Tracking the Clinical Psychiatric literature What Is Out There? Annette L Hanson, M.D., Margaret S. Chisolm, M.D. Marsden McGuire, M.D., Neal G. Ranen, M.D. Anne Marie Stoline, M.D., Constantine G. Lyketsos, M.D. This paper reviews the various resources available to psychiatrists for keeping abreast of the current literature and research in the field and reports the results of a survey that assesses psychiatrists' current practices in tracking the literature. The respondents' knowledge ofavailable resources, their usual searching practices, and their satisfaction with the resource network are presented. The authors draw conclusions about the most efficient means of tracking the literature for various purposes and offer suggestions about improving resources.
S
cientific progress has provided psychiatrists with an abundance of information for research and clinical purposes alike. However, this progress has created its own problems; keeping abreast of and sifting through a deluge of information can be time consuming and confusing. And, although there are adequate available sources of medical information, it is often difficult to know how to integrate them effectively and efficiently. It is therefore surprising that few attempts have been made to investigate how psychiatrists (and physicians in general) use the literature. Bowden and Bowden (1) made one of the first attempts to study psychiatrists' use of the literature. They surveyed 400 psychiatrists and found that journals were the primary information source for 58% of the respondents. Those surveyed read an average of 6.7 hours per week from 4.3 journals; 42% of the respondents used libraries monthly. The authors suggested greater use of abstracting services and review articles to manage the growth of medical knowledge. \(
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Alternative suggestions included increased use of audiotapes, indexes, and noncommercial review publications. In 1974, Rockwell (2) reported on the journal reading patterns of 220 psychiatrists. He found that 50% or more of respondents read several journals. The "average psychiatrist" surveyed read every issue of three journals and some issues of four additional journals. Some of the journals read by 50% or more of respondents included the American Journal of Psychiatry, Archives of General Psychiatry, the Journal of the American Medical Association, and Medical Aspects of Human Sexuality.
In 1986, Haynes et al. wrote a series of
From the Department of Psychiatry and Behavioral Sciences of the Johns Hopkins University School of Medicine, Baltimore, Maryland, where Dr. Hanson, Dr. Chisolm, Dr. McGuire, Dr. Ranen, Dr. Stoline, and Dr. Lyketsos are psychiatric residents. Address reprint requests to Dr. CG. Lyketsos, Department of Psychiatry and Behavioral Sciences, Meyer 143, Johns Hopkins University, Baltimore, MD 21205. Copyright@ 1991 Academic Psychiatry.
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six articles on using the medical literature (3--8). The authors proposed a three-step filtering method to improve reading efficiency. The first step suggested reading only original articles of structured clinical investigations. The second step suggested reading only articles with direct relevance to one's clinical practice. The third step suggested using the Methods section of an article as a screening tool to eliminate articles failing to live up to technical or scientific standards. The authors also proposed methods of expanding the breadth of reading, such as journal circulation clubs, regular library visits, and contact with selective dissemination of information services. Furthermore, the authors explored how to use the literature to solve a given clinical problem, the use of the computer to access medical literature, and a means of establishing a filing system for retrieved articles. As evidence of a new trend in tracking the literature, one entire article by Haynes et al. was devoted to the use of personal computers for literature searches. Although these articles were written for the general medical practitioner, the recommended techniques and suggestions apply TABLE 1. Demographic characteristics of respondents Characteristics Sex Male Female Age,yr 20-30 31-40 41-50 51~
61-70
>70 Marital status Single Married Divorced Widowed Separated Children at home Yes No
':
Number
Percent
64 18
78
4 24 23 12 15 4
5 29 28 15 18 5
8 60 6 1 7
10 73 7 1 9
50 32
61 39
22
to psychiatrists as well. In 1986, Scheidt et al. reviewed the various kinds of information access available to the phYSician by computer (9). The article provides details of start-up and maintenance costs associated with computer searches. The authors show how commercial databases differ in cost, time required in learning to use them, number and type of ancillary services available, number of journals searched, and the time between publication and inclusion in the service. The authors argue that the use of such technology provides physicians with rapid, personalized TABLE 2. Professional characteristics of respondents Characteristics
Number
Percent
Years since MD 22±15 Years since residency 16±13 Years of residency 3±t Type of residency, (N=77) University-affiliation 63 Non-university-affiliation 14 Fellowship, (N=78) Yes 32 No 46 Other residency, (N=78) Yes 8 No 70 Number patients/week, (N=82) 0-10 15 11-20 23 21-30 18 31-40 9 >40 16 Types of patients, (N=76) Adult 56 Child/ adolescent 4 Both 16 University affiliation, (N=79) None 33 Fulltime faculty 7 Parttime faculty 30 Resident 5 Other 4 Orientation, (N =70) Analytical 17 Behavioral 0 Biological 8 Cognitive 1 Eclectic 43 Other 1
82 18 41 59 10 90 19 28 22 11 20 71 5 24
42 9
38 6 5
24 0 11 1 61 3
Note: N=number of respondents.
