Info.Rx Cases

Sources of fiber in your diet: case

2010-09-23T16:15:00.000-04:00

This one comes up so often there is no particular case I can describe.

Here are the resources I recommend to patients at the clinic:

Family Doctor: Fiber: How to increase the amount in your diet
Family Doctor: Irritable Bowel Syndrome: Tips on controlling your symptoms
Mayo Clinic: Dietary fiber: Essential for a healthy diet
WebMD Fibor-o-meter
HealthLink BC: Fibre and your health
BC cancer Agency: Dietary fibre content of common foods

Clinical queries, various

2010-09-23T15:58:00.000-04:00

Lately the Clinical Medical Librarianship (CML) component of the service has been giving me a lot of interesting opportunities to support practice at the clinic. Often clinicians are faced with conflicting evidence, or their patients read something in the news and they need to be able to respond (Check out What Your Patient Reads, developed by the University of Manitoba Health Sciences Libraries).

I thought I would share a few of the topics I've worked on recently that go beyond the usual 5 min clinical question:

Evidence for and against PSA screening for prostate cancer. I put together a fairly extensive annotated bibliography which I would be happy to share with anyone who contacts me. Included in the bibliography:
- Incidence/mortality statistics for Canada & US
- Most recent studies & guidelines 2006-2010 (International)
- Decision aids and evidence to support their use
Evidence to support, or dispute, what has been in the news lately re: calcium supplements and heart disease:
- Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis BMJ July 2010, doi:10.1136/bmj.c3691
- Systematic Review: Vitamin D and Cardiometabolic Outcomes Annals of Internal Medicine May 2010
- Systematic review: Vitamin D and calcium supplementation in prevention of cardiovascular events. Ann Intern Med. 2010 Mar 2;152(5):315-23.
- Vitamin D and calcium: a systematic review of health outcomes. Evid Rep Technol Assess (Full Rep). 2009 Aug;(183):1-420.
- Vascular events in healthy older women receiving calcium supplementation: randomised controlled trial BMJ Jan 2008, doi: 10.1136/bmj.39440.525752.BE
Association between accutane & ulcerative colitis?
- Isotretinoin use and the risk of inflammatory bowel disease: a case-control study Am J Gastroenterol. 2010 Sep
- Isotretinoin and intestinal inflammation: what gastroenterologists need to know Review, Gut 2009, doi:10.1136/gut.2008.170530
- Isotretinoin is not associated with inflammatory bowel disease: a population-based case-control study Am J Gastroenterol Nov 2009
- A causal association between isotretinoin and inflammatory bowel disease has yet to be established Review, Am J Gastroenterol Oct 2009,
- Possible association between isotretinoin and inflammatory bowel disease Am J Gastroenterol July 2006

Drugs & Herbs while breastfeeding: case

2010-04-22T14:55:00.014-04:00

Has it really been 4 months since my last post?! I've been busy training my new assistant who will be handling the suddenly large volume of pamphlet orders and working with me to develop a new and improved classification system so that pamphlets are easier to find. Referrals have been steadily coming in and I am busy fielding requests in the teaching rooms. Our next challenge is to see how I can support the patient education needs of the walk-in centre or Clinique réseau intégré universitaire...

Scenario

A question I got recently was from a woman in her thirties who wanted to be able to find out which medications are safe to take while breastfeeding. Her question was specifically about non-prescription medications, for example those she might take for allergies, colds or stomach upset. She also wanted to know whether certain herbal supplements are safe while breastfeeding.

Resolution

Medications

There are a few places I told here she could look that have reliable and freely accessible information about the effect of medications on breast milk NB these resources are American. Use the generic drug name as brand names can be different in Canada and the US:

Lactmed (from the National Library of Medicine- NLM)

A peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed. Among the data included are maternal and infant levels of drugs, possible effects on breastfed infants and on lactation, and alternate drugs to consider.

The MedlinePlus Drugs, Supplements, and Herbal Information

is available from the American Society of Health-System Pharmacists (ASHP) via AHFS^® Consumer Medication Information , and Natural Standard.
AHFS^® Consumer Medication Information provides extensive information about more than 1,000 brand name and generic prescription and over-the-counter drugs, including side effects, precautions and storage for each drug.
Natural Standard is an evidence-based, peer-reviewed collection of information on alternative treatments. MedlinePlus has over 80 monographs on herbs and supplements.

Drugs.com

Search this database by drug. At the bottom of each description you will find a link to pregnancy and breastfeeding warnings. This is also a good place to search for interactions between drugs, and for detailed information about side effects.

Herbs & supplements

To find information about the safety of herbal supplements while breastfeeding I again recommended the MedlinePlus Drugs, Supplements, and Herbal Information. I also suggested that she speak to her physician, nurse and/or pharmacist before taking anything.

Patient journals/diaries/calendars: case(s)

2009-12-17T14:07:00.027-05:00

I've just realized I haven't posted since October! I guess there has been a lot going on and not much time to write about it. Mostly I have been busy in the teaching rooms which continues to be productive and fascinating. The rest of the time is increasingly taken up with ordering pamphlets and tracking pamphlet orders. For some reason more and more of them are being requested by various nurses and doctors, even though fewer of them are available for order in print format as information goes digital. Finding a balance between print and e-resources is proving to be a challenge which is a topic for another day.

Keeping track

What I' m going to post today is a list of journals/diaries/calendars that can be given to patients and families when they are asked to keep track of behaviours, symptoms and/or side effects of medications. Doing so can help in the diagnostic and treatment process. Because it is often hard remember how often you can't sleep or feel anxious for example, keeping track while it happens helps the doctor/nurse get a better sense of what's really going on. There are a variety of instances in which such a thing can be useful.

Here are some of the most commonly requested:

Sleep:

Health Link BC: Sleep diary

Keeping track of symptoms:

Depression and Bipolar Support Alliance: Mood and anxiety calendar
Mood Disorders Association of Ontario: Mood diary (pdf)
International Foundation for Functional Gastrointestinal Disorders: Bowel disorder symptom diary (pdf)
Ovarian Cancer Action: Ovarian cancer symptom diary
About.com: Daily symptom diary for kids
About.com: Tracking fibromyalgia or chronic fatigue syndrome symptoms
The Lung Association: Asthma diary card (scroll down)
American Urogynecologic Society Foundation: Bladder diary
National Headache Foundation: Headache diary
World Headache Alliance: Headache diary

Medication side effects and pain:

American Cancer Society: Track cancer side effects and pain

Eating/exercise:

WebMD: Food diary and food allergy triggers
American Cancer Society's Great American health challenge: Food diary
US Gov. Weight-Control Information Network: Sample food diary (scroll down)

Unreliable-reliable information: case

2009-10-08T12:53:00.006-04:00

The other day I was in the teaching room and I was putting out some of the new brochures I ordered on the topic of contraception. We have a little display in there so the residents can grab something quickly when I'm not at the clinic.

Information about choosing a contraceptive method is one of the most commonly requested handouts and we keep running out. I found what I thought was a really good one produced by the Society of Obstetricians and Gynecologists of Canada (SOGC). You can't get more reliable and authoritative than that, I figured. I still think that... but....

One of the supervisors opened one up- they look like little brochures but actually they are little posters folded up nicely. When you unfold them you get a comparison chart at the top that shows the number of unintended pregnancies for all the different methods, from Intrauterine system (IUS), through Oral contraception, Condoms, Diaphragm etc., all the way to No contraception (no surprise, pretty high failure rate here: 850 out of 1000, or 85%).

It struck the doctor as odd that Intrauterine device (IUD) had such a high failure rate compared to the others (9 out of 1000 with perfect use vs 3 out of 1000 for the pill for example). It did seem a bit odd. Also for typical use there was a little "-" instead of a number, implying what I'm not sure. No data? Zero failure rate? An asterisk next to the 9 brings you to a little footnote: "This perfect use failure rate corresponds to the Nova-T 200. The typical use failure rate for the Nova-T 200 is likely slightly superior." So then shouldn't there be a number there instead of "-", maybe a higher number than 9?

I decided to check out the references listed right below the chart: Trussell 2007, Trussell 2004, Black 2004* and Andersson 1994.

The paper that seems to have provided the data for the chart is Trussell 2007, or complete reference:

Reducing unintended pregnancy in the United States
Contraception, Volume 77, Issue 1, Page 1
J. Trussell, L. Wynn doi:10.1016/j.contraception.2007.09.001

I am still a bit confused. The paper has a table that shows numbers that correspond exactly to all the other data in the chart except for under IUD we have:

Contraceptive method Typical use Perfect use

IUD
ParaGard (copper T)	0.8	0.6
Mirena (LNG-IUS)	0.2	0.2

So where is the Nova-T 200? And how come the above numbers aren't used? I did not find Nova-T 200 data in the other papers either. Provided I found the right ones.**

I still think the handout is great. It provides much more than just data. Aside from the chart there is information about all the contraceptive methods, what they are, how they work, advantages, disadvantages, stuff that will certainly help people make informed choices. And if they have any questions they can discuss with their GP.

However it is interesting to see that even information provided by the most authoritative sources can be flawed. Considering all the shocking debacles we have seen recently, Elsevier's fake journals, authors ghostwriting for pharmas, this is just one more reason to start assessing the contents of individual resources, and not rely so much on authorship.

* These are the Canadian contraception guidelines: http://www.ncbi.nlm.nih.gov/pubmed/15115624

** Once again, is it too much to ask that people provide the full reference? Some authors are prolific. It took me a while to figure out which Trussell 2007, and which Trussell 2004 etc. Still not sure about all of them. It shouldn't be so hard.

Picky eaters: case

2009-07-30T15:53:00.003-04:00

It's time to revisit picky eaters.

Scenario

A mother comes to see me in my office carrying her 12 month old son who, she tells me, refuses to eat meat. Luckily he will eat just about anything else. She does not want to force him to eat meat, but no one else in the family is vegetarian so she is not sure how to make sure he's getting enough of the vitamins and minerals he needs.

Resolution

I am able to find quite a few good resources that provide information about vegetarian diets for children:

KidsHealth: Vegetarianism
KidsHealth: Snacks for Toddlers
KidsHealth: Toddlers at the table- avoiding power struggles

Vegetarian Society: Infant diet

Caring for Kids: Feeding your vegetarian child

NOAH: Vegetarian diets (for babies)

Challenge: Knowledge translation

2009-07-09T14:18:00.014-04:00

Since the CHLA conference I've been thinking a lot about knowledge translation (KT) and what it means to me and for me i.e. how I understand the concept and how I can put it into practise.

KT came up a lot in the presentations at the conference and on the Tue before I left an entire panel was devoted to discussing it. Three panelists, Orvie Dingwall, MLIS Librarian and Project Manager CPSI-ICSP ( Presentation, Handout), Sara Kreindler, DPhil Winnipeg Regional Health Authority - Research & Evaluation Unit, and Elizabeth Hydesmith, MSc Senior Project Manager NCCID, discussed KT in their organizations (can I take a moment to say kudos to CHLA for making almost all papers and posters immediately available on their website? It would be great if MLA did the same*). While the panel was very interesting it left me wondering what KT means in a hospital library or consumer health resource setting. Dr. Thomas Kerr also mentioned KT in his presentation, Bridging the Gap between Evidence, Policy and Public Opinion: Lessons from the Scientific Evaluation of Vancouver's Supervised Injection Site, and it was he who gave me an idea. More in this later...

It hasn't been easy to find a "plain language" explanation of what KT actually is (CIHR, IDRC) (WHO's isn't bad) which is kind of ironic. I'm not ashamed to admit that KT is term that I was not familiar with before the conference. In my last semester at library school, which I completed at McGill, I was briefly introduced to another "K" term, Knowledge Management or KM, but not to KT. Neither came up in my studies at Dalhousie. I won't try to speculate as to why and don't feel that I was cheated out of anything since I was given the tools to understand the concepts. I think catchphrases and buzzwords are useful, up to a point. Even scholars of KT aknowledge there is some confusion about KT and related terms such as knowledge transfer, knowledge exchange etc. (Lost in translation: Time for a map?, IDRC). I honestly couldn't have stood the discussion that would have ensued, considering how much time we spent on the data vs information vs knowledge debate (only slightly less annoying than the art vs craft debate I suffered through at NSCAD).

The important thing is to own a concept, to understand it on a deep enough level that it becomes part of how you behave and your decision-making process, regardless of what word(s) you use to describe it. This is the very process KT is concerned with and jargon can interfere, as acknowledged by the existance of KT opportunity 3, identified by CIHR, which urges the use of "plain language."

Now we are getting to the "in" that I was looking for. Consumer health information is all about "plain language" and bridging what WHO calls the "know-do" gap. So providing patients and families with easy-to-read health information falls within the KT realm. But there has to be more to it than that since I work with health professionals as well as consumers. KT opportunities 4 and 5 allow me to take things a bit further.

