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Information Skills for the Clinician or “feeling good about not knowing everything” 1 Evans Whitaker, M.D., M.L.I.S. Keck School of Medicine Norris Medical.

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Presentation on theme: "Information Skills for the Clinician or “feeling good about not knowing everything” 1 Evans Whitaker, M.D., M.L.I.S. Keck School of Medicine Norris Medical."— Presentation transcript:

1 Information Skills for the Clinician or “feeling good about not knowing everything” 1 Evans Whitaker, M.D., M.L.I.S. Keck School of Medicine Norris Medical Library Los Angeles, CA (323) stolen from Slawson, D.C., Shaughnessy, A.F., Bennett, J.H. (1994). Becoming a medical information master: feeling good about not knowing everything. Journal of Family Practice, 38(5),

2 Technology interlude Everyone get a “Turning Point” remote, Synchronize  Press “GO”  flashing red/green light  enter “4”, “1”, then “GO” again. Press “1/A”, yellow light = working. We will use this periodically today. Return remote to me or the bag at end of the session. Thanks! Add any feedback about Turning Point system on the evaluation form.

3 There is an evaluation form and a handout which includes: - Information search summary; - Table of information sources; - Table of PDA software; - Advanced Ovid Flow Sheet Please complete the evaluation forms so we can continue to improve! Thanks in advance. Shameless Library Plug Alert: Call, , IM your local medical librarian early and often!! Go to Norris homepage -- Click on the HELP link in right upper corner to reach us.http://www.usc.edu/nml ASK QUESTIONS!

4 Pretest

5 I use MeSH when I search MEDLINE? 1. Always 2. Usually 3. Occasionally 4. Never 5. What’s MeSH?

6 How comfortable are you with EBM? 1. Very comfortable 2. Comfortable 3. So-so 4. Uncomfortable 5. Very uncomfortable

7 My plan to keep up with new medical information is? 1. Look up things as they become relevant 2. Talk to colleagues 3. Use UpToDate 4. Attend medical conferences 5. I don’t have a plan yet 6. Other

8 My favorite source for clinical information 1. Google (Scholar) 2. MEDLINE 3. UpToDate 4. Harrison’s 5. Other

9 The Situation

10 Introduction Today’s topic…an approach to rapid information retrieval designed for clinical settings. As a clinician I use a practical approach to getting information – whatever works as long as the quality of the information is good. I will not spend time reviewing sources you already heard about in years 1 and 2.

11 Introduction 2 The Problem: There are many questions generated during the course of a clinical day. Numbers from research state 15/d or 2 questions per 3 patients seen (Covell, 1985). Clinicians have little time to search for information. Huge and growing volume of medical information to sort through (2 year doubling time). How to solve the problem? Have adequate baseline subject specific knowledge. Know your available information resources. Have the necessary technology and information skills.

12 Introduction 3 Today’s Session: We will discuss an approach to finding and using information in the course of your clinical practice. Objective: At the end of the session you will have heard one way to address this issue; you will have had a little practice with the resources.

13 Introduction 4 Of those 15 questions per clinical day, some are urgent, that is, the results will change the care of your patient, other questions are not so pressing and can be worked on at other times. Today we will focus on urgent questions. These questions require your ability to find valid, relevant answers in 1-5 minutes. Other questions can be noted down in a notebook to be examined later. (Take my word for it, as there is no literature to support this, you will not remember them otherwise.)

14 Point-of-Care Evidence Pyramid - with apologies to the EBM Evidence Pyramid “Raw” Primary Literature Opinions of Experts “Curbside Consult” Opinion of Colleagues Opinion of Colleagues --varying levels of experience and expertise --varying levels of experience and expertise Secondary“Predigested” Primary Medical Literature UpToDate, ACP Pier, Essential Evidence, Clinical Evidence Ovid EBM Databases, National Guideline Clearinghouse, TRIP database, SUMSearch OvidSP Basic Search A Very Traditional Source Another Very Traditional Source Traditional *

15 The Usefulness Equation A quasi-mathematical model of the value of information. (Relevance) x (Validity)‏ x (Size of Effect) (Work)‏ R -- Do the articles, findings and recommendations apply to your patient V – Are the findings true? Are they current? W – Usually synonymous with time, could be synonymous with money if you paid someone to do your research for you. S – How much effect will the intervention have on your patient? (this factor is included in some models)

16 Information Sources

17 Evidence at Clinical Speed - Sources Clinical Information Tools UpToDate – fast, easy, good quality. Is it evidence- based? Is it expert opinion? Does it matter? UpToDate Essential Evidence – previously InfoRetriever Essential Evidence ACP Pier Evidence-Based Medicine Sources Clinical Evidence – eResources, search “clinical evidence” to find Clinical Evidence Ovid EBM databases – Access via Databases  Ovid  select a database, remember Change Databases and Open And Re-execute to speed looking through Systematic Reviews, DARE, ACP Journal Club Ovid EBM databases National Guidelines Clearinghouse (guidelines.gov)-free National Guidelines Clearinghouse TRIP database (tripdatabase.com) - free TRIP database SUMSearch - free, metasearch, UT San Antonio, quirky SUMSearch