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access to several sources of information. Finally, commercially available update services are increasingly popular because they offer a quick update on psychiatric developments for busy practitioners. These services use a panel of experts to determine the most important or relevant articles appearing in the literature, which are then distributed to subscribers as a summary in a journal, on a cassette tape, or on a computer disk. Use of these services has not been reviewed in prior studies of this topic. Little is known about the methods psychiatrists actually use to keep up with the literature and the degree to which they feel able to access it effectively. We attempted to address these issues through a survey of members of a state psychiatric association. In addition, we were interested in the extent to which computers were available to and actually used by psychiatrists in their literature searches. METHODS Survey Our survey contained questions about demographics, education, professional interests, and literature use patterns. We asked respondents why and how they accessed the literature, whether (and how) they used computers to do so, and whether or not they were satisfied with their ability to access desired information. We field tested an earlier survey on psychiatric residents. The sur-
,'\.. ;
I
vey consisted of four pages and twenty-six questions that were either multiple choice or short answer in format. A copy of the final survey is available on request. Procedure The survey was mailed to a random sample of 200 members of the Maryland Psychiatric Society. Demographic and professional characteristics of respondents are presented in Tables 1 and 2, respectively. The survey was mailed under a cover letter explaining the purpose of the study. Recipients were asked to complete the survey within six weeks and to return it anonymously in a preaddressed stamped envelope. One month later, all recipients were sent a postcard reminding them to return the survey and providing them with the opportunity to receive a new copy if necessary. Analysis All survey results were coded and entered into a microcomputer file utilizing the Statview statistical package (10). RESULTS Sample Composition Eighty-six (43%) surveys were returned within the allotted time. Not all respondents answered each question. Two respondents refused to answer any questions, noting the
TABLE 3. Rating of reasons for accessing the literature Reason for accessing literature
N
Rating
To answer a particular clinical question To keep up with new developments To provide patient information To prepare for a clinical conference or round To prepare for a scientific conference or paper To satisfy CME requirements
76 76 70 70
2.066±1.100 2.066±1.268 3.500±1.164 3.629±1.524 4.338±1.780 4.609±1.4B7
68 69
Note: Values are means±SD of rating given to each reason, where 1 is the most important reason for accessing the literature and 6 is the least important.
TABLE 4. Rating of means of accessing the literature Means of accessing literature
N
Rating
Personal journal subscriptions and files Clinical rounds or conferences University or hospital library Source information (or articles) from colleagues Computer database Commercial update service of any kind
78 71 73 75 63 59
1.756±1.107 3.155±1.272 3.193±1.374 3.28O±1.247 4.365±1.790 4.576±1.694
Note: Values are means±SD of rating given to each method used to access literature, where 1 is the most important means of accessing the literature and 6 is the least important. TABLES. Patterns and means of use of the clinica1literature Number Frequency of literature consultation (N=78) Daily Two to three times a week Once a week Every two to three weeks Once a month Less than once a month Hours spent per week reading the literature (N=79) 10 Respondents with computer training (N=80) Yes No Respondents who own a computer (N=79) Yes No Respondents with professional access to computer (N=79) Yes No Frequency of computer use to access the literature (N=68) Daily Two to three times a week Once a week Every two to three weeks Once a month Less than once a month
Note: N=number of res
Percent
9 37 15 12 3 2
12 47 19 15 4 3
13 54 12 0
17 68 15 0
33 47
41 59
36 43
46 54
41 38
52 48
0 1 4 7 7 49
0 2 6 10 10 72
ndents.
survey was too long. Because the survey was anonymous, it was not possible to assess differences between respondents and nonrespondents.
