Information Needs of Primary Care Physicians

Advertisement

Table of Contents

I. Introduction

Shawn Thomas, Dr. Debby Bowers, MacAnthony Cadatal, and Angela Kim investigated the information needs of primary care physicians (PCPs). Shawn worked on editing, web page development, a list of online resources, and information about reference interviews. Debby focused on background information and implications for librarians from a practicing physician's perspective. MacAnthony contributed information such as reasons for information seeking, obstacles to information seeking, physicians' attitudes toward information seeking, and implications for librarians. Angela focused on Continuing Medical Education (CME), public library & medical partnerships, and information for patients.

II. Who are Primary Care Physicians (PCPs)?

Generally, they are the first and most regular physicians that patients see for medical care. They are made up of:

III. What do Primary Care Physicians do?

PCPs:

IV. Why are Primary Care Physicians Important for Patients?

V. How are Primary Care Physicians Trained?

VI. Reasons for Information Seeking

  1. The clinical care of individual patients is a primary reason for seeking information about patient oriented information needs
  2. To keep up-to-date
  3. To obtain information for patients to explain really important risk factors, especially for well-informed patients
  4. To acquire pharmacological information (hard data to guide or back-up prescribing decisions)
  5. To fill specific gaps in knowledge on "new" diagnoses and therapies
  6. To satisfy curiosity, personal interest, and inclination
  7. To resolve issues around uncertainty and evidence

VII. Negative Attitudes Towards Information Seeking

  1. Time consuming and frustrating
  2. Overwhelming information
  3. "Don't feel at all comfortable" about their searching skills (“proper way of searching”)
  4. Feeling a little bit lost

VIII. Work- Generated Information Needs

Primary care physicians are prompted to seek information by needs arising from a combination of professional responsibilities and personal characteristics, such as:

  1. The need to care for individual patients. To provide the best possible patient care, they must have access to resources that will assist them in making clinical decisions
  2. The need to keep up-to-date with new and updated clinical information relevant to their practice
  3. The need to acquire information to explain important risk factors to patients
  4. The need to obtain pharmacological information to back-up prescribing decisions
  5. The need to satisfy curiosity, personal interest, and inclination
  6. The need to resolve uncertainty and acquire evidence

IX. Types of Information Sources

  1. Human resources: patients, colleagues, librarians, outside consultants
  2. Primary resources (original research): clinical research, non-clinical laboratory research
  3. Secondary resources (describe or analyze primary resources): reviews, meta-analyses, textbooks, manuals, encyclopedias, other books
  4. Tertiary resources (a compilation of primary and secondary resources): bibliographies, library catalogs, directories, reading lists
  5. Print resources
  6. Electronic resources available on personal computers such as desktops or laptops
  7. Electronic resources available on handheld computers
  8. Assessment scales/surveys (types include self-report, significant other or observer report, and clinician-administered)

X. Obstacles that Primary Care Physicians Face when Seeking Information

  1. Lack of time to search and review new medical information. Due to the amount of time and effort that it takes to find the needed answers, a lot of questions go unanswered.
  2. Uncertainty about how to know when all the relevant evidence has been found so that the search can stop.
  3. Inefficient use of a resource such as difficulty in modifying the original question, which was often vague and open to interpretation.
  4. To answer questions, one often needs to conduct a Medline search to answer each clinical question. Yet, PCPs rarely seek original research in this manner to answer clinical questions during practice.
  5. Lack of urgency. Physicians seek and retain new knowledge when they have the need to know. In addition, they also require validated evidence that has direct benefit to their patients. However, this information is oftentimes not readily available in primary literature.
  6. Inappropriateness of information sources such as the failure of a seemingly appropriate resource to cover the topic. Resources may not be appropriate to answer questions because of unclear information or the absence of correct information.
  7. The limitations of print resources, which may offer only limited or out-of-date information.
  8. The increasing prevalence of lower-quality information on the Internet.
  9. The electronic format of the resources may also influence decision making through mechanisms of automation bias. “Automation bias is defined as the biases that influence performance when an automated system (i.e., computerization) is placed into an individual’s workflow. Automation bias has several components and can include the individual being less vigilant with the computer system in place, diffusion of responsibility with the system working, belief in the infallibility of the system, and unwillingness to pursue contradictory evidence to that provided by the computer” (McKibbon and Fridsma, 2006).

XI. Overcoming Obstacles with Consultations

Primary care physicians can utilize consultations with other physicians and health professionals to overcome information obstacles. They may employ formal consultation sessions or less formal "curbside consultations," where a consultant is approached in places like a parking lot, hallway, elevator, or cafeteria. In a study by Perley (2006), she gave reasons why curbside consultations take place. (Most of the reasons are practically the same as the one mentioned above but include more personal reasons.)

  1. To confirm what they already know.
  2. To get quick answers.
  3. To continue their education.
  4. To lead into a possible formal consultation.
  5. To negotiate an appropriate course of action in a particular patient case.
  6. To spread the emotional risk during a difficult case. – emotional investment
  7. To create or sustain camaraderie with physician colleagues.
  8. To find like thinkers among their physician colleagues.
  9. To monitor their own knowledge.
  10. To get out of a difficult situation.

