Brief Communications Clinical Medical Librarians: What They Do and Why BY GRETCHEN GEARHART CLAMAN, R.N. Clinical Medical Librarian
Medical Library School of Medicine University of Missouri-Kansas City
WHEN medical librarians get together the title and role of the "clinical medical librarian" or "clinical librarian" prompt curiosity and controversy. The role and its theoretical basis have been described elsewhere [1-7], but the practical question arises, "Just what do clinical librarians do?" As CMLs-the common designation at the University of Missouri-Kansas City (UMKC) School of Medicine-we are basically reference librarians in a medical school-hospital setting. There are, however, two differences between traditional library-based reference work and the work of the CML: (1) We "take the library to the user" on the hospital ward, in the out-patient clinic, and in the medical school teaching areas; (2) We anticipate our users' questions and often provide information before they have asked for it. In order to illustrate how and why this orientation is successful, I will review the setting in which we practice at UMKC. The largest proportion of the medical students' clinical learning takes place on six patient units called docent units, in the adjoining Truman Medical Center, a publicly supported general hospital. Each docent unit consists of four teams that rotate through the inpatient internal medicine wards in two- or threemonth blocks during the course of a year. Each team is supervised by a faculty member called a docent, whose first responsibility is to coordinate academic and clinical learning experiences that acquaint students with realistic health care delivery. The docent heads a team of about twelve medical students, three hospital residents, clinical pharmacists, a dietitian, a social worker, staff nurses, nurse docents and graduate nursing students, basic science faculty, and other personnel involved in teaching and patient care, a total of about one hundred people for the four teams. A CML is part of each docent team, and in the course of a year we work closely with the team
454
assigned to our respective units. We are available to help our team all year round, not just when it is on the hospital rotation. During the rest of the year, students take arts and science courses on the main UMKC campus or are at affiliated hospitals for further clinical specialty experience. Practically speaking, most of our service is provided to members of the team that is currently on its hospital rotation. We attend rounds with our team each morning in the hospital. This takes two hours or more, and the time is divided between "4sit-down" rounds, when cases of newly admitted patients are presented, and "walk-around" rounds, where all patients are seen, their progress over the last twenty-four hours is reviewed, and plans are made for the next twenty-four hours of their care. Because we are literally at the elbows of our users it is easy for them to make direct requests for information about specific diagnostic and treatment problems. More often we anticipate questions simply by listening to the discussion and identifying matters dealt with in recent papers that will contribute to students' and residents' learning and, indirectly, improve patient care. Sometimes there are "spin-off" questions of a humanistic or existential nature in such areas as death and dying, the sociology and politics of health care delivery, or historical milestones in the conquest of illness. After rounds we return to the library with the days' questions and search the literature either by hand in Index Medicus and other print sources or in the MEDLINE data base. We select the best papers relating to each question, have photocopies made, and deliver the latter in a folder to the hospital, where they are readily available in a Princeton file at the nursing station. These papers stay on the ward until after the patient leaves the hospital and then are transferred to a vertical back-up file until they are needed again. Students and house staff are invited to pull papers from this file whenever a patient presents a new problem, and they do so. Our aim is to have highly pertinent papers at arm's length so that it is convenient for users to consult them for quick reference or to read them more thoroughly when the users are on call and find a lull in the rush of patient care activities. A recent addition to the information resources of my own docent unit is a collection of reprints filed in the conference room of the out-patient Bull. Med. Libr. Assoc. 66(4) October 1978
BRIEF COMMUNICATIONS
clinic. This collection in no way duplicates the inpatient file, although it serves the same user group. It contains papers that are more pragmatic than theoretical, dealing with problems presented by the ambulatory patient-the sort of paper that can be scanned quickly, even surreptitiously, by the medical or nursing student while the patient fidgets in the examining room. Materials in this file contain little background in physiology or biochemistry and are chosen for brevity and for fast visual comprehension by means of tables, flowcharts, and protocols. They are likely to come from family practice journals, pharmaceutical house materials (if not too heavily loaded with advertising), and even from "give-away" journals. They often concern the assessment and management of a single symptom, such as a cough, rash, or tremor, rather than an acute condition or complex syndrome. The UMKC School of Medicine is a six-year program to which students are admitted, with a few exceptions, directly from high school. Thus, they have little or no experience with college and university libraries. Their acquaintance with indexes is usually limited to the