Faces of Medicine

August 1, 2007

In this two-part series, MD Net Guide presents the "Faces of Medicine," eight leaders who represent the future of healthcare. We speak exclusively with this remarkable group of individuals who...

In this two-part series, MDNG presents the “Faces of Medicine,” eight leaders who represent the future of healthcare. We speak exclusively with this remarkable group of individuals who are dedicated to advancing the public dialogue about medicine through the television news; building the healthcare infrastructures of impoverished countries; bringing an interoperable EHR system to all Americans; offering convenient solutions to the practice of medicine through health IT; and changing public and political policy to provide relief to our strained healthcare system. In this installment, we speak to four Faces of Medicine to get the inside story of the changing world of medicine, in the words of the very people who are driving that change.

MDNG: How would you describe your responsibilities as you see them as one of the most visible physicians in the country? Do you see yourself more in terms of being a reporter or an educator when it comes to explaining complex medical issues to the public?

SG: It’s interesting. I think with medical news—and my role in particular—I am fortunate to have two roles, not only to provide the news, which we do—and I think it’s the most up-to-date medical and health news—but also to use that platform as part of a public health service. I think it’s probably one of the few positions in which you can be both those things pretty regularly. I view myself, I guess, more as an educator in that I am not a traditional journalist either by training or by background, and I really try to use this position to educate people about healthcare issues that are important to them specifically and about healthcare issues that are important to society in general.

MDNG: How have your colleagues reacted to your celebrity status, and do you often receive suggestions for topics to cover from them?

SG: Let me say first that it was really important for me to continue to practice medicine while having this role in broadcast media. Part of that was so I could continuously and constantly hear from my colleagues what it was that was going on in medicine that was important to them and important to the public as well. So, I do hear from my colleagues quite frequently. The reaction has been very positive and favorable; I get a lot of requests from organized medicine, the AMA, to come speak about how better to communicate actions of significant importance—to doctors and to patients—how to communicate those issues to the public. So, I think the reaction’s been favorable. I’m not the first by any means, but I think we’re sort of at a watershed time where you’re having physicians becoming more and more a part of the communication process, and I think that’s a good thing.

MDNG: How involved are you in choosing the topics that are covered on CNN?

SG: I am very involved in the topics that are covered. In fact, I look at all the topics before we decide to do them. We do have a very large medical unit with several producers and a director, and we all sort of contribute story ideas. But, certainly anything that I’m taking to air, I have a lot of say in. I will say as well that the process by which a story is determined can be several different ways. Generally speaking, they’re either news stories—something actively in the news, such as a recall on a big anti-inflammatory drug like Vioxx or Celebrex, or maybe a story about the persistent vegetative state in Terri Schiavo—or what are called “enterprise” stories; they’re not necessarily in the news, but based on our determination and our homework, and our research, we think that it’s an important story to do and it will serve an important public health message, and so we will do those stories as well.

MDNG: Do you ever feel like you get trapped by the news cycle, where a story takes on a life of its own and pushes some of the things you wanted to do to the side?

SG: That happens, for sure. I just mentioned Terri Schiavo, and then the Pope immediately after that. Those stories were obviously covered 24/7 by all the news channels, and we did the same thing. I don’t know that they so much crowd out being able to do an enterprise story, it just may shift the timing by which we do an enterprise story. The beauty of an enterprise, or evergreen-type, story is that you can do it any time. And being that we’re on

24 hours a day, seven days a week, there’s plenty of time.

MDNG: You were a White House fellow during President Clinton’s administration. How has that experience shaped your subsequent career?

SG: I got a tremendous amount out of being a White House fellow in the sense that I was involved with domestic policy on a lot of health issues. In a sort of different way, we were responsible for getting messages about health and medicine—or health and medicine policy but still related to health and medicine—out to the public. I would write speeches, for example, for Mrs. Clinton on all sorts of topics, including pediatric AIDS. In that sense, when you’re writing words and crafting some language for the First Lady, who people are going to listen to and subsequently maybe make some decisions based on what she’s saying, it’s really very similar to what I do on CNN. Obviously, she has a huge platform, and we have a good sized platform as well. But, it’s part of the same spectrum: getting these health messages out. Although I didn’t know it at the time, my work at the White House actually dramatically affected the sort of work that I do now.