XII. What Kinds of Continuing Certification Are Required?

  1. Continuing Medical Education (CME):
  2. State Licensure: All state licensure boards require PCPs to complete specified numbers of hours of Continuing Medical Education (CME), in order to maintain active licensure.
  3. Board Certification:

XIII. What do Primary Care Physicians Want to Know, and How do They Look for Answers?

Every day, while seeing patients, PCPs seek answers to patient-specific questions. The number of questions dealt with depends on the practice (rural vs. urban), whether the PCP is in a group or solo practice, and other factors. The number of questions investigated, as reported in multiple studies, ranges from 1 to 12 per day. Most are never answered. Whether or not an answer is pursued depends on the urgency of the situation and on whether or not the PCP believes an answer exists. Studies in the medical and library literature show that physicians nearly always consult readily available sources for this information--primarily colleagues, and their personal libraries, including the PDR and journals they happen to have around them. They usually seek this information while actively seeing patients. There is little time to search for and to retrieve and evaluate information from other sources. One study found that the average time spent seeking an answer to a question was 2 minutes. This was why the study reported that most questions remain unanswered. By contrast, another study found that medical librarians found answers to PCPs’ questions almost half the time, by searching an average of 43 minutes per question. Physicians in this and other similar studies felt that the answers would have a “major” impact on patient care for more than a third of the answers retrieved. Studies show that even if PCPs happen to have the searching skills or access to the range of resources that librarians use, they do not have the time to do such searches.

There are a number of electronic medical databases that have been designed to provide direct answers to clinical questions (not citations or articles) when physicians are seeing patients. Studies with these databases found clear-cut answers (answers with enough specific information to guide clinical practice) in half the cases. If help from colleagues and readily available textbooks and journals was added in, acceptable answers were found in 70-80% of cases. PCPs spend considerable group time refining their questions and planning search strategies (even eliminating questions that cannot be answered without further patient information). They then spend even more time looking at the arrived at questions to be sure that they had clinical relevance and that these refined questions were true to the original information need. In addition, database searches are often performed by PCPs who are experienced computer searchers. Yet, as pointed out in a study by PCPs from the University of Missouri, these “point-of-care” searches were not fast enough to be routinely useful to PCPs. “The searches in this study were based on the combination of efforts of 2 experienced physician searchers. These results may not be replicable in the practice setting but do provide an objective best-case scenario assessment of the content of these databases” (Alper et al., 2001). In fact they were allowed a maximum of 10 minutes per question. As noted already, the average time PCPs spend searching is 2 minutes. Another limitation to that study was that the accuracy and currency of the answers found was not evaluated. In other words, the answers were not evaluated based on currently evolving evidence-based criteria. Librarians have played a major role in applying and teaching these criteria. Unfortunately, many of the databases that currently apply evidence-based screening to their information resources are not completely useful or practical for answering clinical questions. Relevant research articles simply do not exist for all daily clinical scenarios. Another issue related to subscription databases is their cost, which is often paid by researchers' institutional libraries, something many PCPs do not have access to. In summary, PCPs look for daily information from readily available, near at hand, quick, and practical sources that are relevant to their patient problems. They do not take the time, or in many cases, have the resources or skills to search for sources that have the highest quality information.

XIV. Implications for Information Resources and Librarians

  1. Having a trained and knowledgeable librarian affected how the library was used.
  2. Pre-selected and screened information sources are more effective in meeting primary care physicians' information needs and also reduce the rate of incorrect answers being given.
  3. Primary care physicians who have experienced library user education sessions indicate that training influences subsequent behavior towards information sources.

Convenience of access, habit, reliability, high quality, speed of use, and applicability makes information seeking likely to be successful and to occur.

The evidence base of the resources must be strong and current. The Dartmouth Biomedical Libraries, Dartmouth College, the Cushing/Whitney Medical Library, and the Yale School of Medicine have developed the EBM (Evidence-Based Medicine) Pyramid and EBM Page Generator which can be accessed at www.ebmpyramid.org to help libraries organize their evidenced-based medicine resources.

In a study conducted by McKibbon and Fridsma (2006), they found that a proscribed collection of resources was more effective than letting the physicians choose their own since some information sources chosen by physicians can be considered poor ones. Alper, White, and Ge (2005) showed that a database of synthesized evidence such as DynaMed helps primary care clinicians answer more of their clinical questions and find more answers that change clinical decision making.

To ease time pressure, clinicians can spend less time answering a question by using knowledge resources that are comprehensive, instantly accessible, and easily searched.

Information resources that can be searched must be available and must also be sophisticated enough to prompt the clinician when he or she has identified a potential area where improvement in care may take place. The integration of information resources into electronic medical record (EMR) systems is one way of improving primary care physicians' access to information relating to patient needs.