This is in fact a solution to a problem I've been mulling over for some time. Since I have been working in the teaching rooms at the Herzl, and I don't have precedent for my service (except one, now defunct), I wanted to have some way, other than just saying so, to show the residents and their supervisors that what I do is evidence-based and not just an idea I came up with and was able to convince a few doctors was a good idea.

It was clear to me that I could not expect anyone to read the needs assessment proposal I wrote several years ago which included an extensive lit review of such concepts as health literacy, shared-decision-making, the doctor patient diad, patient empowerment etc, and how the participation of a librarian and the provision of consumer health information can positively impact all of the above. Nor could I expect them to study the detailed report on the results of that needs assessment.

I needed a much simpler and quicker way. Dr. Kerr mentioned having used "plain language summaries of SIF research" called Insight into Insite. It occurred to me that I could do something similar, one page evidence-summaries on a few relevant topics. Obviously I am not communicating the findings of my own research, but there is research to support what I do, research that can serve to encourage use of my service. Behold the first one of what I hope to be a series: Health information in multiple languages at Herzl. Where do "multidirectional communications and ongoing collaborations among relevant parties, interdisciplinary process etc" come in you might ask? Well, I am using research generated by both librarians and health professionals, and before sending my little summary out I showed it to one of the physicians I work with the most, who suggested an article I might add to it.

At some point I would like to expand to the rest of the hospital, and put out evidence summaries under the library umbrella as well.

*A few hours after writing this post I received my MLA Focus which announced that "full video/audio with synchronized slides of MLA plenary sessions"are now available to members only via the website.

Wolfram Alpha: "computational knowledge engine"

2009-05-21T14:15:00.009-04:00

Wolfram|Alpha has been in the news/blogosphere lately.

Search Principle Blog
Mr.W's lecture at Berkman Center, Harvard
The NYT
The Register's not-so-glowing review
(for more see 1^st item in this list)

I've spent a bit of time fiddling with it to see what it can do and whether it might be useful for either myself, health consumers or the health professionals I work with.

So far I have found one potential use which is to look up disease mortality rates. If you type in lung cancer for example, you will get Canadian & world mortality figures (number of deaths & rate of death, per year). If you type lung cancer Italy, you get the results for that country & the world.

More interesting is the list¹ of background sources and references that pops up when you click on source information for the original query. In this case:

World Health Organization. "Data and Statistics" 2009.
Centers for Disease Control and Prevention. "National health Center for disease Statistics." 2009.
Centers for Disease Control and Prevention. "NCHS--Mortality Data from the National Vital Statistics System." 2008.
The Disaster Center. The Disaster Center. 2009.
[Poodwaddle.com.] World Clock. 2009 This one is mesmerizing and creepy. I'm not sure that Poodwaddle is an entirely credible source (possibly why Wolfram|Alpha leaves that bit of info out), but whoever they are the data apparently comes from "World Health Oragnization, CIA Factbook, US Census Bureau and other sources."
Centers for Disease Control and Prevention. "NCHS--Data Warehouse." 2008.

I guess potentially this is a very quick way to find sources that offer statistics for a particular disease, though you still have to search the resources to find the specific data. Unfortunately Canadian resources are not included. Also not sure which diseases are in there. Only one way to find out...

...even more interesting:

Type in heart attack and you get a risk calculator (based on Framingham) that lets you input age, gender, cholesterol levels, blood pressure, and risk factors, and which then computes the likelihood that the person whose data is inputted will die from a heart attack in the next ten years.² You are also shown the impact of cholesterol and blood pressure on risk.

I look forward to testing it out further over time. My biggest concern is how reliable and authoritative the information we are getting is. So far my confidence has not been inspired,¹ and I'm not ready to recommend it except as something with potential that's fun to play with. Try asking it how old it is.

Cheers,
FF

¹ Here's what W|A has to say about the list:

This list is intended as a guide to sources of further information. The inclusion of an item in this list does not necessarily mean that its content was used as the basis for any specific Wolfram|Alpha result.

Hmm. Interesting way to cite your sources. Not sure this would wash in a term paper. I have a feeling the issue will come up again (it was also mentioned in the question period of Mr.W's lecture at Berkman Center, Harvard.)

² same result if you input myocardial infarction. No link is suggested between the two terms by W|A.

Meta post: challenge

2009-05-14T14:27:00.012-04:00

"What is the brand of this blog?" This is a topic that a former classmate of mine wrote about not too long ago. Now that I reread his post, and more specifically my response to it, I realize that this has been an issue for a while and here I am still thinking about it. Maybe I should take my own advice.¹

One of the blogs I read on a regular basis² is Caveat lector. I think one of the reasons I read it is precisely because Dorothea Salo will write about anything she feels like, most unapologetically. Sometimes that's music, and sometimes it's weekend hikes or loons, though mostly it's to do with librarian/web geekery. Much of it goes over my head to be honest (see footnote no. 2), but that's okay. I don't have to read every post. I also really like Learn to live which is sporadically peppered with posts about non-consumer health related things such as sushi and birds.

So I guess what I'm doing is giving you fair warning that I will henceforth be addressing topics other than consumer health and/or my service. That I will, gasp!, at times be writing about something entirely unrelated to librarianship.

For instance, have I mentioned how proud I am of my non-Luddite grandmother? Over the past 40 years she has slowly transformed a garbage dump into a public garden.³ My sister made a documentary film about it called Pupa's garden which some of you may have the chance to watch someday. It's also a film about my aunt who had MS and how my grandmother found solace in helping green things grow while her daughter's health slowly and drastically failed. There has never been a more poignant illustration of the dicotomy between life and death. And such beauty!

1 Is there a librarian equivalent for physician heal thyself?
2 I don't publish my blogroll here partly because I haven't gotten around to figuring out how- I am still and happily, despite everything, a bit of a vestigial Luddite.
3 How many grandmother's have websites?

Dealing with emotions: challenge

2009-04-16T15:30:00.011-04:00

Today I want to gather my thoughts on what happens sometimes when I am faced with trying to help a patient who is suffering emotionally and so the consult ends up being about more than just finding information. When this happens, not too often thankfully, I am sometimes left with the feeling that I could and even should have done something differently, but at a loss as to how.

Health care professionals are formally taught how to communicate and establish trusting, humanistic relationships with their patients (though of course not all will excel at this).^{1 2 3 4} For obvious reasons, librarians/info professionals do not get such training. We are taught how to conduct a reference interview, sure, but not exactly what to do if a patient is referred to you and then angrily questions what you can do for them. They look from you to the computer and flat out state (with maximum scorn) that they could do what you are about to do for themselves and with the same results. They are not a "problem patron." You know they are suffering from anxiety, or depression, or have just been diagnosed with colon cancer and that their emotions are understandably running high, but you have no script, no checklist to smooth the interaction. Do you sympathize? Do you try to lighten the situation? Do you engage or remain impassive and try to conduct business as usual?

In situations like these my instinct is to throw the idea of finding information out the window in favour of just listening. I know a little bit about active listening (from life as well as from library school) so I try to paraphrase what is being said to me, while repeating as many times as possible that I understand their frustration, that I *might* be able to find something they have missed in the course of their own searches on Google (or at least validate that their search was well done), and that I will be available when they are ready if today is not good.

But this just an instinct. And once in a while I get flustered. Then I forget the above and I try to forge ahead, to prove myself by finding something useful, sometimes unsuccessfully (because of aforementioned flustered-ness). This of course undermines the trust that I am hoping so much to establish, and leaves me feeling inadequate and inadequately prepared.

Either way I have no real formal training to deal with such situations, and no way to establish whether my instincts are correct except based on how the situation resolves itself (i.e. are they still angry when they leave? Did they come away with something useful?). My thinking is that some of the literature developed for health professionals might be of service (just the reading from today was helpful). I wonder if any other information professionals working in my area of speciality have faced this kind of problem and how they have sought to resolve it. Your thoughts are welcome.

1 Branch WT, Kern D, Haidet PWeissmann P et al. The Patient-Physician Relationship. JAMA 2001;286(9):1067-1074. Accessed April 16 from: http://jama.ama-assn.org/cgi/content/abstract/286/9/1067
2 Gask L, Usherwood T. ABC of psychological medicine: The consultation [clinical review]. BMJ 2002;324:1567-1569. Accessed April 16 from: www.bmj.com/cgi/content/full/324/7353/1567
3 Bedell SE, Graboys TB, Bedell E, Lown B.. Words That Harm, Words That Heal [commentary]. Arch Intern Med. 2004;164(13):1365-1368. . Accessed April 16 from: http://archinte.ama-assn.org/cgi/content/full/164/13/1365
4 Hastings A. The Good Consultation Guide for Nurses. s.l.*:Radcliffe Publishing;2006.

*As a total aside- how come both Google Books and Amazon do not include location in their records? Very frustrating. I do not have the patience to check more than 3 sources today (also checked McGill's catalogue to see if they had a copy but no luck). Hopefully my readers will forgive my laziness:-b

Update

2009-04-02T16:34:00.005-04:00

Jeez! Has it really been more than a month since I've posted? (I must apologize to Lori who commented on my last post way back in Feb. but the comment got held up for moderation and I never got an email notifying me- I have now changed back to unmoderated commenting). I guess the reason for my lacklustre attendance on my own blog is that I have been very busy running the service, which is a good thing right? Right!

Since my last confession I have had my contract here renewed (mostly officially) for another three years. I am very excited to be able to stop trying to prove the service is worthwhile and begin providing it full time. Well, full seven hours anyway.

I have my time divided on a weekly basis now, between the teaching room and my "office", so that means I've got three point five hours to do everything administrative, and still provide support for anyone who walks in the door which happens more and more these days, and maintain the pamphlet collection which gets used quite a lot judging by the "missing teeth" I find every Thursday afternoon, and maintain the website which got over 1500 visitors since January. I am not in any way complaining! I love feeling needed.

Tuesday afternoons in the teaching room are great. I get to meet whichever resident is working that day (usually somewhere between three and six) and continue to form new working relationships with them. It's very useful for me to be behind the scenes.

Being there means being able to find teachable moments (rather than just provide information) although this is a skill which I will need to improve. On-the-fly teaching is different than presenting prepared subject matter. I also need to get over feeling weird about teaching doctors. It's one thing to show a surgeon how to use EndNote properly, quite another to step in and say to a GP, here's how you could be doing your job better in this particular area.

It also , and I'm sure I've said this before, allows me to get a much better sense of how the team actually works and what patients really need. It is as important for me to identify information needs of patients and make sure they are being met as it is for me to acknowledge those cases where information is not called for. I now have a real appreciation for how difficult it sometimes is for a GP to figure out what the patient is even there for (similar to conducting a reference interview when your patron doesn't know what their own question is). And we all do it don't we? We all find ourselves in bookstores and libraries and doctor's offices not really knowing what to ask or why we're there. By listening in I can sometimes identify certain needs that are not being recognised by either the GP or the patient.

So that's my little update. I will try to post a case soon...

Health in the news: Cont...

2009-02-23T14:45:00.018-05:00

Myself and the chief librarian will be participating in our hospital's Mini Med this year along with Dr. Eddy Lang. Dr. Lang teaches Evidence-based medicine to McGill medical students, is associate editor of several medical journals and co-authors a health column for the Montreal Gazette. His contributions to journalism are in fact the topic of this post.

HealthWatch runs every other week as a regular Gazette feature where medical journalist Evra Taylor Levy and emergency physician Eddy Lang help make sense of sometimes contradictory medical research.

What is so special about the column is that it does everything I was criticizing journalists for NOT doing the last time I wrote, and even takes it a step further by breaking it all down into clearly marked sections that help readers make sense of the research. Specific sections vary by column but here are a few to give you a sense:

The study: provides the full reference.
What was already known about...: gives a brief overview of the topic.
What was this study about and how was it done?: sometimes this one is broken down into two sections:
What kind of study was this?: explains the study- for example if it was a randomized-controlled trial you get an explanation of what that means. And:
How was this study conducted?: explains the methodology in plain English.
What makes this study unique?: is self-explanatory.
What were the key findings?: see above.
So, what's the bottom line?: what does this mean for the readers? What should they do now that they are aware of this study?
Online resources: provides links to just that, online consumer health resources on the topic at hand.

Can you see why I'm excited? Take a look at this column about diets and see how much easier it is to understand the research. The only thing missing is a link to a full text copy of the study itself.

I swear I only met him after I wrote my last post!

