Computerized literature searching-why more internists are getting wired
By Deborah Gesensway
Internists Donald L. Vine, FACP, and Robert A. McNutt, MD, are ardent believers in the power of computers to help them keep up with the literature and to move closer to an evidence-based practice of medicine. But they might agree on little else, starting with the when, where and how of using computers for medical literature searching.
Dr. Vine, a cardiologist at the University of Kansas School of Medicine in Wichita, has concocted a system for dialing into the National Library of Medicine's (NLM's) Medline citation database and downloading to his PC all the abstracts from eight key journals each month. He saves those to a database and then cuts and pastes the conclusion section of each abstract into a "palmtop" computer he carries with him.
Whether between patients, at home or even on an airplane, "I sit there and read a few pages at a time," Dr. Vine said. "It's great for keeping up," better than lugging a pile of journals around, because this database can be searched by text word. "If a resident wants to know something, I can pop out a reference for him right there," he said.
If Dr. Vine uses computers as a shortcut through the vast medical literature he otherwise would never find time to wade through, Dr. McNutt, chair of internal medicine at the University of Wisconsin in Milwaukee, is counting on computers to transform the theory of evidence-based medicine into practice. He believes simply reading journal articles without reference to particular patients is not worth the time and most journal articles bear "no real relevance to bedside decision-making."
Instead, he has loaded on 10 PCs set up on the medicine ward, in the clinics and in the morning report rooms the entire content of four CD-ROMs that synopsize or otherwise attempt to interpret the medical literature for busy clinicians-ACP Journal Club on Disk, QuickScan Reviews, Scientific American Medicine on CD-ROM and QMR. He requires his residents-and himself-to search these databases for the answers to at least three questions raised by each patient every day.
This has been "my mechanism for keeping up" on the literature, Dr. McNutt said. "I could study every one of my patients for a year and not exhaust things to look up. You would be surprised about how much you forget."
Does it really deliver?
Computers are more likely to be used for literature searching than for anything else in medical practice. And given the increasingly easy access to the Internet, the dramatic improvements in searching programs that can free physicians from the arcane language of librarians, and the explosion of new easy-to-use electronic products that link large databases with point-and-click technology, literature searching promises to entice more physicians to give medical computing a whirl.
Computer-based medical literature searching, however, can be as frustrating as it is liberating. It can eat up hours of time, and still not yield all-or the best-articles. It can be outrageously expensive. And, since full articles are still difficult to come by online, all that computer time can, in the end, still require a trip to the library to photocopy articles from bound volumes.
"You have to be good [at searching] to get useful articles on Medline," Dr. McNutt said. "And then, most of the articles you will find aren't of sufficient quality [so] a doctor probably shouldn't be making decisions based on them anyway."
Other physicians disagree, saying easy access to Medline has become as essential a tool as the curbside consult. Says Robert S. Miller, ACP Member, a Sacramento, Calif.-based oncologist who keeps his desktop Macintosh turned on and connected to the modem all day while he sees patients: "I definitely would feel somewhat naked without the capability [to do literature searching] in my office. Even though I may not use online searching every single day, I've found it an integral part of what I do."
Dr. Miller said it is not uncommon-particularly when he encounters a patient with a rare tumor type-that he will type in a search query after the examination, while the patient is getting dressed, before meeting the patient back in his office. This way he has facts in hand during the discussion of what to do next. Since he can start a search using Grateful Med (searching software created by the NLM to connect physicians to its databases) and then see another patient while it is running, Dr. Miller said consulting the literature frequently doesn't slow him down.
Successful searching
More companies than ever before are trying to help by offering physicians and the public access to Medline-the National Library of Medicine's 8 million-reference citation and abstract database-as well as dozens of other specialized medical literature databases on everything from AIDS to toxicology. The competition is cutting prices, with several vendors, such as Physicians Online and HealthGate Data Corp., now offering free access to physicians willing to put up with advertisements on their computer screens.