18 Google Scholar The library world’s “elephant in the room”* Good resource, like all “tools” it has its “best uses” Pros:  Scholar limits Google searches to “scholarly sites”  Familiar interface  Easy to use  Can link to USC resources (change “Scholar Preferences”) Cons:  Very wide range of quality, validity, currency – requires careful screening of materials  Exclusive users may miss the most valuable, powerful medical information tools *”an English idiom for an obvious truth that is being ignored or goes unaddressed” – stolen from Wikipedia (which is another pachyderm). We will deal with the Google-phant up front

19 Google Scholar -- 2 Uses (One librarian’s opinion):  To begin examining an unfamiliar area.  Can help find the “right words” to use in more specific search engines – Ovid, PubMed, etc.  Strengths: Searches full text of articles; finds non-MeSH terms, looks in places PubMed does not, occasionally finds full-text of articles that USC does not receive.  Weaknesses: Not specialized, care needed to evaluate results prior to using information, high “hit” volume.

20 Google Scholar -- 3 What is it good for?  To begin exploration of a new topic area  To find search terms Limitations  Too much information to sort.  Validity, currency, relevancy vary widely. Set Scholar Preferences for Library to USC on your home computer (full text links)

21 Scirus.com Massive database of “scientific websites” Produced by Elsevier – a huge publishing house – however it is claimed to free of bias?! – good in my experience Easy to use Material is better screened than Google Scholar, but still quite variable in quality Has many of the same uses as Google Scholar

22 OvidSP Basic Allows rapid “Google-like” searches. Make sure “include related terms” box is checked. ≥500 hits is the norm -- all the good ones in first 20 to 30 or so. If nothing good  reword your search. For this class only use Ovid training account: username: sci001; password: medical. Training account vs. Norris – Differences = no full text links, opens in Basic mode, limits, and history not expanded. Create a personal account to save searches and annotate articles.

23 OvidSP Basic Search Search for “ice cream headache” Click “Complete reference” and scroll to the Subject Headings. These can be selected and used to construct a precise search in Advanced Ovid. (ice cream/adverse effects?? – is there such a thing?) Ovid Basic allows combining searches and using limits.

24 TRIP Database (Turning Research Into Practice) tripdatabase.com tripdatabase.com Free EBM database. Checkered past –originally free, then by subscription, now free again, and much improved! Easy to use. EBM information, patient handouts and medical images. Try - “Ankle sprain” in EBM and patient handouts Try - “Ankle” in images Try - “Ottawa ankle” in EBM for X-ray decision rule

25 Hands on exercise 1: Lumps Two simple clinical scenarios follow… Copies of the scenarios are on your desks. Variant Exercise Set

26 Lumps 1 You have recently joined a private practice in a small city after completing your medical training and residency. You are in a group practice with 3 other family practitioners. You have just left the exam room after seeing a 34 y.o. woman who noticed a lump in her left breast while doing a self breast exam. You had added her into your already jammed schedule as she was “freaked out” according to your nursing assistant. Her last period was three weeks ago, cycles are regular 28d. Her maternal aunt died from premenopausal breast cancer. Your exam confirms a 1.5 cm smooth mobile non tender nodule in the upper outer quadrant of the right breast. Otherwise breast and axillary exam are normal for age. What do you do? You have two or three minutes while your patient dresses. You do not have a subscription to UpToDate, your books are still in a box at home, your partners all took vacation for 2 weeks when you started work, and your parents are not doctors.

27 Lumps 2 Same clinical setting as “Lumps 1” 67 y.o. male in for routine exam. He has no health concerns, no significant past medical history. His wife “made him come in.” Incidentally discovered on exam is a 1.2 cm non-tender nodule low in the anterior neck, slightly to the right of midline. You think this is located in his thyroid gland. You point it out to your patient and he states he never noticed anything, and in fact isn’t sure he feels it now. What do you do? Same information dearth as before.

28 This is where you get to do something!! Divide into groups of 2-3. One half of room gets neck nodule, other half gets breast lump. No UpToDate, limit resources to other electronic sources at Norris Medical Library. You have 6 minutes to come up with a plan. I want to know the plan, what resources you drew on to make your plan. How reliable is your information? What else would you like to know? Each group presents -- pick a spokesperson, we’ll discuss afterwards.

