9.5 million references and growing
New tools to help you keep up with medical literature
By Bryan Walpert
Because Rosanne M. Leipzig, FACP, has an academic appointment, she figures that she has more time than most physicians to keep up with the medical literature. Yet she feels it is still an impossible task.
"I feel like I'm drowning," said Dr. Leipzig, who is an internist, geriatrician and vice chair of education at Mount Sinai Medical Center's department of geriatrics and adult development in New York.
She's not alone. When it comes to keeping up with the literature, physicians face an ever-growing ocean of information. Medline, for example, now contains 9.5 million references and grows by about 400,000 citations a year. To put it more colorfully, the references added to Medline in 1997 alone would weigh a whopping 196 pounds in their paper version.
While the information may be overwhelming, it is essential to practicing medicine. "Everyone who practices medicine recognizes you don't go a day without coming upon clinical problems you just don't understand. You finish the day with a whole bunch of unanswered questions," said Donald A. B. Lindberg, MD, director of the National Library of Medicine (NLM). "The literature is all we can turn to."
Many physicians, however, simply don't have time to keep up. William G. Chaffee Jr., FACP, used to spend 10 to 15 hours a week reading journals and attending conferences, but the Phoenix-based internist says managed care forced him to double his patient load. Today, he reads only four or five hours a week, has dropped some of his journal subscriptions and does more skimming than he used to.
"I'd love to be able to sit down and leisurely pick up The New England Journal of Medicine and read it cover to cover," Dr. Chaffee said. "I have a stack of journals two feet high I haven't touched because I don't have the time."
The good news is that the growing body of clinical information is increasingly being summarized, organized, critiqued for scientific rigor and made easier to access in the form of books, CD-ROMs and Internet sites. Not only are citations available electronically, but so are critical reviews of the literature and in many cases full-text journal articles.
Here are some tips on how to keep up:
- Use summary journals. If you have trouble getting through three or four journals, try one of the dozens of summary publications such as ACP Journal Club, Evidence-Based Medicine (published by ACP-ASIM and British Medical Journal Group) and Journal Watch (published by the Massachusetts Medical Society).
These publications select articles that are clinically relevant and meet certain research criteria, then summarize the text. The best approach for physicians who read them: Use the information in the summaries to look up articles that interest you. "You want to find one or two items in each issue, something you didn't know that is pertinent to your patients, and throw the rest away," said R. Brian Haynes, FACP, chief of the health information research unit at McMaster University in Hamilton, Ontario, Canada, and Editor of ACP Journal Club. "If you are going to change your practice substantially, then you should get the full text of the article," as it will contain details that didn't fit into the abstract.
ACP Journal Club reviews more than 35 leading medical journals for articles relevant to internal medicine, concentrating on such core journals as Annals of Internal Medicine, The Journal of the American Medical Association (JAMA), The New England Journal of Medicine, American Journal of Medicine and Archives of Internal Medicine.
Journal Watch publishes concise summaries of the most important research in 50 journals with a focus on internal medicine and family medicine. Journal Watch also has specialty-specific journals in areas such as cardiology, emergency medicine, dermatology, women's health, infectious diseases and psychiatry.
Evidence-Based Medicine has a somewhat broader focus and searches more than 50 journals for articles of relevance to family medicine, internal medicine, general surgery, pediatrics, obstetrics, gynecology, psychiatry and anesthesiology.
Mark Linzer, FACP, professor of medicine and chief of general internal medicine at the University of Wisconsin at Madison, said that reading summary journals works well. "The expert opinions are very short," he explained. "You can read 15 to 20 in a short time.
Another option is Practical Pointers for Primary Care, which abstracts articles each month from such journals as JAMA, The New England Journal of Medicine, Lancet, British Medical Journal, Archives of Internal Medicine and Annals of Internal Medicine. Editor Richard T. James Jr., ACP Member, chooses the articles for clinical relevance and study design. (While Dr. James isn't accepting any new subscriptions, he hopes to have the journal posted regularly on the Internet soon. Write to him for information at Practical Pointers, 400 Avinger Lane, Suite 203, Davidson, N.C. 28036.)
- Use texts that are updated regularly. Popular texts such as "Scientific American Medicine" (www.samed.com) and "Harrison's Principles of Internal Medicine" (www.books. mcgraw-hill.com/medical/eproducts-home.html) are increasingly available on CD-ROM and the Internet.
