Information Skills for the Clinicianor “feeling good about not knowing everything”1

Evans Whitaker, M.D., M.L.I.S.Keck School of MedicineNorris Medical LibraryLos Angeles, CA 90089-9130ewhitake@usc.edu; (323) 442-1128

1stolen 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), 505-517.

SHAMELESS LIBRARY PLUG:Call, email, IM your local medical librarian early and often!!Go to Norris homepage -- http://www.usc.edu/nml. Click on the HELP link in right upper corner to reach us.

ASK QUESTIONS!

Introduction• No EBM today…previous groups felt they knew

enough• Pick up (3) handouts and (1) evaluation form• Time is cut by 15 minutes – we will move briskly• As a long-time 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 from1st and 2nd year

• At the end of the session please complete the evaluation forms -- so we can continue to improve!

• Thanks in advance

I believe I need more training in Evidence-Based Medicine…

0% 0% 0%0%0%

1. Strongly Agree

2. Agree

3. I’ve had about the right amount

4. Disagree

5. I’ve had too much already!

How comfortable are you with EBM?

0% 0% 0%0%0%

1. Very comfortable

2. Comfortable

3. So-so

4. Uncomfortable

5. Very uncomfortable

I search MEDLINE (PubMed/Ovid)…

0% 0%0%0%

*The second full moon in a calendar month, happens about once every 2.5 years

1. Weekly or more frequently

2. Once a month

3. Once in a blue moon

4. Never

I use MeSH when I search MEDLINE (Ovid, PubMed)…

0% 0%0%0%

1. Always

2. Sometimes

3. Never

4. What’s MeSH?

MeSH Medical Subject Headings Collects all synonyms for a term/ concept

under one agreed-upon (by NLM) term Example: heart attack, MI, myocardial

infarction Searches using MeSH retrieve more articles

than those using title or text words Scope Note and Tree help find right term Expand, Focus, Subheadings, and Limits

are all much less important

When I search MEDLINE…

0% 0%0%0%

1. I am confident I will find what I want (or know the information doesn’t exist)

2. I usually find something useful

3. I sometimes find useful material, but almost always wonder what I am missing.

4. I am not confident searching Ovid/PubMed, I’ll stick with UpToDate!

Preferred source for clinical information?

0% 0% 0% 0%0%0%0%

1. eMedicine

2. Google (Scholar)

3. AccessMedicine

4. UpToDate

5. MEDLINE

6. Wikipedia

7. Other

Introduction 2

Today’s Session:• Discuss an approach to finding and using

information in the course of your clinical practice

Objectives: • At the end of the session you will o have heard one way to address this issueo have had a little practice with the resources.

Introduction 3 The Problem:

• Too many questionso 15/d or 2 per 3 patients seen = number of questions

generated in a clinical day (Covell, 1985)• Not enough timeo Little time to search for information

• Expanding universeo 2 year doubling time on biomedical information

How to solve the problem?• Have adequate baseline subject specific

knowledge• Know your information resources• Develop good technology and information skills.

Introduction 4

• Of those 15 questions per clinical dayo a few are urgent - the results will change the care of

your patiento other questions can wait for answers

• Today we will focus on urgent questions.o require the ability to find valid, relevant answers in 1-5

minutes• The other questionso write them down for latero (you will not remember them otherwise)

Where do we get this quick information?Point-of-Care Evidence Pyramid(with apologies to the EBM Evidence Pyramid)

“Raw” Primary Literature

Opinions of Experts“Curbside Consult”

Opinion of Colleagues--varying levels of experience and expertise

PredigestedPrimary Medical

Literature

UpToDate, ACP Pier, Essential Evidence, Clinical EvidenceOvid EBM Databases, National Guideline Clearinghouse, TRIP

database, SUMSearch

OvidSP Basic Search

                

A Very Traditional Source

Another Very Traditional Source

*

Evidence at Clinical Speed

From Y1 and Y2 (will not repeat today) UpToDate ACP Pier Essential Evidence Clinical Evidence National Guideline Clearinghouse

New today GoogleScholar Scirus.com Ovid Basic Search TRIP Database

Clinical Information Tools

Google Scholar• The library world’s “elephant in the room”*• Good resource, like all “tools” it has its “best uses”• Pros:

o Scholar limits Google searches to “scholarly sites”o Familiar interfaceo Can link to USC resources (change “Scholar

Preferences”)o "Sensitive" - searches full text of articles

• Cons:o Wide range of validity, currency, relevance – requires

careful screening of materialso Exclusive users miss the most specific, powerful

medical information toolso Not "specific" - includes articles not truly related to

topic

*”an English idiom for an obvious truth that is being ignored or goes unaddressed” – stolen from Wikipedia (which is another pachyderm).