MDNG: With that said, has your celebrity status afforded you the opportunity to advance an issue about which you feel strongly? Or do you feel uncomfortable leveraging your high profile in such a manner?

SG: I’ll tell you a quick little story. I was in Rwanda in this really tiny town (smaller than Kigali, which is the capital, and most people haven’t even heard of that), and I’m shooting in this sort-of abandoned field trying to get some shots for this AIDS special I’m working on, and this little, rickety van goes by, and this guy shouts out “Hey, it’s Sanjay Gupta.” It was obviously some native of Rwanda, and I was talking to him for awhile and telling him what I was doing. And he was so thankful that we were bringing some attention on HIV/AIDS about Africa to the rest of the World. I think that’s a specific topic that I feel very strongly about, and I’m able use my recognition to advance some of these stories. So, yes, I’m able to leverage that, and with CNN and the support of CNN, I think we get some really important health stories and health messages out there.

MDNG: HIV and cancer fall outside of your particular specialty of neurology/ neurosurgery. Do you find yourself doing a lot of research and going back to check on unfamiliar topics?

SG: I’m doing tons and tons of research. I always tell people I was a veracious reader before I started working at CNN, and I’ve become even more so now that I’m working here. There’s a couple of reasons; one is that some of these things are just outside my area of expertise. And I have colleagues and the experts in this area that I always call—people in cardiology and all these different fields—who I’ll call regularly to get their take on things. But also, we’re doing news, so, by definition, a lot of what we do hasn’t been done before; you haven’t heard it. We might be talking about how Lipitor might prevent glaucoma, for example. It could be based on a brand new study that no one really has known about. So, I’m reading it for the first time, just like any other doctor is reading it for the first time. We just bring it to the public more quickly because of our ability to get access to this information.

MDNG: Before, you spoke a little about why you want to continue practicing at Emory. Is there a specific reason why, or is it more to keep your hands in the mix?

SG: Part of it, for sure, is that becoming a neurosurgeon takes a monumental amount of time—four years of medical school after college, and then seven years of training—and so, I certainly did not want to turn my back on the field. I really enjoy being a neurosurgeon and being able to take care of patients. I think those are the primary reasons that I continue to do it. I don’t think that I would ever give up practicing medicine. But the other reason is, there is a benefit to my career as a journalist. I think being in a hospital every day, taking care of patients every day, talking to my colleagues all the time informs my reporting. I think just being in the thick of things at a hospital or a big academic center, you sort of know what’s going on in the world of medicine at all times. It can be anything from the latest medical breakthrough to tort reform, which is becoming a hot issue. By continuing to practice medicine, I can remain aware of what doctors around the nation and academic centers are saying. So, for those three reasons: I enjoy it; I never wanted to turn my back on medicine; and I think it informs my reporting.

MDNG: What’s your take on the drive to incorporate more technology into the healthcare environment?

SG: I have a couple of thoughts on that. One is that I think that it’s an inevitable thing. I think that we have been a little bit behind in incorporating significant technology into the fundamental ways we practice medicine. I think part of that is because it’s just such a large institution; it’s hard to get people to buy in when it comes to making major changes, such as paperless charting systems, wireless technologies for checking patients’ most recent vital signs, and lab data, and all that sort of thing. But I do think its happening in a lot of places right now. I think that from a public perception standpoint, the public seems to want medicine to be more technologically sophisticated. They believe—and I think, probably rightfully so—that it may cut down, for example, on medical errors, whether it be something as simple as bar coding every single medication that’s given to a patient to having a very legible charting system that’s done on a handheld com-puter, so that there are no errors made in terms of illegible handwriting and that sort of thing. So, I think it’s an inevitable thing. For awhile, there will probably be a cost issue. There may be a time when it’s actually more expensive for start-up costs for big hospitals to incorporate a lot of these technologically sophisticated methods of data collection and charting. But, I think, ultimately, it’ll end up being cheaper for the establishment and medicine as a whole.

