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7/31/2019 Context, Uncertainty and Information Needs of Physicians
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Context, Uncertainty, and Information Needs Within Clinical Practice
Florence M. Paisey
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The real problem is not whether machines think, but whether men do.
B. F. Skinner
Mendels concept of the laws of genetics was lost to the world for a generation
because his publication did not reach the few who were capable of grasping and
extending it; this sort of catastrophe is undoubtedly being repeated all around us,as truly significant attainments become lost in the mass of the inconsequential.
Vannevar Bush
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Information seeking behavior was related to context in the early eighties
when Wilson (1981) asserted that contextual factors precipitated and prompted
information seeking behavior and use. Wilson identified these contextual factors
as environmental aspects such as the social and cultural environment, the
politico-economic environment, and the physical environment. Since the early
eighties, however, little research has been conducted on the effects of context in
information seeking behavior. Other modes of behavior e.g., social, business,
electronic (netiquette, chat), travel, or educational, have commonly been
contextualized and their appropriateness and productiveness understood on the
basis of prescribed expectations or values assigned to behavior in each role. We
often assign measures of normal or deviant, functional or dysfunctional, excellent
or mediocre based on contextual factors, values, and expectations.
We understand how varying contexts and diverse cultures affect behavior
ones values, habits, health, happiness, motivation, attitudes and cultivation. One
can start with Franz Boaz, Ruth Benedict and Margaret Mead; environment and
context have long been understood as key determinants in human development
and behavior, as abundant anthropological, sociological and psychological studies
have demonstrated. Yet, information scientists have spawned a plethora of
information behavior models that attempt to describe information behavior
without placing it in an environment or context until recently.
Times are changing. Investigations of different aspects of context have
been central concerns in studies of information behavior, information seeking
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processes, and information retrieval over the last decade. Currently, it is
recognized that information behavior occurs within multiple, overlapping
contexts that inform, direct, or shape the character of the informational
interaction (Cool & Spink, 2002).
Information seeking, use, and evaluation take place within
multidimensional contexts(ibid). Recent theoretical models of information
behavior (Belkin, 1996) view context as a core variable or level of analysis in
information behavior and information retrieval. This may be news to the
information world, but psychologists have been talking about context since Pavlov
behavior is behavior is behavior. Ones environment, replete with contingencies,
dimensions, and uncertainties, cannot be divorced from ones life or those events
that impact ones life, both overtly and covertly.
Although the value of context has been recognized, it has defied any single,
precise definition or identification of those elements bearing actual or potential
influence on the relationship of context to information seeking and information
retrieval (Cool & Spink, 2002). Several theorists (Vakkari, 1997; Cool, 1991,
Rieh, 2004 ; Allen, 1997; Sonnenwald, 1999) have pointed out the ambiguous,
interchangeable use between the terms context and situation. Dervin (1997)
describes context as an unruly beast due to the difficulty in gaining
methodological control over it. She asserts that her Sense-Making methodology
can provide a framework for studying human behavior contextually,
incorporating time, space, movement, power, gap, constraint, and force, yet
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finds it a slippery concept to define. In 1997, Dervin commented that there is no
term that is more often used, less often defined, and when defined, defined so
variously as context.
Vakkari (1997) contends that situation and context are used
interchangeably without any effort taken to distinguish between the two
conceptually. Cool (2001) simply refers to the distinction between the two
concepts as murky, while Sonnenwald (1999) attempts disambiguation by
characterizing contexts as embedded in situations.
Talja (1999) defines context as:
frames of reference that allow us to choose
the relevant elements for study and concludes[d]
that one way of explaining and understanding
information seeking phenomena is to define
them as patterns of behavior [while] another way is
to understand them as phenomena mediated
by social and cultural meanings and values (p. 762).
Fundamentally, Talja is looking at those factors or variables observed to affect
individuals information seeking behavior: socio-economic conditions, work
roles, tasks, problem situations, communities, and organizations with their
structures and cultures etcetera(Kuhlthau and
Vakkari, 1999). Though Talja approaches the problem of context from two angles,
they intersect at points of observation, behavior, and elements. These points
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characterize her notion of context as something that can be objectified, though
interpreted within the perspectives of cultural and social meaning.