Many of the vendors are also touting their easier-to-use searching programs, which do not require a thorough knowledge of MeSH terms (Medical Subject Headings) and NLM searching tricks. And there are CD-ROM products galore for sale that let physicians own their own copies of Medline, and some that even link to other sources of medical knowledge such as a textbook or a drug database. NLM, in fact, has licensed more than 100 different companies to sell access to Medline and Medlars' 40 other biomedical databases.
"There is some searching that doctors are really good at," said K. Ann McKibbon, a medical librarian and research coordinator at McMaster University Health Science Centre in Hamilton, Ontario, and co-author of the chapter on medical literature management in ACP's book, "Computers in Clinical Practice." A search like one Dr. Miller recently asked his computer-give me a couple of good articles on a new chemotherapy regimen for AIDS patients with Kaposi's sarcoma-is exactly the kind Ms. McKibbon says physicians can become quite proficient at, "if they are computer-literate and they want to."
With all these new programs, fast modems and increased physician interest, the problem, clearly, is not in getting started. "The problem is, once you put your query in, how do you know what you don't know?" said Jana Bradley, president of the Medical Library Association. Most physician-conducted searches result in too many hits, too few or miss the mark. Some of the new searching programs on the market today are easier for non-librarians to use, but they still require practice, she said. "You have to learn how to use those tools," Ms. Bradley said. "Is this what the docs really want to spend their time doing?"
If it is important to find as close to everything as possible on a subject-because you are writing a clinical practice guideline, for instance, or are preparing to testify in court-it probably is best to turn the search over to a professional librarian. And some searches are just too time-consuming for physicians to undertake themselves.
When Phyllis Soben, senior medical librarian at Cedars-Sinai Medical Center in Los Angeles, teaches residents and attending physicians how to do literature searches-a two-hour course now required of all internal medicine residents there-she focuses on how the Medline indexers categorize any given record, so the doctors will be able to use all of the many searching programs.
"One of the things we do in our class is we ask our students to search for the term 'practice guidelines' as a text word. They get about 560 references, and they are quite happy," Ms. Soben said. "Then we show them if they put in the subject heading (MeSH term) 'practice guidelines,' they get 1,600 articles. And if you know to look for 'practice guidelines' under 'publication types,' you get another 1,500 articles. It really points out that where you look determines what you find."
When Dr. Vine in Kansas goes to Medline (usually through Knowledge Index available on CompuServe), a trick he uses to formulate his search is to ask himself, "If I had the answer to the question I'm asking, what words would I have had to use?" This way, he finds that his search of text words sometimes pulls up articles librarians miss. "There are plusses and minuses to both approaches," he said.
Internists who do a lot of Medline searching are split on how much they need to know MeSH headings and other tricks of the NLM databases to avoid frustration. Jeffrey Greenspoon, FACP, an internist/obstetrician/perinatologist in Los Angeles, says knowledge is so essential that he recommends physicians every year either buy the MeSH index book, which spells out NLM medical subject headings, or do as he does: Ask the local hospital's librarian to bequeath him last year's copy.
On the other hand, David Kumaki, FACP, a general internist in private practice in Norway, Maine, says he uses the online searching program PaperChase, available through CompuServe, to do his occasional literature search partly because that program that does not require him to know MeSH terminology.
For physicians like him, who use their desktop PCs to search the literature for clues to clinical conundrums "pretty rarely, once a month or so," Dr. Kumaki said, "PaperChase is easy, and it's cheap. The learning curve is less steep than with Grateful Med." Many internists opt for Grateful Med because ACP members can do unlimited searches there for an annual fee of $200.
Then there's the Internet, where hundreds of home pages promise access to more medical literature than a physician could ever imagine browsing. Dr. McNutt in Wisconsin is about to add a short list of Web sites to his literature-searching PCs because, he said, perhaps 3% of the time he cannot find an answer to a patient-care question on one of his four chosen CD-ROMs. He wants to be able to easily search the National Cancer Institute's "PDQ" or Stanford University's "Primary Care Teaching Modules" and several other helpful home pages.