MDNG: You mentioned that the public wants medicine to be more technologically advanced. With that said, do you think that patients’ increased access to medical information has been beneficial to the doctor—patient relationship, or has it strained it because you’re now flooded with e-mail and things like that?

SG: For the time being, I think there’s not a clear-cut answer. There is a clear desire for autonomy among patients. They want to be able to get information on their own, they want to be able to take information to their doctor and say “How about this medication?” or “How about this procedure?” I think that can be a little bit dangerous—the old adage of a little bit of information is a dangerous thing. On the other hand, doctors do appreciate patients who are well informed about whatever their illness or diagnosis might be. It’s a fine line. I think, ultimately, we’ll fall into the situation where patients are going to become more autonomous, and you’re going to have much better information sources online, on television, on radio, and in magazines. I think as a whole, the media and the people who are providing this content are going to become more responsible—they’re going to be forced to—because they’re realizing more and more that patients and potential patients are relying on this information. I think the doctors have to be the ones ultimately calling the shots, writing the prescriptions, recommending an operation or not recommending an operation. But I think there will be an inevitable increase in patients’ autonomy by being able to gather all this information.

MDNG: Is there anything else you’d like to mention, perhaps about the topics you’re working on with CNN?

SG: For so long, doctors have been reticent and reluctant to communicate other than with patients in the office, and I think most—or at least a lot of doctors—have realized that patients are getting their information in other ways. I think it’s important for all doctors to be able to communicate with their patients in different ways—whether it be on television, on radio, writing articles for magazines—and to just recognize that patients are going to get their information in nontraditional ways and that the medical establishment needs to support that.

To read the full interview, go to www.mdng.com

HEALTH INFORMATION TECHNOLOGYDr. David Brailer, MD, PhD

Dr. David Brailer, MD, PhD, is the National Coordinator for Health Information Technology. Prior to his current appointment, Dr. Brailer was a senior fellow at the Health Technology Center in San Francisco, CA, and served as Chairman and CEO of CareScience, Inc.

“A lot of the issues that are called health IT are really not about healthinformation technology—they are about how doctors are able to practice, how consumers are becoming increasingly engaged, and where we are going as a nation with healthcare.”

MDNG: You were elected by President Bush to be the first ever National Coordinator for Health Information Technology a little over a year ago now. Modern Healthcare magazine, as a matter of fact, last year voted you as the Number 1 most powerful person in healthcare —surpassing the President, even! How would you describe your first year within this very prominent and influential position?

DB: I’m still to this day shocked and pleased by the overwhelming outpouring of support from doctors, hospitals, nurses, consumers, and people in Congress about reporting what we’re doing. We still can’t keep up with the incoming calls and e-mails and letters. And the reason is because the timing is just so right. It’s one of those magic times when the right policies are being put in place at the right time and people really sense that up and down the healthcare spectrum. We are also talking about, under the name of “health IT,” so many significant changes in healthcare. A lot of the issues that are called health IT are really not about health information technology—they are about how doctors are able to practice, how consumers are becoming increasingly engaged, and where we are going as a nation with healthcare. It’s really a privilege to be a part of that. It’s an honor to work with the President and the other Cabinet Secretaries on this topic—they are committed and dedicated civil servants. They really care about this topic.

MDNG: When you spoke last February at HIMSS 2005, you said something that really summed up the essence of healthcare IT; you said, it’s “not software and computers—it is physicians making better treatment decisions, nurses and pharmacists delivering safer care, and consumers making better choices among treatment options. It is the way people connect together across a fragmented delivery system.” Do you think the medical community is completely embracing the idea? Is there still that adoption gap? If so, how are we closing it?

