Primary care physicians only try to answer a limited number of their clinical questions, and, when they do, they first consult colleagues and paper sources. This practice has not really changed through the years, despite the greater availability of and better access to electronic sources of information. One of the main difficulties primary care physicians report when looking for electronic information is the amount of time it takes. The same barrier is identified for using computerized decision support systems [31
] and computerized guidelines [32
]. In spite of all, it has been shown that answers can be found to a substantial number of clinical questions from primary care. Primary care physicians also experience difficulties with formulating a good search question, finding an optimal search strategy, and interpreting found evidence.
Clinical librarians take on a more proactive role, where, under the authority of the primary care physician, they read and filter information and create structured syntheses. Some primary care physicians would rather receive these evidence-based summaries than develop search skills themselves. However, not every primary care physician has this service available, and, in some cases, when available, usage levels are somewhat disappointing.
One limitation of the included studies and thus of this review is that the expected positive effects of searching the literature for clinical questions is mainly based on self-reports. No empirical reports are available that show that consultation of literature leads to a lasting change in professional behavior for primary care physicians or to better patient care. The lack of this information is a serious problem, because primary care physicians increasingly have to take into account clinical effectiveness, cost-effectiveness, and value of interventions for their patients.
They also have to cope with patients who themselves more often look for medical information on the Internet and ask the primary care physician to help interpret this information [33
]. An important way to accommodate these conflicting demands is to answer clinical questions adequately [34
What can be done when a substantial portion of the answers do exist but are not sought? Although the information needs of the primary care physician constitute more than specific clinical information—support, confirmation, or approval—we limit ourselves here to clinical information. Busy primary care physicians are described as overloaded with information and often unable to answer their patients' questions. Doctors seem well aware of this gap in their knowledge, but acquiring the information takes time and hinders the patient flow. The obvious practical advantage of “opinion-based medicine,” however, blocks professional growth and probably has a negative effect on patient care [35
The big problem is to get adequate answers fast. By adequate, we mean valid, convincing, and relevant to primary care. Can this problem be solved? Three possibilities seem available.
“The stamp collection”
Many authors recommend formulating short and to-the-point questions, in other words, according to the Patient–Intervention–Comparison–Outcome (PICO) model [36
]. Others, however, want primary care physicians to ask what they want to know
rather than adapt their questions to the available evidence. A step in the right direction would be to systematically register clinical questions and organize these in a database. The Family Practice Inquiries Network <http://www.fpin.org
> is an example. Instead of blindly adding to an already overwhelming amount of information, information needs should be documented [35
Arguments against such a “stamp collection” are that they would probably be used only by a small number of doctors and that the application of a question to any particular patient would still be limited.
Objections to this approach are the high aggregation level of research outcomes, the limited relationship of these outcomes to the specific problems of specific individuals, and the interpretation of margins of uncertainty.
The third possibility is mediation by a clinical librarian or similar service, which means that the labor intensive part of searching is taken over by a primary care supporter who functions proactively and reads, filters, and synthesizes. The information, however, is asked
by primary care physicians at the moment and in the way they want it. The support of a clinical librarian could partly be given by a query tool like ask
>, which shows a promising efficiency [37
Because searching the literature might be faster, cheaper, and sometimes more useful than other procedures such as a blood test or scan, it has been advocated that medical insurances cover this type of “procedure” [38