How to Answer Your Clinical Questions More Efficiently” [July/August 2005] was a welcome exhortation to ask well-structured clinical questions – and, of course, to answer them efficiently.
In answering foreground questions, busy clinicians want rapid access to the best available evidence. This need points to a potential pitfall in using resources such as those the authors cited (PubMed, InfoPOEMs, ACP Journal Club) that provide abstracts or summaries of individual articles. With this approach, clinicians must read through the multiple identified articles and either synthesize information ourselves from the larger body of relevant and valid evidence, or be made aware of a published synthesis, perhaps a systematic review (e.g., a Cochrane review). The synthetic approach requires more work, but is essential, lest we run the risk of “medical gossip” (to use Slawson and Shaughnessy’s term).
Clinical Evidence and DynaMed are two additional resources that provide ready answers to most clinical questions based on the best available evidence and also synthesize that evidence. I have no financial interest in either of these entities. Clinical Evidence covers 200+ topics and is based on randomized-controlled trials, which makes it most useful for treatment questions. DynaMed offers a systematic literature surveillance approach, which is an alternative to systematic search-based resources like those mentioned by the authors. DynaMed covers more than 1,800 topics. Topics contain a digest of summaries, emphasizing the clinical conclusions and grading the quality of evidence cited, which is useful for answering foreground questions. The DynaMed Web site describes the surveillance methodology and bibliography, which includes over 100 journals monitored directly, more than 400 journals monitored through multiple journal review services, and collections of systematic reviews, guidelines and drug information. This breadth, along with many direct links to other reviews such as American Family Physician articles, also make DynaMed ideal for answering background questions.
We were unable to include many worthy resources because of space limitations. Clinical Evidence and DynaMed attempt to answer higher-level questions using medical literature and are best thought of as resources to answer foreground questions. We agree that the strength of these two resources is that they synthesize evidence about covered topics. Synthesis of information is an important part of evidence-based medicine (EBM). In their landmark book on EBM, Evidence-Based Medicine: How to Practice and Teach EBM, authors David Sackett et al note, “The practice of evidence-based medicine requires integration of individual clinical expertise and patient preferences with the best available external clinical evidence from systematic research.” Physicians answering a clinical question must always evaluate the new information in the context of the known medical literature, their clinical expertise and patient preferences, whether it comes from a single article or synthesis.