DB: There is in fact an adoption gap. The adoption gap is a function of very large organizations having to finance the know-how, the management skills, the organizational capacity to undergo all these substantial transformations of how they do business and relate to their customers and their supply chain and nurses. Some small organizations simply can’t. I think a lot of what our policies focus on is leveling the playing field so that everyone can participate. I believe health information technology, personally, is not a luxury; it’s a necessity. I consider it to be a lifesaving therapy. It’s not optional for it to be available to some and not others, so the question is: where does the capital come from and where do the incentives come from? There was a study published very recently that stated that there was about $200 billion needed to fund overall adoption of health IT. That estimate may be on the high side when all is said and done, but we do know that the cost of adoption will be expensive. Ideally, all the capital would come from the private market or elsewhere if there were the correct incentives in place. But widespread adoption is more then just about money; it is about how we achieve two things: 1). How to take away the barriers that keep doctors and hospitals and other entities from working together. Healthcare has shown many times both practically and, more importantly, at the research level, that collaborative care— team-based care—is more effective in terms of improving health status, particularly for chronically ill people. But there are legal barriers that prevent that collaboration from occurring and we need to remove those barriers. 2). Secondly, we need to be able to start paying for value, in other words doctors should be paid based on delivering good care—currently we pay physicians based on volume. Restructuring our reimbursement system will create the incentives required for a vast transformation of healthcare to modernize it in many ways, including health IT.

MDNG: Last year you laid out a Framework for Strategic Action to make interoperable EHRs available to most Americans within a decade. Are we still on target to meet the President’s deadline?

DB: I think we’re ahead of schedule. I’m certain of that, at this point. I never expected when we published that framework that we would see the tremendous action from the governors and legislators across the United States to start pushing health IT. The support of the health plans that have been involved and large purchasers, the huge interest expressed by doctors and by consumers in health IT, and all of the pending actions of Congress are all accelerators. We also never really envisioned then that we would be able to move this quickly in terms of getting the Office of Personnel Management to make health IT part of the Federal Employees Health Benefits Program procurement or that we would be able to coordinate this quickly with other agencies like CMS. We are well ahead of schedule. I think we can do this in less than seven years.

MDNG: What do you think is the biggest challenge to meeting that goal?

DB: Well, it goes back to our discussion about government. Outside of a government mandate, it’s by definition a voluntary action. We are using the government’s purchasing power to guide this forward. We are trying to make sure that laboratory leaders, pharmacy leaders, health plans, and others understand that now is the best chance to move forward on health IT. It’s better to go voluntary than to have a voluntary effort fail and come back around to a government regulation approach. I think it’s really having people see that it’s now or never and that it’s a very good thing to do. I think we’re getting there, but we still have a ways to go.

MDNG: You were quoted in the June 30 edition of Healthcare IT News supporting pay-for- performance as a way to encourage IT adoption. Do you think pay-for-performance will help small physician practices in their adoption of EHRs as much as it might help larger practices and hospitals?

DB: No. The ability of an organization to deliver sustainable, systematically better care, be more efficient, and have better customer service is something that requires infrastructure, management systems, and tools, so it’s very hard for small practices to do. Pay-for- performance, therefore, is something that I think is a large practice activity. I think small practices have to be able to really take a serious look at how they can improve their performance. So, I think it is something that still could do much for large practices; but, on the other hand, the small practices have other abilities that large practices don’t. They are able to be a lot closer and more accessible to their patients and to their market and be a lot more tailored with their service. I think the question with pay-for-performance, then, becomes how do we make pay-for-performance work well for small practices, as well as big ones.

MDNG: You mentioned before that you’ve received a lot more bipartisan support than you expected. Do you think the work you begin now will be carried on by whoever occupies your position after you move on?

DB: You know, that is imponderable. First, the work that I am doing is evolving. I started out being a conceptualizer. I think one of the things that we really set out to do was to make sure that this discussion was never about the technology, which turns people off and intimidates people. It is about what we wanted healthcare to look like. And I did that a lot. And then we moved into a procurement mode where we are now issuing the RFPs, and soon we will go into a new mode of really executing these new contracts and building up the infrastructure needed for nationwide interoperability. So my role has evolved over time and I would hope it would continue to evolve for any person who would follow me. I would hope that the effort would continue to be committed to the same goals—recognizing that this is about what happens with doctors and patients— not some technical exercise. This effort is about creating options for a future for healthcare.

To read the full interview, go to www.mdng.com

PUBLIC/POLITICAL POLICYRobert Hertzka, MD

Dr. Hertzka is an anesthesiologist at Sharp Mary Birch Hospital for Women and immediate past president of the California Medical Association (CMA); he was the youngest president of the CMA in history. He was also one of the youngest members of the American Medical Association’s political action committee, or AMPAC.

