Are you UpToDate dependent?

Can you make it through hospital rounds or a day in clinic without consulting UpToDate? Do you rely almost entirely on UpToDate to research topics or patient encounters, without going to primary sources? Do you feel you’d be unable to practice competently without it? Do you consider it your “peripheral brain” (translate: substitute for thought)? If you answered yes to any of these questions you may be UpToDate dependent. The habit can be darned expensive as Maria points out in a recent intueri post (h/t to Kevin M.D.).

Surveys and testimonials suggest that UpToDate dependence may be widespread. In one study, abstracted on the UpToDate website, over 90% of users thought UpToDate was “integral” to their decision making. Most usage was in association with patient encounters and 50% of usage was in the presence of the patient. Interestingly, most non-use of UpToDate was associated with lack of familiarity with the resource. Comments submitted to the website include “Can’t be without it”, “In time of need, I turn to UpToDate” and “Essential for my practice.”

Now I’m not here to criticize UpToDate. I love UpToDate and have my own personal subscription. It is a wonderful resource and, other than perhaps the cost, I find no fault with it. The problem is UpToDate dependence, which is symbolic of the larger problem of over reliance on “look up” resources. Although look up resources are essential to the practice of evidence based medicine, over reliance becomes a problem when their use supplants knowledge of basic science, acquisition of medical knowledge, background reading and clinical judgment. These essential skills and attributes help safeguard against an overly formulaic approach to patient care and result in fewer mistakes when patients do not follow the usual scripts.

The problem is symptomatic of growing attitudes which de-emphasize basic science in medical curricula and diminish the importance of medical knowledge as well as an agenda to restrict accredited CME to activities directly related to physician “behavior”.

This topic dovetails with a recent series of Med Rants posts on basic science in the medical curriculum, particularly as it relates to the USMLE Step 1 exam. Medical students sometimes complain about the basic science minutia they are forced to learn. DB, the author of the posts, tends to be in sympathy with their view, pointing out that all too often medical school basic science courses merely “teach for the test”. He suggests that the basic science content should be more focused on clinically relevant material.

I don’t know what the Step 1 exam looks like these days, or what DB has in mind for the curriculum. I suspect I would agree with his vision for medical education although I’m concerned that the de-emphasis on basic knowledge along with uncritical teaching of pseudoscience may reflect a dumbing down of medical education.