Use Patterns Recipients were asked to rate on a sixpoint scale reasons why they might access the clinical literature; the results are presented in Table 3. Similarly, Table 4 shows the results of questions in which respondents were asked to rate means through which they access the literature. Table 5 summarizes patterns of literature use (including computer use). Table 6 presents respondents' level of satisfaction with several items related to their use of the literature. Finally, respondents were asked to describe the specific sources they used and to rank them. As a group, respondents regularly read 3.1±1.2 (SO) psychiatric journals. The American Journal of Psychiatry was ranked as the most important journal they read or browsed by 63 respondents; 5 respondents ranked the Archives of General Psychiatry as the most important. Of note, only one respondent reported not reading or browsing a psychiatric journal regularly. Thirty-three respondents reported subscribing to at least one medical nonpsychiatric journal. Of this group, one-third (11 respondents) subscribed to the New England Journal of Medicine and one-third to the Journal of the American Medical Association. Most respondents (64) reported using a psychiatric textbook regularly, with the Kaplan and Sadock Comprehensive Textbook of Psychiatry ranked as most important by 48 respondents. Finally, 23 respondents reported using a com-
II :,' ", ()\ ";'I \I I
mercial update service. Audio Digest (5 users), Psychiatric Update (4 users), the Harvard Newsletter (4 users), and Drug Alerts (3 users) were the most popular services used.
DISCUSSION Keeping up with the growing volume of information relevant to clinical practice has become a difficult task. Comprehensive, efficient, and targeted use of the literature requires flexible search strategies and multiple resources. The articles by Haynes et al. (3-8) and Scheidt et al. (9) are valuable guides in providing organized knowledge and ideas about accessing the literature in modern medicine. A careful examination of the literature reveals that few studies (none of them recent) have looked at psychiatrists' methods of accessing the clinical literature and maintaining a current knowledge base. This study sought to fill this void. The results, however, are difficult to generalize for several reasons. This was a regional study; only members of a particular professional society were surveyed; and the response rate was low. This study's Significant results can be summarized as follows. Most respondents accessed the literature to keep up with new developments and to answer particular clinical questions. Personal subscriptions and files, libraries, and clinical conferences were the most popular methods. Respondents on average relied on three psychiatric journals to keep up with the literature and, in general,
did not use computers or update services to remain current, although many reported being trained in the use of computers and two-thirds had personal or professional access to computers. The vast majority of respondents consulted the literature at least once each week and read from it between 1 and 10 hours per week. Finally, most respondents felt that the literature had a significant impact on their clinical practice. A number of these findings are similar to those of Bowden and Bowden (1) and Rockwell (2). This degree of concordance supports the view that, in general, methods used by psychiatrists to keep up with the literature have not changed significantly in the past 15 years. If true, this lack of change is disquieting given the vast expansion of the literature during this period. As Haynes et al. (3) have pointed out, it may be possible to stay current using such practices, but any approach to such a wide body of knowledge should be applied in a highly organized fashion. The results of this survey suggest that many psychiatrists have not yet developed an organized approach. This could be due to several factors, including lack of preparation for lifelong reading in medical school and residency education, constantly growing clinical workloads, and the increasing specialization of the literature. The results of the survey also suggest that psychiatrists use a relatively small number of sources for their continuing education. This may reflect confidence in the high quality and consistency of certain publications
TABLE 6. Rating of respondents' satisfaction with various aspects of the use of the literature Aspect of use of the literature
N
Rating
Resources available to keep up with the literature Impact of the literature on your clinical practice Knowledge of resources available to keep up with the literature Efficiency in keeping up with the literature Ability to keep up with the literature Time available to keep up with the literature
69 69 70 70 70 70
2.072±0.975 2.391±O.712 2.829±0.992 2.900±0.965 3.200±0.809 3.614±1.243
Note: Values are means±SD of rating given to each aspect of literature use, where 1 is very satisfied with this aspect of accessing the current literature and 6 is not satisfied.