“One of the things that I teach when I teach people about dealing with legislators is to respect people, even if they don’t agree with you.”

MDNG: Last February, the San Diego Union Tribune published an article highlighting your desire to be in the middle of the action. It briefly recounted an issue you became involved with in school about the dress code. You said, “I got in the middle…somehow I was drawn.” Is it still that desire to be in the middle of the action that drives you today?

RH: It is. I like being in the middle of the action and figuring out how to get things done. One of the things I say frequently is the term “point A to point B.” How do you get from point A to point B where point B is better than point A and get people to support that? But I also think the fact that I seem to be fortunate enough to be someone who can see both sides of any issue better than others has brought me success in my work. One of the things that I teach when I teach people about dealing with legislators is to respect people, even if they don’t agree with you. If you can just figure out what motivates people on the other side of an issue, you can usually come up with a solution.

MDNG: Former California State Senator Larry Stirling last December in the The Daily Transcript, credited you and your efforts to the more widespread adoption of a Health Savings Account (HSA). In your opinion, has the HSA really caught on?

RH: Absolutely. There’s no question that it is a good option—even a great option—for most people. It really addresses what may be the biggest issue in healthcare, which is the need for people to become more engaged in their own healthcare. Here, you can pick and choose and weigh your options. With the HSA, people can make good choices about their healthcare, just like they make choices for what car they want to drive or what food they want to buy. The classic, successful HSA model does not downgrade healthcare at all, it just allocates the dollars differently. The data is clear that the million people with HSAs are among the million happiest people in all of healthcare and I’m one of them. I don’t mind generic drugs. And if I need lab tests, I call around for the best deal.

This concept also ties in with another one of the core issues I would like to see improved. Over the past 15-20 years, people have been losing trust in the healthcare system. There’s been so much bad news about profiteers, fraud, or bad doctors slipping through the cracks. HSAs empower patients to engage in their own healthcare to make sure they are satisfied. As patients become more engaged in decision making for their care, doctors will be increasingly accountable. This kind of system will go far in promoting more transparency in healthcare and, as a result, patient-doctor communication will improve and people will trust the healthcare system again. Done correctly, the HSA will help make everyone happier in the long-run.

MDNG: You practically wrote the book on lobbying and dealing with legislators. Do you have any advice for our physician readers who may be interested in learning how to be more politically involved?

RH: I give a seminar on this, and in the end, I finish with role-plays and have people apply what I’ve taught them. If students remember one thing, I want them to remember the 3 Rs. It’s easy to remember because they all start with “Respect”: 1) Respect the legislators and their staff. If they disagree with you on an issue, that’s okay. Respect their position. They are the ones who went before the voters and got elected, not us. And don’t forget to also respect their staff members. They are abused and underpaid, but they do a lot of work and get a lot done. So spend at least as much time with the staff members as you do with the legislators. 2) Respect your opposition; and 3) Respect the truth. This last one seems obvious, but sometimes, if a legislator asks a question, it’s tough for some doctors to admit they don’t have the answer, but that they will find out and get back to them.

MDNG: Under your leadership, the California Medical Association is pushing a new approach for solving the problem of uninsured patients in California—the mandatory catastrophic health insurance concept. Can you tell us more about that initiative? Does this look like it may come to fruition?

RH: I’ll answer the second question first. Not any time in the next few years. The reality is that today, 97% of voters are insured and fewer than 20% of those people think the healthcare system is unraveling. With these kinds of numbers, meaningful healthcare reform is all but impossible. Despite that, though, our plan is getting an amazing reception from all kinds of folks—particularly bipartisan groups. The response has exceeded any expectation that I may have had when I first convened a group a year and a half ago to try to position the CMA for the debate that is certain to take place in the next four or five years to ensure that more people in California and in the nation get covered.

MDNG: Can you tell us more about the proposal?

