Medical Libraries Today

Although physicians once skimmed printed journals and Index Medicus to keep up with advances, today's practitioners can log onto databases linked to full-text journals and electronic books. Many studies have documented the importance of medical libraries to patient care, and that effect is likely to continue as medical librarians use their expertise to teach information skills and develop the electronic libraries of the future.

Medical libraries endure and evolve because they enhance patient care. One study found that 41% of all MEDLINE searches affected diagnoses, tests, and treatments (JAMA. 1993; 269:3124-9). When clinical medical librarians contribute to patient care, they provide pertinent information 40% to 59% of the time. (Bull Med Libr Assoc. 1992; 80:19-22). In Rochester, 80% of physicians responding to a questionnaire believed that the information gleaned from medical librarians “probably” or “definitely” changed patient management in such areas as diagnosis (29%), testing (51%), drug therapy (45%), length of hospital stay (19%), and advice to patients (72%) (Bull Med Libr Assoc. 1992; 80:169-78).

The advent of personal terminals and user-friendly databases like MEDLINE and GRATEFUL MED have shifted literature searches from the librarian to the physician. As a result, most medical libraries provide training classes or offer one-on-one assistance for physicians, housestaff, and students. “There are ways to search that aren't always obvious,” according to Karen A. Butter, acting university librarian at the University of California, San Francisco (USCF). Indeed, a 1995 study from the University of North Carolina at Chapel Hill found that 97% of do-it-yourself searches missed some available information (Bull Med Libr Assoc. 1995; 83:294-304).

To improve the efficacy of searches, librarians at the Edward G. Miner Library of the University of Rochester Medical Center (URMC) developed filters that combine keywords, medical subject headings, and text words. At UCSF, Butter reported that one of the most popular classes teaches faculty and students how to handle all information gleaned from database searches.

In Vermont, the ambitious VTEDNET project links physicians to bulletin boards, e-mail, inpatient records, databases, continuing medical education, and telemedicine. “We committed $30 million to upgrade both our patient care information system and our statewide network to ensure the infrastructure necessary to supply the best quality of health care, regardless of proximity to the academic medical center,” said Julie J. McGowan, PhD, director of the Dana Medical Library at the University of Vermont in Burlington. This database is popular and successful; 66% of the state's physicians use it regularly.

With VTEDNET, the librarians can field a physician's question, search the literature, and return the two most pertinent articles in as little as 15 minutes. “The system provides information at the point of medical decision making,” said McGowan.

Two recent recipients of the Michael E. DeBakey Library Services Outreach Award have demonstrated how other librarians provide modern information services to physicians far from the academic library. At Allina Health System in Minneapolis, Minnesota, Donna P. Johnson, MLS, director of information services, provides training for on-line searching, Internet basics, and locating relevant Web sites for 22 rural hospitals and clinics. Mary Jo Dwyer, MALS, senior circuit librarian at the University of Texas Health Science Center at San Antonio, oversees information services at 19 health care facilities staffed with circuit librarians who travel to hospitals, public libraries, and physicians' offices to provide training and do literature searches.

Searches by physicians have increased the demand for an electronic library where the full text of an abstracted article is available with the click of a mouse. Valerie Florance, PhD, director of the Edward G. Miner Library at URMC, has negotiated electronic access to 100 electronic journals and more than 50 electronic texts.

According to Florance, electronic text acquisitions have been hampered by the process of bundling, in which academic presses offer a collection of titles for a set price. Often, only a fraction of the journals in the collection are really needed by the library, and the cost of electronic journals are in addition to what the library spends for the print subscription.

The 1996-1997 academic health sciences library survey, edited by Florance, found that the average medical library spends 6% of its collection budget on electronic information and 3% on computer network costs.

Mark Frisse, MD, director of the Bernard Becker Medical Library at the Washington University School of Medicine in St. Louis, Missouri, noted that “Digital information is not cheaper; it's only more convenient in many instances.” Frisse's annual budget to deliver full-text MEDLINE searches is more than $250 000. “The investment in digital journals is high, but the readership is impressive,” said Frisse. All digital patrons must register. “We can see that the allergists are reading journal X and the dermatologists are reading journal Y,” noted Frisse. “This helps us understand our market better.”

Market forces plague the bottom line in an environment where journal costs have increased 38% and library budgets have only increased 16%. Acta Chemica, for example, cost the Miner Library $440 in 1997 and was used only 30 times during the year, putting the cost per use at $15. When deciding whether to keep a journal, Florance compares the cost to obtain articles through a document delivery service with the cost of owning the title. “The only way we can make it is to selectively cancel journals or get more money,” said Florance.

Physicians practicing without access to an electronic library can still obtain full-text articles with GRATEFUL MED, Lonesome Doc, and PubMed services for a fee. “PubMed takes you to full-text articles stored on the home page of the publisher,” said Donald A. B. Lindberg, MD, director of the National Library of Medicine (NLM).

Medical librarians have also used their expertise in information services and audiovisual technology to launch telemedicine services and assist curriculum development at many medical schools. In Minnesota, Johnson manages a telemedicine network with 28 sites. She has helped doctors present patients for consultations through video screen and digital stethoscope with specialists up to 200 miles away.

At URMC, third-year students in an internal medicine pilot project showed great improvement in generating questions about their patients, designing literature searches, choosing articles to read, judging the quality of studies, and deciding whether the studies applied to their patients.

The University of Vermont instituted its four-year Vertical Curriculum in Information Literacy and Applied Medical Informatics in 1992. “Library faculty members … help students develop the information habits necessary to become information-literate physicians for the next century,” according to McGowan.

Medical libraries are also expanding their role as information providers to a new clientele-the general public. “The next frontier is the consumer,” asserted Keith Krueger, president of the Friends of the National Library of Medicine in Washington, DC. The NLM inaugurated this new era of medical information in June 1997 by providing free access to MEDLINE and PubMed on its Web site (www.nlm.nih.gov). Although MEDLINE is a respected source of medical information, librarians have reservations about the quality of some information on the Web. “There are a lot of databases out there and a lot of journals and a lot of choices,” said Frisse. “To just turn people loose without a good sense of what is there is not a responsible thing to do.”

Librarians are rising to the challenge. Florance envisions a virtual advisory council that would include health educators. Right now, however, URMC patients can access university Web pages while they wait to see their physicians. The library will soon put an electronic AIDS information kiosk at a community site.

Again, access and cost will be limiting factors. “What kind of society do we have when information becomes stratified?” asked Krueger. In San Francisco, the Institute for Health and Healing Library at California Pacific Medical Center has provided medical information services to the general public since 1981. “We're empowering people to make informed decisions by providing information,” said Rosalind Kutler, head librarian at the Institute.

This major change in information access for the general public comes at a time when Krueger estimates that only one quarter of health care professionals have access to electronic medical information at their desks. Confronted by patients who have done their own searches, more physicians may come on-line. Krueger, quoting the motto of the Friends of the NLM, said, “The more you know, the better you heal.”

-L.M. Asta, MD

• Copyright ©2004 by the American College of Physicians