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and in their ability to adapt to the changing field. On the other hand, it may represent lack of knowledge about alternative sources. Whatever the case, psychiatrists should consider expanding the number and variety of sources they read. At the same time these traditional printed sources should exercise leadership in encouraging such a change. For example, the major journals might include articles educating psychiatrists about keeping abreast of the literature by reading from a variety of sources. Nontraditional means of keeping up with the literature, such as computers and update services, have now corne into prominence. However, the respondents to our survey showed limited use of these tools, a result that was unexpected and is difficult to explain. Respondents might be unaware of the clear advantages of using computers, such as efficiency, low cost, the ability to search large volumes of information rapidly, and powerful cross-referencing capabilities. Alternatively, they may be inhibited by perceptions, perhaps inaccurate, of complexity or high cost. This question merits further research. In view of the literature's rapid rate of growth, more attention should be paid to finding objective and efficient ways of reviewing and summarizing it. Many such services exist, some of which are affiliated with academic institutions, while others are commercialized. As update services emerge as key tools for continuing psychiatric education, it may be beneficial for universities, professional societies, and peer-reviewed journals to become involved in their devel-
opment to ensure that commercial interests do not bias their content. Further research is needed to describe better how the literature is actually used and the advantages and disadvantages of each method of access. Surveys designed to answer these questions should be undertaken elsewhere in order to reveal regional, national, or international variations in psychiatrists' use of the literature. More detailed surveys, perhaps with larger samples, might show that psychiatrists of different "orientations" have different use habits. Furthermore, psychiatrists need to be educated about the relationship between these habits and their effectiveness in keeping abreast. Finally, psychiatrists should be informed about computer applications and continuing education strategies at the medical school and residency levels. We hope that in the future more effort will be directed toward these goals.
The authors thank the Johns Hopkins University Department of Psychiatry and Behavioral Sciences, especially Drs. P.R. McHugh and C. W. Schmidt, Jr., for their generous support of this project. We also thank the following librarians for their help in this study: Ms. Anne Fredenburg of the Sheppard and Enoch Pratt Hospital Library, Ms. Karen Huckeman of the University of Maryland Psychiatric Library, and Ms. Rebecca Satterthwaite of the Johns Hopkins Hospital Meyer Library. An earlier version of this paper was presented in a special session of the VIIIth World Congress of Psychiatry, Athens, Greece, October 1989.
References 1. Bowden Cl, Bowden VM: A survey of information sources used by psychiatrists. Bull Med Libr Assoc 1971; 59:603-608 2. Rockwell DA: Keeping up: reported journal readings of psychiatrists. JMed Educ 1974; 49:705-707 3. Haynes RB, McKibbon KA, Fitzgerald D, et al: How to keep up with the medical literature: I. Why try to keep up and how to get started. Ann Intern Med
,,>
1986; 105:149-153 4. Haynes RB, McKibbon KA, Fitzgerald D, et al: How to keep up with the medical literature: II. Deciding which journals to read regularly. Ann Intern Med 1986; 105:309-312 5. Haynes RB, McKibbon KA, Fitzgerald D, et al: How to keep up with the medical literature: m. Expanding the number of journals you read regularly. Ann
\
\
III \11 I , ' '\,l \11;11, I • ,->['[,I'\,\
1""1
i I \" -,( 1,\
InternMed 1986; 105:474-478 6. Haynes RB, McI
S
cientific progress has provided psychiatrists with an abundance of information for research and clinical purposes alike. However, this progress has created its own problems; keeping abreast of and sifting through a deluge of information can be time consuming and confusing. And, although there are adequate available sources of medical information, it is often difficult to know how to integrate them effectively and efficiently. It is therefore surprising that few attempts have been made to investigate how psychiatrists (and physicians in general) use the literature. Bowden and Bowden (1) made one of the first attempts to study psychiatrists' use of the literature. They surveyed 400 psychiatrists and found that journals were the primary information source for 58% of the respondents. Those surveyed read an average of 6.7 hours per week from 4.3 journals; 42% of the respondents used libraries monthly. The authors suggested greater use of abstracting services and review articles to manage the growth of medical knowledge. \(
\ I li \ 11 (
! ',> 'I ( I II \ I I, \
Alternative suggestions included increased use of audiotapes, indexes, and noncommercial review publications. In 1974, Rockwell (2) reported on the journal reading patterns of 220 psychiatrists. He found that 50% or more of respondents read several journals. The "average psychiatrist" surveyed read every issue of three journals and some issues of four additional journals. Some of the journals read by 50% or more of respondents included the American Journal of Psychiatry, Archives of General Psychiatry, the Journal of the American Medical Association, and Medical Aspects of Human Sexuality.