Cool and Spink (2002) broadly define the parameters of context in an
editorial introduction to a group of papers focusing on user needs and addressing
context in information retrieval. This definition views context as information
environments in which information behaviors occur. While Cool and Spink (ibid)
refer to information environments and information behavior, there is no mention
of information need. In a previous paper by Wilson (1999a) information needs are
said to arise out of complex, interrelated contexts and roles prompted by a person's
physiological, cognitive and affective needs any one of which may be the person
himself, or the role demands of the person's work or life, or environments. With
regard to clinical information behavior, particular attention might be placed on the
context of the person himself the clinicians own sense of competency and
capacity to resolve issues of professionally-related uncertainty.
Cool and Spink (2002) facilitate an understanding of the dimensions of
context by succinctly identifying four levels of context:
Information environment level where channels of communication would beexamined.
Information seeking level where a persons goals or problem resolutionand the means by which one satisfies them would be examined given a
problem definition one looks at context in terms of the information seeking
behavior performed.
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The information retrieval context that examines the interaction between theuser and the system within search sessions.
The information query level where the linguistic context or the interactionbetween a query and the system is examined. (Does the system interpretthe query correctly in terms of the context assigned?)
The notion of context is one which could easily occupy this paper, becoming a
bid of a red-herring, if you will. However, human behavior does not occur in a
vacuum, nor are human beings unresponsive to contingencies event, uncertainty,
and information issues being one repertoire. I will satisfice(Simon, 1957) myself
with the definition offered in Penguins Dictionary of Psychology:
Generally those events and processes (physical
and mental) that characterize a particular situation
and have an impact on an individuals behavior
(overt and covert). The specific circumstances
within which an act or event takes place
(Reber, 1995, p.159).
Reber describes context as all those complex events processes, stimuli, and
patterns that circumscribe a situation, distinguishing context as a descriptor of
situation. In other words, a situation occurs within a particular context. This
definition seems to reflect Sonnenwalds (1999) view.
Ive explored an aspect of the concept of information seeking in context
(ISIC). Physicians practice in particularly complex and distinct environments that
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impose rigid contingencies, critical outcomes, and a multidimensional context on
their work. No physician or clinician can practice effectively and safely outside of
his or her medical context tools required to carry out their work are embedded in
the context. There are, of course, extenuating circumstances that may necessitate
clinical treatment outside of a standard medical context. However, these are
exceptions and do not characterize the professional context. In some
circumstances, remote diagnosis and treatment could be managed through
telemedical devices and would be contextualized and defined on its unique
elements and conditions.
The context of information behavior for physicians is fraught with
complications, obstacles, barriers or, as termed, within Wilsons general
framework of information behavior (1999a), intervening variables. These
barriers or intervening variables exist at the start of the patient encounter and
throughout patient treatment to the end, in any medical situation. It is well to
employ the concept of intervening variables as there are many contingencies, some
of which may interact cohesively or randomly, decreasing uncertainty or
escalating it. These contingencies bear on a clinician, where uncertainty presides
and drives the need for information and subsequent information behavior. In the
context of clinical care, uncertainty and a need for information are implicit with
every patient appointment. Studies relating to how the context of a physicians
work affects information behavior, a physicians pursuit or avoidance of
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information, and informationist strategies to support clinical care occupy the
remainder of this paper.
Balsa (2003) maintains that uncertainty is a powerful force in medicine
and supports Wennberg (1985) in viewing uncertainty as the single most
important influence on a physicians [information] behavior (ibid) implying
that the method by which a physician manages uncertainty will determine the level
of expertise a patient will receive as well as the outcomes of that treatment.
Numerous general models of information behavior view uncertainty as the prompt
triggering an information need and ensuing information seeking behaviors
(Wilson, 1981, 1996, 1999a; Belkin, 2005; Dervin, 1983; Krikelas, 1983;
Kuhlthau, 1993, 1996). Wilson and Kuhlthau both employ the term uncertainty,
while Belkin uses anomaly, and Dervin gaps.
Wennberg (1985) identifies several types of clinical uncertainty:
uncertainty about the patients ailment, uncertainty about whether treatment will
be effective, and uncertainty about a patients personality their ethics and
standards. Balsa (2003) identifies several additional roles of uncertainty,
particularly with groups that differ ethnically from the clinician. Some of these
uncertainties are not traditionally viewed as clinical information needs, however
much they may affect the outcome of treatment. The relationship between doctor
and patient has altered notably since the eighties, though traces of this alteration
have been apparent since the seventies.
