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What information do doctors need and want and how are we doing


  • pg 1
									 Trying to meet the
information needs of

    Richard Smith,
     Editor, BMJ
   What I want to talk
• What do we know about
  what information they
• How are we doing in
  meeting their needs?
• How could we do better?
What does research tell
us about the information
   needs of doctors?
Research on doctors’ information
      needs: Covell, 1985
• 47 LA physicians in internal medicine in
  office practice ; 12 generalists and 35
• Saw 1-16 patients during the half day.
• A closed questionnaire completed before
  the office interviews
• An interview after each patient was seen
  to identify any questions that might need
• An interview at the end of the office visit
Research on doctors’ information
      needs: Covell, 1985
• Physicians said they needed
  information about once a week
• But 269 questions were raised
  during the interviews after 409
  patient visits - about two questions
  for every three patients seen.
• Questions were about:
• Treatment of specific conditions: one third
• Diagnosis: one quarter
• Drugs: 14%
Research on doctors’ information
      needs: Covell, 1985
• Questions of fact (“What are the side
  effects of bromocriptine?”) 40%

• Questions of medical opinion (“How do you
  manage a patient with labile
  hypertension?”) 45%

• Non medical information (“How do you
  arrange home care for a patient?”) 16%
Research on doctors’ information
      needs: Covell, 1985
• Many questions were asked in a “non-
  generalised but practice related

• Not “What are the indications for
  measuring serum procainamide?”

• But “Should I test the serum
  procainamide level in this patient?”
    Reported and observed
information sources of doctors
   Info rmatio n so urce       Repo rted   Obse rved

   Print sources               62          27

   General and specialist      25          3
   textbo oks

   Pharmaceutical textbo oks   14          9

   Journals                    18          7

   Drug company information    1           1

   Self made compendia         4           7

   Human sources               33          53

   Specialist doctors          18          24

   Generalist doctors          1           1

   Office partner              3           4

   Pharmacist                  6           3

   Other                       5           21
Research on doctors’ information
   needs: Osheroff et al, 1991

•  24 doctors and medical students in a university
  based general medical service in Pittsburgh.
• Observed by an anthropologist, then internal
  medicine physicians identified information
  requests by reviewing texts prepared from field
• 519 information requests during 17 hours of
  observation on inpatient and outpatient activity.
• During this time the 24 doctors and students
  cared for about 90 patients
Research on doctors’ information
   needs: Osheroff et al, 1991

• 454 “strictly clinical”
  information requests--five for
  each patient
• 75% related to patient care
• 60% about specific patients
• 25% about treatment
• 16% about drugs
Research on doctors’ information
  needs: Forsythe et al, 1992
• Same study, only 35 hours of observation
• Many information needs are not expressed
  as grammatical questions or even verbalised
• The “information seeking messages may be
  interpretable only within the particular
• The needs may be for much more than
  specific clinical information. Doctors and
  students may be asking for support,
  guidance, and approval of what they are
 How many questions arise
when doctors meet patients?

   Study            Setting             Subjects          Method            Questions per
   Covell et al     Doctorsoffices     47 primary care   After visit       0.66
   1985                                 doctors           interview

   Timpka et al     Four Swedish        12 general        Videos of         1.85
   1990             health centres      practitioners     consultations

   Osheroff et al   University          24 physicians     Anthropological   5.77
   1991             based internal      and medical       observation
                    medicine            students

   Ely et al        Doctorsoffices     34 family         Observation       0.07
   1992                                 physicians

   Gorman et al     Doctorsoffices     49 family         After visit       0.57
   1994                                 doctors           interview

   Guise et al      AIDS                7 health          Record review     2.22
   1994             outpatient clinic   professionals
    Conclusions from studies of
   information needs of doctors
• Information needs do arise regularly when
  doctors see patients
• Questions are most likely to be about
  treatment, particularly drugs.
• Questions are often complex and
• The need for information is often much more
  than a question about medical knowledge.
  Doctors are looking for guidance,
  psychological support, affirmation,
  commiseration, sympathy, judgement, and
    Conclusions from studies of
   information needs of doctors
• Most of the questions generated in
  consultations go unanswered
• Doctors are most likely to seek answers
  to their questions from other doctors
• Most of the questions can be answered -
  but it is time consuming and expensive
  to do so
• Doctors seem to be overwhelmed by the
  information provided for them
How are we meeting the
  information needs?
     Current problems
• Think of all the information that
  you might read to help you do
  your job better

• How much of it do you read?

