Dear Listmembers,
I've not contributed before, but have enjoyed many of the discussions. The
comments and ideas about searching strategies point to the need for
centralized access to timely and reliable evidence. Most of us have
established our own patterns for answering clinical questions as they arise
in practice. Some were kind enought to share their methods, so will I.

Collecting the answers to clincial questions is helpful and I appreciate the
efforts that have gone into that and which are widely available. For most
important questions, evidence-based systematic reviews remain extremely
useful. But these remain insufficient to provide current answers to many (or
most) clinical questions. New questions arise with new research, new drugs,
new procedures and new ideas. An answer to a single question may be useless
in another context or may become outdated relatively quickly. Countless
clinicians repeating searches for hundreds of thousands of questions is very
labor-intensive, and as it was pointed out, may produce varying evidence,
hence varying clinical strategies.

Likewise, collections of critically appraised articles from selected
journals provide a useful resource, but remain incomplete and still require
additional synthesis by the questioner. Most clinicians have neither the
time nor resources to search and analyze evidence during practice, so this
effort must be done ahead of time and made available for rapid use by
practicing clinicians.

There is another strategy. Large-scale systematic literature surveillance
seems like a potential ally in cataloging relevant, valid evidence for rapid
retrieval. Systematic literature surveillance, in which research articles
are appraised when published and then summarized for appropriate uses, is
more efficient than systematic searches, especially when scaled up to global
efforts. Each article is singly "handled" and applied to questions it
potentially answers. The volume of questions for which answers exist
increases and the currency of answers is maintained.

Surveillance would naturally include our high-quality sources for systematic
reviews, and perhaps be integrated with SRs, updating them as new relevant
information is identified instead of waiting for searches to be repeated.

This is not just an idea, but has been demonstrated in an ongoing project.
DynaMed (www.DynamicMedical.com) is a database developed by a family
physician researcher to provide rapid clinical reference support.

I've personally used DynaMed as my primary source for answering clinical
questions for over 6 years and have watched it improve by (1) providing
synthesized, integrated content summaries, (2) providing direct citations
and links to evidence supporting the statements in the content summaries,
(3) developing a network of 116 reviewers and authors and 24 editors, and
(4) establishing a protocol for systematic literature surveillance to update
the database daily.

What one sees at DynaMed are fairly simple, yet impressive, results of a
systematic literature surveillance effort -- covering 5-7 years and reaching
>400 journals directly or through journal review services. Yet this effort
has resulted in a database that: answers answers 70% of clinical questions
in primary care and answers are found in less than 5 minutes; has been shown
to answer more questions and change clinical decisions more often than other
common information sources; has been shown to provide answers with levels of
evidence that meet or exceed the combination of 4 electronic clinical
references selected for being evidence-based and/or broad-based to represent
the best chance of finding the best available evidence quickly; (The
research for the above statements was conducted January to June 2004 so is
not published yet.)

As Martin pointed out, if everyone answered 2 questions a year, we'd still
be woefully short of what's needed. The answer proposed was support from
governments (or philanthropists) to provide help to produce answers on an
on-going basis. I suggest that we can do it more easily and far less costly
by using a systematic surveillance system. What could happen if the EBM
community can take the system driven by evidence-based principles developed
for maintaining DynaMed and scale it up to global efforts? We may reach a
state in fairly short order where practicing clinicians can quickly find the
best available evidence for most questions.

If you are unfamiliar with DynaMed (www.dynamicmedical.com), register
for a free trial and take a look. (If you are in a resource-poor
country, you may get free access. If not, you may continue access through a
low-cost subscription OR by helping as a reviewer or author -- described in
detail on the website. This feature is a unique way of spreading the labor
and sharing the benefits.)

The originator and editor of DynaMed is Brian S. Alper, MD, MSPH and may be
contacted at [log in to unmask] (I have taken the liberty to invite
him to this list.) I have no disclosures except that I've been a contributor
to DynaMed and assisted with the research efforts.

Best regards,
Richard Schamp MD
Associate Professor, Community and Family Medicine and Geriatrics
St. Louis University, St. Louis, MO, USA