RH: We are trying to hammer out a plan based on two basic principles we can all agree on, regardless of political affiliation: that no one should go bankrupt over healthcare costs and that everyone with the financial means to do so should pay something back into the healthcare system. We came up with a mandate similar to what we have in California regarding auto insurance. But we are not mandating that people have to buy comprehensive, expensive insurance that covers every single thing. The mandate is for catastrophic insurance, which protects people from bankruptcy on the one hand, and helps save our failing safety net institutions that are drowning in many millions of dollars in unpaid medical bills. The plan also provides subsidies for low-income patients and does it in a way that does not raise taxes. Again, we have had innumerable people in high levels, Congressional offices, and bipar-tisan think tanks tell us that this is the best thing they’ve seen in years. The result is that we are now positioned very well as a state medical association. The AMA has actually adopted many of our provisions, and we’re hoping that they’ll adopt our entire proposal as their own in the next year or two.

MDNG: Just switching topics, for a minute. We wanted to get your opinion on the issue of skyrocketing malpractice insurance costs. What do you think is the real cause of this?

RH: Well, the General Accounting Office took an extensive look at this in a report that came out in the summer of 2003. They found basically that most of it has to do with increasing awards in certain states that have pretty litigious environments, like Texas, Mississippi, Illinois, Pennsylvania, and New Jersey. The bottom line is that over a five-year period in most of these states, their malpractice premiums had more than doubled. Contrast that to California since 1986, when our MICRA law was upheld. Over the past 20 years, our premiums have gone up only a third as much as the states without MICRA. This is a situation that naturally fuels itself unless you put a MICRA cap on pain and suffering awards like California. Florida actually puts some very strong limits on contingency fees, which also is effective, because then the lawyers don’t even want to take the business. Unfortunately though, many of our elected leaders or legislators are often persuaded by the trial lawyers. So this is one area we haven’t been successful in bridging. It has frankly exceeded the ability of any of the organizations I’m involved with to work out a meaningful compromise.

MDNG: Dr. Hertzka, in closing, do you have any other comments or advice for our physician readers?

RH: I think that unlike past eras, part of the definition of a 21st century physician leader is to be engaged in public policy. In my mind, you aren’t a physician leader if you are not in touch with your members of Congress, if you are not in touch with your state legislators, if you are not in touch with the media and talking to your local health reporters. As a profession, we need more than ever before to be deeply engaged in public policy. It’s a big leap for people who spend their lives learning about disease and treatments and nothing about the real world—this is a whole other world that doctors need to know about.

To read the full interview, go to www.mdng.com

POINT-OF-CARE INFORMATIONBurton D. Rose, MD

Burton D. Rose, MD, is founder and editor-in-chief of UpToDate. He has authored medical textbooks in renal physiology and kidney disease, and brings his passion for teaching and learning to help doctors apply the best evidence to improve patient care.

“We provide the best evidence available to answer a particular question, but still make recommendations even when good evidence is not available.”

MDNG: What does UpToDate do that online guidelines clearing houses do not?

BR: Guidelines are very important because they are put together by a consensus of experts and we quote them extensively in UpToDate; in addition, the full text of many society guidelines are included in UpToDate. That said, there are limitations to guidelines. UpToDate is continuously updated; on average, we add about 1,200 updates per month and those updates are put within each specific topic and appropriate alterations are made in the preexisting material. In contrast, guidelines are updated at two- three- or four-year intervals and, as a result, some of the things that guidelines say are no longer applicable.

A second limitation is that guidelines generally only address topics for which there is evidence. Doctors often have to make decisions for which there is not a lot of published information. Our view is that we provide the best evidence available to answer a particular question, but still make recommendations even when good evidence is not available. All of the recommendations in UpToDate go through several layers of peer review.

UpToDate also differs from guidelines in that we address all kinds of other issues that are not directly related to management and that are often not included in guidelines. Examples include the genetics of the disease, or the clinical manifestations, differential diagnosis, etc.

MDNG: Has UpToDate been equally successful across all the specialties or is it more popular with some than others? Or have you noticed that this tool lends itself more readily to some specialties over others?

BR: The growth of all of the specialties that have been out for some time (primary care, family practice, the medical subspecialties, and OB/GYN and women’s health), has been pretty similar when measured as the percent penetration in the market over time.

MDNG: In your opinion, what is the most direct, significant way that UpToDate has impacted the medical practice?