Reader's Guide to Periodical Literature. The CMLs present a library orientation series to each group of new students covering general organization of the library and use of the card catalog and major reference tools, including dictionaries, directories, and handbooks. One session deals with use of MeSH and Index Medicus, and in another we show them how to use a computer terminal on which they themselves can access an in-house data base called DOCLINE. This includes some six thousand journal citations that have proven relevant to our students' needs and our patient population. The students carl also use this computer terminal to access a 12,000-item question bank for a selfguided review of all phases of the curriculum. We also introduce them to other indexes and abstract systems such as Science Citation IndexO, Excerpta Medica, Biological Abstracts, Psychological Abstracts, NLM literature searches, and Current Contents®. We suggest methods to organize their personal reprint files using either MeSH or the table of contents of a comprehensive text such as Harrison's Principles of Internal Medicine. In actual practice students rely heavily upon their CMLs to do both hand searches and computer (MEDLINE) searches because our service saves them time. We aim to teach them the rudiments of library research, and we expect them first to consult such standard works as Harrison Bull. Med. Libr. Assoc. 66(4) October 1978
or Goodman and Gilman's Pharmacological Basis of Therapeutics and then to check Index Medicus when their information need is an uncomplicated one-term concept. If preliminary searching on their part does not yield appropriate material, or if they require a complex search involving two or more concepts, we carry on for them. Depending on the user's needs (for immediate patient care, for preparing an oral or written presentation, or for research), we provide either a computer printout from which he selects citations, or we select one or more journal articles that in our judgment will meet his needs. A statistical study of our service has shown that the information selected by the CML for the user was pertinent to the question in 95.3% of the 684 cases evaluated. Furthermore, our users reported that the information provided by the CML completely answered 65.2% of their questions on specific subjects and was nearly complete in an additional 29.4% of the transactions [8]. Because the CML role was created by this medical school as an integral part of its teaching plan our activities aim toward implementing that plan. It is almost impossible to quantify our impact on student learning and patient care. Certainly, we do not know any more about basic sciences or clinical specialities, or about how to use printed reference works or to run computer searches, than our counterparts in traditional medical libraries. The chief difference is simply our increased availability in the patient care and educational settings of the school. With this in mind I have formulated a Triage Theory of Librarianship. There are students in any school who will read widely and judiciously no matter what style of librarianship is offered. There are other students who will resist reading beyond their textbooks no matter how accessible the library is. The CML must recognize these two extremes, realizing that we may make little difference in the education of either group. (Certainly the "good" scholars will use our services heavily, and we find warm personal satisfaction in helping them, overlooking the probability that they will read a lot anyway.) But most students are in the large middle group who will read more or read less, depending upon how convenient it is for them to locate current papers dealing with questions they encounter. For this reason, we believe that library service in the clinical setting is a significant aid to students and residents under constant pressure to set priorities in their use of time. We also believe that providing information in the hospital and clinical units assists in planning
455
BRIEF COMMUNICATIONS
diagnostic work-ups and treatment plans for our patients. As CMLs we continually evaluate our role and procedures, modifying old ways and experimenting with new ones. We seek feedback from our users through informal conversation and occasional questionnaire surveys. The results encourage us to believe that we are not only serving students and health care staff better but that we also are developing a new and expanded role for librarians in hospitals and medical schools. REFERENCES 1. ALGERMISSEN, V. Biomedical librarians in a patient care setting at the University of Missouri-Kansas City School of Medicine. Bull. Med. Libr. Assoc. 62: 354-358, Oct. 1974. 2. And now, 'clinical librarians' on rounds. JAMA 230: 521, Oct. 28, 1974. 3. Clinical librarians accompany physicians on rounds. Natl. Libr. Med. News 29: 3, Nov. 1974. 4. COLAIANNI, L. A. Clinical medical librarians in a private teaching-hospital setting. Bull. Med. Libr. Assoc. 63: 410-411, Oct. 1975. 5. DRAGONETTE, D. B. The health sciences library's contributions to patient care. Bull. Med. Libr. Assoc. 61: 29-32, Jan. 1973. 6. ROACH, A. A.; AND ADDINGTON, W. W. The effects of an information specialist on patient care and medical education. J. Med. Educ. 50: 176-180, Feb. 1975. 7. SCHNALL, J. G.; AND WILSON, J. W. Evaluation of a clinical medical librarianship program at a university health sciences library. Bull. Med. Libr. Assoc. 64: 278-283, July 1976. 8. REID, CAROLYN ANNE. Clinical medical librarianship at the University of Missouri-Kansas City School of Medicine: results of research and continuing activities. Paper presented June 14, 1978, at the Seventy-eighth Annual Meeting of the Medical Library Association, Chicago, Illinois.