29 Points of Discussion Breast Patient is premenstrual, aunt’s hx does not appreciably increase risk. SBE finding most common reason for visit to PCP for breast lump evaluation. Waiting until 3-10d post next menses is reasonable, although this kind of waiting and re-exam is only specifically mentioned in one guideline I found. Persistent nodule merits aspiration, consideration of US, Mammography, referral to Surgery (or OB/GYN, depending on community). Breast cyst aspiration is potentially a primary care procedure. Answers found in UTD, EE, ACP Pier, NGC, Multi- eBook search, etc.

30 Points of Discussion 2 Thyroid 4-7% of population have thyroid nodules (Mazzaferri, E.L.,1993). There is an increased cancer risk in those >60 y.o. Cancer risk is 75% of those with thyroid nodules, but when men have a nodule they have a higher risk of cancer. This patient is asymptomatic. Bottom line is that FNA needs to be performed by experienced practitioner. Many recommend TSH or ultrasound before FNA. Although that is debated. Answers once again are found in multiple sites. The answers are essentially consistent with one another.

31 Other things you could try…for these two questions… In Ovid, there are no useful answers in the 3 EBM databases – Database Systematic Reviews, DARE, and ACP Journal Club. Clinical Evidence from BMJ has a nice summary of thyroid nodules. Free EBM information is available from:  TRIP (Turning Research Into Practice) was a subscription service from Now free.http://www.tripdatabase.com/index.html  Agency for Healthcare Research and Quality (http://ahrq.gov/) and U.S. Preventive Services Task Force (http://www.ahrq.gov/clinic/uspstfix.htm).http://ahrq.gov/http://www.ahrq.gov/clinic/uspstfix.htm National Guidelines Clearinghouse (http://guideline.gov/ ) has good EB summaries of both entities.http://guideline.gov/ FPIN (http://www.fpin.org ) Family Physicians Inquiries Network is a “national, not-for-profit consortium of academic family physicians, family medicine residency programs and departments, medical librarians, informaticians, computer scientists, other primary-care providers and consultants dedicated to using information technology to improve healthcare.” FPIN has a searchable collection of questions from family practitioners and answers from FPIN-member FP residencies, medical libraries, etc. This is an organization for institutions. Search here did not yield useful results. USC is not affiliated. Cost is $ to do so.http://www.fpin.org

32 Other things…philosophical It is OK to tell your patient that you don’t know the answer to their question or problem, and that you will get back to them with information and a plan. Of course, only make this pledge if you will get back to them! This gives you the time necessary to make a reasoned plan, by consulting information sources, talking to other healthcare providers, etc. It also allows you to (more or less) stay on schedule. Limit how often you do this to avoid interminable days, and too many loose ends. Patients are surprisingly accepting of the admission that you need to research, think and discuss their case before making a plan. Set an agenda for yourself to get back in touch with your patient and follow through on it. Some clinicians re-schedule patients for a day to a week to “guarantee” closure.

33 Hands-on interlude 2: Blood Similar to the Lumps exercise. Stay in your same groups. All information sources are available for use this time, including UpToDate, OvidSP, Dr. Woehrle, and your parents.

34 Blood Two problems: First 50 y.o. man in for routine exam requests PSA testing. Father with prostate cancer at 75 y.o. Prostate exam (DRE) normal today. Wants free and total PSA. What do you tell him? What is your advice based on?

35 Blood 2 Second 49 y.o. woman with fasting blood sugar of 128 on routine testing. Father with type 2 diabetes diagnosed in his 60’s. Recent physical exam normal except BMI of 27. What do you do? Find one or more sources to justify your answer.

36 Would you order his PSA? 1. Yes, he wants it and evidence supports the decision. 2. Yes, he wants it, “the patient is always right”. 3. Unsure. 4. No, evidence does not support ordering it.

37 Does she have diabetes? 1. Yes 2. No 3. Not sure

38 Discussion -- PSA “Contentious issue” Other sources mention since science is unclear, the decision is best based on your discussion with your patient. The sentiment above ignores cost aspects. If not clearly effective should we spend national healthcare dollars here? We in the US are used to getting what we want, including medical care. Can we continue in this mode?

39 Discussion - hyperglycemia This woman may have diabetes. Two readings of ≥ 126 on a fasting specimen, or 2 random sugars ≥ 200, or a value ≥ 200 during a 3 hour, 75g OGTT is considered diabetes. This is almost certainly type 2 diabetes. How would you manage this woman – drugs, diet, exercise?? This will be the beginning of a patient education interaction in which treatment plans are made, follow up is arranged…

40 How to stay afloat in the deluge…some ideas Subscribe to eTOCs for chosen journals to or RSS (example NEJM or JAMA)NEJMJAMA Save searches about topics of interest to you in Ovid or PubMedOvidPubMed Updates from Faculty of 1000-MedicineFaculty of 1000-Medicine Check “What’s New” at UpToDateUpToDate Those who attended 8/19 please see additional information in the notes area below

