Doctors spend four years in medical school, still more years in residency, and some devote even more years to fellowship training. All of this work is done under direct supervision, and throughout the process, trainees learn from their teachers, mentors, and supervisors. But medicine changes very rapidly. After all of this training—i.e., once the doctor is “out in the real world”—how does he or she keep up with the latest developments?
Medical journals are the most obvious place to start. Many doctors subscribe to popular journals like the New England Journal of Medicine or JAMA, or they get journals as a perk of membership in their professional society (for example, the American Journal of Psychiatry for members of the APA). But the price of journals—and professional society memberships—can accumulate quickly, as can the stacks of unread issues on doctors’ desks.
A second source is continuing medical education credit. “CMEs” are educational units that doctors are required to obtain in order to keep their medical license. Some CME sources are excellent, although most CMEs are absurdly easy to obtain (e.g., you watch an online video; answer a few multiple-choice questions about a brief article; or show up for the morning session of a day-long conference, sign your name, then head out the door for a round of golf), making their educational value questionable. Also, lots of CMEs are funded by pharmaceutical or medical device manufacturers (see here), where bias can creep in.
Direct communication with drug companies—e.g., drug sales reps—can also be a source of information. Some universities and health-care organizations have “cracked down” on this interaction, citing inappropriate sales techniques and undue influence on doctors. While docs can still contact the medical departments (or “medical science liaisons”) of big drug companies, this source of info appears to be running dry.
So what’s left? Medical textbooks? They’re usually several years out of date, even at the time of publication. Medical libraries? Unless you’re affiliated with a teaching hospital, those libraries are off-limits. “Throwaway” journals? Every specialty has them—they arrive in the mail, usually unrequested, and contain several topical articles and lots of advertising; but these articles generally aren’t peer-reviewed, and the heavy advertising tends to bias their content. Medical websites? Same thing. (WebMD, for instance, is heavily funded by industry—a point that has not escaped the attention of watchdog senator Charles Grassley.)
Thus, the doctor in the community (think of the psychiatrist in a small group practice in your hometown) is essentially left alone, in the cold, without any unbiased access to the latest research. This dilemma has become starkly apparent to me in the last several months. Since last summer, I have worked primarily in a community hospital. Because it is not an academic institution, it does not provide its employees or trainees access to the primary literature (and yes, that includes psychiatry residents). I, on the other hand, have been fortunate enough to have had a university affiliation for most of my years of practice, so I can access the literature. If I need to look up the details of a recent study, or learn about new diagnostic procedures for a given disorder, or prepare for an upcoming talk, I can find just about anything I need. But this is not the case for my colleagues. Instead, they rely on textbooks, throwaway journals, or even Wikipedia. (BTW, Wikipedia isn’t so bad, according to a recent study out of Australia. But I digress…)
Obviously, if one uses “free” resources to obtain medical information, that info is likely to be as unbiased as the last “free” Cymbalta dinner he or she attended. Many doctors don’t recognize this.
When it comes to journals, it gets potentially more interesting. All of the top medical journals are available online. And, like many online newspapers and magazines, articles are available for a fee. But the fees are astronomical—typically $30 or $35 per article—which essentially prohibits any doc from buying more than one or two, let alone doing exhaustive research on a given subject.
Interestingly, some articles are freely available (“open access” is the industry term). You can try this yourself: go to pubmed.gov and search for a topic like “bipolar disorder” or “schizophrenia.” You’ll get thousands of results. Some results are accompanied by the “Free Article” tag. You can guess which articles most docs will choose to read.
Why are some articles free while others aren’t? What’s the catch? Well, sometimes there is no catch. For one, the National Institutes of Health (NIH) requires any research done with its funding to be freely available within six months of a paper’s publication. This makes sense: NIH funds are our tax dollars, so it’s only fair that we get to see the data. (But even this is coming under attack, since the publishers want to protect their content—and revenue stream.)
