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, 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 sourceReportedObserved Print sources6227 General and specialist textbooks 253 Pharmaceutical textbooks149 Journals187 Drug company information11 Self made compendia47 Human sources3353 Specialist doctors1824 Generalist doctors11 Office partner34 Pharmacist63 Other5 21

Research on doctors’ information needs: Osheroff et al, 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, “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?

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?

Less than 1% 1%- 10% 11%- 50% 51%- 90% More than 90% Amount read Percentage Series2 Series1

Current problems Do you feel guilty about how much or how little you read?

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 Overwhelming Overwhelming Overwhelming 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?

Reading of Bristol general practitioners

How far behind are you with your reading? Number of journals New articles a week Time to read article30 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

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 physicians in US 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