Received March 23, 1978; accepted April 25, 1978.
A Clinical Reference Program in the Department of Medicine, Tufts-New England Medical Center Hospital BY LISA CORNELISSE, Clinical Librarian Tufts University Medical-Dental Library Boston, Massachusetts
THE Tufts Medical-Dental Library clinical reference program began in July 1977 following an agreement reached with the then Acting-Chief of Medicine at New England Medical Center Hos456
pital. Previous discussion led the medical librarian to decide upon the Department of Medicine as the most appropriate department to approach with this extension program. This decision was based upon reports in the literature of similarly conceived programs [1-5], the sizes of the various departments (personnel directly involved), and the feasibility of incorporating such a program into the patient care structure of the department concerned. In a series of preliminary discussions with the Department of Medicine, it was decided that a clinical librarian might best serve the house staff by providing bibliographic coverage of two types: short, specific literature searches to cover daily clinically encountered problems and broader review searches also suggested by daily patient encounters. A liaison member from the junior resident staff was designated to assist the librarian in identifying search topics in the initial stages of the program. This liaison role was later assumed by the chief resident of the department. The Department of Medicine functions with a "6morning report" conference, held daily from 9:00-10:00 A.M. following morning rounds by the twelve junior residents of the house staff. Attendance varies from ten to fifteen participants, including the chief resident of the department, who acts as informal mqderator of the report, an attending staff member, who acts as group leader, and variable attendance by senior residents of the department. The librarian also attends these daily conferences. Following the conference, from one to three topics are suggested by either the chief resident, the attending group leader, or one of the residents, and the searches are then carried out by the librarian. All junior and senior residents are strongly encouraged to approach the librarian with search topics at any time during the day; however, the morning report structure serves as an extremely effective means of communicating on a regular basis with the users of the program. Following the searches an on-line printout of the citations retrieved from MEDLARS searches, as well as other citations located by the librarian, is presented to the search requester. Citations on broad search topics are shown exclusively to the chief resident. Specific articles are then noted for inclusion either in the "core collection" or in selected bibliographies to be compiled by the librarian. Copies of this unrefined bibliography are made available to the requester, while the originals are kept in a file for possible future reference. Bull. Med. Libr. Assoc. 66(4) October 1978
Medical Library School of Medicine University of Missouri-Kansas City
WHEN medical librarians get together the title and role of the "clinical medical librarian" or "clinical librarian" prompt curiosity and controversy. The role and its theoretical basis have been described elsewhere [1-7], but the practical question arises, "Just what do clinical librarians do?" As CMLs-the common designation at the University of Missouri-Kansas City (UMKC) School of Medicine-we are basically reference librarians in a medical school-hospital setting. There are, however, two differences between traditional library-based reference work and the work of the CML: (1) We "take the library to the user" on the hospital ward, in the out-patient clinic, and in the medical school teaching areas; (2) We anticipate our users' questions and often provide information before they have asked for it. In order to illustrate how and why this orientation is successful, I will review the setting in which we practice at UMKC. The largest proportion of the medical students' clinical learning takes place on six patient units called docent units, in the adjoining Truman Medical Center, a publicly supported general hospital. Each docent unit consists of four teams that rotate through the inpatient internal medicine wards in two- or threemonth blocks during the course of a year. Each team is supervised by a faculty member called a docent, whose first responsibility is to coordinate academic and clinical learning experiences that acquaint students with realistic health care delivery. The docent heads a team of about twelve medical students, three hospital residents, clinical pharmacists, a dietitian, a social worker, staff nurses, nurse docents and graduate nursing students, basic science faculty, and other personnel involved in teaching and patient care, a total of about one hundred people for the four teams. A CML is part of each docent team, and in the course of a year we work closely with the team
454
