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

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

Trying to meet the information needs of doctors Richard Smith, Editor, BMJ What I want to talk about What do we know about what information they need? 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 subspecialists 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 answering

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 nongeneralised but practice related fashion Not What are the indications for measuring serum procainamide? But Should I test the serum procainamide

level in this patient? Information source Reported Observed Print sources General and specialist textbooks Pharmaceutical textbooks Journals Drug company information Self made compendia

62 27 25 3 14 18 1 4 9

7 1 7 Human sources Specialist doctors Generalist doctors Office partner 33 18 1 3 53

24 1 4 Pharmacist Other 6 5 3 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 notes 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 context 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 doing. How many questions arise when doctors meet patients? Study Setting Subjects Method Questions per consultation

Covell et al 1985 Doctors offices 47 primary care doctors After visit interview 0.66 Timpka et al 1990

Four Swedish health centres 12 general practitioners Videos of consultations 1.85 Osheroff et al 1991

University based internal medicine 24 physicians and medical students Anthropological observation 5.77 Ely et al 1992

Doctors offices 34 family physicians Observation 0.07 Gorman et al 1994 Doctors offices

49 family doctors After visit interview 0.57 Guise et al 1994 AIDS outpatient clinic 7 health

professionals Record review 2.22 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 multidimensional 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 feedback. 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? Percentage 0.5 0.4 0.3 0.2

0.1 0 Series2 Series1 Less 1%than 1% 10% 11%- 51%- More 50% 90% than 90% 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? Yes No 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 Impossible Impossible Impossible Impossible Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Difficult Difficult Difficult Difficult Daunting Daunting Daunting Pissed off Choked Depressed Despairing Worrisome

Saturation

Vast Help Exhausted Frustrated Time consuming Dreadful Awesome Struggle Mindboggling Unrealistic Stress Challenging Challenging Challenging Excited

Vital importance The information paradox: Muir Gray Doctors are overwhelmed with information yet cannot find the information they need Information paradox Water, water, everywhere Nor any drop to drink The Rime of the

Ancient Mariner, Samuel Taylor Coleridge Information: the poets view Where is the wisdom we have lost in knowledge? And where is the knowledge we have lost in information? T S Eliot How much time did you spend reading around

your patients in the past week? Stage of their career Median reading time (minutes) Medical students 90 % who reported no reading in the previous week 0

House offi cers 0 75 Registrars 60 40 Consultants who

graduated since 1975 Consultants who graduated before 1975 45 30 30 40 Reading of Bristol general

practitioners Activity Minutes Reading in the library 35 Driving to and from the library 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 J ournal articles

L ow High Textbook Medium Colleague High Interactivity Nil

Work to access Utility High L ow Medium Nil Medium Medium Medium High

L ow High Whats wrong with medical journals Dont meet information needs Too many of them Too much rubbish Too hard work Not relevant Too boring Too expensive Whats wrong with medical

journals Dont add value Slow every thing down Too biased Anti-innovatory Too awful to look at Too pompous Too establishment Whats wrong with medical journals Dont reach the developing world Cant 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 months Issues 3-14 circulating to 500 000 physicians in US

40 000 sold to the NHS Features of Clinical Evidence 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

questions Connected to a large valid database 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 record A servant of patients as doctors Responds to the need for psychological support and affirmation

Conclusions Many questions arise as doctors consult with patients 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 wont be easy and will take time, money, and culture change

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