Maviglia et al. (2005) studied the effects of an info button called KnowledgeLink which provides patient-specific and context-sensitive links from medications that appear in a patient's EMR directly into the relevant information resources. “Infobuttons are a way to bridge the gap between electronic clinical applications (such as EMRs) and electronic sources of reference information. Unlike a simple and static hyperlink to a knowledge resource, an infobutton is a message-based content retrieval function embedded within another application that dynamically returns information that is relevant to the situation/task at hand and that may be specific to the patient situation” (Maviglia et al., 2005).

According to Perley (2006), acknowledging and understanding physicians' use of the curbside consultation to obtain and construct knowledge can suggest new ways for health sciences librarians to work with physicians in the diffusion and dissemination of clinical information.

  1. Understanding the tacit rules physicians use to guide the curbside consultation can be useful in evaluating the process by which library staff communicate with physicians as well as the manner in which the results of clinical information searches are packaged and delivered.
  2. Health sciences librarians can design selective dissemination of information (SDI) services specific to to the concerns of primary care physicians because the diffusion of information from one physician to another may better serve the information needs of clinical care than the dissemination of information directly from the library to individual physicians.

Ward, Meadows, and Nashelsky (2005) describe the contributions in evidence-based search expertise and knowledge of information systems by medical librarians who are members of the Family Physicians' Inquiries Network (FPIN), to the creation of a database of clinical questions and answers that allows family physicians to practice evidence-based medicine using high-quality information at the point of care.

One result of the collaboration between the FPIN and the The University of Washington is the PrimeAnswers project, accessible at www.primeanswers.org. PrimeAnswers, a National Library of Medicine (NLM) information technology grant project, is a simple, context-sensitive Web interface to a filtered set of content designed to make it easier and faster for primary care physicians to find answers to questions in their daily management of patients. Librarians who are part of the FPIN at least have two years of experience searching electronic databases and Internet resources, including MEDLINE; a basic understanding of evidence-based medicine; experience performing clinically oriented searches for point-of-care questions; and a master's degree in library science.

Training programs should be tailored to helping PCP’s effectively formulate questions and search available information sources. Learning in the workplace is one example because it emphasizes problem solving and learning skills—such as how to find relevant answers fast—not learning facts.

Another resource:

Writing a Clinical Inquiry: A Collaborative Tool for Learning and Teaching Evidence-based Medicine at http://www.fmdrl.org/index.cfm?event=c.AccessResource&rid=582

XV. Conducting a Reference Interview with a Primary Care Physician

You must not only satisfy the physician, but you must also try to elicit enough background information to insure that your response is as relevant as possible. According to Malone et al. (2006), desirable, relevant responses can be characterized as:

In addition, systematic approaches to reference interviews can lead to better responses. As cited in Malone et al. (2006), Host and Kirkwood (1987) outlined a modified systematic approach to responding to drug information requests:

Step I. Secure demographics of requestor
Step II. Obtain background information
Step III. Determine and categorize ultimate question
Step IV. Develop strategy and conduct search
Step V. Perform evaluation, analysis, and synthesis
Step VI. Formulate and provide response
Step VII. Conduct follow-up and documentation if necessary

Obtaining appropriate background information is necessary to insure that the rest of the steps are performed correctly. According to the Drug Information Service, Department of Pharmacy Services, Medical College of Virginia Hospitals (1990; as cited in Malone et al., 2006), key background information includes:

According to Bopp (2001), success in a reference interview is based on three key factors:

  1. Gain the person's trust.
  2. Pursue an accurate understanding of the person's question in order to answer it as complete as possible.
  3. Insure that the person is satisfied with the answer or resources provided.

In addition, success can result from proper question asking. According to Bopp (2001),

Additional links to sites that concern reference services are available at http://www.neurotransmitter.net/odp/index.php/search/Reference/Libraries/Library_and_Information_Science/User_Services/Reference_Services/

XVI. A Practicing Primary Care Physician's Perspective on how Medical Librarians can help PCPs To Access Quality Information and Answers to Clinical Questions

This role has been evolving over time and is most evident to those PCPs who have access to academic medical libraries or whose large tertiary care (specialist-oriented) hospitals support training programs and have full-service libraries. Many PCPs who are not affiliated with academia have been largely unaware of this evolution in library services. Medical librarians are involved in tremendous outreach programs (even “circuit rider” type programs) in many parts of the country. National Library of Medicine grants, in particular, have funded programs in several parts of the country to help bridge the digital information divide between urban vs. rural (or in many cases urban community clinic vs. urban academic) medical centers and practices. One grant in North Carolina was called the ”Community Clinics Internet Connection Project.” Such grants have helped increase professional broadband Internet access and have helped with purchases of computer equipment and installation. The mandate in North Carolina is called the "library without walls" and encourages making library resources and services accessible at the point of need. This program included visiting librarians who trained PCPs to use Medline and other electronic resources. These librarians quickly learned that PCPs would only access online resources if computer connections and interfaces were quick, convenient, and uncomplicated. They preferred one interface for multiple resources and simplified login procedures. The librarians also found that regular outreach visits are essential for ongoing technical support and training. Since electronic resources change over time, continued reevaluation is necessary.

