Western Libraries: Need to Know

Family Medicine Residents

Robin Featherstone, MLISClinical Medicine Librarian University of Western Ontariorfeathe@uwo.ca

Agenda• Medical information in context• Library services• Accessing Western Libraries’ resources• Methods of information gathering• Finding answers to background questions• Finding answers to clinical questions

JASPA Criteria (journal-associated score of personal angst)

Can you answer these five simple questions?

J Are you ambivalent about renewing journal subscriptions?

A Do you feel anger towards particular authors?

S Do you use journals to help you sleep?

P Are you surrounded by piles of periodicals?

A Do you feel anxious when another journal article lands on your desk?

Reference:

Modified from ‘Polythenia gravis: the downside of evidence-based medicine.’ British Medical Journal (1995) 311: 1666-1668.

Score (Yes = 1; No = 0):0 : Lying1-3 : Normal> 3 : Sick, at risk for ‘polythenia gravis’ and related conditions

“In 2005, 55 new trials were published every day... To keep up to date on RCTs alone, a GP would have to read more than one study report every half hour, day and night.”

Reference:

Glasziou, P. Evidence-based Practice Workbook: Bridging the Gap Between Health Care Research and Practice . 2nd Ed.Oxford: Blackwell Publishing, 2007.

Lots of evidence...

Lots of questions...

Study conducted in 2000• 64 residents in 2 hospitals• 401 consultations• 280 questions (2 questions for every 3 patients seen)• Answers were sought for 80 (29%) of the questions

References:

Green ML, Ciampi MA and Ellis PJ (2000). Residents’ medical information needs in clinical: are they being met? AmericanJournal of Medicine 109:218-233.

Lots of barriers...Qualitative study conducted in 2005• Focus groups were conducted with 34 residents• Barriers to answering clinical questions were reported as:

Technical or pragmatic– Access to electronic information resources– Skills in searching information resources– Clinical question tracking– Time

Emotional or cultural– Clinical question priority– Personal initiative– Team dynamics– Institutional culture

Reference:

Green ML, and Ruff TR (2005). Why do residents fail to answer their clinical questions? A qualitative study of barriers topracticing evidence-based medicine. Academic Medicine, 80(2): 176-182.

Information Services for Family Medicine Residents

1. Western Libraries

2. Hospital Libraries

3. Canadian Library of Family Medicine

Canadian Library of Family Medicinehttp://www.cfpc.ca/English/cfpc/CLFM/main/

Canadian Library of Family Medicine: Key Points

• Based at UWO• National service for all CFPC members (includes all

residents)• Small library service (3 staff)• Most services are free for members• Experts in the family medicine literature and can

help with research projects– Will conduct searches with residents or just send search

results – Contact through website or email: clfm@uwo.ca

Libraries

1. Western Libraries: What we’ve got Journals

and databases

Books

Clinical Tools

Learning modules

Calculators

Drug Identification Tools

Images

2. Family Medicine Info: How to access- Go to: http://www.lib.uwo.ca/

- Log in to Off-Campus Access with your UWO username and password (same as email)

- Select Browse by Program

- Select Medicine and Dentistry

- Select Family Medicine

http://www.lib.uwo.ca/programs/familymedicine/Use this page to find selected resources for family medicine

Electronic Books

Point of Care Tools

Databases

Image and video collections

And more...

2. How to search our collectionsSelect “Catalogue”

Search the Catalogue to find anything Western Libraries owns or subscribes to

...including:

• Journals• Books• Databases• Point of Care Tools

http://alpha.lib.uwo.ca

You can even search for electronic full-text journals.

Select “Journal Title”

Then enter the name of the journal

And select “Go”

Tip: For best results, use the Advanced Search

Parts of a Catalogue Record

Full title of the journal

Links to electronic articles

Coverage dates

Call # & location of print volumes

Other ways to access electronic full text

• When searching for articles in databases, use the button to link to full-text

Tip: To see the buttons in PubMed • Use the PubMed links from the library website• Change the display in PubMed to Abstract or AbstractPlus

Access Exercise 1

• How would you get a hold of this article?