Google Scholar

• What is it good for?o To begin exploration of a new topic areao To find search terms• Limitationso Too much information to sorto Validity, currency, relevancy vary widely• Thing to know: o Set Scholar Preferences for Library to "University of

Southern California" on your home computer (full text links)

Scirus.com

• Massive database of “scientific websites”• Product of Elsevier• Material is better screened than Google

Scholar, but still variable in quality• Same uses as Google Scholar• Can set library preferences like GS

OvidSP Basic

• Rapid “Google-like” searches• “Include related terms” must be checked• ≥500 hits is the normo “Good ones” in first 20 to 30 hitso Nothing good?  reword your search or go to Advanced

• For this class only use Ovid training account:o http://ovidsp.ovid.com o username: sci001; password: medical

• Create a personal accounto save searcheso have new articles from saved searches sent to youo annotate articles

OvidSP Basic Search

• Search for “laparoscopic colectomy”• “Complete reference” of a good article

• “MeSH Subject Headings” -- can be used to construct a search similar to Advanced Ovid Search

• Example • Ovid Basic

• can combine with AND or OR • can use limits

TRIP Database (Turning Research Into Practice) tripdatabase.com 

• Free EBM database• Information pulled from multiple sources• Lacks full text links• Keyword searches• Contains:o EBM informationo patient handoutso medical images

• Try - “Ottawa ankle rules” in EBM for X-ray decision rule

Hands on exercise 1: LumpsTwo simple clinical scenarios follow…

Copies of the scenarios are on your desks.

Lumps 1

• 34 y.o. woman G1 P1 L1 (1.5 year old girl) noticed a lump in her left breast while doing a self breast exam.

• Menarche 12.5Y• Her last period was three weeks ago, cycles are regular 28d. No

hormonal medications.• FMHx: Maternal aunt died from premenopausal breast cancer.• PE: Your exam confirms a 1.5 cm smooth, mobile non-tender nodule in

the upper outer quadrant of the left 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.

Lumps 2

• Same clinical setting as “Lumps 1”• 67 y.o. male in for routine exam. He has no health

concerns, no current symptoms, no significant past medical history. His wife “made him come in.”

• PE: 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.

In-class Assignment 1

• Divide into groups of 2-4• One half of room gets neck nodule, other half gets breast

lump• No UpToDate, use electronic sources at Norris Medical

Library• You have 6 minutes to come up with a plan. • I want to know o The plano What resources you drew on to make your plano How reliable is your information? o What else would you like to know?

• Each group prepare to present...o Pick a spokesperson, we’ll discuss afterwards.

Points of Discussion -- Breast

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. "Triple-test"

• Answers found in UTD, EE, ACP Pier, NGC, Multi-eBook search, etc.

Points of Discussion -- Thyroid

Thyroid• 4-7% of population have thyroid nodules (Mazzaferri, E.L.,1993)• Increased cancer risk in those >60 y.o. • Overall cancer risk in a given nodule is <5%. • Women constitute >75% of those with thyroid nodules; men

have higher risk of cancer in a given nodule• This patient is asymptomatic• Bottom line is that FNA needs to be performed by experienced

practitioner. Many recommend TSH or ultrasound before FNA. That is debated

• Answers found in multiple sites. The answers consistent with one another

Other things…philosophical

• It is OK to tell your patient that you don’t know the answer...• Tell them you will investigate and get back to them• Do not forget to follow up!!

• Set an agenda for yourself to get back in touch with your patient and follow through on it. 

• Some clinicians re-schedule patients a day to a week later to “guarantee” closure.

Hands-on interlude 2: Blood

Similar to the Lumps exercise. Stay in your same groups.

Try using different resources this time, continue to stay away from UpToDate!

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?

Blood 2

Second• 47 y.o. woman requesting BRCA1/2 genetic

testing. She is a mother of 2 and healthy.• Mother and older sister with breast cancer --

both before menopause. Neither family member has been genetically tested.

• Do you order the test?

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.

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Discussion -- PSA

• “Contentious issue”• The science is unclear discuss pros/cons

with your patient informed decision• What about cost aspects?

• If not clearly effective should we spend national healthcare dollars here?

• In the US the “haves” get what we want• The “have nots” don’t get basic medical care• Can we continue in this mode?

Would you order BRCA testing on your patient?