In North Carolina, a “virtual clinical campus” was created. This helped community-based PCPs access the resources of the academic medical library, as well as colleagues, feedback, and faculty. University librarians and AHEC (Area Health Education Center) librarians created a curriculum to teach database searching, use of the Internet, and the evolving resources of evidence-based medicine (EBM). Librarians were already teaching EBM to students and residents as part of patient care teams in universities, and now they are reaching out to rural and other underserved PCPs. In North Carolina, two medical librarians developed a web-based tutorial on EBM. Use of EBM in patient care depends on “efficient literature searching and on the application of formal rules of evidence in evaluating the medical literature”. One limitation to EBM is that there may not be good evidence in the literature to support all medical decisions. However, librarians can improve PCPs' chances of retrieving the best evidence there is by identifying the best resources and teaching PCPs the best, most efficient searching skills. The tutorial teaches the PCP to formulate questions that arise about patient care in such a way as to point to the type of study to look for. It then further analyzes studies in terms of the “evidence pyramid.” At the top of the pyramid there is less available literature, but the literature there is the most relevant to the clinical circumstances. If the best evidence to answer the question does not exist, the PCP can move down the pyramid to examine other types of evidence from other types of studies. The tutorial contains a chart that matches the type of information sought to the best type of study to supply the information. It then proceeds from the question to the best search strategy for Medline (and for other databases and review sources). Lastly, it teaches evidence analysis. This analysis looks at the studies retrieved to see how valid and how clinically useful they are. I did learn to analyze studies for methodology and validity 30 years ago in Medical School. What I did not have to do then was electronically wade through the millions of studies, journal articles, published reports, and correspondence available now. It seems that it is important to methodically review these (or access good databases that apply EBM standards) in order to retrieve the best information upon which to base patient care decisions. This approach seems to depend on focused, efficient, patient-based searching, evaluation, and then use of the best available evidence. One physician’s summary of the evidence-based approach is “Ideally, when you have a question, you want an immediate answer containing the most valid and most current existing information written in a format that is easy to follow and covers everything you need to know, nothing more, nothing less” (Alper, 2003).

As a primary care physician, a key study that describes my favorite way to access quick, helpful information is Perley (2006). The investigator asked, “…how do physicians describe the purposes and rules for doing a curbside consultation and what happens if the rules are not followed” (Perley, 2006, p.139)? The study described the reasons physicians ask for and respond to these consultations. It analyzed and underscored how significant informal consultation is in meeting physicians’ information needs. Specifically, such consultations helped provide rapid, reliable, locally appropriate, and locally relevant answers to clinical questions. These consultations also helped further education, helped with the triaging of referrals, improved patient care, and kept referral costs down. For the physicians consulted, such consultations fulfilled “professional obligations” and encouraged referrals. When physicians consult each other, we are meeting our needs for the best, most reliable, locally appropriate patient care information. We meet our need for information just where we need it, by consulting colleagues we have come to know and trust through the process of cumulative curbside consultations, sometimes even consulting the same trusted colleagues, going back to medical school and residency. Also, we are meeting needs for collegiality, social interaction, and emotional support for difficult situations. Curbside consultations can help with practice building, as specialists refer patients to primary care physicians, and as these physicians refer patients to specialists. Given these findings, it is hard to envision how a medical librarian could be a part of this process. The paper does concede the challenge physician curbside consultations present to librarians in its next to last sentence: “In some cases, diffusion of information from one physician to another may better serve the information needs of clinical care than dissemination of information directly from the library to individual physicians” (Perley, 2006, p. 142). However, another passage states: “If they [library staff] can identify the local customs in place—where and how physicians interact and share clinical information—they can use that information in the strategic allocation of library resources and services” (Perley, 2006, p. 142).

XVII. Public Library & Medical Partnerships

Given that medical libraries are often the first area in hospitals to be cut, they are becoming smaller and less common. In today’s society, typically only larger hospitals have them. One way to bridge this loss is for public libraries in rural areas to step up and work with hospitals, forming partnerships to provide much needed access to information for medical professionals. To accomplish this goal, one will need to secure funding, provide marketing such as pamphlets, and have a library liaison communicate with the hospital and medical staff (including attending medical staff meetings periodically and possibly speaking at such events). Many physicians are unable to utilize online medical resources because they do not have the time to search for information or are unfamiliar with newer resources. An experienced librarian can perform well-considered literature searches and obtain articles that physicians need. Librarians who wish to serve physicians that lack the time to meet face-to-face can take advantage of online tools such as instant messaging and e-mail .

