Final Paper: Literature Review of Physician
Information Behaviors
(George Nichols 12/9/05)
INTRODUCTION
This literature review covers the existing body of research knowledge on
physicians' information behaviors. Physicians routinely make choices that have serious
consequences on their patients' health; however, little research in recent years has
analyzed the information behaviors driving these decisions. This process generally
involves doctors identifying information needs through questioning, deciding which
resources to consult for answers, and appraising information quality in order to determine
the best course of action.
PURPOSE OF RESEARCH
Information seeking is a topic that has been thoroughly explored by researchers in
the last several decades. Yet, only more recently has this body of knowledge expanded to
include the study of information behavior, which Case (2002) defines as "encompass[ing]
information seeking as well as the totality of other unintentional or passive behaviors
(such as glimpsing or encountering information), as well as purposive behaviors that do
not involve seeking, such as actively avoiding information."
Some of this research has analyzed the subject in the occupational context of
healthcare professionals, particularly doctors. At the most fundamental level, this
research seeks to answer questions that underlie many other information behavior
population studies: What are the knowledge gaps commonly found in this group? What
resources are consulted to answer these questions? Why are certain resources preferred
over others? Further examples include a study by Gruppen that explicitly asks: "What is
the context in which physicians seek additional information?" and "What sources of
information will physicians access and find more or less useful?"
Researchers must consider additional characteristics inherent to clinical settings.
Most notably, this environment includes patients. The stakes of physician decisions are
usually measured in patient health outcomes, thereby assigning a greater urgency to
doctor questions relative to the information needs of many other populations. In fact, a
survey noted that medical library information facilitated lower mortality rates at
hospitals in the Rochester, NY area (Quinn, 1991). Also relative to other demographic
or vocational groups, doctors stand out by virtue of their extensive training and
educational attainment. When making information decisions, doctors draw heavily on a
personal knowledge base that includes many years of schooling, residency, and practice.
LITERATURE REVIEW
The studies in this literature review were located in several databases, particularly
ISI Web of Science (accessed through Florida State University's online library). Search
terms used include "information seeking" and "information behav*" (single and plural
form of both "behavior" and "behaviour"), in conjunction with "doctors," "physicians," or
"healthcare."
The results were usually abstracts, with additional searches conducted to find each
individual article through electronic journals. In many cases, nothing more than an
abstract was available. Some of these articles were difficult to obtain given their age-many of these studies were conducted in the 1980's or early 1990's.
This search strategy yielded research heavily biased toward English-language
journals, and particularly American periodicals. These studies were not conducted in
other countries (which comprise the majority of the world's population), thereby limiting
the generalizability of research in those areas.
The majority of these studies used questionnaires or administered surveys to
physicians. Some studies collected data through direction observation. In totality, this
physician sample varied widely in field of specialty, age, and experience levels.
INFORMATION NEEDS: COMMON DOCTOR QUESTIONS
The existing body of research is not particularly deep. Dawes (2003) opines on
the "remarkably low number of studies that have explored information seeking behavior
of clinicians." Furthermore, much of the research is outdated -- many of the studies were
conducted in the early 1990's and prior decades; since then, there have been major
changes in the medical field (e.g. evidence-based medicine) and information technology
(e.g. adoption of online information sources).
Much of this research literature suffers from a lack of depth and generalizability.
Specifically (as implied in Detlefsen, 1998), many studies are descriptive in nature using
surveys or questionnaires to report actions, but are not prescriptive by providing
information behavior models proffering heuristics on the underlying variables driving
these behaviors.
A rare exception comes from Paul Gorman, a general internist and medical
informatics specialist. Gorman made a breakthrough in this area when he introduced a
classification model (1995) for two parameters. First, he categorized the type of
information used into five groupings: patient data, population statistics, medical
knowledge, logistical information, and social influences. Secondly, Gorman classified
information needs into four groupings: recognized, pursued, satisfied, unrecognized.
These latter four categories may be considered a refinement of Osheroff's (Osheroff et al,
1991) earlier typology that categorized information needs as consciously recognized,
unrecognized, or currently satisfied.
