most [clinicians] probably focus their literature reviewing efforts on the ten or so journals most relevant to their specialty. But is this enough?

You are all familiar with the problem: how can any clinician possibly keep abreast of all the new data that are pertinent to their practice? In the attempt, most probably focus their literature reviewing efforts on the ten or so journals most relevant to their specialty that have the best reputation for publishing high-quality information. But is this enough? A study published recently in Kidney International would suggest not.

According to the bibliometric analysis (Garg AX et al. [2006] Kidney Int 70: 1995–2005), half of all renal practice evidence is published in 'nonrenal' journals. The authors of the study analyzed 2,779 papers cited in 195 systematic reviews that addressed specific clinical nephrology questions. Just 49% of the papers had been published in what the authors referred to as the 'top 20' journals, which included renal (e.g. American Journal of Kidney Diseases, Kidney International, Nephrology Dialysis Transplantation, and Journal of the American Society of Nephrology) and general medical (e.g. New England Journal of Medicine and Lancet) titles. Surprisingly perhaps, the remainder of the articles had been published in 446 different journals, in subject areas as diverse as radiology, pharmacology, urology, anesthesiology, obstetrics, nutrition and gastroenterology.

These findings have some worrying implications. It is unlikely that busy nephrologists can find the time to regularly browse the top renal journals, let alone dip into an additional 400 on the off chance that a paper relevant to their practice will have been published therein. Are clinicians, therefore, missing out on important practice updates?

This concern was the impetus behind the establishment of the Nature Clinical Practice series. Within our department, editorial staff scan every new issue of more than 300 publications spanning a wide variety of clinical specialties and basic research fields (for a full list of journals scanned, see the December 2006 issue of Nature Clinical Practice Nephrology or go to http://www.nature.com/clinicalpractice/about_site/monitored.html). The highest quality articles that are most relevant to clinical practice are covered as Research Highlights and Practice Points in Nature Clinical Practice Nephrology.

'Secondary' journals such as Nature Clinical Practice Nephrology are not the only means of streamlining literature review. Internet-based search engines are increasingly used, by both physicians and their patients, to rapidly extract medical information. A study published in the British Medical Journal (Tang H and Ng JHK [2006] BMJ 333: 1143–1145) has shown that searching Google throws up a potentially correct diagnosis in almost 60% of cases.

Using a small sample of case studies published in the New England Journal of Medicine, two clinicians blinded to the correct diagnosis selected about four keywords from the case record with which to search Google. The search yielded a correct diagnosis for 15 of 26 cases, generally within the first 30 search results.

Widely misreported in the media as showing that Google is a more accurate diagnostician than doctors, the study generated almost 50 letters to the editor of the British Medical Journal. Some correspondents were shocked that “lazy” physicians were resorting to such “potentially dangerous” methods of diagnosis. Most, however, acknowledged that the internet is now integral to the information retrieval practices of an increasing number of physicians and proposed means by which the reliability of such tools could be improved. The utility of search engines to clinicians without access to well-stocked medical libraries, for example those who work in the developing world, was highlighted.

Whichever way you look at it, it seems that a change in how clinicians gather information is inevitable. The new tools must be an adjunct to—rather than a substitute for—the knowledge, open-mindedness, judgment and imaginative thinking that doctors should bring to bear.