What is the preferred resource between UpToDate (UTD) and Harrison's for clinical decision-making in patient care?

Clinical Decision-Making Resources: UpToDate vs Harrison's

Neither UpToDate nor Harrison's should be used as standalone resources for clinical decision-making; instead, clinicians must integrate multiple knowledge sources—including clinical practice guidelines, pathophysiologic reasoning, and clinical experience—while recognizing that no single resource type holds universal superiority in all clinical situations. 1

The Fundamental Problem with Resource Hierarchies

• No predetermined hierarchy of medical knowledge can guide clinical decision-making in all situations. 1
• Rankings based solely on resource type or study design cannot be directly applied to individual clinical decisions, as exceptions always exist and must be acknowledged. 1
• Sound clinical judgment requires negotiating between potentially conflicting information from different sources when determining the best course of action for individual patients. 1

How to Approach Clinical Resources

Prioritize Clinical Practice Guidelines First

• Clinical practice guidelines should serve as the primary framework for clinical decisions, as they represent systematically developed statements synthesizing large amounts of evidence into practice recommendations. 2
• Guidelines developed using transparent, robust methodology with systematic evidence retrieval minimize bias and focus on patient-relevant outcomes. 2
• However, guidelines often differ in content, recommendations, and development methodology, with most based on expert opinion combined with scientific evidence that remains untested in real-world settings. 1

Recognize the Limitations of All Resources

• Even high-quality evidence from randomized trials is often incomplete, contradictory, or absent, even in extensively studied areas. 3
• The overall results of trials cannot be assumed to apply to any particular individual, even those meeting all entry criteria, because therapy is not the only determinant of outcome. 3
• Guidelines are not intended to be rigid substitutes for well-educated providers informed by good research. 1

Practical Application for UpToDate vs Harrison's

UpToDate's Role

• UpToDate functions as a point-of-care clinical decision support tool that doctors use in diverse clinical scenarios to influence clinical practice, benefiting patients, physicians, and healthcare organizations. 4
• It provides rapidly accessible, synthesized information during patient encounters but should not replace systematic guideline consultation or clinical reasoning. 4

Harrison's Role

• Harrison's serves as a comprehensive textbook providing pathophysiologic rationale and foundational medical knowledge.
• While pathophysiologic understanding allows incorporation of individual patient differences, reasoning from this alone may introduce bias or result in focus on wrong outcomes. 1

The Correct Clinical Decision-Making Algorithm

Step 1: Identify Relevant Clinical Practice Guidelines

• Search for current, high-quality guidelines from major professional societies (e.g., ACC/AHA, EAU, ASCO, AGA). 1
• Verify guideline currency, as evidence evolves rapidly and guidelines may not reflect the most recent data. 1

Step 2: Assess Guideline Applicability

• Explicitly identify whether the guideline population matches your specific patient, considering that guidelines address populations in general circumstances. 1
• Recognize that ultimate judgment regarding care must be made by the healthcare provider and patient in light of all circumstances presented. 1

Step 3: Integrate Multiple Knowledge Types

• Combine guideline recommendations with pathophysiologic rationale and clinical experience. 1
• Be able to concisely outline and justify your clinical reasoning process, articulating the sources and kinds of knowledge supporting your decision. 1

Step 4: Engage in Shared Decision-Making

• Elicit patient preferences and expectations regarding their care. 5
• Discuss treatment options and level of patient involvement in decision-making. 5
• Consider patient values, aims, and priorities regarding treatment. 5

Step 5: Use Point-of-Care Tools Appropriately

• Employ resources like UpToDate for rapid information access during clinical encounters. 4
• Use these tools to supplement, not replace, guideline-based and evidence-based decision-making. 4

Critical Pitfalls to Avoid

Don't Rely on Single Resource Types

• Relying solely on clinical experience introduces multiple biases that clinicians cannot completely avoid even with training. 1
• Experience alone does not guarantee expertise or better patient outcomes. 1

Don't Assume Guidelines Are Always Sufficient

• Guidelines may have considerable variability reflecting different methods, expertise, and contexts. 1
• Frequent use of terms like "optional" or "targeted individuals" leaves much to physician discretion. 1

Don't Ignore Context and Individual Variation

• Guidelines do not account for individual variation among patients or local resource availability and expertise. 1
• Deviations from guidelines may be appropriate in specific circumstances. 1

Don't Mechanically Apply Evidence

• Good clinical research produces knowledge that minimizes bias, but that knowledge cannot be deductively or mechanically applied to individual patients. 1
• Clinical reasoning remains essential even in the era of evidence-based medicine. 3

Quality and Availability of Expertise Matter

• Clinical decision-making should consider the quality and availability of expertise in the area where care is provided. 1
• For rare or complex conditions, referral to centers of expertise is recommended. 1