitis. Remission rates were 85% in both groups.

Crohn's disease

Capsule endoscopy was not a cost-effective third test for establishing the diagnosis of Crohn's disease after a negative ileocolonoscopy and either a CT enterography or small bowel follow-through x-ray.

Azathioprine in combination with infliximab or infliximab alone had a higher rate of glucocorticoid-free clinical remission than those treated with azathioprine alone. Combination therapy and infliximab monotherapy led to significantly more complete bowel healing than azathioprine alone.

Obscure gastrointestinal bleeding

Double balloon enteroscopy (DBE) detected bleeding sources in 78% of patients with obscure gastrointestinal bleeding. Small intestinal ulcers and erosions were the most common findings.

References:
What's new in gastroenterology and hepatology. UpToDate.

"With UpToDate, students and interns may be as capable of teaching the resident (or attending) as visa versa"

From Wachter's World:

"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.

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."

Note: UpToDate is a peer reviewed medical information resource (paid, not free access) published by a medical company called UpToDate, Inc. It is available both via the Internet and offline. An update is published every four months. The material is written by over 3600 clinicians and has over 7300 topics. The website was launched in 1992 by Dr. Burton D. Rose along with Dr. Joseph Rush. A new online subscription for 1 year costs $495, $195 for trainees (source: Wikipedia).

References:

Substituting Coffee Cake for Journal Articles: Another Unforeseen Consequence of IT. Wachter's World.

Are You Dependent on UpToDate for Your Clinical Practice?
Small association between use of UpToDate and reduced patient length of stay, lower mortality (study sponsored by UTD) http://goo.gl/zSG8R

95% of junior doctors consider electronic textbooks the most effective source of knowledge. 70% of junior doctors read the medical literature in response to a specific patient encounter. BMJ, 2011. http://goo.gl/QZyJE

Image source: UpToDate.