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Previous to the eighties, physicians played a role in the therapeutic
relationship characterized as authoritarian or paternal. Few patients questioned a
physicians diagnosis; fewer arrived at the medical consultation with professional
information regarding their ailment or known illness. Physicians carried a
mystique(Plutchak, 2000) and were often felt to be unapproachable and
inscrutable. This loftiness has faded as health care policies have changed,
removing some of the privileges as well as preferred treatment and pharmaceutical
courses that physicians once held in full control. Healthcare costs have soared and
health benefits have decreased as a result of health insurance policies and the
limitations placed on physician reimbursement and treatment. Rather than open
ended consultations with ones physician, medical time is now, virtually, regarded
monetarily, resulting in brief appointments that are routinely scheduled, offering
little time to discuss the way one is feeling, the clinical questions a physician has
time to ask, and the health-related questions a patient may need to ask. Though the
physician may still be the source of diagnosis and treatment, the informed, health-
literate patient arrives at the clinic or the physicians office prepared with a series
of questions, often written as a time-saving list. These questions are clinical
questions to which a patient either receives an answer or doesnt.
Gorman (1995) identifies four categories of clinical needs, yet relates none
of these needs to the notion of uncertainty, anomaly or gaps. If there were no
stimulus/uncertainty (anomaly, gap) no problem, no clinical question, or
clinical information would exist or be necessary. It seems the issue of uncertainty
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is vital in gaining a full or holistic account of the doctor/patient encounter. The
four categories that Gorman (ibid) identifies include:
Unrecognized needs: inferred by measurement of physicianknowledge or observation of clinical practice.
Recognized needs: those articulated by the physician. Pursued needs: information seeking behavior is either observed or
recalled at a later time.
Satisfied needs: those needs for which information has been neededand for which information as been found and satisfied.
Gormans identification of unrecognized needs serves as a crude gauge of
many uncertainties and problems that critically affect patient care, yet go
unreported as they may not be viewed as clinical in nature. Since the IOM reports,
To Err is Human(1999) and Speaking of Health(2002) policy centers and the
Centers for Disease Control have identified dimensions of the doctor/patient
relationship as of clinical concern, and identified these concerns as issues of health
care. Uncertainty, as it relates to information needs and seeking, may insidiously
cause corrosion in doctor/patient relationships. These unrecognized needs,
activated by uncertainty are discussed briefly.
One obvious, fundamental way in which uncertainty can affect clinical care
is in the physicians own confidence in their skills. This variable or source of
uncertainty results in varying behaviors. Such uncertainty may inhibit the
initiation of information behavior, resulting in a barrier or placebo-like treatment.
It may trigger vital information seeking behaviors that may include consulting
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other physicians, or it may result in a referral to another physician or specialist.
The relationship a physician has with himself/herself will decisively influence
their efficacy as a clinician and incentive to resolve clinical uncertainty through
purposive goal-oriented information behavior.
Uncertainty also arises from the variables inherent in complex subjective,
or discretionary tasks demanded in diagnostic and therapeutic evaluations. This
uncertainty arises from the diagnostic ambiguity of clinical symptoms, laboratory
tests, and unresolved differences of opinion or perspectives regarding the
reliability of diagnostic and laboratory interventions. Numerous other sources of
uncertainty affect a clinicians treatment.
The Institute of Medicine (IOM, 2002) has identified language and cultural
barriers as significant sources of mistrust, misunderstanding, and misdiagnosis.
Various forms of communication barriers significantly affect doctor/patient
relationships and account for considerable noise or uncertainty, and mistrust. A
few communication barriers have been identified and may be briefly discerned as:
Possible (and frequent) miscommunication between clinician andpatient.
Inability of the patient to understand the physicians direction,diagnosis, and/or prescribed treatment.
Doubt about quality and reliability of the clinicians assessment,particularly when cultural barriers exist.
Communication noise between physician and patient may interferewith a patients confidence in the physicians judgment resulting in
non-compliance with prescribed treatment.