One advantage of electronic texts is that they often provide links to references on the Web, Dr. Haynes said. For example, the electronic text of the CDC immunization guidelines might provide a link to the most recent guidelines on the Web. Electronic texts also make it easier for physicians to search across multiple volumes, and to reproduce a page to include in a patient chart.
Another advantage is that publishers can also update the information in electronic texts more quickly than in print versions. The CD-ROM version of "Harrison's Principles of Internal Medicine," for example, includes updates not offered in the latest print version and provides online updates every two weeks.
Though it is not a traditional textbook, the CD-ROM title UpToDate Inc. (www.uptodateinc.com) allows users to click on references within its text to see the Medline abstracts of articles on patient care and treatment information. Written by clinicians and teachers, UpToDate includes internal medicine/primary care, nephrology, hypertension, pulmonary disease, critical care, cardiovascular medicine, endocrinology, diabetes, rheumatology and gastroenterology. An updated CD is published every four months.
Another way to get the latest information about a variety of primary care issues is through "Clinical Evidence," a joint effort of the BMJ Publishing Group and ACP-ASIM. This book, slated to come out next year under the title "Clinical Evidence 1999," will compile important clinical questions and answers for a variety of common disease areas. It will be updated every six months and will eventually be put on the Web.
The book will focus on evidence. If the evidence is equivocal, the review will come out and say the question is not answerable with evidence, explained David R. Goldmann, FACP, North American editor of the book and Senior Deputy and Editor of the Annals of Internal Medicine. "It's not like offering cookbook medicine, where we say do this or that based on what's always been done," he added. "It's only going as far as the evidence goes."
- Use electronic sources. A number of electronic sources are available, depending on how broad you want your search—and your results—to be.
Medline casts the widest net, with citations and abstracts from more than 4,000 biomedical journals published in the United States and 70 other countries. Users can access Medline through software like PubMed or Grateful Med, available at the NLM's Web site (www.ncbi.nlm.nih.gov). PubMed allows you to search with key words or phrases to links to related article references, and it allows you to link to full-text articles through the Web sites of participating publishers. (There may be a charge for the full text.) Grateful Med is similar to PubMed; while it does not link to related references, it does allow you to search additional NLM databases such as Aidstrials and Cancerlit.
You can search back issues of Journal Watch for key words or authors at www. jwatch.org. Although anyone can search the site for the article references, only print subscribers can pull up the full text.
Best Evidence (www.acponline.org) is an electronic compilation of ACP Journal Club and Evidence-Based Medicine. This is a good place to start if you have internal medicine questions; it's fast and includes only what the editors considered the most reliable studies and systematic reviews covering treatment, prevention, diagnosis, cause, prognosis, clinical prediction, economics and quality improvement.
Another source is the Cochrane Collaboration (www.update-software.com/ccweb/cochrane/revabstr/ccabout.htm#other). An international effort created to pull together the best therapies, the project offers a library that contains a database of systematic reviews, mainly of randomized controlled trials. The reviews cover therapies, not diagnoses, prognoses or etiologies.
In essence, Cochrane saves you the time of tracking down studies through Medline and deciding which are strong enough to influence your practice. Each review consists of an abstract, a review report, a discussion of the results of the analysis, implications for practice and research, citations of the studies incorporated in the review and other information.
Unlike Best Evidence, which summarizes articles or reviews, Cochrane provides topic reviews, which give users a look at the evidence from a variety of studies related to a particular therapy. It also in some cases contains meta-analysis of data.
Evidence-Based Medicine Reviews (www.ovid.com), a database owned by Ovid Technologies Inc., combines information from all of the above. It allows users to search the Cochrane Database of Systematic Reviews as well as Best Evidence. For an additional fee, users can also access Medline and the full-text of articles from 200 journals. Physicians can search Medline, limiting the results to evidence-based articles, then link directly to the reviews in Best Evidence or Cochrane. In some cases, users can also link directly to the full text of the journal articles and the text of other articles mentioned in the reviews.
Prices for these electronic services vary. For more information, go to the site or call the toll free numbers listed in the box on this page.
Bryan Walpert is a freelance writer in Denver.
Phone numbers to get started
If you're not on the Web, here are some toll-free phone numbers that can put you in touch with the latest developments from the literature:
- ACP-ASIM: 800-523-1546
- Massachusetts Medical Society: 800-843-6356
- Scientific American Medicine: 800-328-6604
- Harrison's (McGraw-Hill): 800-262-4729
- UpToDate: 800-998-6374
- National Library of Medicine: 888-346-3656
- Ovid Technologies Inc.: 800-950-2035, ext. 249
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