1: Weber M. Achieving blood pressure goals: should angiotensin II receptor blockers become first-line treatment in hypertension? J Hypertens. 2009 Jul;27 Suppl 5:S9-14. PubMed PMID: 19587555.

Access Exercise 2

• How would you get a hold of this article?

1: Olsson SB, Orndahl G, Erneström S, Eskilsson J, Persson S, Grennert ML, Johansson BW. Spontaneous reversion from long-lasting atrial fibrillation to sinus rhythm. Acta Med

Scand. 1980;207(1-2):5-20. PubMed PMID: 7368973.

Access Exercise 3

• How would you get a hold of this article?

1: Tempera G, Mangiafico A, Genovese C, Giudice E, Mastrojeni S, Nicolosi D, Ferneri PM. In vitro evaluation of the synergistic activity of neomycin-polymyxin B association against pathogens responsible for otitis externa. Int J Immunopathol Pharmacol. 2009 Apr-Jun;22(2):299-302. PubMed PMID: 19505383.

To Register for RACER (InterLibrary Loan ordering system)

http://www.lib.uwo.ca/ill/firsttimeracer.shtml

Access Key Points

• Off-Campus Access – Remember to log in• Browse by Program > Family Medicine• Search the catalogue to find anything UWO owns

or subscribes to• Use Getit@Western button to access full-text• Request electronic copies of ARCC (storage) items

for desktop delivery• Request items using ILL (InterLibrary Loan) -

RACER

Information GatheringTechniques

Why not just Google it? Study conducted in 2007• 71 question test using clinical questions (ex. Are cultures

necessary in a routine case of acute otitis externa?) • 34 emergency medicine residents participated in the test

Pre-Test (no outside resources) Results– 32% of questions were answered correctly– 28% were answered incorrectly– 40% were answered as unsure

Google Test Results– 59% were answered correctly– 33% were answered incorrectly– 8% were answered as unsure

Reference:

Sinha, S., R. Krause, R. Moscati, D. Schwartz, and J. Abbas. "48: Are Internet Searches a Reliable Source for Answers toResidents' Clinical Questions in the Emergency Department?" Annals of Emergency Medicine 52, no. 4,

Supplement 1 (10, 2008): S57-S57.

“Just in case” vs. “Just in time”

There are two ways in which we all get information

1. Just in case – in an ad hoc way from the vast amount of information that crosses our desk or arrived in our inbox daily

2. Just in time – in a targeted way, by seeking out information in response to a specific question

Reference:

Glasziou, P. Evidence-based Practice Workbook: Bridging the Gap Between Health Care Research and Practice . 2nd Ed.Oxford: Blackwell Publishing, 2007.

Best Strategies for gathering “Just in Case” Information

• Maximize time by reviewing synthesized evidence – Systematic reviews, meta-analyses, summaries, etc..– Cochrane reviews, POEMS (through Essential Evidence Plus),

Recommended readings from the National Guideline Clearinghouse, etc...

• Minimize searching through alert features and subscription services– PubMed email updates of search results– RSS from: BMJ, JAMA, Lancet, NEJM, Open Medicine,

BioMedCentral (BMC), Nature Publishing – Medicine, etc...– Podcasts/Videocasts from: McGraw-Hill’s AccessMedicine,

Cochrane Collaboration, JAMA, NEJM, etc...

Best Strategies for gathering “Just in Time” Information

• Formulate an answerable question (PICO) • Identify your question type and know what

evidence will best answer it• Target your search for synthesized

information

Exercise

• Answer the following background question:

What are the general preventative measures for otitis externa?

Good Resources for Background Questions

• Run a keyword search of the library catalogue to find both print and electronic textbooks

• Search Books@Ovid (623 electronic titles)

Clinical/Foreground Questions

Using the Evidence to Answer Clinical Questions

Identify your problem

Define a structured question

Find the best evidence

How valid is the evidence?

What are the results?