Interestingly, though, some journals also have a “pay-for-open-access” policy, in which an author can pay a higher publication fee to make his/her article freely available. In other words, if I publish a (non-NIH-funded) study but want it to reach a wider audience than simply those ivory-tower types with access to fully-stocked libraries, I can just pay extra. That’s right, some publishers give me the option to pay to attract readers like community docs, the lay public, journalists, and others (not to mention potential investors in a company with which I’m affiliated). The policy for Elsevier, one of the world’s largest academic publishers, on such “sponsored articles” can be found here.
You can see where this might lead. Call me cynical, but paying for more eyeballs sounds a lot like advertising. Of course, these are peer-reviewed articles, so they do meet some standards of scientific integrity. (Or do they? A recent article suggests that “narrative reviews” often misrepresent or overstate claims of medication efficacy. See also this summary of the article by Neuroskeptic.)
Anyway, the take-home message is, unfortunately, one that we’ve heard all too often. Science is supposed to be pristine, objective, and unbiased, but it’s clearly not. Even when you take out the obvious advertising, the drug-rep showmanship, and the pharma-funded CME, there are still ways for a product-specific message to make its way to a doctor’s eyes and ears. And if our medical journals supposedly represent the last bastion of scientific integrity—the sacred repository of truth in a world of direct-to-consumer advertising, biased KOLs, and Big Pharma largesse—we should be particularly cautious when they fail to serve that purpose.
A terrific evidence-based resource is Up-to-Date. There’s a subscription fee, but it’s well worth it. Some (ahem!) EMR’s come with Up-to-Date free (like mine, e-ClinicalWorks)
And don’t forget the blogosphere, the true marketplace of ideas, where all this stuff can get chewed up and regurgitated free of cost.
Rob, yes, thank you for mentioning Uptodate. It is an excellent service, unbiased and, well, up to date. There’s also Journal Watch, another good one. And I’m glad you mention blogs. Interestingly, I get most of my information these days from a select group of blogs and Twitter feeds. It can be difficult to separate the wheat from the chaff, but once you do, it can be a great resource.
Journals are not free of bias. NEJM republished a study done by the neurosurgeon who paralyzed my face and called facial paralysis a “major and common complication.” In the article facial paralysis was not mentioned as a risk. I wrote NEJM and suggested this oversight, a devastating complication when it happens, be corrected. They replied they did not have any room to do so. The neurosurgeon is a big name in neurosurgery. They kowtowed to him rather then to informing their readers.
I also always suggest if at all possible people go to university hospitals because the docs tend to be more up on the most current info. (but maybe now I need to asterisk that)
There are some relatively unbiased and relatively inexpensive newsletters like the Medical Letter and Biological Therapies in Psychiatry that sum up and review recent developments in the literature, but it’s still caveat emptor to some degree.
Doctors certainly do not absorb information from the FDA. See FDA Warnings Not Heeded Equally http://www.medpagetoday.com/PublicHealthPolicy/FDAGeneral/30794
Seems that FDA warnings about adverse effects, risks, and drug-drug interactions are variably heeded. How unfortunate, given that every warning indicates some number of already-occurred injuries.
From my experience, they don’t even look in the PDR.
Great post again, Steve! Your self-awareness is admirable.
Your blog is definitely in my “select group.”
A source of information (not mentioned)…
The Public Library of Science (PLoS) –
I’m sorry to sound like an old repeating record, but have you had any encounters with academic detailing? I’m interested in learning what benefits and limitations this type of information provides from the perspective of users of it.
aek, thank you for posting this again (and yes, I have seen your previous comments on this subject). Academic detailing would seem to be the perfect solution to the problems I posed here. And I regret that I didn’t present it as an option, although I was trying to emphasize the free-text journal-article problem.
Anyway, to answer your question, I’ve had NO experience myself with academic detailing, but, in theory, it sounds like an excellent idea. Of course, then again, so does universal health care. When it comes down to it, it might suffer the same resistance from physicians: namely, outrage at government meddling in our ability to practice medicine freely. (See this NEJM article: http://www.nejm.org/doi/full/10.1056/NEJMp1011713) Sure, maybe an academic institution or non-profit enterprise might take on this task, but we’re back to the money problem: there’s little money available for it, so those who do it would be susceptible to the same sorts of Pharma influences we’re trying to avoid.