"People say there is so much junk on the Web, which is true-but, in fact, there is a great deal of very good health information there," said MLA's Ms. Bradley. "But if you think searching in a structured database is chaotic, then searching the Web is so much more."
Physician-friendly database searching: a product guide
From CD-ROMs to the Internet, there are hundreds of ways to electronically search the vast library of modern medical literature.
One database alone--Medline--contains 8 million references dating back to 1966. It is the computer version of the Index Medicus monthly subject/author guide to articles in 3,000 journals. More than 7.3 million searches were made last year to Medline and 40 other medical databases on specific subjects from AIDS and toxicology to health systems research, according to the National Library of Medicine (NLM), which produces the guides.
Access to these databases is through NLM's own Grateful Med software and through more than 100 vendors and organizations licensed by NLM to sell their own searching systems to the index of citations and abstracts. The list that follows includes some of the products most commonly used by physicians.
Before logging onto any of these, internists may want to check out several past issues of ACP Journal Club (available now on CD-ROM and on ACP Online's World Wide Web site) for some tips and strategies for effective Medline searching.
- Grateful Med. Available through a special ACP program, internists can get an NLM account that allows unlimited searching for a flat fee of $200 a year. The program works on PCs and Macs, and includes access to a toll-free telephone number for assistance on crafting searches and getting the technology to work. To subscribe, call NLM at 800-638-8480 or call ACP Customer Service at 800-523-1546.
- Internet Grateful Med. ACP's flat fee program applies to Grateful Med on the Internet as well as to the original Grateful Med. If you have an NLM account and password and World Wide Web access, just go to http://igm.nlm.nih.gov. If you do not already have an account, you can sign up online.
- PaperChase. Founded in 1978 by Harvard Medical School physicians and operated by Boston's Beth Israel Hospital, PaperChase charges $16-$24 per hour plus a fee for hits, but has also just introduced an option for unlimited access at $150 per year. For information, call 800-722-2075 or visit its home page at http://www.paperchase.com.
- Physicians' Online. Free access to Medline and four other NLM databases as well as other sources of information such as Physicians Gen RX and QMR are just a few of the services offered by this doctors-only interactive online service. For information, call 800-332-0009 or visit POL's home page at http://www.po.com.
- Ovid Technologies. Formerly known as CDP Colleague, and before that, BRS Colleague, Ovid Medline is the program favored by many medical libraries and health systems because of the robustness of its searching system. More than 80 databases can be accessed through Ovid's system, either online or through CD-ROMs. Ovid Technologies has just introduced a new Internet product, called "Web Gateway," and is offering a product called "Ovid On Call," which includes 300 Medline citations and one full-text article a month for a flat monthly fee of $25. For information, call 800-950-2035 or visit its home page at http://www.ovid.com.
- Knight-Ridder Information Inc. Known to many as Dialog, Knight-Ridder is also favored by libraries and large systems that want access to its more than 500 databases on everything from medicine to engineering to newspapers. Dialog services, including the popular "Knowledge Index," are available through CompuServe. For information, call 800-334-2564 or visit its home page at http://www.krinfo.com.
- HealthGate Data Corp. One of the newer research tools available to physicians, founded by several former PaperChase executives, HealthGate provides access to 20 databases from Medline to "Medical Software Reviews" and "Well Connected Consumer Health Reports." Users can search the databases and view titles for free; detailed information about references incurs a charge. Unlimited access to 20 databases costs $14.95 per month. For information, call 800-434-4283 or visit its home page at http://www.healthgate.com.
- Aries Knowledge Finder. Many physicians like the searching engine offered by Aries Systems Corp., and starting later this year access to Medline and other medical literature databases will be available through the Internet as well as on Aries' popular CD-ROMs. For information, call 508-975-7570 or visit its home page at http://www.kfinder.com.
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