A key obstacle to the creation of other physician information-behavior models is
the lack of standardization in defining terms or classifying phenomena. A study of family
practitioners (Ely et al, 1999) addressed this concern by developing a taxonomy to
classify most questions under generic types. In doing so, the study found doctors' most
common generic questions were: "What is the cause of symptom X?," "What is the dose
of drug X?," "How should I manage disease or finding X?," and "How should I treat find
or disease X?"
Other studies also shed light on information seeking by highlighting the most
common types of physician questions. According to Thompson (1997), physicians seek
information for two reasons: 1) to obtain answers to patient questions whose answers are
not contained in their personal knowledge base, and 2) to stay abreast of developments in
their field. Meanwhile, Ely's (1992) study of family physicians found that the most
common type of question was about drug prescribing, while orthopedic questions ranked
second.
DEPENDENCE ON INFORMAL SOURCES
This literature review on preferred information sources revealed one particularly
salient theme. Most studies indicated that colleagues (e.g. other physicians) were the
most preferred information source, by a substantial margin.
This may come as a surprise to some casual observers. Indeed, it seems to come
as a surprise to physicians themselves considering multiple studies (particularly Covell
et al, 1985) found that physicians substantially under-reported (relative to actual
numbers) uses of colleagues and/or over-estimated use of text sources.
So arises the question "Why the great dependence on colleagues?" Convenience
and relevance were among the leading factors (as detailed below in this paper's
"evidence-based medicine" discussion). Additionally, the British Medical Journal (Smith,
1996) provided a good description of psychological factors:
"...the need for information is often much more than a question
about medical knowledge. Doctors are looking for guidance,
psychological support, affirmation, commiseration, sympathy, judgment,
and feedback. This 'information need' is particularly poorly explored, and
yet it may well be the most important need and the biggest stumbling block
to a technical solution [medical information system]."
BARRIERS TO INFORMATION SEEKING
Studies on physicians' information behaviors note that many questions are not
pursued, leading researchers to hypothesize why physicians abandon the information
seeking process. Gorman & Helfand (1995) noted that only around 30% of questions are
pursued and are driven by two specific factors: the urgency of the patient's problem, and
the physician's belief that a definitive answer existed. Numerous other studies (Dawes,
2003; Thompson, 1997; Ely et al, 2002) confirm the latter point -- if physicians believe
that a clear, relevant answer could not be found in reasonable time then the pursuit for an
answer is often abandoned immediately.
Electronic sources of information tend to be far less popular than the use of
colleagues. There are varying explanations as to why this is the case. Ely (1999) makes a
persuasive argument when claiming "Information retrieval systems have been
designed for the researcher who needs an exhaustive search on a single topic, not for
the practitioner who needs bottom-line answers on the fly."
Various barriers strongly affect the information seeking behaviors of certain subpopulations within the physician occupational group. Rural doctors form one such group.
(Ely et al, 1992) noted that urban physicians pursued more questions than rural
physicians (one question per 9 patients, versus only one per 24 patients, respectively).
Use of electronic sources lagged as well--Chimoskey (1999) reported that rural doctors
make less use of Medline despite the likelihood they will benefit disproportionately given
their relatively limited access to other resources. Lack of time and database searching
skills have been among the barriers cited, but the true impact of these variables is unclear
since they are also frequently mentioned as barriers for non-rural physicians.
LIBRARIANS SUPPLEMENTING PHYSICIAN INFORMATION BEHAVIOR
Doctors face a dilemma: It requires significant time and effort for them to conduct
literature searches in order to extract useful information for patient treatment. Combined
with the fact that they are much more comfortable using colleagues instead of text
resources, doctors may be exhibiting deficient information seeking behavior by not
seeking the best available information in order to maximize patient welfare. Some
research has addressed the feasibility of whether medical librarians can help doctors fill
this serious information gap; the results have been mixed.
In arguing for "informationists" Davidoff (2000) notes:
"the medical profession falls far short in its efforts to make the critical link
between the huge body of information hidden away in the medical
literature and the information needed at the point of care. This failure
means not only that many opportunities for improved patient care and
continued learning are missed but also that much of the effort, creativity,
and money that go into biomedical research is simply wasted."
Such intermediaries have been referred to by various names in the literature:
medical librarians, informationists, informaticists, clinical medical librarians, and most
interestingly, roving medical librarians (who attend medical rounds alongside doctors).