Health in the news: Discussion

2009-01-29T10:28:00.024-05:00

Recently David Rothman published a post in which he talked about "sites that critique journalism." These sites exist in order "to fill the information gap which can arise from:

confusion caused by media reports on the publication of new scientific studies relating to the same medical area, but with contradictory conclusions;
inaccuracies in some media reporting caused by - difficulties in communicating complex medical information to a non-medical audience; over-zealous sub-editing to make news items/articles 'fit to size' and the issuing of press releases, by medical journals, which may not always report limitations in newly published studies - leading to further miscommunication of information;
a reluctance from some doctors to speak to the media, due to perceptions within the medical profession that doctors may be misrepresented or misunderstood;
public perceptions that 'official' medical or scientific advice may be influenced by policy matters; and
difficulties in knowing where to obtain independent quality-assured medical information. (Behind the medical headlines: about, retrieved 29 Jan. 2009)

I've being thinking about this a lot lately and have been meaning to write about it. My particular peeve has to do with the fact that news articles rarely, if ever, cite their sources. Articles in the news will at most mention in passing that such and such study was published in the October issue of the New England Journal of Medicine. The researcher's names are usually mentioned.

That is enough information for me to find the article, but is it enough for the lay person? Since a big part of my job is teaching health professionals how to find articles they sometimes have difficulty finding when they have the complete citation and access to McGill's full complement of journals and databases, I suspect that it is not enough for your average person reading the paper.

It took me half an hour of skilled digging to find the research discussed in this article a friend recently posted to Facebook: Surrounded by friends? It's all in your genes. Eventually "...I was able to find out that it was published in the Proceedings of the National Academy of Sciences in the Early edition ("published online before print January 26, 2009") which is available by subscription only- the copy I have linked to here is not the final published draft."*

Interestingly the proper citing of sources does not seem to be considered of much importance by the sites mentioned by David, or the site I usually recommend (Behind the medical headlines). Health News Review.org states that

An Unsatisfactory story may:
• Fail to identify the source of the story (news release, journal article, editorial, scientific meeting presentation, etc.) and fail to make obvious the extent to which that source is likely to be conflicted... (Health News Review: About us, retrieved 29 Jan. 2009)

Media Doctor.ca states that "No mention of sources or possible conflicts of interest" (MediaDoctor: Rating information, retrieved 29 Jan. 2009) is unacceptable in all relevant categories (Diagnostic Test, Harm Stories, Other, Pharmaceutical, Surgical Procedure). However, mentioning or identifying information sources is not the same as providing enough information about the sources that they can be easily accessed.

How difficult is it to include the journal issue and volume? Since more and more medical research is becoming freely available thanks to open access initiatives, why not go so far as to include a link to the full text? And if it is as yet unpublished shouldn't that be mentioned too?

I am continually emphasizing to patients and their families the importance of evaluating consumer health information resources, and one of the most important criteria is precisely: does the resource cite its sources? The HonCode lists this as number four out of eight principles that need to be followed in order to be certified. The National Cancer institute lists it fifth on its list of criteri a, and the American Medical Library Association lists it third.

When will news media be held to the same principles?

*Speaking of citing your sources, to be honest I'm not sure how to cite something that I wrote in a Facebook post. If anyone can tell me I'd be glad to know. In any case my comment was posted on at 8:14am January 28.

Topic: Parenting resources

2009-01-12T15:42:00.012-05:00

Today I thought I would focus on parenting resources as this is a question that has come up a few times lately and there are quite a few good ones to recommend. Even the best parents have doubts and they certainly have questions! I have chosen to focus on Canadian resources as these are the ones I recommend to my families.

Ca ri ng for Kids (Eng/FR)

In their own words:

Caring for Kids is designed to provide parents with information about their child's health and well-being. Because the site is developed by the Canadian Paediatric Society—the voice of Canada 's 2,000+ paediatricians—you can be sure the information is reliable.

Most documents on Caring for Kids are based on CPS position statements, which are created by our expert committees and approved by our Board of Directors. Position statements are reviewed each year to ensure they are up-to-date.

Best Start (Eng/FR)

In their own words:

Best Start: Ontario's Maternal Newborn and Early Child Development Resource Centre supports service providers across the province of Ontario working on health promotion initiatives to enhance the health of expectant and new parents, newborns and young children.

Growing Healthy Kids: A guide for positive child development (Eng/FR)

In their own words:

Growing Healthy Canadians: A Guide for Positive Child Development, was created to promote and illustrate a simple idea: that the healthy development of children and youth is a shared responsibility. There has been much debate about who should be doing what in order to grow healthy children. The truth is, everyone has important contributions to make in ensuring that young people grow up in the kinds of conditions they require to thrive. At the same time, no one type of contributor – not families, communities, workplaces, nor governments – can successfully raise the next generation on their own.

Invest In Kids (Eng/FR)

In their own words:

Invest in Kids is [a national charity] dedicated to helping parents become the parents they want and need to be. By translating the science of parenting and child development into engaging, easy-to-understand, relevant resources for parents and professionals, Invest in Kids aims to strengthen the parenting knowledge, skills and confidence of all those who touch the lives of our youngest children to ensure the healthy social, emotional and intellectual development of children from birth to age five.

For information about the history, people and research of Invest in Kids visit the about us section of their website. You can also visit Parent Help Line for links to useful resources.

Canadian Association of Paedeatric Health Centres (CAPHC)

In their own words:

CAPHC was established in 2001 through a transformative process of organizational renewal of the Canadian Association of Paediatric Hospitals. This watershed activity was undertaken to respond to member needs arising from emerging healthcare challenges and the shifting landscape of child and youth health service delivery in Canada - child healthcare organizations were undergoing fundamental structural changes.

Today CAPHC is a forty-two member organization representing multidisciplinary health professionals that provide health services for children, youth and their families within: quaternary and tertiary health centres; community health centres; rehabilitation centres; and home care provider agencies nationwide.

All children’s hospitals and their respective Children’s Hospital Foundations in Canada are members of CAPHC, thereby providing linkages to clinical care, education and research. A complete list of CAPHC member organizations can be found here.

Montreal Families (Strangely this resource is only available in English, however many of the resources listed are French)

In their own words:

Montreal Families is locally owned and operated. Our mission is to provide local information and professional advice to enhance all aspects of parenting and family life.

Montreal families also publishes a free monthly newspaper, a biannual resource directory, and organize camp and education fairs. There isn't a whole lot of information about them on their website but the fairs are listed on the Government of Canada website so they seem to be considered a reliable source of information. Certainly the local information they provide is useful.

Punjabi diabetes information: case

2008-12-04T10:15:00.012-05:00

Recent events in Mumbai, India, have left me feeling saddened by the tragedy and homesick for the place. I am Italian, but I spent many years of my childhood in India. We stayed many times at the Taj Mahal hotel, and at the Oberoi, brief moments of luxury before we made our way to where we were really going to stay, often in places where we ran around barefoot, got water in clay pots from a nearby well, milk and yogurt from the cow farm next door, and read our bedtime stories by the light of candles. Today I post a case from India.

Scenario

A family comes into my room (father, mother and two young boys) and tell me they have just visited their doctor who recommended that they come see me. The father has diabetes and is having trouble understanding everything the doctor says because his first language isn't English. I can tell from their accent that they are probably from India or Pakistan. When I ask what language they feel more comfortable with they tell me it is Punjabi. They tell me they are from Chandigarh, which is the capital of the part of Punjab that remained part of India.

The Open Hand Monument in Chandigarh

They are pleased and surprised when I tell them I visited Chandigarh even though I unfortunately don't remember it because I was too young.

We chat a bit more and then I let them know that I may be able to find some information for them in Punjabi which pleases them very much.

Resolution

I have a feeling that resources from the UK will be most likely to have information in Punjabi.* Sure enough Diabetes UK has information on several topics related to diabetes: What is diabetes?; Managing diabetes; Healthy lifestyle; Diabetic complications; Your eyes and diabetes etc.

The UK Department of Health also has some information in Punjabi** about diabetes: Living with diabetes: your future and wellbeing.

I prefer to offer at least some Canadian content, and because the family is computer literate, I also give them a link to a video from Fraser Health, BC: Living well with diabetes, and a booklet: On the road to diabetes health. I tell them that if any of the information from the Canadian resources is different from the UK information, they should follow the Canadian recommendations, and if they are not sure they should ask their doctor to clarify.

We say goodbye and are both a little more cheerful for having met.

* They also have information in Arabic, Bengali, Chinese, Gujarati, Hindi, Somali/Soomaali, Urdu and Welsh Cymraeg.

** They also have this leaflet in Bengali, Chinese, Gujarati and Urdu

Fundraising: challenge

2008-11-17T10:53:00.006-05:00

My agreement with Herzl was that they would pay for a 2-year pilot project after which, if all went well, we would seek external support. Those two years are up in April of 2009, so finally the time has arrived for me to do some serious fundraising.

The good news is that the service is thriving. I have a steady stream of referrals, as well as direct requests from patients and from health professionals. The web site is being well used with somewhere in the ball park of 400 visits per month.* I am now in charge of managing the clinic's pamphlet collection which is steadily growing (I'm starting to run out of room), and which I supplement with handouts I have been developing on various topics.**

And there has been an exciting new development. Last week one of the GP's suggested that we test out a way for me to further integrate my service. This suggestion was made after reading a preprint of a forthcoming PLoS paper, which the authors kindly agreed to share with me, and which I will provide a link to once it is published. The research shows that a "just-in-time" librarian information service had a positive impact on "time, decision-making, cost savings and satisfaction" in primary care.*** While this just-in-time service works quite differently from mine (clinical questions are sent to librarians using hand-held devices) it still provides compelling evidence of the positive impact a point-of-care information service can have on clinical practise.

In the case of our service, the idea is that I spend some time in the teaching room so that I can participate in cases as they occur and provide support and instruction to residents in "real time" so to speak. I spent a few hours in the teaching room last week and it was a great success all around. I learned a lot about what really goes on in consultations and was able to see ways in which I could be of service, the residents were able to benefit from my immediate support and in some cases were visibly relieved to have me there. And I have to admit, it was very cool to be able to really be a member of the team. If we can replicate this with some of the other teaching doctors, I would like to make it a regular component of the service.

All this to say that it would be lovely to be able to continue developing what is a unique and cutting edge service, one that has the potential to positively impact the quality of care being provided at the clinic.

I am new to the fundraising process, which I am hoping will not be a liability. So far, aside from continuing to develop the service and the website, I have been in touch with the hospital's foundation, and with public affairs who will be helping me to increase visibility of the service. I have also begun compiling a list of foundations and potential donors but I fear that I won't have the time to follow up on that.

If any of my readers has suggestions or knows anyone who might be interested in being a donor please don't hesitate to contact me.

* I am not a statistician so I don't have the exact figures. The content management software we use allows us to keep track of unique visits to each page, which if I add them up amount to over 400 visits, however I am sure that each visitor is going to more than one page. This is why I say visits and not visitors, though I'm sure that statistically I am not quite correct.

** These handouts consist of recommended online resources on various topics, such as Teen health, Pregnancy, Menopause etc. which one of the GP's at the clinic has requested. They are available on our website as well.

*** McGowan J, Hogg W, Campbell C, Rowan M. Just-in-time information improved decision-making in primary care: a randomized controlled trial. PLoS. Forthcoming 2009. [I will have to verify the correct publication date]

Topic: Medical videos

2008-11-03T16:12:00.015-05:00

Not too long ago David Rothman published a post on where to find embeddable medical videos. I thought I would expand on that list and provide a few more good resources that let you watch videos for free, no download and no subscription necessary (Some offer an optional free subscription that lets you access added features).

Centres for Disease Control: CDC TV

In their own words: CDC-TV is a new online video delivery resource available through CDC.gov. Web visitors can now view or download videos on a variety of health, safety and preparedness topics. Most videos are short and all include closed-captioning (some videos are also open-captioned), so they are accessible to all interested viewers. The library of videos will expand to include single-topic presentations as well as different video series focused on children, parents, and public health professionals.

eMedTV

In their own words: We employ a multi-step process to create and review all information on eMedTV. Content is created by healthcare professionals on staff at Clinaero. These professionals use a variety of medical references to create this content, including medical reference textbooks, specialty medical journals, and drug-prescribing information approved by the FDA. This information is then reviewed by full-time professional editors for clarity. These writers and editors work closely with the Clinaero medical team, which includes on-staff physicians and pharmacists. We will often use specialists in various branches of medicine and research to review the content. Many of these specialists are considered key opinion leaders in their respective fields.

Insidermedicine

In their own words: The Insidermedicine Project is a physician-led news and knowledge-translation initiative that allows patients, doctors and medical students to keep up on the latest medical information by watching our unique videos that are created each and every weekday by our team of medical experts. Our goal is to reach patients, medical doctors and students around the world to ensure that each is receiving a daily "evidence based" health and medical update.

MD Kiosk

MD Kiosk can also be visited in Second Life on Virtual Health Island.