XVIII. Patient Information

There are many online databases that physicians and medical institutions can use to provide medical information for patients. Many resources such as educational videos are available by subscription. Print materials can get out-of-date and take up a lot of space to store, so online resources are an alternative providing one has the staff needed to search for and print information. One has to be aware of copyright law when using such resources. Government information is free of copyright, and paid subscription databases specifically for patient education usually allow for making multiple copies for educational use. Web sites such as Stanford's Copyright & Fair Use Center and the University of Georgia's Regents Guide to Understanding Copyright & Educational Fair Use are excellent guides to copyright law.

XIX. References:

AHEC Digital Library. Retrieved from http://library.ncahec.net

Alper, B. S. (2003, July/August). Practical evidence-based internet resources. Family Practice. Retrieved from American Academy of Family Physicians Web site: http://www.aafp.org/fFPMprinter/20030700/49prac.html

Alper, B. S., Stevermer, J. J., White, D. S., & Ewigman, B. G. (2001, November). Answering family physicians' clinical questions using electronic medical
databases. The Journal of Family Practice, 50(11). Retrieved from http://www.jfponline.com/Pages.asp?AID=2383

Alper BS. White DS. Ge B. Physicians answer more clinical questions and change clinical decisions more often with synthesized evidence: a randomized trial in primary care. Annals of Family Medicine. 2005 Nov-Dec, 3(6):507-13. Retrieved from http://home.mdconsult.com/das/journal/view/67244266-4/N/15914651?ja=514948&ANCHOR=text&PAGE=1.html

Andrews, J. E., Pearce, K. A., Ireson, C., & Love, M. M. (2005, April). Information-seeking behaviors of practitioners in a primary care practice-based research network. Journal of the Medical Library Association, 93(2). Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1082937

Banick, C. R. (2005, November). Rx for Medical Libraries. Library Journal, 32-34. Retrieved from http://www.libraryjournal.com/article/CA6282616.html

Bopp, R. E., & Smith. L. C. Reference and information services: An introduction (Third Edition). Englewood, CO: Libraries Unlimited.

Bryant, Sue Lacey. The information needs and information seeking behaviour of family doctors. Health Information and Libraries Journal 2004, 21 (2), 84–93. Retrieved from http://www.blackwell-synergy.com/doi/full/10.1111/j.1471-1842.2004.00490.x

Coumou, H. C., & Meijman, F. J. (2006, January). How do primary care physicians seek answers to clinical questions? A literature review [Electronic version]. Journal of the Medical Library Association, 94(1), 55-60. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1324772

Dawes M, Sampson U. Knowledge management in clinical practice: a systematic review of information seeking behavior in physicians International Journal of Medical Informatics 2003;71(1):9-15. Retrieved from http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T7S-48GPCPF-1&_user=186797&_coverDate=08%2F31%2F2003&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000013678&_version=1&_urlVersion=0&_userid=186797&md5=8f0a2d06902413d04e4f27501a2c4cb7

Domino, F. J., & Culpepper, L. (2003, November/December). Clarifying EBM resources [Letter to the editor]. Family Practice. Retrieved from American Academy of Family Physicians Web site: http://www.aafp.org/fpm/FPMprinter/20031100/letters.html

Dorsch, J. L. (2000, October). Information needs of rural health professionals: A review of the literature [Electronic version]. Bulletin of the Medical Library Association, 88(4), 46-54. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=11055302

Ebell, M. H., Slawson, D., Shaughnessy, A., & Barry, H. (2003, November/December). Evaluating online EBM [Letter to the editor]. Family Practice. Retrieved from American Academy of Family Physicians site: http://www.aafp.org/fpm/FPMprinter/20031100/letters.html

Ely JW. Osheroff JA. Ebell MH. Chambliss ML. Vinson DC. Stevermer JJ. Pifer EA. Obstacles to answering doctors ' questions about patient care with evidence: qualitative study. BMJ, 2002 Mar 23. 324(7339):710. Retrieved from http://www.bmj.com/cgi/content/full/324/7339/710

Galt, K. A., Rule, A. M., Houghton, B., Young, D. O., & Remington, G. (2005, April). Personal digital assistant -based drug information sources: potential to improve medication safety [Electronic version]. Journal of the Medical Library Association, 93(2), 229-236. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15858626

Host, T. R., & Kirkwood, C. F. Computer-assisted instruction for responding to drug information requests [abstract]. Paper presented at the 22nd Annual ASHP Midyear Clinical Meeting; December 1987; Atlanta, GA.

Introduction to Evidence-Based Medicine. Retrieved from http://www.hsl.unc.edu/Services/Tutorials/EBM/index.htm

Leonhardt, D. (2006, February 22). Why doctors so often get it wrong. The New York Times. Retrieved from
http://www.nytimes.com/2006/02/22/business/22leonhardt.html

Malone, P. M., Kier, K. R., & Stanovich, J. E. (2006). Drug information: A guide for pharmacists (Third Edition). New York, NY: McGraw-Hill, Inc.