0% 0%0%

1. Yes

2. No

3. Unsure

Discussion – BRCA testing

• This woman has a high risk family history – raised her lifetime risk from US average of ~11% to ~25%

• She is at increased risk of carrying a BRCA mutation – 5% have the mutation

• If she has BRCA mutation risk is ~65-80%• The consensus seems to be that she should be referred

for genetic counseling• To understand the implications of testing (insurance, cost, etc.)• To consider asking her family members to be tested• To consider whether knowing the result changes anything about:

– screening– consideration of chemoprevention– prophylactic mastectomy, etc.

Changing topics….

• PDA’s … an opinionated view

Do you now use a PDA or “smart phone”?

0% 0%0%

1. Yes

2. No, but I soon plan to

3. No

PDA users...what do you use?

0% 0% 0% 0%0%0%0%0%

1. Smartphone, not Blackberry or iPhone

2. Blackberry

3. iPhone

4. SymbianOS device

5. Google Android

6. PDA - PalmOS

7. PDA – Windows Mobile or PPC

8. Other

Favorite medical software for your PDA?

0% 0% 0%0%0%What other medical PDA software do you recommend?What do you like about it?http://www.usc.edu/e_resources/hsl/lists/sub_127.php

1. Epocrates

2. Essential Evidence

3. UpToDate

4. ACP Pier

5. Other

Assumptions

One gadget is better than two

Availability of medical software is

driven by demand for the device

Browsing capability is important

Choose a company with a future

Smartphone

Blackberry, iPhone

are ascendant

As above

As above

Blackberry vs. iPhone

•True keyboard (except Storm)

•3G connectivity•microSD card storage 1-2GB•Medical applications now, many more to come

•Bold $299 (with current discount) and $40/mo. phone, $30/mo. Data

•Several service providers•“What you need”

•Touch screen “keyboard”with “intelligent fill”

•3G connectivity•8 vs. 16 GB (iTunes fxn.)•Medical applications few at present, with unclear plans to encourage development in the future•iPhone 3G 16GB $299, with same mo. Costs

•Must switch to AT&T•“What you want”

Review of Reviews Reviewers complained about slow typing/

high error rate with iPhone vs. BlackBerry Reviewers felt that all other aspects seemed

similar (and good) Noted on recent poll that 79% iPhone users

were “very satisfied” or better, vs. 54% of BlackBerry users

Reviewers felt that Apple planned to tightly control software development – unknown future for new medical products. BlackBerry software development moving rapidly.

Wrap Up

Strategy…1• Bookmark Norris home page - starting point for all

information seeking during your USC career

• First• UpToDate

• (Off-campus? … • Use ACP Pier, Essential Evidence, Clinical Evidence)

• Enter one central concept; scan results; select best match.

Interesting 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!

Strategy…2• If you are not finding what you want in the

clinical information tools…

• Second Option• OvidSP Basic Search

• You may be able to find a paper, scan it for information within a short time frame.

• OR• Consider EBM sources

• Tripdatabase.com OR Clinical Evidence

• Third Use GoogleScholar, Scirus.com for failures of more specific biomedical sources.

Thanks for your attention!!

• Please fill out evaluations before you leave!

• Feel free to contact me if you have information questions.

References• Adair, R.F., Holmgren, L.R., (2005) Do drug samples influence resident prescribing behavior? A randomized trial.

American Journal of Medicine, 118, 881-884.• Allison, J.J., Kiefe, C.I., Weissman, N.W., Carter, J., Centor, R.M. (1999). The art and science of searching MEDLINE to

answer clinical questions: Finding the right number of articles. Intl J Tech Assess in Health Care, 15(2), 281- 296.

• 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), 437-442.

• Campbell, R. (2006). An evaluation of five bedside information products using a user-centered, task- oriented approach. J Med Lib Assoc, 94(4), 435-440.

• Covell, D.G., Uman, G.C., Manning, P.R. (1985). Information needs of office practitioners: are they being met? Annals of Internal Medicine, 103, 596-599.

• 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, 3rd ed. Malden, MA: Blackwell.

• Mazzaferri, E.L. (1993). Management of a solitary thyroid nodule. N Engl J Med, 328, 553-559. • 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),1665-1668.• Shaughnessy, A.F., Ebell, M.H., Slawson, D.C. (2008). Information mastery: Basing care on the best available

evidence. In Essentials of Family Medicine, 5th 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), 505-517.• Slawson, D.C. (2005). Teaching evidence-based medicine: should we be teaching information management

instead? Acad Med, 80(7), 685-689• Wilczynski, N.L., Walker, C.J., McKibbon, K.A., Haynes, R.B. (1995). Reasons for the loss of sensitivity and

specificity of methodologic MeSH terms and textwords in MEDLINE. Proc Annu Symp Comp Appl Med Care, 19, 436-440.