Module 2: The Evidence Hierarchy

Priests have their holy books, farmers have their almanacs, and third year medical students have their UpToDate log in information.

In line with so many other medical students across the country, my day to day resource is UpToDate. It has served as a great tool students can use to “not look dumb” on rounds, or so I have been told. It falls within the “synthesis summaries” level of evidence hierarchy. Living up to its name, it is typically on the cutting edge of the newest data that are available. What immediately comes to my mind is an experience during my Gyn-Onc rotation a few weeks back. We had a 6:45 conference detailing all the new rage that is the usage of PARP-inhibitors in the treatment of some ovarian cancers. The lecture covered 2 NEJM articles that had been released in the month prior. While the fellow was reviewing the ins and outs of the studies, I was doing what any good medical student on Gyn-Onc does in the morning: attempting to memorize my patient presentations. Little did I know that I would be fielding questions about this PARP-i lecture an hour later outside the room of one of my patients who had presented with metastatic ovarian cancer. After the 4^th or 5^th straight wiff I was told to read up on the studies and be ready for questions tomorrow. UpToDate had a great synopsis about these studies on the treatment of ovarian cancer that I was able to use to efficiently read up on the topic. I never would field another PARP-i question but at least I can say I gave it the good ole college try. I would argue that the main limitation of UpToDate is that it is so often “a mile wide and an inch deep” and may be incomplete in its coverage of a particular topic. In my experience it is wonderful at covering the “bread and butter” knowledge needed to manage a disease process but is often lacking when the knowledge desired is particularly subspecialized or outside of the norm.

I found the ACCESSSS federated search engine to be an efficient tool for reviewing the literature on certain topics. I used it to review the evidence on the management of gestational diabetes and was greeted with a breadth of knowledge ranging from lifestyle changes to the management of DKA. I liked that it stratified the literature by evidence hierarchy. I also found it interesting to see how different types of literature stratify between the evidence hierarchies. I feel like the only limitation that it may have for me is that I am already used to utilizing UpToDate. I have an app on my phone that is always logged in and ready to go and force of habit is a difficult thing to overcome. I believe as I progress through my education, a resource that is more comprehensive such as ACCESSSS would be useful in matching up my level of training with the depth of knowledge I should desire from my educational resources.