Maviglia SM. Yoon CS. Bates DW. Kuperman G. KnowledgeLink: impact of context-sensitive information retrieval on clinicians' information needs . Journal of the American Medical Informatics Association. 2006 Jan-Feb , 13(1):67-73. Retrieved from http://www.jamia.org/cgi/content/abstract/13/1/67

McConaghy, John R. Evolving medical knowledge: moving toward efficiently answering questions and keeping current. Primary Care; Clinics in Office Practice. 2006, 33(4):831-7, v, Accessed February 23, 2007 at http://home.mdconsult.com/das/journal/view/67244266-2/N/16703952?ja=562239&ANCHOR=text&PAGE=1.html

McDuffee, D. C. (2000, October). AHEC library services: From circuit rider to virtual librarian [Electronic version]. Bulletin of the Medical Library Association, 88(4), 362-366. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=11055304

McCloskey, K. M. (2000, October). Library Outreach: Addressing Utah's "Digital Divide" [Electronic version]. Bulletin of the Medical Library Association, 88(4), 367-373. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=35259http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=35259

McKibbon KA. Fridsma DB. Effectiveness of clinician-selected electronic information resources for answering primary care physicians ' information needs. Journal of the American Medical Informatics Association. 2006 Nov-Dec, 13(6):653-9. Retrieved from http://www.jamia.org/cgi/content/full/13/6/653

Perley, Cathy M. Physician use of the curbside consultation to address information needs: report on a collective case study. Journal of the Medical Library Association, 2006, vol. 94, issue 2, p 137. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1435836

Pifalo, V. (2000, October). The evolution of rural outreach from Package Library to Grateful Med: Introduction to the symposium [Electronic version]. Bulletin of the Medical Library Association, 88(4), 339-345. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=35255

Ward D. Meadows SE. Nashelsky JE. The role of expert searching in the Family Physicians' Inquiries Network (FPIN). Journal of the Medical Library Association. 2005 Jan. 93(1):88-96. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=545127

Wyatt, Jeremy C and Frank Sullivan 2005. Keeping up: learning in the workplace BMJ 2005 331: 1129-1132. Retrieved from http://www.bmj.com/cgi/content/short/331/7525/1129

XX. Important Online Resources for Primary Care Physicians

Online Resource URL Description
MEDLINE/PubMed http://www.pubmed.gov MEDLINE is the National Library of Medicine’s bibliographic database for life sciences literature. MEDLINE contains over 17 million references, primarily to biomedical literature from scholarly, peer-reviewed journals. The most common means to access MEDLINE is PubMed. In addition to MEDLINE citations, PubMed includes OLDMEDLINE for pre-1966 citations, citations for out-of-scope articles from MEDLINE- indexed journals, in-process citations, citations that precede the date that a journal was selected for indexing in MEDLINE, some life sciences journals that are included in PubMedCentral but not MEDLINE, and certain physics journals that were part of a prototype PubMed in the early to middle 1990s.
NLM Mobile (PDA only) http://www.nlm.nih.gov/mobile/ This page lists the National Library of Medicine's projects for PDAs such as PubMed for handhelds and NCBI Bookshelf for mobile devices.
Neurotransmitter.net Feature Rich Web Directory: Medicine http://www.neurotransmitter.net/odp/index.php/Health/Medicine/ The Neurotransmitter.net Feature Rich Web Directory offers links to over 11,000 medical web sites and a variety of other sites. Based on the Open Directory Project's collection of links and annotations, the Feature Rich Web Directory offers automatically generated links to Google searches for sites that mention a web site, Google images searches, the Internet Wayback Machine at Archive.org, and more. In addition, thumbnails from Thumbshots.org complement the broad array of unique features.
Hardin MD: Medical Information + Pictures http://www.lib.uiowa.edu/hardin/md/index.html Hardin MD includes collections of links to medical information and pictures from a wide variety of conditions.
Martindale's Virtual Medical Center http://www.martindalecenter.com/Medical.html Martindale's offers a huge collection of links for a variety of medical topics.
Netting the Evidence http://www.shef.ac.uk/scharr/ir/netting/ Netting the Evidence includes a variety of links and annotations for resources such as databases, software, journals, organizations, and guides to searching, appraising, and implementing evidence.
Cochrane Reviews and the Cochrane Library

Cochrane Reviews: http://www.cochrane.org/reviews/

Cochrane Library: http://www3.interscience.wiley.com/cgi-
bin/mrwhome/106568753/HOME?CRETRY=1&SRETRY=0

The expert members of the Cochrane Collaboration contribute to detailed reviews of topics in over 40 clinical specialties. The public is free to search abstracts associated with the Cochrane Reviews.