BR: UpToDate allows doctors to make the most evidence-based decisions for most problems that arise, with the background information that led to these decisions. Because the literature is so vast and rapidly changing, individual physicians, even specialists, have great difficulty keeping up with and interpreting the published literature. Another advantage for specialists is the broad coverage that UpToDate provides. As an example, a cardiologist may have a patient with diabetes and heart disease and may have a question related to diabetes, which is covered in the Endocrinology section of UpToDate.

MDNG: In UpToDate’s June 2005 newsletter you talked about three published articles that caught your attention: one finding a decreasing level of physician performance with increasing years of practice, a second that found that physicians pursue answers to only about half of the questions that arise in clinical practice, and a third that found internal medicine residents were able to answer around 90% of their questions, primarily by using the combination of UpToDate and Medline.

BR: Let me address each of these studies. The first is the decreasing level of physician performance with age, which became a hot topic on the news after a article appeared in the Annals of Internal Medicine in the February 15, 2005 issue.* Among board certified internists who were re-tested five to 15 years after certification, the scores were progressively lower with increasing time since certification. That’s not because doctors don’t want to be good at what they do. As I mentioned above, I believe it’s largely related to the difficulty any individual has in keeping up with and interpreting the medical literature. We allow a physician to get an answer to most questions that arise within 15 to 30 seconds; the answers are current and specific—evidence-based recommendations are made.

The second article found similar results, and really highlights the fact that physicians need help. The third piece was a study from the University of Colorado that was published in the journal Academic Medicine in January 2005.** The authors wanted to assess how residents get information and how often they can answer the questions that arise. There were two major findings: First, the residents were able to answer 90% of their questions. They did this by using two major resources, Medline and UpToDate, which were used 73% and 70% of the time [respectively]. The next most frequently used resource was used in 6% of questions. The numbers add up to more than 100% because more than one resource was often used. These findings are what we expected because have we always considered Medline and UpToDate to be perfect complements, since they are best used for different questions. If you have a question that requires a synthesis of the literature (eg, What is the role of angiotensin converting enzyme inhibitors in the treatment of hypertension in diabetes?), then UpToDate is preferable, since Medline would return a very large number of individual articles. In essence, we have done the synthesis and interpretation for you.

On the other hand, Medline is usually better if you want to find out some rare side effect of a drug or some rare symptom or manifestation of a disease. The authors note this distinction in their article.

MDNG: Do you see UpToDate being incorporated at all into EMRs over the next several years?

BR: Given that UpToDate is a point-of-care resource, it would be natural for UpToDate to be integrated into EMRs. We are currently exploring this with some of the major EMR companies.

MDNG: How do you see point-of-care information evolving in the future?

BR: We’re trying to become better and better at providing point-of-care information to doctors. One way in which we think it’s going to evolve is increasing the scope of what we cover. We currently have three specialties in development—emergency medicine, allergy and immunology, and neurology —and are considering others.

Another goal is to make it easier for users to find the information that is in UpToDate. Studies that we have performed with our users have shown that there is a small percentage of questions that are answered in UpToDate, but the user did not find the relevant information. In an attempt to make it easier and faster for users to find the information they need, we have designed a new search engine that permits a free-text search.

The last project is that, although UpToDate has been evidence-based from the beginning, we’ve been working with opinion leaders in evidence-based medicine to improve how we present the information. The main change is that we are going to start grading the recommendations that we have, based upon the strength of both the recommendation and the evidence supporting it.

MDNG: The benefits of point-of-care resources like UpToDate are obvious; but are there any possible downsides to this technology that physicians should be aware of?

BR: Some program directors have commented that sometimes trainees follow the recommendations in UpToDate relatively blindly. The data may not apply to your particular patient. Thus, the physician has to apply his or her own clinical knowledge and the characteristics of the patient when determining whether the approach we recommend is applicable. UpToDate is there to help physicians be better doctors.

The following studies are referenced in this interview:

* Choudry et al, Systematic review: the relationship between clinical experience and quality of health care, Annals of Internal Medicine, February 2005.

** Shilling et al, Residents’ patient-specific clinical questions: opportunities for evidence- based learning, Academic Medicine, January 2005.

To read the full interview, go to www.mdng.com