Showing posts with label
resources of interest to librarians.
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Showing posts with label
resources of interest to librarians.
Show all posts
From a recent systematic review (my italics):
Objective To systematically review studies that examined the questions clinicians raise in the context of patient care decision making...
Results In 11 studies, 7012 questions were elicited through short interviews with clinicians after each patient visit. The mean frequency of questions raised was 0.57 (95% CI, 0.38-0.77) per patient seen, and clinicians pursued 51% (36%-66%) of questions and found answers to 78% (67%-88%) of those they pursued. Overall, 34% of questions concerned drug treatment, and 24% concerned potential causes of a symptom, physical finding, or diagnostic test finding. Clinicians’ lack of time and doubt that a useful answer exists were the main barriers to information seeking.
Conclusions and Relevance Clinicians frequently raise questions about patient care in their practice. Although they are effective at finding answers to questions they pursue, roughly half of the questions are never pursued. This picture has been fairly stable over time despite the broad availability of online evidence resources that can answer these questions. Technology-based solutions should enable clinicians to track their questions and provide just-in-time access to high-quality evidence in the context of patient care decision making. Opportunities for improvement include the recent adoption of electronic health record systems and maintenance of certification requirements.
I would like to know what evidence supports that last statement.
This recent paper from the Journal of the Medical Library Association describes how faculty members utilize information resources. A major limitation is that it is a single center study and may reflect trends that are peculiar to the culture of the institution. It is available as free full text and there is a lot to unpack. An area of particular interest to me was that of faculty members' preferences for patient care look up:
..the 180 respondents to the question rarely searched the 13 point-of-care databases listed in the survey for clinical or patient-care information. Over 90% stated that they never used 5 of the databases for clinical or patient care, and another 5 databases had between 75% and 90% of respondents never using them. For example, UpToDate was used daily by 4.8% of respondents but was never used by 64.1% of respondents for clinical or patient care purposes. MD Consult was the most used by all respondents, with 43.6% reporting using it at least a few times a year or more for clinical or patient care information.
There's a lot of scatter here but a few patterns are suggested. Filtered resources such as DynaMed and UpToDate, wildly popular among residents and private physicians, were hardly used at all by faculty, who tended to prefer repositories of books and journals such as MD Consult and Access Medicine. The filtered resources are more geared for focused clinical questions whereas the repositories are better suited for background reading and that may be more suitable for the teaching objectives of faculty.
Evidence based medicine (EBM) has evolved concerning information retrieval. Original teaching held that a Medline search and critical appraisal (a phrase coined for this use by the founders of EBM) should be done by the user at the point of care. That teaching has given way to a shift toward the use of filtered resources (secondary sources) which deliver information that has been searched and critically appraised by others. Proponents of filtered resources argue that primary searching and critical appraisal is too time consuming for clinicians. Purists decry this practice as capitulation to laziness. I discussed this trend in greater detail in a recent post on the history of EBM:
Dr. Brian Haynes was asked whether EBM was too much work for the busy clinician. When one considers the steps involved in searching, critical appraisal and application it does seem a daunting task. Certainly it would have been too time consuming before the era of computer searching. On line searching was available in the 1980s (you had to go to considerable trouble to set it up) but had not yet reached prime time even by the time EBM was announced to the world in 1992.
Haynes said that he and his colleagues were working from the beginning to make the process user friendly in everyday practice. They have been exploring ways to put best evidence into secondary sources, including even textbooks (some EBM purists decry the use of textbooks) so that doctors will not have to do primary literature searches and critical appraisal. Currently available secondary resources, said Haynes, may not be where they need to be yet but are improving.
As Guyatt pointed out the leaders realized early on that getting all clinicians to search and critically appraise the literature individually was an unattainable ideal. The best that could be done was to educate clinicians in the principles of EBM so they could then make more intelligent and effective use of secondary sources. Evidence derived from such sources has already been critically appraised and has been referred to as “pre-processed” evidence. Some EBM purists, taking a negative view of this approach, consider it an unfortunate compromise and have called it “evidence based capitulation.”
Findings from a new study in Circulation:
Methods and Results—Articles were randomized to receive targeted social media exposure from Circulation, including postings on the journal's Facebook and Twitter feeds. The primary end-point was 30-day article page views. We conducted an intention-to-treat analysis comparing article page views by the Wilcoxon Rank sum test between papers randomized to social media as compared to those in the control group, which received no social media from Circulation. Pre-specified subgroups included article type (population/clinical/basic), US vs. non-US corresponding author, and whether the manuscript received an editorial. Overall, 243 manuscripts were randomized: 121 in the social media arm and 122 in the control arm. There was no difference in median 30-day page views (409 [social media] vs 392 [control], p=0.80)...