Wiley's subscription only Cochrane Library includes the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects (DARE), the Cochrane Central Register of Controlled Trials, the Cochrane Database of Methodology Reviews, the Cochrane Methodology Register, the Health Technology Assessment Database, and the NHS Economic Evaluation Database.
TRIP: Turning Research Into Practice http://www.tripdatabase.com The TRIP database includes links to information from a wide variety of sources that include databases for evidence based synopses, clinical guidelines, medical images, systematic reviews, calculators, core medical journals, and others.
CRD: Centre for Reviews and Dissemination databases http://www.crd.york.ac.uk/crdweb/ CRD databases include the Database of Abstracts of Reviews of Effects (DARE), the NHS Economic Evaluation Database (NHS EED), and the HTA database (for health technology assessments from around the world).
FDA's Drug Information Pathfinder http://www.fda.gov/cder/Offices/DDI/pathfinder.htm This pathfinder informs users about the FDA's drug- related resources. The list of links includes pointers to chronological lists of approvals, consumer drug information sheets, drug availability information, importation policy information, links to state boards, "hot topics," and other useful drug information.
Drugs@FDA http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm The Drugs@FDA database offers official information about FDA approved brand name and generic drugs as well as therapeutic biological products. The database includes FDA approved labels for some drugs, manufacturers of brand name and generic drugs, dosage information, initial approval dates, and a list of all drugs with a specific active ingredient. Data about both current and discontinued drugs is available from Drugs@FDA.
MedWatch: Medical Product Safety Information http://www.fda.gov/medwatch/safety.htm MedWatch includes FDA- generated alerts for drugs, biologics, devices, and dietary supplements. It is an excellent source of information about safety-related drug labeling changes.
RxList http://www.rxlist.com RxList contains a wealth of drug information drawn from FDA approved product labels/prescribing information. Users can search by drug name or with a variety of advanced options such as searching by imprint code. On the index page, lists of the most popular prescription drugs are available.
MD Consult (PDA version available) http://www.mdconsult.com Elsevier's MD Consult includes over 50 important medical texts, articles from more than 70 clinical journals, practice guidelines, drug information, patient education handouts, CME, and daily medical updates.
FirstCONSULT (PDA version available) http://www.firstconsult.com FirstCONSULT offers evidence-based clinical information resources such as differential diagnoses, weekly-updated medical topics, patient education, and procedures.
InfoPOEMS (PDA version available) http://www.infopoems.com/ Wiley's InfoPOEMS offers summaries of important, recent findings from over 100 worldwide medical journals
UpToDate (PDA version available) http://www.uptodate.com/ UpToDate is a evidence-based clinical information resource available online, on CDs, and on PDAs.
PDR.net: Physician's Desk Reference Web Site (PDA version available) http://www.pdr.net PDR.net provides news, clinical guidelines, full FDA-approved product labeling, a multi-drug interaction checker, and more. Free memberships are available for qualified health professionals in the United States.
Medscape (from WebMD) http://search.medscape.com/drug-reference-search Medscape allows registered users to search for full text articles, CME content, conference coverage, news, MEDLINE, drug interactions, and combined drug content from the FDA, First DataBank, and the AHSP Pharmacopoeia.
Epocrates (PDA version available) http://www.epocrates.com/ Epocrates offers a free drug and formulary reference, a free CME resource, and free add-on applications for their software. In addition, users can purchase integrated drug and disease information suites, a medical dictionary, and more.
Facts & Comparisons (PDA version available) http://www.factsandcomparisons.com/ Wolters Kluwer's subscription only Facts & Comparisons offers information about drugs, reviews of natural products, drug interactions, patient information, and more.
AHFSfirst WEB (PDA version available) http://www.ashp.org/ahfs/web/index.cfm This subscription only service offers thousands of drug monographs, bibliographies, and information about herbal products.
AccessMedicine (PDA version available) http://www.accessmedicine.com/ McGraw-Hill's AccessMedicine provides regularly updated information from physicians for clinical decision making.
Clinical Pharmacology (PDA version available) http://www.clinicalpharmacology.com/ Gold Standard's subscription only Clinical Pharmacology resource offers drug monographs, customizable drug comparisons, drug interaction reports, adverse reaction reports, product identification, patient education materials, lists of drugs classed by indication, and information about herbal products.
DynaMed (PDA version available) http://www.ebscohost.com/dynamed/ EBSCOhosts's subscription only DynaMed includes over 2,000 clinical topic summaries designed to facilitate the practice of evidence-based medicine.
Drug InfoNet http://www.druginfonet.com This free service provides package insert information for health professionals and for consumers.
Drugs.com http://www.drugs.com/ Drugs.com offers basic drug information (mostly useful for consumers), a drug interactions checker, a pill identification tool, and drug related news.
mediLexicon (PDA version available) http://www.pharma-lexicon.com/ MediLexicon offers a dictionary of over 200,000 medical, pharmaceutical, and biomedical acronyms and abbreviations. Medical news is also provided by the web site.