In their own words: The information provided by MD Kiosk is written and edited by board-certified physicians from a variety of different specialties. The aim of the MD Kiosk TOUCHSCREEN, WEB and other products is to improve the quality of patient health education by offering a multimedia alternative to traditional brochures or handouts that are (sometimes) given in the clinical setting. Physicians write and review transcripts of the videos.

Virtual Medical Centre

In their own words: Virtual Medical Centre is Australia's leading medical information website, which delivers the "latest medical information" written by medical professionals.
The Virtual Medical Centre website reaches medical patients their families and friends searching for medical treatment information and also medical specialists involved in the diagnosis, treatment, and support of patients with a disease, illness or medical condition.

MedlinePlus: Videos of Surgical Procedures

In their own words: This page provides links to prerecorded webcasts of surgical procedures. These are actual operations performed at medical centers in the United States since January 2004. The videos last an hour.

University of Maryland Medical Center On-line Videos

In their own words: The videos... include interviews with University of Maryland Medical Center and School of Medicine experts -- most of which initially aired on the TV show Maryland Health Today -- patient success stories, surgical Webcasts, overviews of our programs and services and much more.

Enjoy!

IBS: Challenge

2008-10-10T11:31:00.015-04:00

I get a lot of questions about irritable bowel syndrome (IBS), so I thought I would feature it today. It is another one of those conditions that gets you a list of questionable sites intermixed with authoritative ones.

As usual it is not always easy to tell one from the other, and some of the less trustworthy ones are often the most tempting because they make promises and sometimes seem to have more detailed information.

Trustworthy sites rarely, if ever, make promises, and can be very general which may be discouraging. But promises and information that are not evidence-based are unfortunately not worth much. Evidence Based Medicine provides a very good and easy to understand explanation of, you guessed it, evidence-based medicine and why it's so important.

Of course sometimes the reason there is no evidence is that the research hasn't been done, which can also be frustrating.

Another thing to keep in mind is that even trustworthy sites recommend treatments that haven't yet been approved by, say, Health Canada, but have by the FDA, the European Medicines Agency (EMEA), or whatever your country's equivalent of these bodies is (or vice versa), so it's important to be aware of what country the information is coming from.

If you are ever unsure whether you can trust a source of information, ask your health care provider, local librarian, or ask me and I'll be happy to help. The Oakland Public Library gives some good suggestions for how to judge online health information, and Behind the Medical Headlines provides expert commentary on what you're hearing about in the news.

Behind the Medical Headlines aims to provide the public and health professionals with authoritative and independent commentaries from leading medical experts on articles or news items which appear in our daily media (nationally and internationally) in an attempt to reduce the confusion which can often arise from conflicting, incomplete or misleading media reports of medical areas.

And don't forget to check for the HonCode symbol .

Finally, here are some of the evidence-based consumer resources I recommend for IBS:

Irritable bowel syndrome: tips on controlling your symptoms (American Academy of Family Physicians)
Irritable bowel syndrome (National Library of Medicine)
IBS diet: can yogurt ease symptoms? (Mayo Clinic)
Symptoms of IBS (International Foundation for Functional Gastrointestinal Disorders)
Irritable bowel syndrome (IBS) Health Center (WebMD)
Should I have tests for irritable bowel syndrome? (WebMD)
Irritable bowel syndrome: Controlling symptoms with diet (WebMD)

Omega 3 and ADHD: case

2008-09-25T12:39:00.003-04:00

Scenario

About 15 minutes before I leave for the day, a woman calls me and would like to know whether there is any evidence that Omega 3 is a good treatment for ADHD.

Resolution

Since I don't have much time I decide to use David Rothman's Consumer Health and Patient Information Search Engine. Here's what David says about his search engine:

This (recently re-created) Custom Search Engine searches authoritative and trusted consumer health information and patient education resources recommended by the U.S. National Library of Medicine and/or by CAPHIS (the Consumer and Patient Health Information Section of the Medical Library Association).

This is a great way to do a quick search of lots of trustworthy resources at once, and there is no need to weed through crappy results the way you would using Google. Thanks David!

I run a search for Omega 3 ADHD, and sure enough every single hit on the first page is relevant, authoritative and no one is selling anything (the same search in Google retrieves a first page listing a bunch of questionable blogs and websites selling alternative therapies).

I email the following links to my patron and still have time to shut down my computer and tidy my desk:

WebMD: ADHD Medications and treatments

WebMD: ADHD diets

WebMD: How effective is Omega 3 in treating ADHD?

Medscape: Fatty acid supplementation for ADHD

Mayo Clinic: Flaxseed and flaxseed oil

Converting blood glucose measurements US > CA: case

2008-09-04T11:10:00.006-04:00

Scenario

A young man tells me he would like to be able to convert US blood glucose levels (milligrams per deciliter: mg/DL) to Canadian (millimoles per liter: mmol/L).

Resolution

After much searching in various resources, and finally Google, I am able to find an online converter from Lifescan Inc., the people who make the OneTouch® System for monitoring blood glucose levels.

I would like to make it clear that I am in no way endorsing their products (I am not qualified to make any judgement about them), and usually I prefer to avoid information offered by such companies as it is likely biased, but in this case I decide to make an exception. The tool they provide is freely accessible and actually quite handy.

I would suggest that if you are looking for reliable information about diabetes there are other better resources. To list just a few:

Canadian Diabetes Association
recipes
Diabetes Quebec
Public Health Agency of Canada
Neuro-Patient Resource Centre
MedlinePlus - diabetes
UpToDate - diabetes

And now, without further ado, here is the link to the converter:

Blood glucose monitoring: converting measurements

Like other online converters, you can plug in the number you have and you will be given the number you want.

You can also use it to convert plasma results to whole blood results.

Support groups and community resources: online resources

2008-08-28T12:39:00.004-04:00

I recently discovered a new resource (new to me at least) that I thought I would share. I came across The Self-Help Sourcebook Online when I was doing some collection developement at the Patient and Family Resource Centre.*

The Self-Help Sourcebook Online is a searchable database that includes information on over 1,100+ national, international and demonstrational model self-help support groups, ideas for starting groups, and opportunities to link with others to develop needed new national or international groups.
This database uses information provided by the American Self-Help Clearinghouse, a department of the Behavioral Health Center of Saint Clare's Health Services in Denville, NJ, which published The Self-Help Sourcebook, 7th Edition in Fall, 2002.

Type in your keyword or select a "problem" from a drop down list, and you are provided with a list of support groups and community resources. It is very comprehensive, providing links to groups for everything from acne scars to albinism to selective mutism to cancer to workaholics to depression... well you get the idea.

One of the things I especially like about it is that it provides guidance for those people who would like to develop their own support group, in case there isn't one locally.

You can also browse a list of similar international clearinghouses. The Information and Referral Centre of Greater Montreal is particularly interesting to me of course. Check to see if your state/province or country is listed.

*I found the Sourcebook listed in the CAPHIS Consumer Health Bibliography for the Small Public Library.

Tetanus vaccine: case

2008-08-18T15:07:00.007-04:00

I haven't posted a case in while so I thought I would put my discussion of shared-decision-making and decision aids on hold, and spend the next couple of posts writing up cases instead.

Scenario

A man sends me an email. He would like some information about tetanus shots. He is scheduled for one the following week and would like to know what to expect in terms of normal reactions because a friend of his told him her arm swelled up a week after getting her shot.

Resolution

Judging from the man's email he has relatively high literacy and so I an able to give him information at a fairly complex level.

MedlinePlus - Medical encyclopedia entry on tetanus vaccines.

Immunization Action Coalition - vaccine information for the public and health professionals: Questions & answers about the tetanus vaccine.

The Immunization Action Coalition works to increase immunization rates and prevent disease by creating and distributing educational materials for health professionals and the public that enhance the delivery of safe and effective immunization services. The Coalition also facilitates communication about the safety, efficacy, and use of vaccines within the broad immunization community of patients, parents, health care organizations, and government health agencies.

UpToDate - Adult immunization (there is a nice section that covers possible side-effects from mild to severe, and a brief description of tetanus the disease).

Discussion

Immunization is THE top subject of interest to patients at the Herzl. Aside from a few questions I've received on the topic, my website statistics show that so far 832 people have visited the Vaccinations page 501 times since April (when the page was created). In second place is the page providing links to online Resources in French with 627 visits by 224 people (since January); and Heart disease and stroke in third place with 402 visits by 202 people (since March).

Shared-decision-making interventions

2008-08-08T13:14:00.003-04:00

Last time I posted I promised that I would talk more in depth about models that help health professionals implement shared-decision-making (SDM). The evidence suggests that such a model would be useful since health professionals find it difficult to implement SDM even when they feel it would positively impact patient outcomes.¹

I was hoping to find something like the PLISSIT model.* PLISSIT outlines the steps that a health professional can take to address the issue of sexuality with cancer patients, and one of the steps involves addressing their information needs:

P = permission (follow above link for explanation)

LI = limited information i.e. addressing the patient's information needs, conducting the reference interview, either providing information, discussing information that has already been found, or directing the patient to trustworthy information on the topic. Here's where a librarian or an information service might come in handy.

SS = Specific suggestion (follow above link for explanation)
IT = Intensive therapy (follow above link for explanation)

Unfortunately, besides LI, these steps are not particularly relevant to SDM, so the model is not transferable.

I have since had the chance to take a closer look at the literature and found exactly just such a model: The Ottawa Decision Support Framework (ODSF). Hurray! I love when I find exactly what I'm looking for. It also comes with a handy implementation toolkit, and evidence to support that it reduces decisional conflict between patients and physicians.²

Unfortunately the model does not provide a clear point at which information needs are addressed, making it more difficult to use it in conjunction with an information service. At the very least however, such a service could support the process by providing on-demand access to decision aids, which are known to

help patients participate in decision making, leading to informed choices that are consistent with their values.³

I also found a useful scale for measuring patient involvement,⁴which seems like an important step to take before attempting to facilitate or improve implementation of SDM.

*
As mentioned in my last post, I came across this model recently while researching the question of how to help HPs bring up sexuality issues with gynecologic cancer patients.

1 Gravel K, Légaré F, Graham ID. Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals' perceptions. Implementation Science 2006; 1:16

2 Légaré F, O’Connor AM, Graham ID, Wells GA, Tremblay S. Impact of the Ottawa Decision Support Framework on the Agreement and the Difference between Patients’ and Physicians’ Decisional Conflict. Med Decis Making 2006; 26:373–390

3 O’Connor AM, Wennberg JE, Legare F, Llewellyn-Thomas HA, Moulton BW, Sepucha KR, Sodano AG, King JS. Toward The ‘Tipping Point’: Decision Aids And Informed Patient Choice. Health Affairs 2007;26(3): 716–725

4 G Elwyn, A Edwards, M Wensing, K Hood, C Atwell, R Grol. Shared decision making: developing the OPTION scale for measuring patient involvement. Qual Saf Health Care 2003;12:93–99

Barriers to use and referral: challenge

2008-07-21T15:37:00.010-04:00

As time has passed I have been able to identify some of the potential barriers to use and to referral. I thought I would share these as they may benefit those of you who are interested in implementing a similar health information service at point of care (I know of at least one other centre that is considering doing so). That said I feel I should emphasize that this is based on my own personal observations and on the casually reported observations of others, rather than on any systematic study of the issue. We do intend to do a formal evaluation of the service, at which point we will be able to see whether these hypothesis are correct.

Not in order of importance:

Distractions in the waiting room. We have two big, beautiful, flat screen TVs in the waiting room that are impossible to ignore if you're sitting there, no matter which way you're facing. I just went out there to see what's playing. On one you have a talk show and on the other a soap opera. Even on mute they seem to be serious competition for my service. Gone are the interminable boring waits during which patients had time to think about where they were (the doctor's office), why they were there (sickness, checkup etc.), and maybe formulate a few questions they'd like answered. You may want to think about what could potentially distract your users from dropping in with questions. It could be TVs. It could be something else.

The good a) patient satisfaction no doubt increases (time flies when you're having fun), b) as far as the TVs are concerned, there is an opportunity for promotion, to develop programming that could include information about the clinic and the service. The bad people may be distracted from asking questions while they wait.
The InfoRx. On the part of the HP, there may be uncertainty about how to insert the referral into a transaction with the patient. It may be hard for HPs to know when would be a good time to mention it, or who might benefit. Time is certainly a factor and it is probably all too easy to forget to write up an InfoRx. Telling HPs that they should consider referring a patient whenever they make a new diagnosis, prescribe a new medication, or the patient is faced with a treatment decision may not be enough. The idea that a librarian is now acting as a member of the team at point of care and can have patients referred to them same as any other specialist may be new and it may take a long time before knowledge becomes practice, even when everyone buys in to the idea. My feeling is that this is a change management issue. It has to do with the gap between theory and practice, between intention and action.

