Interview with Dr B.D. Rose

Dr B.D. Rose Editor-in-Chief of UpToDate Clinical Professor of Medicine Harvard Medical School Boston, MA, USA

Zoccali: UpToDate is perhaps the most-used resource for evidence-based clinical practice in Nephrology worldwide. Could you tell us how the idea of UpToDate originated, and how it has evolved into the present format?

Rose: An article published by Covell in the Annals of Internal Medicine in 1985 observed internists in practice and assessed the frequency with which questions arose and how often they were answered. There were three main conclusions: approximately two-thirds of patient visits generated a question to which the doctor did not know the answer; less than one-third of these questions were answered, most often by asking a colleague; and, if all questions could be easily answered, as many as four management decisions would be changed in each half day of practice. UpToDate was designed from the beginning to address this point of information need, which is very difficult to do with textbooks. Our idea was to identify the questions that doctors ask, get experts to write answers to these questions, and then to update the material continuously as new information became available.
We started in nephrology because that is what I knew. UpToDate in nephrology was immediately successful after its initial release in August 1992. We then built an organization to do all of the other subspecialties in internal medicine, primary care, family practice, obstetrics gynecology and women’s health, and, to be released next year, general pediatrics.

Zoccali: We are now in the Internet era. Finding relevant information to all sorts of problems is a reality. Paradoxically, new authoritative sources of well selected and well-pondered clinical information is even more important than in the past. UpToDate has an Internet version. Is the Internet version much used or it is still behind the CD or the “palm” version of the program?

Rose: UpToDate began on floppy disks, switched to CD-ROM in 1994, released a web version in 2000, and a PDA (Pocket PC only) version in 2003. Compared to CD-ROM, the web version is becoming increasingly used because one can access the information from any computer with Internet access. There is also increasing use of our PDA version.

Zoccali: How many hours per week do you spend teaching? How important is traditional teaching for you in order to perceive the needs of students, and more in general, of learners?

Rose: At present, I spend about 5 percent of my time teaching. We feel it is essential for all people responsible for the generation of UpToDate content to remain clinically active for the reasons that you cite. We need to know the clinical issues that arise so that we can continually improve the utility of UpToDate for our users.

Zoccali: Electrolytes and AB physiology is an area where the clarity of your teaching talent had a major impact. Have you planned a new edition of your Electrolytes and AB manual on line, enriched with short videos to fully exploit the new communication tools?

Rose: There has been no thought about making an on-line version of Clinical Physiology of Acid-Base and Electrolyte Disorders. Short videos would add visual appeal, but I am not certain that they would enhance learning in any important way.

Zoccali: Guidelines are now produced on major clinical problems. Do you believe that a greater effort should be made to render official guidelines more enjoyable to read and easier to apply in everyday clinical practice?

Rose: UpToDate in a sense creates its own consensus guidelines, using our authors, section editors, outside reviewers, and published guidelines such as K/DOQI. I believe that K/DOQI represents a major evidence-based advance in nephrology. However, with all guidelines, there are two major limitations: they are not regularly updated as new material comes out; and most guidelines represent the consensus of a small group of “experts.” The guideline would be different if another group had been formed. As an example, a major society published two guidelines in different areas of its specialty within a few months of each other, as well as a section on screening for a particular disease. Both concluded that routine screening was not warranted, but there was almost no overlap in their recommendations for who should or might be screened.

Zoccali: Which general advice would you give to a medical teacher in the early years of his/her career?

Rose: I am not certain that my recommendations to a teacher would be so different to my recommendations to any doctor. To provide the best care, you must engage in a continuous process of learning. This includes looking up what you don’t know and ALSO periodically reviewing what you think you do know to see if you are still right.

Zoccali: Today distance learning and various kinds of tutoring arrangements tend to reduce the direct contact between the teacher and the student. Do you feel that this may lead to weakening the mentor-student link?

Rose: I am a great believer in face-to-face contact. This kind of interaction is mostly likely to result in more questions asked by the student, which allows more subtle issues to come to the fore for discussion.

Zoccali: Which is the most important progress you envisage in nephrology during the next decade or so?

Rose: This is too broad to answer easily because advances will be made in all areas. Probably most important will be greater implementation of measures to slow the progression of chronic kidney disease, which will include both better and more specific therapies for underlying disease (eg, lupus nephritis, diabetic nephropathy), better dialysis modalities (eg, nocturnal or daily hemodialysis), better treatment of coronary risk factors in patients with kidney disease (as has occurred in patients with diabetes), and perhaps better measures to prolong renal allograft survival.

Zoccali: Which advice would you give to a young colleague entering a career in Nephrology?

Rose: Nephrology remains as intellectually exciting today as it was when I entered. Current and future advances will dramatically enhance our understanding of disease and allow to us to deliver better care to our patients. Finally, as mentioned above in advice to a medical teacher, delivering the best care requires continuing ongoing education.

Zoccali: UpToDate apart, which is your favorite hobby?

Rose: Tennis: although age seems to be progressively diminishing my skills.