41 Changing topics…. Need more voting from you all…

42 Do you want to hear a bit about PDAs? 1. Yes 2. No

43 Do you now use a PDA? 1. Yes 2. No, but I plan to. 3. No

44 PDA users… What do you use? 1. Smartphone, not Blackberry 2. Blackberry 3. PDA – Palm OS 4. PDA –Windows Mobile or PPC 5. SymbianOS based 6. Other

45 What medical software do you use on your PDA? What other medical software for PDA do you recommend? What other medical PDA software do you recommend? What do you like about it? s/sub_127.php 1. Essential Evidence 2. Epocrates 3. UpToDate 4. ACP Pier 5. Other

46 PDA Introduction

47 Information “Technologies” Once you are in your own clinical practice, you will find that your information resources boil down to: Tech -- Desktop, Laptop, PDA/SmartPhone Print materials --Textbooks, Drug References, Journals, “Throw-aways”, etc. Human -- Other Medical Professionals We will briefly discuss PDA’s today.

48 PDAs PDA’s date from the mid-90s; they were not more than electronic calendars/rolodexes At this point most users want a device that can “do it all”. The SmartPhone takes care of phone, , pager, web browsing, plus more traditional PDA tasks of providing drug information, clinical guidelines, performing calculations, organizing addresses and keeping track of your calendar.

49 PDAs 2 This is a rapidly changing area for which I will not even try to provide specifics. OSs are Palm, Windows Mobile/PPC, RIM (BlackBerry), and Symbian (open-source handheld OS). PalmOS has the largest amount of software. Vast amounts of freeware/shareware. WindowsMobile (PocketPC) has caught up on commercial side. Freeware and shareware limited. BlackBerry offerings are rapidly increasing, making this a much more attractive offering. Little free/share ware Symbian is making inroads in US.

50 Point of care clinical information software for PDA

51

52 Wrap Up

53 Strategy for finding clinical answers “on the fly” during FP Rotation -1 Norris home page - starting point for all information seeking during your USC career. Bookmark it! USC Username and Password, when prompted by Remote Access Portal. First look in UpToDate. If off-campus  ACP Pier, Essential Evidence, Clinical Evidence. Enter one central concept; scan results; select best match. Study: ACP Pier, InfoRetriever (now Essential Evidence), UpToDate, FirstCONSULT, and DISEASEDEX were compared (Campbell, 2006). The 18 participant were each given 3 clinical questions, and given 3 minutes to answer each question. Results showed that users found significantly more answers with UTD than other products. They heavily preferred UTD interface, and felt more confident about the results from UTD!

54 Strategy… 2 If you are not finding what you want in the clinical information tools… Try OvidSP Basic Search. You may be able to find a paper, scan it for information within a short time frame. Consider Ovid EBM sources or Tripdatabase? Use GoogleScholar, Scirus.com for failures of more specific biomedical sources.

55 Thanks for your attention!! Please fill out evaluations before you leave! Feel free to contact me if you have information questions.

56 References Adair, R.F., Holmgren, L.R., (2005) Do drug samples influence resident prescribing behavior? A randomized trial. American Journal of Medicine, 118, Barry, H.C., Ebell, M.H., Shaughnessy, A.F., Slawson, D.C., Nietzke, F. (2001). Family physicians’ use of medical abstracts to guide decision making: style or substance? Am Board of FP, 14(6), Campbell, R. (2006). An evaluation of five bedside information products uisng a user-centered, task-oriented approach. J Med Lib Assoc, 94(4), Covell, D.G., Uman, G.C., Manning, P.R. (1985). Information needs of office practitioners: are they being met? Annals of Internal Medicine, 103, Guyatt, G., Rennie, D. (2002). Users’ Guides to the Medical Literature: Essentials of Evidence-Based Clinical Practice. Chicago: AMA. Greenhalgh, T. (2006). How to read a paper: The basics of evidence-based medicine, 3 rd ed. Malden, MA: Blackwell. Mazzaferri, E.L. (1993). Management of a solitary thyroid nodule. N Engl J Med, 328, Michaud, G., McGowan, JL., van der Jagt, R., Wells, G., & Tugwell, P. (1998). Are therapeutic decisions supported by evidence from health care research? Archives of Internal Medicine158(15), Shaughnessy, A.F., Ebell, M.H., Slawson, D.C. (2008). Information mastery: Basing care on the best available evidence. In Essentials of Family Medicine, 5 th ed. Philadelphia: Wolters. Slawson, D.C., Shaughnessy, A.F., Bennett, J.H. (1994). Becoming a medical information master: feeling good about not knowing everything. Journal of Family Practice, 38(5), Slawson, D.C. (2005). Teaching evidence-based medicine: should we be teaching information management instead? Acad Med, 80(7),


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