assigned to our respective units. We are available to help our team all year round, not just when it is on the hospital rotation. During the rest of the year, students take arts and science courses on the main UMKC campus or are at affiliated hospitals for further clinical specialty experience. Practically speaking, most of our service is provided to members of the team that is currently on its hospital rotation. We attend rounds with our team each morning in the hospital. This takes two hours or more, and the time is divided between "4sit-down" rounds, when cases of newly admitted patients are presented, and "walk-around" rounds, where all patients are seen, their progress over the last twenty-four hours is reviewed, and plans are made for the next twenty-four hours of their care. Because we are literally at the elbows of our users it is easy for them to make direct requests for information about specific diagnostic and treatment problems. More often we anticipate questions simply by listening to the discussion and identifying matters dealt with in recent papers that will contribute to students' and residents' learning and, indirectly, improve patient care. Sometimes there are "spin-off" questions of a humanistic or existential nature in such areas as death and dying, the sociology and politics of health care delivery, or historical milestones in the conquest of illness. After rounds we return to the library with the days' questions and search the literature either by hand in Index Medicus and other print sources or in the MEDLINE data base. We select the best papers relating to each question, have photocopies made, and deliver the latter in a folder to the hospital, where they are readily available in a Princeton file at the nursing station. These papers stay on the ward until after the patient leaves the hospital and then are transferred to a vertical back-up file until they are needed again. Students and house staff are invited to pull papers from this file whenever a patient presents a new problem, and they do so. Our aim is to have highly pertinent papers at arm's length so that it is convenient for users to consult them for quick reference or to read them more thoroughly when the users are on call and find a lull in the rush of patient care activities. A recent addition to the information resources of my own docent unit is a collection of reprints filed in the conference room of the out-patient Bull. Med. Libr. Assoc. 66(4) October 1978
BRIEF COMMUNICATIONS
clinic. This collection in no way duplicates the inpatient file, although it serves the same user group. It contains papers that are more pragmatic than theoretical, dealing with problems presented by the ambulatory patient-the sort of paper that can be scanned quickly, even surreptitiously, by the medical or nursing student while the patient fidgets in the examining room. Materials in this file contain little background in physiology or biochemistry and are chosen for brevity and for fast visual comprehension by means of tables, flowcharts, and protocols. They are likely to come from family practice journals, pharmaceutical house materials (if not too heavily loaded with advertising), and even from "give-away" journals. They often concern the assessment and management of a single symptom, such as a cough, rash, or tremor, rather than an acute condition or complex syndrome. The UMKC School of Medicine is a six-year program to which students are admitted, with a few exceptions, directly from high school. Thus, they have little or no experience with college and university libraries. Their acquaintance with indexes is usually limited to the Reader's Guide to Periodical Literature. The CMLs present a library orientation series to each group of new students covering general organization of the library and use of the card catalog and major reference tools, including dictionaries, directories, and handbooks. One session deals with use of MeSH and Index Medicus, and in another we show them how to use a computer terminal on which they themselves can access an in-house data base called DOCLINE. This includes some six thousand journal citations that have proven relevant to our students' needs and our patient population. The students carl also use this computer terminal to access a 12,000-item question bank for a selfguided review of all phases of the curriculum. We also introduce them to other indexes and abstract systems such as Science Citation IndexO, Excerpta Medica, Biological Abstracts, Psychological Abstracts, NLM literature searches, and Current Contents®. We suggest methods to organize their personal reprint files using either MeSH or the table of contents of a comprehensive text such as Harrison's Principles of Internal Medicine. In actual practice students rely heavily upon their CMLs to do both hand searches and computer (MEDLINE) searches because our service saves them time. We aim to teach them the rudiments of library research, and we expect them first to consult such standard works as Harrison Bull. Med. Libr. Assoc. 66(4) October 1978
or Goodman and Gilman's Pharmacological Basis of Therapeutics and then to check Index Medicus when their information need is an uncomplicated one-term concept. If preliminary searching on their part does not yield appropriate material, or if they require a complex search involving two or more concepts, we carry on for them. Depending on the user's needs (for immediate patient care, for preparing an oral or written presentation, or for research), we provide either a computer printout from which he selects citations, or we select one or more journal articles that in our judgment will meet his needs. A statistical study of our service has shown that the information selected by the CML for the user was pertinent to the question in 95.3% of the 684 cases evaluated. Furthermore, our users reported that the information provided by the CML completely answered 65.2% of their questions on specific subjects and was nearly complete in an additional 29.4% of the transactions [8]. Because the CML role was created by this medical school as an integral part of its teaching plan our activities aim toward implementing that plan. It is almost impossible to quantify our impact on student learning and patient care. Certainly, we do not know any more about basic sciences or clinical specialities, or about how to use printed reference works or to run computer searches, than our counterparts in traditional medical libraries. The chief difference is simply our increased availability in the patient care and educational settings of the school. With this in