Hoping to find something along the lines of the PLISSIT model* that could be used to assist health professionals at that crucial moment during their visit with the patient and family, I've been doing some reading about barriers to improving practice, and barriers to implementing practice guidelines and shared-decision-making. I think the latter is particularly relevant, because helping a patient or family member become well informed is a crucial component of the shared-decision-making process.**

The bad this is a very complex issue that may be difficult, if not impossible, to solve, The good this could be an opportunity to further develop a new model of health care, and there may be evidence to help us in the process.
The Internet. You will likely wish to have a web component to your service, as I have done. Our website is advertised in our H-PHIS brochures which are disappearing from the displays at a steady rate. Statistics show that the website is being visited regularly. From this I feel I can say that I am successfully helping people help themselves. I wonder if this makes them less likely to ask for help.

The good people will probably use a website if you have one, The bad people may go to your website instead of using your service.
Availability. It is unlikely that you will be on site and available every day all day. I am only on site 7 hrs per week, and the librarian at the Monkfield Medical Practice was also there only part time. This means that you may not always be available when needed, and not always be around to remind people to use the service and to guide people through the process. The point of having a service on site is to avoid the whole "out of site out of mind" thing.

The good the demand may be greater than the supply, which may justify an increase in staffed hours The bad not having enough hours to make the service work.

I would love to know your thoughts on these issues, so any comments or suggestions from my readers are very welcome. Since I began writing this post I have found a couple of models that may be useful in facilitating shared-decision-making. Stay tuned. I will discuss them in my next posts...

*
I came across this model recently while researching the question of how to help HPs bring up sexuality issues with gynecologic cancer patients.

**
Haines A, Kuruvilla S, Borchert M. Bridging the implementation gap between knowledge and action for health. Bulletin of the World Health Organization 2004;82:724-32.

Cabana MD, Rand CS, Powe N, et al. Why don't physicians follow clinical practice guidelines?: A framework for improvement. JAMA 1999;282(15):1458-1465 (doi:10.1001/jama.282.15.1458)

Freeman AC, Sweeney K. Why general practitioners do not implement evidence: A qualitative study. BMJ 2001;323:1100-2.

Gravel K, Legare F, Graham ID. Barriers and facilitators to implementing shared-decision-making in clinical practice: A systematic review of health professionals' perceptions. Implementation Science 2006;1:16. (doi:10.1186/1748-5908-1-16)

These are just a few of the articles I've found. I will try to include a more detailed list in a future post.

Sleep apnea (French and Italian): case

2008-06-30T13:59:00.004-04:00

Scenario

I'm always excited when I get to look stuff up in Italian. This time I'm asked to find information about sleep apnea in either French or Italian (preferably both).

Resolution

I look both terms up in HonSelect:

French: syndromes d'apnées du sommeil
Italian: sindromi di apnea del sonno
apnea: disturbi del sonno

I decide to look for the French first. I go to Passeport santé and type in apnées du sommeil. That brings me to two pages of interest: Apnée du sommeil: signe précurseur d'un AVC? and Vaincre les ennemis du sommeil, a book by Charles M.Morin.

CISMeF directs me to the website for the Ordre des dentistes du Québec. This has some information on snoring which also talks about apnea.

Next I look for information in Italian.

Benessere.com has an introduction to apnea but does not have the HonCode stamp of approval, so I keep looking.

I find another site called Dica33 which has some information on sleep disturbances including the complications of apnea. The site looks dinky but surprisingly has the HonCode badge right up at the top of the page for a change (I guess either they are really proud of it, or they are aware that the dinky design of the site might turn people off) and it turns out the site is developed by Edra spa, una società del gruppo ELSEVIER. Roughly translated they are a member of the Elsevier group.

Ureteral cancer: case

2008-06-23T15:51:00.006-04:00

Scenario

One of the GPs asks me for patient level information on the topic of ureteral cancer. One of his patients has been recently diagnosed and would like to have some information about it. Also he would like his patient to have some information about treatment options.

Resolution

There is a lot of information on urethral cancer but not a lot on ureteral cancer,* so I try a few places before finding a good overview on the BC Cancer Agency website.

BC Cancer agency > Patient/public info> Types of cancer > ureteral.

MedlinePlus has an entry in the encyclopedia: Cancer - renal pelvis or ureter.

Neither one goes into whole lot of detail about treatment options.

For that I find the National Cancer Institute's (NCI) PDQ®** on the subject through Onkolink. This can also be found on the NCI website of course, but Onkolink presents the information from the PDQ® in a way that is easier to navigate and read.

To get to the PDQ® though Oncolink: Oncolink > Types of Cancer > Urinary Tract Cancers > Urethral Cancer > NCI Resources.***

To get to it on NCI's website: NCI > A-Z list of cancers > S-Z > Ureter and Renal Pelvis, Transitional Cell Cancer

Last but certainly not least I Google ureteral cancer treatment options and find a great overview of ureteral cancer on the Fox Chase Cancer Center website which also discusses treatments at the various stages of the disease and the information is based on the NCI PDQ® as well.

* Click here for a definition of the two terms.

** What is PDQ ®?

*** To be perfectly honest this is the path as it appears on the Onkolink website. If you try to follow it it doesn't work. Urinary tract cancers does not appear on the list of cancers! But if you do a site search for ureter it will be the first hit on the list.

Parkinson's info English and Italian: case

2008-06-12T15:44:00.001-04:00

It's been a while since I posted a case. Here's one I like.

Scenario

A young man is referred to me by his GP. His father has been diagnosed with Parkinson's and he would like some information on the disease.

Resolution

As usual my first stop is MedlinePlus. I type in Parkinson's and in addition to the disease overview, find an interactive tutorial that might be helpful, as well as being directed to family doctor's page on the topic. I also recommend Mayo Clinic's section on the topic.

I can see that the man wants as much information as possible, as this is a new diagnosis and he is the primary caregiver. So, I add eMedicine's section on Parkinson's to my recommendations. I also don't want to get lazy and just recommend the same ones over and over out of habit, while overlooking other excellent ones.

A couple of other useful resources I recommend for someone wanting as much information as possible:

CMA.ca provides Canadian drug information (the drugs Canadian doctors prescribe are often not listed in American resources by the same name) .

Lab tests online, which provides information on whatever tests might be ordered in relation to a specific condition. In this case, Parkinson's is not listed as one of the conditions, however I explain that he can look up each test separately as well.

While we are talking he wonders whether it might be possible to find some information for his father in Italian. Luckily I speak Italian which will make the search easier, however I have already discovered that there is a dearth of reliable resources in Italian.

The first thing I do is take a look at Medline's new multiple language resource to see if anything is there. Unfortunately there is not. I was very excited when the resource was launched a few weeks ago, as I'm sure many people were. Since then the initial excitement has worn off. There is great potential, but not much on offer just yet. I will keep checking as new topics are entered.

The first thing I do is look up the exact term in Italian. I go the the HONselect tool that allows you to look up MeSH headings in different languages. I type in parkinson's, select Parkinson disease, click on Italian and am told that the correct term is Malattia di parkinson. So far so good. I then go to the one Italian HONcode resource I have been able to find: Paginemediche.it*. I type in the term and get a list of clustered results. Under malattie e condizioni (diseases and conditions) I see 9 hits. Unfortunately none of these hits is directly relevant. I click on one to see how it relates to Parkinson's and discover that in this resource it is listed as Morbo di Parkinson. So now I do a search for that, only to discover that, while listed in the glossary and referred to in relation to malnutrition, incontinence, Huntington's etc., there is no page on that topic. So I have reached a dead end.

I do a Google search which I am unable to recall at the time of writing, and am able to find a multiple language resource that is new to me, NSW Multicultural Health Communication Service, and this one has a long list of topics in Italian, including the one I'm looking for. I am not surprised to find that NSW is Australian, as the country always has excellent health resources in multiple languages. Along with the one on Parkinson's I print the full list of topics for the man in case any other questions come up., and I add the resource to MyHq.

*This resource is only useful if you speak Italian, as there is no English version.

Privacy and professional autonomy: challenges

2008-06-09T14:19:00.006-04:00

Dean Giustini recently brought me to the attention of his readers on the Google Scholar blog which prompted some very interesting questions in the comments. I promised to respond to those questions here.

Q: The first question raised by Anon had to do with patient privacy, a question that was not raised at the CHLA conference and has in fact not come up at all until now. The poster expressed legitimate concerns over whether placing my consults in the patient charts* is "a violation of the librarian's code of ethics to keep questions confidential."

A: I completely agree that when I am in the library and a person approaches me with a question it should be kept confidential, and this is our practise, except when I am seeing a Herzl patient at the library, in which case I make a copy of the consult and place in the their chart at the clinic, this being considered an extension of my service there. In the case of the Herzl service, it is being delivered at point of care, and the expectations of privacy and confidentiality are different. I am recognized as being a member of the team who participates in the provision of care. Most people come to me having been referred by their physician or nurse in the first place which means that the question is already known to them.

I make a point of explaining to anyone who comes to me without a referral or meets with me in the library exactly how the system works i.e. that the consult will end up in their chart and why this is so. I also let them know that if this bothers them I will keep it confidential. So far no one has expressed concern over this or refused to have their consult put into the chart. Perhaps I should try to make the process more transparent by explaining it every time. I haven’t always done this for the same reason I know it is difficult for health professionals to remember to send their patients to the library or to my service: time can be an issue, and also it doesn’t always occur to me when I am focused on conducting a thorough reference interview and answering the question. You have given me something to think about.

Q: The second question/comment had to do with professional autonomy. Anon wondered whether it would be difficult for a librarian to maintain professional autonomy given the hierarchical nature of the clinical setting.

A: If I understand correctly, Anon is expressing concern that a librarian in my situation could be pressured to provide information to patients in support of whatever treatment decision was being recommended by the referring health care professional. It is not always easy for librarians, even for those of us working in a clinical setting, to uphold another of our professional codes which is to provide access to balanced and unbiased information to all, regardless of what our own opinions are on the question or the asker. We are human after all. And often we are limited by what information is actually available to us. Regardless, I do my very best to uphold this code. I am also very careful to make it clear that I cannot interpret the information I am providing access to, nor can I offer any kind of opinion regarding treatment.

There have been a a few cases where the information I have provided has suggested a different course to the patient than the one originally proposed by their referring physician. There have also been cases where the patient only agreed to the proposed treatment after receiving information from me. I see both as examples of shared decision-making and am pleased to have played a part in that process. My impression is that the health care providers I work with are aware that it could go either way when they send someone to me, and this is a risk they take because they believe in the process.

*Important note: the charts I am referring to are kept at the Herzl and are not available hospital-wide or electronically.

Canadian Health Libraries Association conference: update

2008-06-06T12:35:00.006-04:00

Halifax was lovely as always but it's good to be home.

As promised I have posted a link to my April 10 lecture at McGill's Continuing Medical Education (CME) Thursday Evening Learning Series. I think I did a better job at McGill CME so I'm glad that's the one filmed for posterity. It seems I do better in front of the camera than I do playing Twister while I present.* Good to know.

I won't try to summarize the conference itself. Greg Rowell has done a much better job than I could. He's written a series of letters that Dean Giustini posted on his Google Scholar blog on June 2-4 (I get a mention in letter no. 3:-). Ryan Deschamps has recapped his own presentation here. Ryan and I went to school together and I was sorry not to have been able to see him speak (I arrived in Halifax the next day).

All the presentation slides (including mine) should be available on the CHLA website soon.

The two things the conference has got me thinking most about are Professional development (what should my next steps be?) and society participation (what's the big deal and how can I get involved?). I know there are proven ways to do both, but I am an unconventional cookie and will have to find my own way.

One of my favourite sessions at the conference was the round table discussion which asked the question: are we preparing health information professionals for the future? The panel included a spanking new graduate from Dalhousie SIM, Annie Noble, a slightly less but still recent graduate, Lori W. Leger, Ada Ducas who is the head of the Health Sciences Libraries at University of Manitoba, and two library school directors, Margaret Ann Wilkinson from Western University, and Fiona Black from my very own SIM (a wonderful speaker).

The presentations were very interesting and the discussion that followed even more so. It was unfortunate that we ran out of time just as things were getting good. I would have willingly given up the half hour break that followed (hint hint).

The overall consensus was that we are indeed preparing information professionals for the future, or at least the immediate future, although Ada Ducas expressed concern over the quality of candidates accepted into LIS programs. For myself, I did feel prepared when I graduated.

Here's another question: are we preparing information professionals for the less immediate future? i.e. not the first job out of school, but the one after that (hence my preoccupation with Professional development). Any thoughts?

*At CHLA the set-up was a bit awkward. The mic was way to the right and the laptop way to the left with the tiniest mouse I've ever seen. This meant that I had to reach over and across with my right hand (I am right handed) in order to switch slides, while keeping my mouth close enough to the mic to get sound.

