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Jeremy C Wyatt
93 pp Price £12.95 ISBN 1-85315-483-0 (p/b)
London: RSM Press, 2001 .
First come I; my name is Jowett;
There's no knowledge but I know it.
I am master of this College;
What I don't know isn't knowledge.—Balliol Rhymes
Jowett was regius professor of Greek at Oxford and master of Balliol in the 1870s. He had a brilliant memory and intellect which he applied only to the things that interested him—though his interests were broad. His students and colleagues wrote the rhyme with just a little irony, and much admiration.
Each branch of medicine has its modern-day Jowetts, whose advice is sought in the most difficult cases. But we are all in the ‘knowledge industry’. Can the rest of us (and the organizations in which we work) do anything to keep ahead of what Wyatt calls the tidal wave of new data? Or are we doomed to become increasingly out of date as we get older? Wyatt mentions a randomized study in which Canadian doctors were sent (in fourteen weekly instalments) an education pack about the management of hypertension. The best predictor of the target doctors' subsequent decisions about antihypertensive treatment was their year of qualification, not whether or not they had received the pack. Perhaps most doctors do not read unsolicited information, do not believe things they read from an unfamiliar source, or are unconvinced about the need to change.
Wyatt is director of the Knowledge Management Centre at the School of Public Policy in London. He is a physician with a longstanding interest in medical informatics, and his ten articles on ‘knowledge for the clinician’ appeared monthly in JRSM from April last year. These are the basis for Clinical Knowledge and Practice in the Information Age: the chapters appear in a slightly different order from the original articles, a preface and index have been added, and Sir Michael Peckham has written a foreword (mentioning that the Government recommends the creation of a National Health Informatics Forum—something which I expect Wyatt to be headhunted for).
Wyatt is a convincing advocate for the problem-based approach, ‘which means finding solutions to clinical problems at the time they arise, or soon after, with minimum effort. It means looking up the answer whenever we are unsure about what happened or what to do. It means transferring CME [continuing medical education] from an intensive two hours a week (or a few days a year) to a minute here, three minutes there... it emphasizes problem solving... such as how to find relevant answers fast—not the learning of facts’. If the answer cannot be found immediately, he recommends various actions (including eventually, if still unsuccessful, quietly moving on to something else). He also recommends that we occasionally look things up even when we think we do know them, since we may well find that we were very wrong.
Wyatt analyses the pros and cons of various information sources including published guidelines, textbooks, journals, electronic databases, multimedia packages, the Internet, local intranets and colleagues. Each is discussed in an illuminating way, with many highly quotable nuggets of information. Did you realize that, as a matter of public policy and to encourage the dissemination of knowledge, book authors and publishers are ‘never’ found liable for negligence due to errors, but that guideline writers (and people who blindly follow inappropriate guidelines) may be? Or that, even after finding the relevant ‘page’, it takes 40% longer to read something on-screen than to read it from paper? Or that abstracts disagree with the actual journal article in almost 30% of cases? As if by example, I was disappointed to see that one of my favourite nuggets—the assertion that general practitioners receive 15 kg of guidelines alone each year—is not substantiated in the original paper.
In other sections of the book, Wyatt discusses decision support systems, barriers to change, ways to improve the quality of patient information, and (briefly) patient-held electronic medical records. The latter should be a great timesaver, since we spend so much time asking patients the questions they have already been asked by other doctors.
The book is well-referenced throughout, often referring to journals available online. This, and the discussions of many intriguing online information sources, means that you will probably want to be near a computer when you first read it. At the moment, of course, you can access Wyatt's articles on JRSM's website. I'm sure he would approve, but the printed handbook is much more convenient for frequent use. Order extra copies of this thought-provoking book for your information and technology department, your librarian, and (if they have been slow in funding the necessary infrastructure) your business managers.