More on UpToDate

Following recent blog posts on “UpToDate dependence” by intueri, Kevin M.D., Caseblog and myself considerable discussion ensued on medical library lists and blogs about not only the addiction but also the cost of feeding the doctors’ habits. It’s something medical libraries grapple with every year or two when renewal time rolls around.

Medical information specialist David Rothman predicts:

As time passes, UpToDate will have more and more well-designed, well-maintained, effectively-marketed, affordable competitors. The competition will bring subscription costs down to a more reasonable level.

(Can’t wait for it to happen!).

The Krafty Librarian believes UpToDate’s business tactics are heavy handed and its prices are---well, pricey. I knew individual subscriptions were steep (I’ve got my own) but the institutional subscriptions, it seems, are through the roof:

Apparently there are some institutions starting to consider eliminating institutional access leaving their physicians to pay for the product on their own. UpToDate bases their prices on the institution's total number of outpatient and inpatients. No wonder some very big and successful institutions are rethinking the cost of UpToDate. It is not unheard of for small community hospitals to pay $10,000 -$15,000 for online access. I have heard of larger institutions paying $80,000 - $100,000 for access (which of course can't be used at home).

Emphasis mine on that last phrase! That’s a huge downside, particularly when UpToDate’s competitors provide home access for no additional cost! Why is home access important? Because home is where you do background reading, underappreciated but every bit as important as point of care reading. UpToDate has a wealth of background reading content in the form of pathophysiology, detailed disease descriptions, tutorials and case studies, but I suspect the background content is vastly underutilized since most use of UpToDate is at the point of care (to look up diagnostic algorithms and the latest treatment recommendations) when there’s insufficient time for in depth reading.

Dr. Thomas E. Brittingham, master clinician and director of the third year Medicine clerkship at Vanderbilt knew the importance of background reading and, in his letter to students at the beginning of the rotation, said this:

Dr. Carl Moore, Chairman of the Department of Medicine at Washington University, tells me that he finds it necessary to read medicine for 3-4 hours every day, 365 ¼ days yearly. If he finds it so necessary to read in order to remain competent, we probably need to read too in order to become competent. Half of your evenings are unscheduled so that you may have the opportunity to read about the patients you have seen. Read and think extensively about their disease problems….

Read and think extensively. You don’t have time to do that at “the point of care.” And it’s not just for junior medical students. It’s part of life long learning. Of course, back in the days of my medical clerkship point of care reading like we have now didn’t exist. So what’s the ideal reading routine for doctors today? I think it’s a combination of point of care and background reading. At or shortly before the patient encounter use point of care resources to determine the best and most current evidence for treatment decisions. Then go home and read in more depth about the pathophysiology and clinical features in the patients you encountered that day.