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It is clear that a physician faces a multilayered, multidimensional set of
uncertainties during a doctor/patient encounter, particularly with a new patient.
Those behaviors outlined above are sources of uncertainty that arise in a routine
context with ostensibly few complicating clinical variables. Yet, many of these
sources of uncertainty underlie the performance of critical health-related behavior
(IOM, 2002; 1999).
Wilson (1999) maintains that information behavior is relevant to levels of
uncertainty and the solution of a problem or resolution of uncertainty. He argues
that an individual progresses from uncertainty to increasing certainty through
identifiable stages in a problem resolution process. The need to reduce
uncertainty underlies purposive, goal-seeking behavior, identified as information
seeking behavior. Basically, he views information behavior as a problem-solving
process based on the notion of uncertainty reduction.
Wilson et al. (2002) conducted a qualitative study of uncertainty and
information seeking as it relates to Wilsons problem solving model (1999a) and
factors originating in Ellis behavioral model, and Kuhlthaus process model.
Wilson et al. (ibid) found that the uncertainty concept served as a useful variable
in understanding information behavior. This finding supports the long-standing
notion that uncertainty brings about information seeking due to a lack of
understanding, a gap in meaning, or a limited construct (Kuhlthau, 1993a).
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In a case study where one subject was a medical resident, Kuhlthau (1996)
looked at the relationship between uncertainty and the complexity of a task. The
medical resident reported that the complexity of the task affected her approach to
information seeking. Complex tasks were identified by the participant as those
needing substantial searching to acquire adequate information to meet her
information goals.
Kuhlthaus (ibid) findings support the notion of redefining roles and tasks
associated with providing information service in the workplace. The medical
resident in this study identified four levels of informational assistance she had
encountered during her medical training. Three informational encounters with
librarians were ineffectual; the first was described as just a room of journals;
the second was described as just a person who sits behind the desk and has the
job of filing things; the third was described as a real library where the librarian
does searches for you; the fourth was described as quite apart from the others.
When asked about the fourth librarian the resident described her as
collaborative and interactive. The resident explained that when she gave the fourth
librarian some keywords she would respond with what about this, and what about
that, and let me see what I come up with. She regarded her as helpful to have her
there and be able to interact. This fourth librarian was engaged with the
researcher and associated information needs. The characteristics of the effective
librarian advised on resources and process in addition to interpreting and
connecting disparate pieces of information. This interactive librarian differs
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from the traditional librarian whose role or relation to the patron has been more
passive, providing access to references and sources on a particular topic.
While the medical resident in Kuhlthaus (1996) study understood that the
complexity of the task influenced her information behavior, she provided only a
general statement about how she dealt with the complexity of a task complex
tasks required substantial searching to acquire adequate information to meet her
information goals. In this case an intermediary, the librarian, performed her
substantial searching. For whatever reason, she did not manage the task herself.
Kuhlthau (ibid) supported her notion of redefining roles and tasks in the
workplace by illustrating the difficulty a medical resident experienced in seeking
information that would address a complex task or problem. The context of this
study involved research that a medical resident was conducting, either to resolve a
clinical problem that arose in a clinical context or a research problem that an
instructor or professor had assigned.
In either context, the task for which the resident required intervention was
perceived as a complex task, a task that the resident could not perform herself and
required information to meet her goal. In this scenario the librarian (either in a
hospital or university) intervened by locating sources and assisting with the
interpretation and integration of information, reducing the residents uncertainty,
or anomalous state of knowledge.
The more complex the task the greater the potential uncertainty and need
for information. The complexity of a task is a central feature in determining
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consequent information needs (Vakkari, 1999). The concept of
predeterminability and structuredness are both features of task complexity, or
perhaps task architecture. If one has prior knowledge of a task, one can determine
its structure and consequently the information required for its accomplishment,
reducing uncertainty. The more one knows about the dimensions or structure of a
task, the less complex it becomes. Complex tasks are new and genuine decision
tasks where the information required for accomplishment can not be determined in
advance (Vakkari, 1999). Such tasks, particularly of a critical nature, in a time
constrained context, require intervention.
Clinical medicine is a fertile source of scenarios that illustrate the
complexity of tasks where the information need may be unexpressed or
imperfectly understood. The strategy one employs in approaching complex tasks
in the context of clinical medicine may also differ as one extracts, synthesizes, and
applies knowledge to a clinical problem complicated by all those elements that
individual personalities bring as patients.