Promotion: challenge

2008-05-23T12:10:00.007-04:00

I have discovered that promotion is a huge and ongoing component of what I do at the clinic (and in the library as well). Without it I could easily be forgotten, no matter how useful my service is and how necessary, because it is new.

Last week I began distributing our new brochure. I've placed them at strategic points throughout the clinic and was pleased to discover that more than 20 were missing a few days after I first put them out, and I have had several requests from non-referred patients. Success!

Canadian Health Libraries Association Conference: challenge

2008-05-23T11:15:00.014-04:00

Next week I will be presenting a paper at the Canadian Health Libraries Association (CHLA) Conference in Halifax, Nova Scotia. My paper is titled: Implementing an integrated health information service in a family medicine setting. I think you can guess what it's about;-)

I'm very excited and also a little nervous. I did my undergraduate degree at the Nova Scotia School of Art and Design (NSCAD), now NSCAD University, and my MLIS at the Dalhousie School of Library and Information Studies, now the School of Information Management (SIM). Schools have a way of changing names on me it seems. So I will have plenty of people to see . I'm looking forward to seeing the new Management building which is where my alma mater can now be found, a modern construction of glass and light in contrast to its home when I was last there: the windowless cement cube rolled in pebbles that is the Killam Library. Neither of them as lovely of course as NSCAD's historic buildings. In a serendipitous twist I'll be staying with a friend of mine from library school who is now running NSCAD's Visual Resources Collection. Two of my old NS friends have had babies this year. A friend, another librarian, who now lives and works in the States will be visiting home and celebrating her birthday... Hence excited. This is my first time presenting in front of my colleagues and peers, in the Lord Nelson Hotel's Imperial Ballroom no less. Hence nervous.

Not as nervous as I could be though: a few weeks ago I was invited to speak at McGill's Continuing Medical Education (CME) Thursday Evening Learning Series, which was filmed and broadcast live for those members of the audience who were unable to attend (some of these are rural doctors). I have updated my presentation to suit the library crowd, so it won't be exactly the same, but I will post a link to my CME lecture after the CHLA conference, along with slides from next week's presentation.

Kegel exercises: case

2008-05-08T09:53:00.004-04:00

Case

A woman in her fifties is referred to me by her GP. She would like some information on kegel exercises in French.

Resolution

I do a search in CiSMeF and find the following resources:

Quand faire l'amour est douloureux- le vaginism (also available in English)
From the Society of Obstetricians and Gynaecologists of Canada (SOGC). This document explains how to do the excercises.

A few other resources are listed (on menopause, vaginal dryness, incontinence) but none of them provide much information on the topic, so I do a search in Passeportsante as well and find the following:

Incontinence urinaire. This document provides another explanation of how to do the exercises.

Hoping to find something accompanied by illustrations I also do a Google search (keywords exercises kegel) and find the following:

Excercises de kegel(pdf, also available in English)) . From the Women and Child Program Team at St.Boniface General Hospital which is a Catholic tertiary health care facility in Winnipeg affiliated with the University of Manitoba. This pamphlet provides a much more detailed explanation of how to do the excercises and includes an illustration of the pelvic region.

I print out each of these documents and give them to the patient.

Discussion

I find myself wondering how necessary it really is to keep looking for more information when the question has already been answered. What often ends up happening is that you find the same information repeated. In this case I was eventually able to find an illustration, and more detailed instructions so it seems that continuing the search was worthwhile. But what if that were not the case? What if I found the exact same information three times over?

I think the answer to the question is that it's always a good idea to keep looking even after the question has been answered. There are several reasons for this:

Once several documents have been found that provide the same information, this confirms that you have fully answered the question.
Sometimes the initial question has been answered, but additional information comes to light with a more extensive search suggesting that the topic is more complex than initially believed.
Things like layout, print size and reading level can make a difference to the person reading the information.
Repetition helps with the absorption of information.

Can anyone think of more reasons to keep looking? Can anyone think of reasons not to keep looking?

Prostate cancer treatment options and decision aids: case

2008-04-07T15:27:00.003-04:00

I have gotten several requests for information on the topic of prostate cancer, both from patients and from health professionals, so I thought I would share what I found.

Before I do so, I thought it might be helpful to explain what a decision aid (or guide) is, in case anybody reading this has never seen one or is not sure what one is.

I had a hell of a time finding a definition. I checked MedlinePlus' medical dictionary and encyclopedia, and neither had one. Cambridge Dictionaries Online didn't list the term, and neither did the Merriam-Webster online medical dictionary. This time even Google failed me. (I am searching online since I am at the clinic and so don't have access to print resources, much as the average patient or family member wouldn't.) I am finally able to find one definition though. According to the US Department of Health and Human Services,

Decision aids are mechanisms or interventions that have been developed to improve communication between health professionals and patients, and to help involve patients in making decisions regarding their health care. Decision aids can include brochures, videotapes or interactive computer programs. Recent reviews have suggested that decision aids may be effective in supporting general health care decisions.

But what does that mean in plain English? You could say that any information that helps you make a decision could be considered a decision aid, but there two types of tools that are usually referred to using the term decision aid or decision guide.

One kind works like a sort of "choose your own adventure." At each step in the process you are given your options and depending on which you pick, or which is recommended based on test results, other choices are then offered and so on, branching out like a little tree. This makes it possible to see what might happen if you chose one treatment over another.

The other kind brings up important questions and help you make a list of pros and cons, much the same way you might do if you were making any other decision.

Scenario

Information on prostate cancer treatment options and decision aids.

Resolution

Here are a few resources that I found useful:

Treatment options:

National Cancer Institute: What you need to know about prostate cancer.

National Cancer Institute: Prostate cancer treatment

Family Doctor: Prostate cancer treatment options

Canadian Cancer Society: What is prostate cancer?

Decision aids:

Mayo Clinic: Prostate cancer guide

American Cancer Society: Detailed guide- prostate cancer

National Comprehensive Cancer Network treatment guidelines for patients: prostate cancer (for very advanced readers)

These are for screening but might still be of interest:

Centres for Disease Control and Prevention: Prostate cancer screening decision guide

Lab Tests Online: Prostate cancer tests

Lab tests: case

2008-03-21T13:25:00.007-04:00

Scenario

A middle-aged woman makes an appointment to see me. She has been feeling very tired lately and has an assortment of aches and pains and her GP has ordered several tests in the hopes of zeroing in on a diagnosis. She would like to know exactly what is being tested for. I do not get the impression that she is likely to jump to conclusions regarding her diagnosis. It seems rather that she is curious about the process and wishing to be an active participant.

Resolution

The woman has a computer at home with Internet access, and often searches for health information online, so I give her a tour of Lab Tests Online (HONcode accredited) so that she can look up each of the tests on her own at her leisure.

This is one of my favourite resources. You can type in keyword or look up the test alphabetically by name. You can also select a disease or condition to see which tests are typically used in diagnosis or monitoring, or by age group to see what screening tests are routinely ordered.

The reason I like the site so much is that it gives a very comprehensive overview of each test, why it is ordered, how it is done, what is being tested, and in addition to that, information about the disease or condition is provided (signs and symptoms, treatments, other tests), along with answers to common questions specific to each test (such as: how will exercise or diet affect the element being tested, what other tests might be given for the same condition etc.), and links to other relevant resources. Any question that remains unanswered can be asked by following the link to a confidential request form on the American Society for Clinical Laboratory Science website, which is then answered by a certified clinical laboratory scientist.

Testing boundaries: how much is too much? Challenge

2008-03-14T12:30:00.008-04:00

Sometimes you're sitting with a patient or family member, conducting your reference interview so you can determine what their information needs are, perhaps trying to find a balance between what their health care provider suggested they be given (say, information about hormone replacement therapy), and what they themselves are truly or additionally interested in learning about (say, returning to a normal sex life after surgery), and it becomes clear that what's really important here is not the information but the time spent talking to someone, being heard.

There are times when I find myself talking with someone for far longer than it took to meet their information needs. One person will want to tell me about his children, how they're doing at school, how he met his wife, another might go into more detail than necessary about a previous surgery, about a seemingly unrelated health issue, or about her love of gardening. On the surface it all seems unrelated, but if you put yourself in their shoes for a moment, then it's clear that everything is intimately related because it's their life we're talking about, not just their illness, and the one cannot be separated from the other.

So I listen, and I listen for clues to what might be hidden information needs. Sometimes what seems on the surface like chit chat is secretly or unconsciously a question. My job is not only to help people find information but to show them what kind of information is available, and even to help them figure out what it is they really want to know, because this is not always clearly formulated from the get go.

On rare occasions it feels like I'm having hundreds of questions fired at me all at once, and I can't be sure which to take seriously. When this happens I try to bring things back to the matter at hand and keep things focused. I have to wonder though, where exactly to draw the line. Is an hour too long if all of it is spent researching the question? Is it too long if 30% of it is spent researching the question? How many questions can reasonably fit into one session? And how much do I want to know? What is it appropriate for me to know? Is okay for this to be dependent on my own personal and professional sensibilities balanced with the desires of the person I'm helping?

Other times I get asked difficult questions, like "what would you do?", or "what should I do?" In these cases I must be extremely careful to not give any answer other than, "I am not a health professional. I cannot give you advice about what to do or how to interpret this information. Your doctor or nurse will be happy to go over this with you." Sometimes I have to say this over and over.

It's tough. I want to help people and feel that they're satisfied with my help, but in these cases everyone involved is left with a feeling of dissatisfaction. I know that their doctor or nurse will not always be able to go over it with them in the kind of depth they want or need, not because they don't wish to but because there isn't the time. I also know that consultations with doctors and nurses are often stressful and all the hundreds of questions can fly straight out of a person's head when it comes time to ask, even if they've been organized and proactive and have brought a list with them. But I still cannot give any other answer. It helps that I genuinely don't know it.

Depression: case

2008-03-07T15:18:00.006-05:00

Scenario

A young man visits me at the clinic. He believes he is suffering from depression and would like to have some information on the topic, as well as about various medications, and alternative therapies. He admits that he is hesitant to go on medication, but also realizes that this may be his best option. He would like to be better informed before discussing his situation with his doctor. He has already looked online, but admits that most of what he's read is not particularly trustworthy and would like some advice on better resources.

Resolution

The first thing I do is show him MedlinePlus. I run a sample search and show him how he can also search the encyclopedia, and the drugs and supplements. It occurs to me that a decision aid might be useful to him, since he is in the process of trying to make a decision. I search the Ottawa health research Institute A-Z Inventory of Patient decision aids and find the Mayo Clinic's Depression guide which includes information on antidepressant meds, complementary and alternative therapies, personal stories and things to consider.

While we are talking it becomes apparent that he is a voracious reader, and quite prepared to actively participate in managing his own health, so I decide to also recommend a couple of books that he might find useful:

The Noonday demon: An atlas of depression, by Andrew Solomon, provides an astute and in depth look at depression through the ages and the controversy. The book is an engrossing read, is well researched, and provides a balanced look at the pros and cons of medication as treatment.

Full catastrophy living: Using the wisdom of your body and mind to face stress, pain and illness, by Jon Kabat-Zin. This book is a companion to the Stress Reduction Clinic at the University of Massachusetts Medical Centre, founded by the author. Yoga and mindfulness meditation are taken out of the realm of spirituality and religion, and used as practical and effective stress, pain and illness management tools. The program can be followed independently using guided yoga and medication tapes.

Discussion

It feels good to recommend books as well as online resources for a change. I don't often get the chance to do so since most of the questions I get are better answered in a relatively quick and dirty way. Usually people who come to me are looking for immediate and timely answers: information about clinical trials, medications, back exercises, dietary recommendations related to various conditions etc.

Total time: 1 hr

Ethics resolved: challenge

2008-03-07T14:11:00.004-05:00

It's been a couple of weeks, during which time I had a much needed vacation, and was able to resolve the ethics dilemma I mentioned in my last post. I am relieved to report that I will be able to continue posting cases. It's really quite simple: the cases need to be unrecognizable to the people involved and not just to everyone else. So what is required is a bit of fictionalization. The idea is to keep the important details that make each case interesting and potentially useful to my readers, and to fib on the ones that are unnecessary but unique enough to allow someone to recognize themselves. I have added a bit about this under Author's note:

Important: While based on real consultations, the cases posted in this blog have been mashed up, fictionalized, posted out of sequence, and otherwise tinkered with in order to maintain the privacy and comfort of the parties involved.

With this in mind, over the next few weeks I will be editing and reposting the cases from before, and adding new ones as I go. This makes me think about a recent interesting post of David Rothman's in which he discusses the problem of versioning in blog posts. It occurs to me that if I chose not to be transparent about this process, there would be no way (that I know of) for anyone to know for sure that anything had changed. I have chosen transparency for the same reason I decided to create this blog in the first place, which is to share the challenges I encounter in the course of implementing this new service with others, and, selfishly, to allow myself a space in which explore my experiences and thoughts. But I also feel that in these cases it's a good thing that the new version overwrites the old.

