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 “non-generalised 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 ObservedPrint sources 62 27General and specialisttextbooks 25 3

Pharmaceutical textbooks 14 9Journals 18 7Drug company information 1 1

Self made compendia 4 7

Human sources 33 53Specialist doctors 18 24Generalist doctors 1 1Office partner 3 4

Pharmacist 6 3Other 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 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 perconsultation

Covell et al1985

Doctors offices 47 primary caredoctors

After visitinterview

0.66

Timpka et al1990

Four Swedishhealth centres

12 generalpractitioners

Videos ofconsultations

1.85

Osheroff et al1991

Universitybased internalmedicine

24 physiciansand medicalstudents

Anthropologicalobservation

5.77

Ely et al1992

Doctors offices 34 familyphysicians

Observation 0.07

Gorman et al1994

Doctors offices 49 familydoctors

After visitinterview

0.57

Guise et al1994

AIDSoutpatient clinic

7 healthprofessionals

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?

00.10.20.30.40.5

Less

than 1%

1%-10%

11%-

50%

51%-

90%

More

than

90%

Amount read

Per

cen

tag

e

Series2

Series1

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 poet’s 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 theircareer

Median readingtime (minutes)

% who reportedno reading in theprevious week

Medical students 90 0

House officers 0 75

Registrars 60 40

Consultants whograduated since1975

45 30

Consultants whograduated before1975

30 40

Reading of Bristol general practitioners

Activity Minutes

Reading in the library 35

Driving to and from thelibrary

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

J ournal articles Low High Nil High Low

Textbook Medium Medium Nil Medium Medium

Colleague High Medium High Low High

What’s wrong with medical journals

• 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 journals

• 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 journals

• Don’t reach the developing world• 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 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 won’t be easy and will take time, money, and

culture change