It is well to understand information behavior as a form of human activity in
an attempt to understand human lifehow individuals and groups behave in
varying cultures, what is of significance and meaning, what we can do to improve
conditions, ensuring quality life. Over the last two decades, scientific and
technological developments have led to the means of producing and distributing
information in exponentially greater quantities. Electronic communication has
impacted and transformed the tools we employ to communicate and interact in
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society and culture. It has added yet another tool that socio-economic affluence
will offer to those who have it, yet deny the tool to those who havent. New
expressions to communicate this impact have emerged: the digital divide, the
global South, the World Information Society Day (sponsored by the U.N.).
As information has become more and more profuse, the process of finding
needed information has also changed. Quality sources are buried among tiers of
sources, some relevant, some disreputable, all requiring the skill of discernment.
This process of identifying required sources amid abundance is a sophisticated
skill, but of enormous importance. Within the an incomprehensible quantity of
information, is a slim slice of knowledge or piece of information that can save a
life, forecast disaster, manufacture fuel. The problem information professionals
face is developing interactive indexing and retrieval systems that provide efficient,
accurate access when we need it, where we need it, and how we need it with
efficiency and ease. These systems can be designed and built, but first, it is
necessary to understand the information behavior characteristics of specific user
populations, and build systems that complement and meet their needs.
No profession is in greater need of possessing such technology and skill
than medicine. The proliferation of information in medicine is endemicmore
information is produced, more research is conducted, more papers are published.
How does one keep up, and if not keep up, simply gain accurate, efficient access?
Right now, most clinicians dont; a scant few who research and practice in
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bleeding-edge research and teaching hospitals do, but how many patients reach
those few?
Practicing medicine well, and applying current research findings, requires
expert management as well as innovative information systems, finely organized
with ground-breaking retrieval features. Information overload requires
professionals trained in information management as well as expert knowledge
managers who can search these systems once theyre built. Ultimately, one would
want an information system so intuitive, so efficient, that any literate search,
within context, could satisfy a question put to it. Evidence-based, point-of-care
medicine will drive this effort, but, these systems have yet to be built, and
information behavior has yet to be adequately understood to design such systems.
Many systems have already been built, but few have come systems are still too
inefficient, too imprecise, too crude to be effective for general practitioners.
To illustrate the proliferation of medical literature and the urgent need for
advanced retrieval systems, one might consider that about two million biomedical
articles are publishedeach year. A physician would have to read six thousand
articles a day to keep up with all possible relevant biomedical literature
(Verhoeven, 1999). And if that isnt sufficiently staggering, consider that
biomedical literature has grown 267% in ten years (ibid) and the rate of
publication is still climbing. In view of this quantity of biomedical literature, when
practicing clinicians are uncertain and perceive an information need, they need to
engage in effective information searching behavior.
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Leckie et al. (1996) performed a meta-review of information seeking
characteristics of physicians and healthcare workers (among other professionals).
They found that the range of information behavior among physicians in the role of
clinician varied significantly and organized their reported findings as variable-
related differences relating to context, demographics, and complexity. Variables in
reported specialties included: the focus of patient care, and those who looked at
psychological aspects of illness. Variables in information behavior were widely
scattered and identified as:
The specialty or discipline Experience, Age Type of practice Location or work site The number of questions posed.
The number of questions answered. The size of the primary hospital.
In terms of patient care surgeons focused on routine monitoring,
While pediatricians looked at what psychological effects may be influencing the
illness. Recent graduates were contrasted with the variable of age use of library
resources, and books increased with recency of training, and consultation with
colleagues decreased as physicians grew older. This demographic of age as a
descriptor of information behavior may be questionable. Does age predict
information behavior or some other variable? A more recent study by Ely (1992)
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refuted age as a descriptor, finding no significant difference between those
demographics. It seems that looking at age as a demographic variable has some
inherent bias. Recent clinicians may have been researchers during early years,
changing to practice later. Those who choose to practice when young or as recent
graduates, may re-tread as researchers and lecturers. Often, particularly in higher
end practices, clinicians do both, practice a few days while teaching and
researching others. As stereotypical notions regarding any population, in this
caseage, fade, a more accurate notion of what drives professionals to scholarly
literature may surface.
