This detailed examination of the clinical questions illustrates the role of the information specialist as an integral member of the patient care team. The significant differences among clinical units revealed in the redundancy and category analyses substantiates our perception that each clinical team has unique information needs. CICS librarians provide in-depth representation and synthesis of the medical literature with regard to each question, tailored to the unit and the clinical case at hand.
While clinicians have an obvious imperative to maintain awareness of current research to sustain high-quality patient care, the realities of day-to-day practice may often preclude spending an adequate amount of time answering every clinical question. Internal CICS benchmarking statistics indicate that experienced librarians spend an average of approximately two hours with each question; moreover, they may spend five or more hours working with complex questions that require extensive searching and filtering of the literature. Davidoff and Florance assert, “Physicians don't, and never will, have [one hour or more] to look for the answers to most of their clinical questions themselves” [34
]. It is simply not feasible for physicians to devote such a significant amount of time to clinical queries, particularly when we consider that physicians often encounter multiple questions during daily clinical practice [35–38
]. Indeed, studies indicate that many questions generated during patient care may never be pursued or answered [39, 40
]. Not only do these unanswered questions represent missed opportunities for education and improvement of clinical practice [41
], but also “much of the effort, creativity, and money that go into biomedical research is simply wasted” when research fails to inform patient care [42
Answering questions for which there is no clear consensus in the literature can be particularly time consuming; however, neglecting to locate or examine all possible treatment options, for example, may significantly handicap a clinician's delivery of care. As demonstrated by the viewpoint analysis, if librarians stop searching the literature after finding the first article, additional viewpoints would have been missed in more than half of the treatment-related questions. This situation represents a significant opportunity for librarians, who are generally comfortable with the importance of providing a comprehensive representation of the literature. With high recall as a chief goal and expertise in both searching knowledge and the clinical context, librarians are uniquely positioned to assist clinicians in bridging the gap between the wealth of information available and the incorporation of new knowledge into clinical practice.
The lack of significant differences in the number of represented viewpoints across units supports our belief in the importance of the EBL focus on representation of all views in the literature by CICS librarians regardless of unit.
The category classification illustrates the types of questions for which CICS librarians are consulted by clinical teams. We found that VUMC clinicians use the service most frequently for treatment-related requests—more than half of the questions fall in these categories. Requests for disease-related information account for the bulk of the remaining questions. This prevalence of clinician requests for disease descriptions or treatment information during daily practice is echoed in other discussions of physicians' information needs [43–47
The initial impetus for construction of the CICS Knowledge Base was to capture the time and expertise that librarians contribute to VUMC clinical units, with the expectation that this resource would become increasingly reusable over time [48
]. The redundancy data in the current study emphasizes the value of this reusable resource for both librarians and clinicians. The three highest redundancy rates in the current study occur in the clinical units with the greatest duration of CICS service. Ely et al. note the utility of this type of resource in capturing knowledge and avoiding duplication of effort [49
]. As CICS grows, we expect that the trend toward repeated questions will continue and that this tool will become an increasingly important educational resource for our teams. Currently, one unit has taken advantage of this resource by hosting, on its departmental Web page, a dynamic link to that team's past questions and answers in the CICS Knowledge Base. Clinicians rotating onto the unit use this resource as a means of becoming familiar with the librarian's past presentations and acquainting themselves with the team's previous discussions of the medical literature. Librarians on rounds are currently promoting this type of link to all CICS clinical units as a case-based educational opportunity for the teams.
While available time remains an important limitation on clinicians' forays into the medical literature, physicians equipped with a basic level of training in locating and evaluating evidence are able to conduct online database searches with recall comparable to that of librarians [50, 51
]. With the goal of utilizing CICS as a mechanism for training clinical team members, we have employed a new CICS model since December 1999. Our initial category analysis indicates that a portion of questions received on rounds are requests for general overview information. For these relatively quick, straightforward queries, CICS librarians now provide resource selection and search strategy assistance tailored to the clinical case rather than a fully filtered information packet. With the understanding that the residents and other clinicians may eventually move to health care environments in which differing levels of library service will be available, we hope to help our clinicians acquire a sound foundation of skills to meet their own basic information needs.
CICS librarians continue to provide searching and synthesis of the literature in response to the more complex queries that may take up to several hours to complete. These questions range from those that require complex search strategies and use of multiple resources to those that require representation of multiple viewpoints to thoroughly represent the current thought on a topic.
Resources that provide varying levels of synthesis of the medical literature with regard to assorted topics, such as the Cochrane Library or UpToDate, have been suggested as a means of promoting the incorporation of research evidence into clinical practice [52, 53
]. Though such resources are expanding and becoming more widely available, issues of coverage and maintaining currency remain chief concerns for all evidence-based tools. Incorporated into the framework of the CICS Knowledge Base is a mechanism for updating the records. The librarian who completes the initial CICS packet becomes the owner of the question; daily automated reports identify records for updating every six months. Librarians review the CICS Knowledge Base records for which they are responsible to assess whether new articles should be added to each record. An automated link from the record to the PubMed search strategy created by the librarian provides a quick method for such review and supplies clinicians with an expert strategy for locating additional information on the topic.
As the number of questions in the CICS Knowledge Base continues to grow, we anticipate that the categories will provide convenient access points for clinicians browsing the resource. As new information specialists are trained in CICS, we also expect that this resource will become an integral part of building a subject knowledgebase for work with the various units.
The growth rate of the medical literature, the volume of unpursued clinical questions, and the increasing time constraints faced by clinicians provide a disconcerting picture of knowledge-related issues in current clinical practice. The information specialist is uniquely positioned to assist clinicians in bridging this gap between the medical literature and patient care. As illustrated by this analysis of questions addressed by CICS librarians, trained information specialists working in the clinical context can provide valuable assistance in the practice of evidence-based medicine and function as the “critical link between the huge body of information hidden away in the medical literature and the information needed at the point of care” [54