mind I have formulated a Triage Theory of Librarianship. There are students in any school who will read widely and judiciously no matter what style of librarianship is offered. There are other students who will resist reading beyond their textbooks no matter how accessible the library is. The CML must recognize these two extremes, realizing that we may make little difference in the education of either group. (Certainly the "good" scholars will use our services heavily, and we find warm personal satisfaction in helping them, overlooking the probability that they will read a lot anyway.) But most students are in the large middle group who will read more or read less, depending upon how convenient it is for them to locate current papers dealing with questions they encounter. For this reason, we believe that library service in the clinical setting is a significant aid to students and residents under constant pressure to set priorities in their use of time. We also believe that providing information in the hospital and clinical units assists in planning
455
BRIEF COMMUNICATIONS
diagnostic work-ups and treatment plans for our patients. As CMLs we continually evaluate our role and procedures, modifying old ways and experimenting with new ones. We seek feedback from our users through informal conversation and occasional questionnaire surveys. The results encourage us to believe that we are not only serving students and health care staff better but that we also are developing a new and expanded role for librarians in hospitals and medical schools. REFERENCES 1. ALGERMISSEN, V. Biomedical librarians in a patient care setting at the University of Missouri-Kansas City School of Medicine. Bull. Med. Libr. Assoc. 62: 354-358, Oct. 1974. 2. And now, 'clinical librarians' on rounds. JAMA 230: 521, Oct. 28, 1974. 3. Clinical librarians accompany physicians on rounds. Natl. Libr. Med. News 29: 3, Nov. 1974. 4. COLAIANNI, L. A. Clinical medical librarians in a private teaching-hospital setting. Bull. Med. Libr. Assoc. 63: 410-411, Oct. 1975. 5. DRAGONETTE, D. B. The health sciences library's contributions to patient care. Bull. Med. Libr. Assoc. 61: 29-32, Jan. 1973. 6. ROACH, A. A.; AND ADDINGTON, W. W. The effects of an information specialist on patient care and medical education. J. Med. Educ. 50: 176-180, Feb. 1975. 7. SCHNALL, J. G.; AND WILSON, J. W. Evaluation of a clinical medical librarianship program at a university health sciences library. Bull. Med. Libr. Assoc. 64: 278-283, July 1976. 8. REID, CAROLYN ANNE. Clinical medical librarianship at the University of Missouri-Kansas City School of Medicine: results of research and continuing activities. Paper presented June 14, 1978, at the Seventy-eighth Annual Meeting of the Medical Library Association, Chicago, Illinois.
Received March 23, 1978; accepted April 25, 1978.
A Clinical Reference Program in the Department of Medicine, Tufts-New England Medical Center Hospital BY LISA CORNELISSE, Clinical Librarian Tufts University Medical-Dental Library Boston, Massachusetts
THE Tufts Medical-Dental Library clinical reference program began in July 1977 following an agreement reached with the then Acting-Chief of Medicine at New England Medical Center Hos456
pital. Previous discussion led the medical librarian to decide upon the Department of Medicine as the most appropriate department to approach with this extension program. This decision was based upon reports in the literature of similarly conceived programs [1-5], the sizes of the various departments (personnel directly involved), and the feasibility of incorporating such a program into the patient care structure of the department concerned. In a series of preliminary discussions with the Department of Medicine, it was decided that a clinical librarian might best serve the house staff by providing bibliographic coverage of two types: short, specific literature searches to cover daily clinically encountered problems and broader review searches also suggested by daily patient encounters. A liaison member from the junior resident staff was designated to assist the librarian in identifying search topics in the initial stages of the program. This liaison role was later assumed by the chief resident of the department. The Department of Medicine functions with a "6morning report" conference, held daily from 9:00-10:00 A.M. following morning rounds by the twelve junior residents of the house staff. Attendance varies from ten to fifteen participants, including the chief resident of the department, who acts as informal mqderator of the report, an attending staff member, who acts as group leader, and variable attendance by senior residents of the department. The librarian also attends these daily conferences. Following the conference, from one to three topics are suggested by either the chief resident, the attending group leader, or one of the residents, and the searches are then carried out by the librarian. All junior and senior residents are strongly encouraged to approach the librarian with search topics at any time during the day; however, the morning report structure serves as an extremely effective means of communicating on a regular basis with the users of the program. Following the searches an on-line printout of the citations retrieved from MEDLARS searches, as well as other citations located by the librarian, is presented to the search requester. Citations on broad search topics are shown exclusively to the chief resident. Specific articles are then noted for inclusion either in the "core collection" or in selected bibliographies to be compiled by the librarian. Copies of this unrefined bibliography are made available to the requester, while the originals are kept in a file for possible future reference. Bull. Med. Libr. Assoc. 66(4) October 1978