Conclusion—A social media strategy for a cardiovascular journal did not increase the number of times an article was viewed. Further research is necessary to understand the ways in which social media can increase the impact of published cardiovascular research.
The major weakness in this study is that it looked only at the effect of Circulation's own social media outlets, not the effect of medical social media in general. The social media influence may be more than this study indicates although other studies suggest that it remains low despite the growing enthusiasm for FOAM and similar initiatives.
More from Cardiobrief and the Mayo Social Media Health Network.
--- and being replaced by Clinical Key.
This review was negative. I have tried Clinical Key and found it, like MD Consult, to be a decent product although it is apparently more expensive. It is essentially a re-branding by Elsevier of MD Consult with a few bells and whistles and additional journals added. I don't know why they made this decision when MD Consult performed so well at what it was supposed to do. The interface has a new look and appears more geared to searching as opposed to browsing, suggesting a move to be more of a point of care reference for evidence based searching as opposed to an electronic version of the traditional medical library, which was MD Consult's strength.
UpToDate and DynaMed are examples of point of care look-up sites. They are well designed for getting quick answers to focused clinical questions in real time. MD Consult and Clinical Key are less suited for that purpose. Clinical Key's search engine, although powerful and even fun, is imprecise. It searches across a vast array of sources but they are diverse and not filtered in any systematic way as far as I can tell. Search results tend to be random, almost luck of the draw. While searching in that manner can be productive it is not systematic or rigorous according to the standards of EBM. Resources like this are great for background reading such as you might do during down time when you want to dive deep about your patient's disease process. They are less useful when trying to quickly answer focused clinical questions. I use UpToDate to get fast, focused answers during patient care. It is possible though more difficult to use it for background reading. If you use UpToDate to try and assemble something akin to a monograph or a textbook chapter you'll be jumping from page to page and may get lost in what seems an endless trail of links.
A sharp distinction needs to be made. Point of care sites such as UpToDate and DynaMed differ from electronic libraries like MD Consult, Clinical Key and Access Medicine. Confusion results when the distinction is lost. You can use either type of resource for either purpose but certainly UpToDate is optimized for one type of research and MD Consult and Clinical Key for another. No single site works well in both areas.
If Clinical Key is trying to compete with UpToDate it's the wrong focus. Clinicians need both types. They are complementary and neither should replace the other. Several years ago I wrote a post about these two uses of on line resources, reflecting the two distinct reading objectives. In that post I borrowed a couple of terms I had heard form a speaker somewhere: background reading and foreground reading.
Which approach is better? Findings from a recent study might come as a surprise:
Method: In 2011 and 2012, 48 internal medicine interns from two classes at Rutgers University Robert Wood Johnson Medical School, who had been trained to use three evidence-based summary resources, performed four-minute computer searches to answer 10 clinical questions. Half were randomized to initiate searches for answers to questions 1 to 5 using Google; the other half initiated searches using a summary resource. They then crossed over and used the other resource for questions 6 to 10. They documented the time spent searching and the resource where the answer was found. Time to correct response and percentage of correct responses were compared between groups using t test and general estimating equations.
Results: Of 480 questions administered, interns found answers for 393 (82%). Interns initiating searches in Google used a wider variety of resources than those starting with summary resources. No significant difference was found in mean time to correct response (138.5 seconds for Google versus 136.1 seconds for summary resource; P = .72). Mean correct response rate was 58.4% for Google versus 61.5% for summary resource (mean difference −3.1%; 95% CI −10.3% to 4.2%; P = .40).
Conclusions: The authors found no significant differences in speed or accuracy between searches initiated using Google versus summary resources.
Does this mean Google is as good as filtered “evidence based” resources? Not necessarily. The filtered resources available to the participants were quite limited, consisting only of First Consult, DynaMed and Wiley’s Essential Evidence Plus. Certainly not representative of the best selection in that category. Participants using Google landed on a wider variety of sites including the primary sources themselves: journal articles.
How many of the Google users hit on social media? None! Social media are rising in their perceived importance as resources for answering clinical questions and are increasingly being promoted through initiatives like FOAM and Blitter. But this study, though limited by being small, suggests that penetration remains low. So for now it would appear that most users who Google clinical questions end up in non social media resources although most who do land on social media do so via Google (at least for my blog). These trends are likely to change over time.