Thank you for your patience!

Staff requests: 2 cases and Ethics: challenge

2008-02-09T11:49:00.003-05:00

It has recently been brought to my attention that there may be ethical problems with posting cases the way I have been, even though I have been very careful to remove any personally identifying information. Hopefully I will be able to continue once I have spoken to the ethics consultant at the hospital in order to confirm that all is indeed okay.

In the meantime I have taken the cases offline (hopefully temporarily), and today I will write about a couple of requests I've gotten from staff.

Case#1

Scenario

One of the health professionals (HP) at the clinic asks me to find some information regarding which vaccines that do not contain thimerosal (a mercury-based preservative used in multi-dose vials to prevent contamination) are available in Canada, as one of his patients has expressed concerns over the additive. He gives me a list of possible vaccines.

Resolution

I run several searches in Google which verify the correct spelling and allow me to narrow my results to those pertinent to Canada. Unfortunately, as I write this, I do not remember my exact searches, except that I did not include the vaccines from the list in my searches. I do remember running several relatively convoluted ones before I was able to find the information I was looking for. I have tried to reproduce my search for the purposes of this post and for some reason I am only able to find an older 1 March 2003 version of the 2007 document I am ultimately able to find for the HP:

Canada Communicable Disease Report
Volume 33 • ACS-6
1 July 2007 An Advisory Committee Statement (ACS) National Advisory Committee on Immunization (NACI)
Thimerosal: Updated Statement

Discussion

I find the older version by typing in thimerosal canada which is a search I know I would have run the last time, so I am doubly confused at to why I did not find the older version last time but have now found it so easily. Having found it there would have been no reason to keep looking as there is no indication that there is a more recent version available. This is yet another example of why searching for information using Google can be hit and miss. I have tried to reproduce searches before and have had similar problems, something I demonstrate in the Google course I developed for the Health Sciences Library: Google-eyed? Don't despair! How often do we take screen captures of our search results? It is way too easy for us to doubt ourselves and not the tool we have become so dependent on.

Total time: 30 mins

Case#2

Scenario

One of the GPs at the clinic asks me where he can find decision aids to use with his patients and their families.

Resolution

I happen to have a very useful site already bookmarked in MyHq so I show it to him: Ottawa health research Institute A-Z Inventory of Patient decision aids.

I also show him a really neat one I have found recently during an encounter with a family member in the Gynecologic Oncology department: Ovarian Cancer Treatment Guidelines for Patients– Version III, April 2007. The reason I like this one so much is that is not just a list you can print out and tick off, but rather a fully interactive tool that works something like a choose you own adventure.

Total time: 5 mins

Low back pain week: 2 cases

2008-01-11T11:55:00.002-05:00

I am glad to report that this week I was presented with not one, but two cases, both having to do with low back pain.

Case #1

Scenario

A French-speaking middle-aged man has been referred to me by his physician at the clinic. He suffers from chronic low back pain and would like to know which exercises might help.

Resolution

First I go to Passeportsanté, hoping to find something in French similar to the MedlinePlus interactive tutorials, or at least with illustrated exercises.

Passportsant é > A-Z > D > Dos (mal de). This takes you to the same page as Douleurs lombaires.

Unfortunately there are no illustrations and certainly nothing interactive. I print it out anyway and then try CiSMeF (sites médicaux francophones à destination des patients et de leurs familles) to see what they have there.

CiSMeF > keywords: "exercises dos." I get two results, neither of which include illustrations, or even examples of exercises. Somewhat interesting though, so I print them out too.

Mal de dos: guide pratique
Mal de dos: pour faire le point

At this point I decide it's time to go to MedlinePlus. Since the information is illustrated, and the patient does speak some English, he will still be able to benefit from it.

MedlinePlus > keywords: "back exercises." I print out the list of results so he can access it again at home, and also print out the text summary of the interactive tutorial (which includes illustrations), and the second hit on the list which is a Low back pain exercise guide from the American Academy of Orthopaedic Surgeons.

Case #2

Scenario

One of the health professionals (HP) at the clinic comes into my room and asks if there is a pamphlet on back exercises. I know which one he is thinking of but we have run out.

Resolution

Since the patient speaks English and I have already fielded a similar question earlier in the week, I go directly to MyHq where I have bookmarked some useful links under the Pain management section.

I show the HP the aforementioned MedlinePlus interactive tutorial which he thinks is great (it really is), and Low back pain exercise guide from the American Academy of orthopaedic Surgeons, and this time I also include Low back pain: tips on pain relief and prevention from familydoctor.org.

I ask the HP to fill out an Rx so I can document the consultation and he is happy to do so even though it means returning to the exam room to get the patient's information (name, chart no.). I run into him later in the hall and he tells me he was impressed by how quickly I was able to find the information and that he is going to go back and explore MedlinePlus for himself.

Discussion

I often find that the French language information I am able to find is rich in theory and somewhat lacking in terms of image/illustration and maintaining an appropriate reading level. Fortunately most of the patients I see at the clinic are able to read enough English to still benefit from those resources. It is interesting to note that CiSMeF links directly from each topic to the corresponding section in MedlinePlus. All roads lead...

It is also interesting to note that this resource that we (librarians/information professionals) take for granted, is still not well known to all health professionals. I think this is true of many of the resources we use on a regular basis. I have noticed that health professionals at the clinic often request information in pamphlet form, even though they are all too aware that their patients are going online for information. The clinic used to have a "pamphlet room" and a pamphlet database, so I suspect that this is partly due to habit rather than ignorance.

Lull or languish?: challenge

2007-12-14T11:59:00.003-05:00

First I must apologize for not posting anything last week. I had some last minute consulting work that absolutely had to get done by the end of the day. I also had another reason for not posting, one that brings me this week's topic, which is that I have not had a case to post in the past couple of weeks. It is too soon to tell whether this is the beginning of a trend, or whether the holidays are coming and the snow is piling up and people have their minds on other things. It is probably a bit of both.

In any case it will soon be time to promote the service again, to both staff and patients/families.

Promotion is a tricky thing. You don't want to overload people with email reminders and fliers and posters and so on because you risk having them tune out and basically ignore the message. On the other hand you don't want to be completely passive about it, quietly hoping that people with remember you exist.

We had already decided that I would make up a brochure for the service which I could then hand out to people in the waiting room, and place strategically around the clinic. Now the thought is that we also need to make the space more welcoming. Right now it looks like an office and when people come in it is usually to apologetically capture a straying child, because they think I am someone else, or because they need a telephone. Only very rarely has someone come in to browse the pamphlets or ask a health information related question.

The first step has been to improve signage. I made an unfortunate mistake when I ordered our sign. See if you can spot it:**

Mistakes are often opportunities in disguise. Our new sign will not only have a correct title, it will also have a large red arrow pointing to the entrance and an invitation to drop in and ask questions.

In addition to the new sign, on my list so far are:

A smaller, less obtrusive, desk for me
A name plate for my desk
Posters for the walls
A comfortable chair (or two, depending on space)
More shelves for pamphlets
More pamphlets
A computer for patients to use (part of our original plan for the room and already ordered)

The filing cabinet can be moved away from the door further opening up the space.

Hopefully the combination of promotion and space redesign will increase use of the service in the new year. I will keep readers updated.

** The word "health" was left out of the English title, completely altering the sense.

Librarian floating in a sea of MDs: report from a medical conference*

2007-11-16T13:09:00.002-05:00

As mentioned in the "About me" section of this blog, last week I attended the STFM Conference for Practise Improvement: Patient Education and Health Information, where I presented a paper titled: Implementing an integrated information prescription model in family medicine. The PowerPoint presentation is available at the Family Medicine Digital Resources Library for anyone who is interested. You need to register to have access but registration is free.

The presentation went very well. I had a mere 20 mins to present but discussion continued for another 20. Two MD's have expressed an interest in implementing a similar model and we will hopefully be in touch.

I would like to share some thoughts about what it's like to be a librarian attending a non- librarian conference. The problem is that I have never been to a library conference so I don't have any basis for comparison. I can't say whether certain aspects of my experience are unique to me, to this particular conference, whether they are unique to medical conferences, or whether they apply to conferences in general. Perhaps I will hold off on trying to analyse my experience on any profound level until I have attended an actual library conference.

I will say that I met and spoke with many interesting people, particularly at the poster sessions where I was able to chat with the representative from UptoDate who told me that librarians are their toughest critics, and with several people from the Mayo Clinic who
work in the area of patient education and were surprisingly modest about their work, and the incredible resources they have at their disposal.

What was missing to some degree was the urge to connect again in future, which I suspect would have been there had we been professional colleagues. In general my impression is that librarians are respected for the work they do, it is recognized that much of what we do overlaps and even sometimes duplicates the work of health care workers in the area of consumer health education, and our resources are being used with enthusiasm. But we are nonetheless justifiably considered separate entities from the health care team. This model (perception? habit? philosophy?) is of course what I am working to change at my own clinic, for the most part successfully.

If teams are to be truly multi and interdisciplinary, then it stands to reason (at least to my mind) that they should include members of any profession who brings added value to the care the team provides. In order for this to happen, more of my professional colleagues will need to enter the trenches (this is a challenge in every sense of the word).

The question is: why is this so important?

The first and most important reason in my mind is that of trust. This is something I got to thinking about when I was preparing my presentation. It was of course necessary for me to answer the question: why in house? There were several reasons (the library is far, the health professionals need support too, the librarian is better placed to understand the needs of the community) but the one that resonated most, for myself and for my audience, was trust. Trust can come into the equation in several important ways:

The health professional may be more likely to trust the librarian to provide health information to his or her patient if the consult is treated as a clinical encounter and documented in the chart.
The patient or family member may be more likely to trust the librarian to provide health information if their doctor or nurse has referred them to a service which is down the hall from the exam room.
Perhaps most importantly: the patient or family member may be more likely to trust that their doctor or nurse wants them to be informed and is willing to discuss the information they are accessing, if the information is being provided by a member of the health care team. The message then is this: we want you to be empowered, we support shared decision making.

*My apologies for not posting last week. I was hoping to be able to publish a post from the conference but at $4 per 15 mins of Internet time it didn't end up being reasonable.

Privacy: challenge

2007-11-02T14:29:00.000-04:00

Challenge

I am in the H-PHIS room creating a handout on local fibromyalgia resources for patients and it is a busy day in the waiting room. People are starting to browse the pamphlets which we have displayed in two very nice wooden displays along the wall. Small children especially seem to like to run into my room and play with the pamphlets on the bottom row. I will have to think of something more interesting to put there for them to play with.

Today I see the beginnings of what will be a great challenge. My room opens directly onto the waiting room which is good because I am visible and people can feel free to drop in and ask a question or browse pamphlets even when I'm not there. What's not so good is that there is no privacy, either for me when I am working (it can be hard to concentrate when a four-year-old runs in and fake-sneezes on you), or for any person who wishes to ask me to help them find information on a topic that requires privacy. One of the dietitians has to go through my room to get to her office and, while she has put up shades, the glass door and wall do not give her patients much privacy either. How to balance the two? How to make sure that people are welcome to come in and use the service, and that if they need they can have a little privacy?

Picky eaters: case

2007-11-02T13:40:00.003-04:00

Case/challenge

Scenario

A young man follows his child into the room and sees a pamphlet he's interested in but we only have the French version displayed. He asks if we have it in English and I pull it out from one of the many boxes I am keeping under the extra desk until we can find someplace to store them. Eventually the plan is to have an extra computer at that desk that patients and their families can use while they wait. The pamphlet is called Feeding your child ages 2-5. The man tells me his daughter is 2 years and 7 months old and a very finicky eater. I offer to see if I can find some other resources. He's nervous about staying in the room with me as he might not hear his name being called. The waiting room is quite animated this morning and a vacuum is being used nearby. I offer to find some information for him and tell him she can pick it up after his appointment.

Resolution

I find a few good resources that will supplement the pamphlet nicely:

From Eat Right Ontario: Picky eaters and serving sizes
From Kids Health: Nutrition & Fitness section
From the BC Ministry for Children and Families: Feeding your toddler with love and good food (pdf)

I print these out and place them handily on my desk for the man to pick up when he leaves. He never returns for them.

Discussion

I'm not sure what to do with the 10 pages or so that I have printed. We have not yet established a procedure for this eventuality but I am now inspired to create one. Some things to consider: a way for patients to be located when they are with me and their name is called; a way to get printed information to a patient in case they forget it (email, fax?); a place to put abandoned printed information that may be used at a later time.