In 1986, Haynes et al. wrote a series of
From the Department of Psychiatry and Behavioral Sciences of the Johns Hopkins University School of Medicine, Baltimore, Maryland, where Dr. Hanson, Dr. Chisolm, Dr. McGuire, Dr. Ranen, Dr. Stoline, and Dr. Lyketsos are psychiatric residents. Address reprint requests to Dr. CG. Lyketsos, Department of Psychiatry and Behavioral Sciences, Meyer 143, Johns Hopkins University, Baltimore, MD 21205. Copyright@ 1991 Academic Psychiatry.
~
,
I I~ \,
~
I '\. t
,
I 1II ( I 1'\.1, '\ I 1''"' ') ( I II \ I 1-\ I ( 1 1I I 1< \ I l 1-\ I
six articles on using the medical literature (3--8). The authors proposed a three-step filtering method to improve reading efficiency. The first step suggested reading only original articles of structured clinical investigations. The second step suggested reading only articles with direct relevance to one's clinical practice. The third step suggested using the Methods section of an article as a screening tool to eliminate articles failing to live up to technical or scientific standards. The authors also proposed methods of expanding the breadth of reading, such as journal circulation clubs, regular library visits, and contact with selective dissemination of information services. Furthermore, the authors explored how to use the literature to solve a given clinical problem, the use of the computer to access medical literature, and a means of establishing a filing system for retrieved articles. As evidence of a new trend in tracking the literature, one entire article by Haynes et al. was devoted to the use of personal computers for literature searches. Although these articles were written for the general medical practitioner, the recommended techniques and suggestions apply TABLE 1. Demographic characteristics of respondents Characteristics Sex Male Female Age,yr 20-30 31-40 41-50 51~
61-70
>70 Marital status Single Married Divorced Widowed Separated Children at home Yes No
':
Number
Percent
64 18
78
4 24 23 12 15 4
5 29 28 15 18 5
8 60 6 1 7
10 73 7 1 9
50 32
61 39
22
to psychiatrists as well. In 1986, Scheidt et al. reviewed the various kinds of information access available to the phYSician by computer (9). The article provides details of start-up and maintenance costs associated with computer searches. The authors show how commercial databases differ in cost, time required in learning to use them, number and type of ancillary services available, number of journals searched, and the time between publication and inclusion in the service. The authors argue that the use of such technology provides physicians with rapid, personalized TABLE 2. Professional characteristics of respondents Characteristics
Number
Percent
Years since MD 22±15 Years since residency 16±13 Years of residency 3±t Type of residency, (N=77) University-affiliation 63 Non-university-affiliation 14 Fellowship, (N=78) Yes 32 No 46 Other residency, (N=78) Yes 8 No 70 Number patients/week, (N=82) 0-10 15 11-20 23 21-30 18 31-40 9 >40 16 Types of patients, (N=76) Adult 56 Child/ adolescent 4 Both 16 University affiliation, (N=79) None 33 Fulltime faculty 7 Parttime faculty 30 Resident 5 Other 4 Orientation, (N =70) Analytical 17 Behavioral 0 Biological 8 Cognitive 1 Eclectic 43 Other 1
82 18 41 59 10 90 19 28 22 11 20 71 5 24
42 9
38 6 5
24 0 11 1 61 3
Note: N=number of respondents.
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·,,,1
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access to several sources of information. Finally, commercially available update services are increasingly popular because they offer a quick update on psychiatric developments for busy practitioners. These services use a panel of experts to determine the most important or relevant articles appearing in the literature, which are then distributed to subscribers as a summary in a journal, on a cassette tape, or on a computer disk. Use of these services has not been reviewed in prior studies of this topic. Little is known about the methods psychiatrists actually use to keep up with the literature and the degree to which they feel able to access it effectively. We attempted to address these issues through a survey of members of a state psychiatric association. In addition, we were interested in the extent to which computers were available to and actually used by psychiatrists in their literature searches. METHODS Survey Our survey contained questions about demographics, education, professional interests, and literature use patterns. We asked respondents why and how they accessed the literature, whether (and how) they used computers to do so, and whether or not they were satisfied with their ability to access desired information. We field tested an earlier survey on psychiatric residents. The sur-
,'\.. ;
I
vey consisted of four pages and twenty-six questions that were either multiple choice or short answer in format. A copy of the final survey is available on request. Procedure The survey was mailed to a random sample of 200 members of the Maryland Psychiatric Society. Demographic and professional characteristics of respondents are presented in Tables 1 and 2, respectively. The survey was mailed under a cover letter explaining the purpose of the study. Recipients were asked to complete the survey within six weeks and to return it anonymously in a preaddressed stamped envelope. One month later, all recipients were sent a postcard reminding them to return the survey and providing them with the opportunity to receive a new copy if necessary. Analysis All survey results were coded and entered into a microcomputer file utilizing the Statview statistical package (10). RESULTS Sample Composition Eighty-six (43%) surveys were returned within the allotted time. Not all respondents answered each question. Two respondents refused to answer any questions, noting the
TABLE 3. Rating of reasons for accessing the literature Reason for accessing literature
N
Rating
To answer a particular clinical question To keep up with new developments To provide patient information To prepare for a clinical conference or round To prepare for a scientific conference or paper To satisfy CME requirements
76 76 70 70
2.066±1.100 2.066±1.268 3.500±1.164 3.629±1.524 4.338±1.780 4.609±1.4B7
68 69
Note: Values are means±SD of rating given to each reason, where 1 is the most important reason for accessing the literature and 6 is the least important.