Del Mar (2001) found that general practitioners were generally satisfied with a literature
research service, but that cost effectiveness was an issue that warranted further study.
A study (Verhoeven & Schuling, 2004) of an evidence-based answering service
showed it had an impact on 81% of the participating general practitioners and saved their
time. Another study (Gorman et al, 1994) found that librarians, on average, answered
questions in 43 minutes at a cost of $27. He found the results encouraging considering
librarians provided clear answers to 46% of questions; versus 30% for physicians
(using any knowledge source) and just 1 to 2% when physicians used a database
such as Medline.
EVIDENCE-BASED MEDICINE (EBM): CONFLICTS WITH INFORMATION
BEHAVIOR?
Evidence-based medicine (EBM) is an approach that has gained tremendous
influence in the past decade. Vividly illustrating this trend, a Medline search for the term
revealed its first hit in 1992, a handful more in 1993, and skyrocketing to nearly 600 hits
in 1997 (Bensing, 2000), and much greater frequency in recent years. Although not yet a
household term, EBM is now mentioned frequently in wider contexts (e.g. job postings
for medical librarians).
A British Medical Journal article (Sackett, 1996) defines EBM as [emphasis
added] "the conscientious, explicit, and judicious use of current best evidence in making
decisions about the care of individual patients. The practice of evidence based medicine
means integrating individual clinical expertise with the best available external clinical
evidence from systematic research."
This last point is emphasized here due to its tremendous potential impact on
physician information behavior. The EBM model is increasingly taught to a new
generation of medical students and is taking greater hold in the medical world.
This shift poses a serious conflict considering physician information behavior
(as illustrated earlier in this paper) clearly contradicts EBM tenets. Rather than
conducting extensive literature searches to unearth the best information from
external sources, physicians are strongly dependent on their colleagues as
information sources.
Even in the few cases where they do conduct a thorough literature search, doctors
appraise the resulting information based on anecdotal experience rather than the scientific
EBM model. Dorsch (2000) points to a study finding that "90% of practitioners compared
the findings in the literature to their own experience rather than appraised the findings
based on study methodology and statistical significance."
Also, Ely (1999) makes this striking observation about physician information
behavior:
The physician, when faced with an unfamiliar clinical problem, is
advised to critically evaluate original research and to practice evidencebased medicine. Studies have found that this advice is generally ignored.
Instead, most practicing physicians seek highly digested information from
books and colleagues. In the pressure-cooker atmosphere of a busy
practice, physicians value rapid access and understandability more than
the quality or recency of information.
Research on information behaviors in the context of EBM is very scarce,
which is why this reviewer strongly believes it is an area clearly meriting further
attention. This literature review uncovered only one study (Greenhalgh, 2002) that
touched on the issue--albeit indirectly--when noting:
"although most clinicians support the notion of evidence based
health care in principle and wish to use evidence based information
generated by others, only a tiny fraction seek to acquire all the requisite
skills themselves...the commonest reason cited [in another study] for not
practicing evidence based health care was lack of time."
This brief excerpt suggests practitioners endorse EBM in theory but do not have
the time to practice it. Further studies should be conducted to determine how thoroughly
clinicians support the EBM model, while observing and measuring actual information
behaviors to quantify their deviation from the EBM ideal. In self-reports, physicians
frequently overestimate their use of certain formal sources; therefore, such research
should be in the form of behavioral observations rather than surveys. This research
should also focus on the reasons why physicians are not showing a greater incorporation
of these methods and whether the dependence on colleagues as an information source
will wane among those who do.
CONCLUSION
A casual observer may errantly assume that doctors are maximizers (rather than
satisficers) considering: 1) relative to other populations under study--they are not
constrained by deficiencies in education or financial resources and 2) the high stakes
(patient welfare and mortality) associated with their decision making.
Nevertheless, the research suggests that many physicians accept EBM tenets yet
fail to conduct the proper research of literature sources and appraisal of the resulting
information. In other words, they appear to be satisficers. Further study is needed to
understand such information behaviors and to determine if there are interventions
that will--if warranted--modify such behaviors to potentially improve patient
outcomes.
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