Further resolution & discussion

The following week I decide to try and track down the man and see if he still wants the information. I go to the chief administrator at Herzl to ask if she can suggest how to find the man using only a first name. Medivisit, the clinic's appointment scheduling software, only allows a search using both first and last. She randomly calls one of the team coordinators, who as it happens knows the man we are looking for. I have contact information in my hands within 2 minutes. I call the man and he does still want the information. I leave it with the team coordinator for him to pick up at his next visit. I am very impressed with how well the teams seem to know their patients.

What not to feed gout & whose pager is it anyway?: case

2007-10-26T15:47:00.002-04:00

Case/challenge

Scenario

I am at the library helping to conduct a workshop for a small group of residents. They are reviewing how to use selected EBM resources to answer clinical questions and a couple of the cases at the end of the session are specifically related to providing health information to patients and families. This is why I have agreed to assist during a time when I would normally be on site and available to patients. It is also an opportunity to promote the service to residents, who have so far been extremely enthusiastic about using the service. A short way into the workshop a beeper goes off. After a moment's pause I realize it's mine. I excuse myself to call in and am told that a patient is waiting for me at the clinic which is in an entirely separate building. I run over to the clinic and arrive slightly out of breath to find a young woman waiting for me. Her father's physician would like him to have some information about which foods to avoid when suffering from Gout.

Resolution

I do a quick search on MedlinePlus and find a link to the Arthritis Foundation that answers the question (literally since it is a Q&A from the Arthritis Foundation's consumer health magazine Arthritis Today, in the On call section). I ask if she thinks her father would like more information and shen answers that for now she thinks it will be enough and will contact me if she or her father have more questions. I run back to the library in time to cover the 2 cases that deal with the information needs of patients and families.

Discussion

In this case what is interesting is not so much the information need or how it was met, but rather the challenge that was presented by the fact that I was engaged in other aspects of my position which required that I be off-site during a time when I would normally be available to patients. In the end my having a pager helped to resolve the issue to everyone's satisfaction and the timing worked out just right. Had the person been unable or unwilling to wait the ten minutes it took for me to arrive on site, an opportunity to provide the service would have been lost. This has already happened once so far. The fact that a librarian was paged in a room full of physicians was an added bonus! I could not have found a better way to promote the service than that.

CAM for HCV: case

2007-10-19T16:00:00.002-04:00

Case

Scenario

One of the health professionals (HP) at Herzl comes to me asking that I meet with one of her patients (a young man) who has Hepatitis C and is resisting interferon. The HP tells me her patient is interested in complementary and alternative therapies (CAM). Although she would prefer that he accept the recommended treatment she is open to discussing alternatives with him. She hopes the young man's specialist will be open to exploring CAM treatments.

Resolution

When the young man meets with me I mention to him that since he is not sure about interferon a decision aide might help him decide. He hesitates but is amenable once I explain that the aid will not force him to decide one way or another but will rather give him a structure for clearing his thoughts. While we talk he shows me a link to a resource he has already accessed on the subject. It turns out to be a good resource, www.hepatitis-central.com, that has HONcode accreditation which is at present undergoing annual review.

I give the patient some information I had prepared ahead of time: information about HCV and CAM on the Public Health Agency of Canada website and about interferon from MedlinePlus, a decision aid from the Ottawa Health Research Institute, and a research report from the National Centre for Complementary and Alternative Medicine, as well as some fact sheets from the HCV Advocate website.

The patient is very happy with what I have printed for him. In addition he would like to find some information about the use of vitamine C as a therapy, having heard that it can cure HCV completely. We look together and find a few references to vitamin C and HCV but I am not able to find anything definitive or evidence-based, although something is mentioned on Hepatitis Central that might be worth showing to his specialist. We discuss some criteria to use in order to judge whether a website can be trusted including: who maintains the site? who wrote the article? when was it updated? is the information cited?

Discussion

It remains to be seen whether the patient will decide to accept the interferon treatment or whether his specialist will be amenable to exploring CAM therapies.

Pushing boundaries or juggling hats: challenge

2007-10-12T19:37:00.001-04:00

Although my two positions at the hospital are intricately connected, I am paid for them separately, so I try to keep my work in each location as separate as possible in order to honour my obligations to both.

When I got the request for information at the library on pediatric MS from a Herzl resident, it had not yet been established what to do when a Herzl request comes to me when I am at the library. I had another request at the library from Herzl that same week so it seemed imperative that a decision be made regarding procedure.

It has since been decided that I will treat the request as a PFRC request, and also fill out a consult at the Herzl which can then be placed in the chart, which is what I had instinctively thought to do. This seems like a reasonable solution, although it does mean that I may be occasionally counting a single encounter twice.

The head librarian is also available to consult with patients and has said she is happy to help with Herzl requests coming to the library should I not be able to. This is where having the additional support of a library and especially of an existing patient resource centre makes having an in-house service slightly more feasible, especially when the librarian is only on site part-time.

Pediatric MS: case

2007-10-12T18:36:00.003-04:00

Case

Scenario

One of the Herzl health professionals (HP) comes to see me while I am working in the library. She has a young patient, a nine year child, who has been diagnosed with pediatric MS. She would like some information for the family.

Resolution

This diagnosis is relatively rare and we are both thinking it may be difficult to find information. As she will be visiting the Montreal Children's Hospital that Friday I suggest they go to the Family Resource Library there, which is excellent, in case they have any special resources on the topic. I tell the HP I will follow up when I am at the Herzl and ask her to write up an InfoRx and leave it for me so that I can fill out a consult.

The next day I call the Family Resource Library at the Children's to see if they do in fact have any special resources on the topic, which it turns out they do not. I decide to do a quick Google search first thing Monday to see what might be out there. I don't normally turn to Google first unless I looking for the US name of a drug before looking it up in a US resource, but this time it seems like the thing to do. I am surprised to see how many excellent resources come up right off the bat:

Search: pediatric multiple sclerosis

Results:

For the health professional:

MS Society of Canada
Hospital for Sick Children Paedetric Multiple Sclerosis (MS) Clinic

National MS Society (US)
Pediatric MS

Quebec chapter of MS Society of Canada

For the patient and family:

MS Society of Canada publications on young persons with MS
Includes an activity book for children with MS, a guide for parents, and answers to FAQ

University of California Children's Hospital
Pediatric MS Center

National MS Society (US)
About MS: Pediatric (Childhood) MS

Children's Hospital of Philadelphia
Neurology: Pediatric Multiple Sclerosis Clinic

National Pediatric MS Center at Stony Brook University Hospital

I also search NOAH (New York Online Access to Health), as well as the default MedlinePlus, to see what they have on the topic. Noah has a couple of links to to the National Multiple Sclerosis Society, ones I have already found, but MedlinePlus does not have anything at all on the topic.

Discussion

(Also see Challenges post for today)

I recently gave a course to hospital staff on using Google wisely and well, and one of the things I made a point of stressing is that Google is just a means to an end. There is a lot of controversy surrounding the use of Google as a diagnostic tool, and especially on its use by consumers to find health information. I believe that *if* you know what you're doing, and more importantly *if* you know how to evaluate what you find, then it can be a really useful, if unreliable, tool for finding information quickly in multiple resources.

Nutrition information in Cantonese: case

2007-10-05T12:58:00.002-04:00

Scenario

A middle aged man is referred to me. He leaves a phone message telling me he is interested in information on Type II Diabetes and diet in Cantonese for his father who is a patient at the Herzl.

Resolution

I search the following resources*:

The 24 languages project
Health Information Translations
Healthy Roads Media
HICUP
NLM Consumer Health Information in Many Languages Resources
SPIRAL

I am able to find some good information in Chinese on the SPIRAL site:

SPIRAL > Patient information by language > Chinese > select "diabetes"

Unfortunately I am not able to determine whether this information is specifically in Cantonese (health information is generally available in either traditional or simplified Chinese). I call the man back and he asks me to email the links and says he will ask his father whether he is able to read the information. I tell him I will be happy to continue looking if necessary. He then asks if I can find something that might help his father understand the different food groups and portion sizes. I do a web search using Google: canadian food guide chinese. The first hit is a copy of the guide translated into Chinese (pdf).

I email these links to the man including some information about navigating the SPIRAL site.

I place a copy of the consultation form in the attending physician's mailbox.

*All of these resources have been bookmarked in the list of public MyHq bookmarks I have created for myself and the Herzl health staff.

Total time: 20 mins

Discussion

I consider every encounter an opportunity to teach people how to find information and not just hand it over. At the very least I show the path from the resource's home page to the desired information. This also minimizes dead links.

Genetic counseling, uninsured population & birth order: 3 cases from the Patient and Family Resource Centre (PFRC)

2007-09-28T14:49:00.003-04:00

Case #1

Scenario

A pregnant woman in her late twenties comes into the library. To my untrained eye she looks like she is in her 3rd trimester. She speaks halting French and asks if we have any information on genetic counselling. I conduct a reference interview, asking a few questions in order to narrow down her information needs. She wishes to know whether there is someone she can speak to confidentially at the hospital about the results of a DNA test done recently on her baby.

Resolution

I phone one of the GPs I provide research assistance to at the Herzl. He suggests that I contact the hospital's genetic counsellor, which I do. I am advised to inform the patient that she will be able to speak with the genetic counsellor but that she will need a referral from her GP in order to do so. I relay this infomration to the woman.

Total time: 20 mins

Case #2

Scenario

A woman phones and asks for information about admission and regarding the costs of delivery at the hospital (both vaginal and C-section). The woman's sister is 8 months pregnant, has recently immigrated and does not have Quebec insurance.

Resolution

I contact one of the nurses in Maternal-child health who I have recently assisted with the creation of patient handouts. She advises that the woman contact JGH Admissions for this information. She suspects that the sister is without status and likely has not yet seen a GP in this country, and gives me several names of GPs who are accustomed to accepting uninsured patients. I call the woman back with contact information for JGH Admissions. I also provide the names and tel. nos. of the aforementioned GPs and tell her she can contact them if her sister needs to see a GP before her due date, regardless of insurance status.

Total time: 40 mins

Discussion

Had the woman contacted JGH Admission directly it is unlikely that they would have detected her sister's underlying and more important need to see a GP.

Case #3

Scenario*

A older female Herzl patient contacts me at the library. Her husband has recently passed away and her three children, who are in their late teens and early twenties, have been arguing over their inheritances. She would like to read 1 or 2 journal articles on the subject of social dominance and sibling rivalry. She believes that reading about these dynamics might help her to cope with her situation.

Resolution*

I contact my colleague at the Institute of Community and Family Psychiatry (ICFP) Library as our collection does not include psychiatry or psychology and this is not my area of expertise. She suggests I do a search in PsychInfo, and provides a couple of key words I might find useful. (PsychInfo does not index using the MeSH vocabulary). I do a quick search in the database and find several articles that may be of interest.

I get back to the woman and conduct a more extensive reference interview, wanting to confirm that I have correctly understood her information needs. She speaks to me at length about her family history and this present situation. She tells me that she wants something that will be simple to read, and I suggest that perhaps she should consider going to Chapters or Amazon instead. She then admits that several weeks ago she found some very interesting articles in our library's Journal of Psychosocial Nursing at which point I am confident that she will be able to read the articles I have found.

Total time: 1 hour

Discussion

This is an example of an information need that requires access to a library and the assistance of a librarian in order to be filled.

Reinventing the wheel, changing habits & time management in the first months after implementation: challenge

2007-09-28T13:06:00.004-04:00

Because the UK service we are basing our model on is no longer operational following the retirement of its librarian, we are in essence reinventing a structure we know exists but do not have the blueprints for. Much of the first months have been spent dealing with the practicalities of setting up the service, establishing policies and procedures, and promoting the service to health care, administrative and support staff as well as to patients.

One of the biggest challenges has been to get health care staff into the habit of referring patients to me. It is my hope that the cases presented here will help. For now I have given the following guidelines:

When to use the service:

Anytime anything is new (i.e. treatment, diagnosis, medication etc.)
When more information would help your patient make a decision
When you’ve been asked for more info but don’t have time to provide it
When info is needed in a language other than English and French
When info is needed at an easier reading level

**** do not discount patients you suspect have low literacy****

I am only on site 7 hours per week and this is problematic because I am not always immediately present to fill prescriptions. This will necessitate that those needing my services be prepared to make appointments for a later date and/or to send me their request by phone or email. It has taken some time to establish me in the system so that patients can make appointments to see me with their team coordinators. It is only this week that this has become possible. in the meantime I had asked that referrals be left for me in my mailbox. I have received my first referrals (yellow InfoRx sheets torn from the pads I had printed) in the past two weeks. I have left messages for patients and made contact with one: my first appointment is on Oct. 1st, this coming Monday.

Since I do not yet have cases to present I will instead describe a few I have handled in the past several months at the Library's Patient and Family Resource Centre (PFRC)- see next post.