TABLE 4. Rating of means of accessing the literature Means of accessing literature
N
Rating
Personal journal subscriptions and files Clinical rounds or conferences University or hospital library Source information (or articles) from colleagues Computer database Commercial update service of any kind
78 71 73 75 63 59
1.756±1.107 3.155±1.272 3.193±1.374 3.28O±1.247 4.365±1.790 4.576±1.694
Note: Values are means±SD of rating given to each method used to access literature, where 1 is the most important means of accessing the literature and 6 is the least important. TABLES. Patterns and means of use of the clinica1literature Number Frequency of literature consultation (N=78) Daily Two to three times a week Once a week Every two to three weeks Once a month Less than once a month Hours spent per week reading the literature (N=79) 10 Respondents with computer training (N=80) Yes No Respondents who own a computer (N=79) Yes No Respondents with professional access to computer (N=79) Yes No Frequency of computer use to access the literature (N=68) Daily Two to three times a week Once a week Every two to three weeks Once a month Less than once a month
Note: N=number of res
Percent
9 37 15 12 3 2
12 47 19 15 4 3
13 54 12 0
17 68 15 0
33 47
41 59
36 43
46 54
41 38
52 48
0 1 4 7 7 49
0 2 6 10 10 72
ndents.
survey was too long. Because the survey was anonymous, it was not possible to assess differences between respondents and nonrespondents.
Use Patterns Recipients were asked to rate on a sixpoint scale reasons why they might access the clinical literature; the results are presented in Table 3. Similarly, Table 4 shows the results of questions in which respondents were asked to rate means through which they access the literature. Table 5 summarizes patterns of literature use (including computer use). Table 6 presents respondents' level of satisfaction with several items related to their use of the literature. Finally, respondents were asked to describe the specific sources they used and to rank them. As a group, respondents regularly read 3.1±1.2 (SO) psychiatric journals. The American Journal of Psychiatry was ranked as the most important journal they read or browsed by 63 respondents; 5 respondents ranked the Archives of General Psychiatry as the most important. Of note, only one respondent reported not reading or browsing a psychiatric journal regularly. Thirty-three respondents reported subscribing to at least one medical nonpsychiatric journal. Of this group, one-third (11 respondents) subscribed to the New England Journal of Medicine and one-third to the Journal of the American Medical Association. Most respondents (64) reported using a psychiatric textbook regularly, with the Kaplan and Sadock Comprehensive Textbook of Psychiatry ranked as most important by 48 respondents. Finally, 23 respondents reported using a com-
II :,' ", ()\ ";'I \I I
mercial update service. Audio Digest (5 users), Psychiatric Update (4 users), the Harvard Newsletter (4 users), and Drug Alerts (3 users) were the most popular services used.