EMBASE http://www.embase.com Elsevier's EMBASE offers a combination of more than 18 million records from the EMBASE collection of pharmaceutical citations and the MEDLINE collection of biomedical literature citations. Over 7,000 journals are indexed at EMBASE.com, which is around 2,000 more journals than the EMBASE or MEDLINE database offers on its own. An impressive array of international journals from over 70 countries is included in the resource. EMBASE.com's coverage of MEDLINE includes citations for content dating back to 1966, and the EMBASE database indexes content dating back to 1974.
BIOSIS http://www.biosis.org/ The BIOSIS database indexes articles from over 3,700 life sciences journals, making it one of the most useful databases for biological citations and abstracts available.
HighWire Press: Free Online Full-text Articles http://highwire.stanford.edu/lists/freeart.dtl HighWire Press offers the largest archive of free full text science articles on the web.
ScienceDirect http://www.sciencedirect.com/ Elsevier's subscription only ScienceDirect includes a huge collection of full text journal articles, over 4,000 books, and a variety of other useful science content.
IPA: International Pharmaceutical Abstracts http://www.ovid.com/site/catalog/DataBase/
109.jsp?top=2&mid=3&bottom=7&subsection=10		 Ovid's IPA indexes pharmaceutical abstracts dating back to 1970. Its bibliographic database offers worldwide coverage and over 350,000 records.
Faculty of 1000 Medicine http://www.f1000medicine.com The subscription only Faculty of 1000 Medicine draws attention to important new articles, chosen by around 2,500 expert clinicians and researchers. Users' comments on articles make this an unparalleled resource for the online discussion of interesting medical developments.
Web of Science http://scientific.thomson.com/products/wos/ Web of Science offers records for articles from over 8,700 journals. Its integration of extensive citation information and links makes Web of Science one of the most popular scientific databases available today.
CINAHL Plus http://www.epnet.com/thisTopic.php?topicID=171&marketID=1 The subscription only CINAHL Plus focuses on nursing and allied health journal literature. CINAHL Plus now indexes journal articles, books and book chapters, dissertations, audiovisual materials, evidence-based care sheets, and quick lessons . Previously, CINAHL included citations to content published since 1982, but EBSCO has expanded the database to offer indexing for articles dating back to 1937.
ClinicalTrials.gov http://www.clinicaltrials.gov ClinicalTrials.gov offers information about federally and privately funded clinical research that involves human participants.
Clinical Evidence http://www.clinicalevidence.com BMJ's Clinical Evidence resource integrates a variety of original evidence-based medicine reviews for clinicians with a wide range of other EBM related resources.
CenterWatch http://www.centerwatch.com CenterWatch offers lists of over 41,000 ongoing clinical trials as well as drugs used in clinical trials. Some parts of the site are subscription only.
DIRLine http://dirline.nlm.nih.gov/ The National Library of Medicine's DIRLINE is a directory of resources and organizations related to health and biomedicine.
The Merck Manuals http://www.merck.com/pubs/ Merck offers several free resources online, such as The Merck Manual of Diagnosis and Therapy, The Merck Manual--Second Home Edition, The Merck Manual of Health & Aging, The Merck Manual of Geriatrics, and The Merck Veterinary Manual.
GeneCards http://www.genecards.org Because of its extensive integration of data and links from multiple major genetic resources, GeneCards stands out as one of the most useful genetics resources ever created. GeneCards collects content from a growing number of databases such as Entrez Gene, UniProt/Swiss-Prot, Ensembl, OMIM, GeneLoc, KEGG, PharmGKB, and PubMed.
OMIM: Online Mendelian Inheritance in Man http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM The free OMIM resource is a catalog of human genes and genetic disorders. Maintained by experts at Johns Hopkins and elsewhere, OMIM offers a large collection of detailed information along with references to PubMed records.
MetaDB: A Metadatabase for the Biological Sciences http://www.neurotransmitter.net/metadb/metadb.php The MetaDB Metadatabase for the Biological Sciences is a sorted, searchable collection of biological databases. Most entries in the metadatabase include a relevant peer-reviewed abstract or excerpt along with a link to the abstract or full text article. Key categories include metadatabases and directories, public health databases, general human genetics databases, and neuroscience databases.
TOXNET http://toxnet.nlm.nih.gov/ The National Library of Medicine's TOXNET allows users to search a variety of databases related to toxicology, hazardous chemicals, environmental health, and toxic releases. The databases include TOXLINE, GENETOX, Haz-Map, Household Products, and more.
PsycINFO http://www.apa.org/psycinfo/ The PsycINFO database offers abstracts and metadata for psychological literature dating back to the 1800s.
BehaveNet http://www.behavenet.com/ BehaveNet's clinical capsules and resource lists offer a variety of information related to behavior disorders. Freely available is the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision), but the statistics from the book are not included.
MEDAL: The Medical Algorithms Project http://www.medal.org MEDAL offers over 10,000 free medical algorithms, organized into 45 chapters. The medical algorithms, defined as computations, formulas, surveys, or look-up tables useful in healthcare" are available as spreadsheets or HTML files.
Outcome Scales Repository http://www.rar.duhs.duke.edu/
wiki/index.php/Outcome_Scales_Repository		 Duke's Outcome Scales Repository lists over 200 outcome assessment scales for a variety of conditions and regions.
POPLINE http://db.jhuccp.org/ics-wpd/popweb/ POPLINE is a database of over 300,000 abstracts for articles, books, and unpublished reports in the fields of population, family planning, and reproductive health.