Type of practice or specialty were found to influence information behavior
or methods of research. General practitioners used unsolicited medical literature
and consulted colleagues. Ob/Gyns preferred consultations with colleagues, rather
than research professional literature or other sources. Internists were found to
prefer journals and textbooks, while family practitioners consulted colleagues.
Those clinicians working in an urban setting were found to use colleagues more
than in other locations and clinicians in institutional practice informally consulted
colleagues.
A significant area of concern that Leckie et al. did not deliberate regards
questions and time. Those physicians practicing in urban areas asked more
questions given time, but pressured by a heavy case load, tended to ask the fewest.
The statistics reported on answering questions were particularly disconcerting.
Covell (1985) as cited by Leckie et al. (1996) reported that only 30% of perceived
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and recognized physician information needs were met; this finding was
corroborated by Murrays (1992) finding that only 1 out of 4 questions arising
from a patient visit was met. Given that statistic, 75% of physician information
needs are unsatisfied.
Leckies research on the information seeking of professionals was
published in 1996, a decade ago. Her findings were based on literature researched
and published prior to that, some back to the eighties. It would be interesting if she
conducted the same study now, comparing data. Much more information on types
or categories of clinical questions are available Ely et al. (2000) have developed
a taxonomy of clinical questions in order to better understand the information
needs of clinicians.
Verhoeven (1999) conducted an extensive study on the information needs of
general practitioners, offering a rich source of information on their clinical
uncertainties, information needs, and information seeking behaviors.
Leckie et al. (1995) produced a general model of information seeking for
professionals, based on their literature review. The model identifies work roles
and tasks as fundamental to understanding a professionals (in this case, clinicians)
practical information needs. Context was not included in their model, although it is
implicit that contextual elements and structure will impact work performed in
varied sites. According to their model of information seeking, the user is identified
as seeking information with the objective of outcomes. No behavioral strategies,
such as Ellis model or Kuhlthaus are included in this model. It seems that such
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strategies are assumed in the seeking process. Outcomes, in a clinical sense could
be interpreted as laboratory results, or any diagnostic technology employed to
provide clinical information, aiding in a diagnosis. It seems that if outcomes
suggest some ambiguity or uncertainty, the model depicts the user seeking
information from sources. Sources, in the model, remain unidentified.
The strength of Leckies model lies in her contextualization of information
needs and the connection of context to a professionals role and consequent tasks.
There are a few weaknesses: the lack of identifiable behaviors in seeking
information in sources and the lack of reference to who will do the information
seeking. In view of the vast sources of clinical research findings and publications,
it seems unrealistic to expect physicians to conduct information seeking as a
matter of routine. Clearly there are some issues that are best handled through ready
reference or possibly a simple search. However, if 75% of clinical questions go
unsatisfied, it is clear that not only do systems require greater efficiency, but a
professional skilled in dealing with clinical questions and biomedical literature
would be of great service.
This paper has only skirted over the issues that the medical professional is
facing with regard to clinical context, uncertainty, information needs, and
searching. It is clear that research findings are not being used optimally, and
cannot be use optimally, given the amount of biomedical literature available and
the time it takes to search, filter the search and identify studies of direct relevance
to the immediate clinical information need. Davidoff and Florance (2000)
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proposed that a clinical librarian, an informationist, as they have termed the
specialization, take on a clinical role as an integral member of a clinical group
with a specialized expertise that can contribute vitally to clinical situations. The
clinical librarian would read the full text of pertinent articles, extract relevant
findings, write up a synopsis and present the research findings on rounds.
With evidence-based medicine at the door, information overload, patient
overload, and research findings that are lying in waste, unread, and unknown to
the general practitioner in all specializations, the concept of a clinical librarian, an
informationist, standing tall on a medical team and ready to pick up on any clinical
uncertainties expressed or unperceived is a rescue conscientious clinicians would
welcome with open arms. How will such a librarian be trained? Who will pay?
These are the issues on the table. But, as Scott Plutchak, President of the Medical
Library Association has said, If you think the information profession has changed
over the last few years, you aint seen nothing yet. (Plutchak, 2000)
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