DISCUSSION Keeping up with the growing volume of information relevant to clinical practice has become a difficult task. Comprehensive, efficient, and targeted use of the literature requires flexible search strategies and multiple resources. The articles by Haynes et al. (3-8) and Scheidt et al. (9) are valuable guides in providing organized knowledge and ideas about accessing the literature in modern medicine. A careful examination of the literature reveals that few studies (none of them recent) have looked at psychiatrists' methods of accessing the clinical literature and maintaining a current knowledge base. This study sought to fill this void. The results, however, are difficult to generalize for several reasons. This was a regional study; only members of a particular professional society were surveyed; and the response rate was low. This study's Significant results can be summarized as follows. Most respondents accessed the literature to keep up with new developments and to answer particular clinical questions. Personal subscriptions and files, libraries, and clinical conferences were the most popular methods. Respondents on average relied on three psychiatric journals to keep up with the literature and, in general,
did not use computers or update services to remain current, although many reported being trained in the use of computers and two-thirds had personal or professional access to computers. The vast majority of respondents consulted the literature at least once each week and read from it between 1 and 10 hours per week. Finally, most respondents felt that the literature had a significant impact on their clinical practice. A number of these findings are similar to those of Bowden and Bowden (1) and Rockwell (2). This degree of concordance supports the view that, in general, methods used by psychiatrists to keep up with the literature have not changed significantly in the past 15 years. If true, this lack of change is disquieting given the vast expansion of the literature during this period. As Haynes et al. (3) have pointed out, it may be possible to stay current using such practices, but any approach to such a wide body of knowledge should be applied in a highly organized fashion. The results of this survey suggest that many psychiatrists have not yet developed an organized approach. This could be due to several factors, including lack of preparation for lifelong reading in medical school and residency education, constantly growing clinical workloads, and the increasing specialization of the literature. The results of the survey also suggest that psychiatrists use a relatively small number of sources for their continuing education. This may reflect confidence in the high quality and consistency of certain publications
TABLE 6. Rating of respondents' satisfaction with various aspects of the use of the literature Aspect of use of the literature
N
Rating
Resources available to keep up with the literature Impact of the literature on your clinical practice Knowledge of resources available to keep up with the literature Efficiency in keeping up with the literature Ability to keep up with the literature Time available to keep up with the literature
69 69 70 70 70 70
2.072±0.975 2.391±O.712 2.829±0.992 2.900±0.965 3.200±0.809 3.614±1.243
Note: Values are means±SD of rating given to each aspect of literature use, where 1 is very satisfied with this aspect of accessing the current literature and 6 is not satisfied.
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~
lin,
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IIII ( I I,I( \1 1''-,')( III \ 11';1, I I' il,"\ [ I\i
and in their ability to adapt to the changing field. On the other hand, it may represent lack of knowledge about alternative sources. Whatever the case, psychiatrists should consider expanding the number and variety of sources they read. At the same time these traditional printed sources should exercise leadership in encouraging such a change. For example, the major journals might include articles educating psychiatrists about keeping abreast of the literature by reading from a variety of sources. Nontraditional means of keeping up with the literature, such as computers and update services, have now corne into prominence. However, the respondents to our survey showed limited use of these tools, a result that was unexpected and is difficult to explain. Respondents might be unaware of the clear advantages of using computers, such as efficiency, low cost, the ability to search large volumes of information rapidly, and powerful cross-referencing capabilities. Alternatively, they may be inhibited by perceptions, perhaps inaccurate, of complexity or high cost. This question merits further research. In view of the literature's rapid rate of growth, more attention should be paid to finding objective and efficient ways of reviewing and summarizing it. Many such services exist, some of which are affiliated with academic institutions, while others are commercialized. As update services emerge as key tools for continuing psychiatric education, it may be beneficial for universities, professional societies, and peer-reviewed journals to become involved in their devel-
opment to ensure that commercial interests do not bias their content. Further research is needed to describe better how the literature is actually used and the advantages and disadvantages of each method of access. Surveys designed to answer these questions should be undertaken elsewhere in order to reveal regional, national, or international variations in psychiatrists' use of the literature. More detailed surveys, perhaps with larger samples, might show that psychiatrists of different "orientations" have different use habits. Furthermore, psychiatrists need to be educated about the relationship between these habits and their effectiveness in keeping abreast. Finally, psychiatrists should be informed about computer applications and continuing education strategies at the medical school and residency levels. We hope that in the future more effort will be directed toward these goals.
The authors thank the Johns Hopkins University Department of Psychiatry and Behavioral Sciences, especially Drs. P.R. McHugh and C. W. Schmidt, Jr., for their generous support of this project. We also thank the following librarians for their help in this study: Ms. Anne Fredenburg of the Sheppard and Enoch Pratt Hospital Library, Ms. Karen Huckeman of the University of Maryland Psychiatric Library, and Ms. Rebecca Satterthwaite of the Johns Hopkins Hospital Meyer Library. An earlier version of this paper was presented in a special session of the VIIIth World Congress of Psychiatry, Athens, Greece, October 1989.
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