How should I apply the results to patient care?1

1 Guyatt, Gordon, Drummond Rennie, Evidence-Based Medicine Working Group, and American Medical Association. Users‘Guides to the Medical Literature :A Manual for Evidence-Based Clinical Practice. Chicago, IL: AMA Press, 2002.

We’ll be focusing on two steps

Case study

Using the PICO model, formulate an answerable question

A patient with atrial fibrillation wishes to discontinue taking warfarin. You consider aspirin as an alternative therapy for reducing the patient’s risk of stroke when a colleague suggests you prescribe both aspirin and clopidogrel

Create an answerable question

In patients with atrial fibrillation is aspirin alone more effective than aspirin combined with clopidogrel in preventing stroke?

Population Patients with atrial fibrillation

Intervention Aspirin alone

Comparison Aspirin combined with clopidogrel

Outcomes Prevention of stroke

Clarify the question type

In patients with atrial fibrillation is aspirin alone more effective than aspirin combined with clopidogrel in preventing stroke?

What kind of question is this?

6 Question Types

1. Aetiology: the causes of the disease and their modes of operation

2. Diagnosis: signs, symptoms or tests for diagnosing a disorder

3. Prognosis: the probable course of the disease over time4. Therapy: selection of effective treatments which meet

you patient’s values.5. Cost-effectiveness: is one intervention more cost-

effective than another?6. Quality of life: what will be the quality of life of the

patient? 3

3 Heneghan, Carl, and Douglas Badenoch. Evidence-Based Medicine Toolkit. 2nd ed. Malden, Mass.: BMJ Books/Blackwell Pub., 2006.

Find the Best Evidence

• Studies which best answer each question type

Type of Question Type of Evidence

Aetiology Case-control or cohort study

Diagnosis Diagnostic validation study

Prognosis Inception cohort study

Therapy Randomized controlled trial

Cost-effectiveness Economic evaluation

Quality of life Qualitative study4

4 Heneghan, Carl, and Douglas Badenoch. Evidence-Based Medicine Toolkit. 2nd ed. Malden, Mass.: BMJ Books/Blackwell Pub., 2006.

Evidence Pyramid

Less time

More time

http://www.mh.org.au/royal_melbourne_hospital/www/353/files/pyramidopt.jpg

Exercise

• Search the following resources to answer the question: In patients with atrial fibrillation is aspirin alone more effective than aspirin combined with clopidogrel in preventing stroke?

1. Cochrane Library2. Micromedex3. PubMed4. EMBASE5. e-CPS

Conclusions

• Number of results

Source Hits

PubMed 100 (11 if searching narrow/therapy study category)

Cochrane Library 6

Embase 256

Micromedex 2

e-CPS 1 drug monograph

Evidence Pyramid

Cochrane Library

Micromedexe-CPS

PubMed

EMBASE

Summary & Key Points

• Access– Log in to off-campus access– Browse by Program > Family Medicine– Search the Catalogue (use the Advanced search)– Access full text by using the Get it @ Western button

• Searching– Just in Case: Maximize time and minimize searching by

using auto-alerts, podcasts, RSS– Just in Time: Define your question, identify the best

evidence, and target synthesized information sources

And, finally...• Who to call for help:

– Research Help: General or access type questions• Service Desk• Phone: 519 661 3168• Email, Chat: http://www.lib.uwo.ca/taylor/researchhelp.shtml

– Subject Librarian (Robin): Specific searching questions• Phone: 519 661 2111 ext: 86383• Email: rfeathe@uwo.ca• Chat: http://www.lib.uwo.ca/programs/familymedicine/

Orientation Evaluation

• Residents at St. Joe’s: Please fill out the paper evaluations• Residents who participated via videoconference: Please fill out

the online survey @ http://tinyurl.com/familymed

• Residents at St. Joe’s: If you are willing to be contacted via email with links to online tutorials, please add your name to the sheet being circulated

• Residents who participated via videoconference: If you are willing to be contacted via email with links to online tutorials, please add your name to the online form @ http://tinyurl.com/librarycontact