             0.3                                  Series2
             0.2                                  Series1
                     Less 1%-10% 11%- 51%- More
                   than 1%       50% 90% than
                             Amount read
     Current problems

• Do you feel guilty about how
  much or how little you read?
Do you feel guilty about how much or
           little you read?

     Current problems

• Think of your information supply
  and think of an adjective to
  describe it
      Words used by 41 doctors to
    describe their information supply
•    Impossible Impossible           •   Vast
     Impossible Impossible           •   Help
     Impossible Impossible           •   Exhausted
•    Overwhelming Overwhelming       •   Frustrated
     Overwhelming Overwhelming
     Overwhelming Overwhelming       •   Time consuming
•    Difficult Difficult Difficult   •   Dreadful
     Difficult                       •   Awesome
•    Daunting Daunting Daunting      •   Struggle
•    Pissed off                      •   Mindboggling
•    Choked                          •   Unrealistic
•    Depressed                       •   Stress
•    Despairing                      •   Challenging Challenging
•    Worrisome                           Challenging
•    Saturation                      •   Excited
                                     •   Vital importance
The information paradox:Muir

• Doctors are overwhelmed with
  information yet cannot find the
  information they need
Information paradox
          • “Water, water,
          • Nor any drop to

          • The Rime of the
            Ancient Mariner,
            Samuel Taylor
Information: the poet’s
            • Where is the
              wisdom we have
              lost in knowledge?

            • And where is the
              knowledge we
              have lost in

            • T S Eliot
How much time did you spend reading
around your patients in the past week?
Stage of their     Median reading   % who reported
career             time (minutes)   no reading in the
                                    previous week
Medical students   90               0

House officers     0                75

Registrars         60               40

Consultants who    45               30
graduated since
Consultants who    30               40
graduated before
   Reading of Bristol
  general practitioners
Activity                  Minutes

Reading in the library      35

Driving to and from the     70
    How far behind are you
      with your reading?
•   Number of journals        10 000
•   New articles a week       40 000
•   Time to read article      30 mins
•   A doctor spends all day reading;
    after six weeks how far behind is
    he or she with his or her reading?

•A century
  Utility of information

• Utility=relevance x validity x interactivity
                work to access
    Utility of different
  sources of information
Information Source Relevance   Validity   Interactivity   Work to access   Utility

Journal articles   Low         High       Nil             High             Low

Textbook           Medium      Medium Nil                 Medium           Medium

Colleague          High        Medium High                Low              High
    What’s wrong with medical
•   Don’t meet information needs
•   Too many of them
•   Too much rubbish
•   Too hard work
•   Not relevant
•   Too boring
•   Too expensive
    What’s wrong with medical
•   Don’t add value
•   Slow every thing down
•   Too biased
•   Anti-innovatory
•   Too awful to look at
•   Too pompous
•   Too establishment
 What’s wrong with medical
• Don’t reach the developing
• Can’t cope with fraud
• Nobody reads them
• Too much duplication
• Too concerned with authors
  rather than readers
 How to do better with
meeting the information
  needs of doctors?
Clinical Evidence
         • Compendium of the
           best available
           evidence for effective
           health care
         • Updated every six
         • Issues 3-14
           circulating to 500 000
           physicians in US
         • 40 000 sold to the
    Features of Clinical
• “We provide the evidence; you and the
  patient make the decision”
• Topics and questions guided by
  clinicians and patients
• Explicit, evidence based methodology
• Identifies gaps in the evidence
• Evidence on benefits and harms
• Web version
 “The thing” that will save us

• Able to answer highly complex
• Connected to a large valid
• Electronic - portable, fast, and
  easy to use
• Prompts doctors - in a helpful
  rather than demeaning way
“The thing” that will save us

• Connected to the patient
• A servant of patients as
• Responds to the need for
  psychological support and
• Many questions arise as doctors consult with
• Most are not answered
• We are doing badly with meeting the information
  needs of doctors
• They are overwhelmed with information but
  cannot find information when they need it
• New technology opens up the possibility of doing
  much better
• It won’t be easy and will take time, money, and
  culture change

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