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Recent rapid responses
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Displaying 1-10 out of 11 published
Access to medical information is becoming more and more easy. This has resulted in an incomparable abundance of medical information. This situation, although it seems perfect, does not facilitate the life of the student. The student now faces an information overload.
The aim of our study was to evaluate the information overload in 5th year medical students, the degree of stress it causes and the means used by students to deal with this overload.
Materials and methods: We conducted a self-study questionnairy administered to 5th year medical students in Marrakech school of medicine. The questionnaire consisted of 8 items.
Results: 100 students have participated freely in the study. 30% were male. 91% of our students think that medical education is overloaded and they gave an average note of 3.77 / 5 (? 1.40) to this overload. The stress caused was estimated to 8.68 / 10 (? 2.45). To deal with this overload students use summaries, deadlocks, prioritization of information and collective learning. Algorithms and mnemonics are used by less than 20% of students. 70% of the interviewed students often feel overcome by the amount of medical information being taught.
Discussion: The student today does not only work so as to learn what their teachers give. It also requests criticize, analyze, manage, expand, and to judge. Many difficult skills in the eyes of the student, which is then torn between different medical information which he access and are often contradictory or at least non-concordant. To cope, the student adopts several techniques of learning. Transmitted from generation to generation of students, some of these techniques have proved their effectiveness.
Conclusion: The new reforms of medical education should consider the concept of overload. Education should then be focused not on the information itself but on knowledge acquisition techniques and develop the ability to synthesize and criticise in the student.
Competing interests: None declared
Oral maxillo-facial surgery unit. Mohammed VI University Hospital. Marrakech. Cadi Ayyad University
13 January 2011
In addition to the BMJ, I believe www.medical-journals.com too, is "good at pointing you towards something important or interesting information" and that is "a fine way of navigating through the jungle of information" as indicated by Richard Smith.
Competing interests: Founder www.medical-journals.com
1 January 2011
I must thank Vasumathi Sriganesh and her foundation for the drive and initiative. As drug information specialiss and clinical pharmacists by profession we handle such scenarios in our hospital setup. Now in India we have specialized Pharmacy courses to cater for the need in clinical and critical information to assist in proper health delivery. Your view of super specialist is needed. To be very brief what we do as pharmacists in clinical setup is assisting the doctors for better health care delivery. We try to fill the lacuna of latest and reliable information.
We clinical pharmacists have been trained in providing drug information using optimum search strategies. We use the Cochrane reviews, Thomson Reuter's Micromedex and the well know Iowa Drug Information System (IDIS). Our university offers us complete and optimized search references. Even after these we find some problems, to include "the system is still under utilized", " no much response from the physicians on online hospital drug information system" and "lack of staffing facility in drug information services to cater the complete of the large teaching hospital with super specialties". The reason identified behind the current problems is that there is no time for the doctors to neither ask for a query nor time to wait till a query has been answered. The doctors need clinical pharmacists all the time both in inpatient and as well as out patient services. We the clinical pharmacists are trying to expand our services to offer the barest minimum support.
On the issue on reporting adverse reactions, we agree that there is under reporting. Again we are working hard in helping and encouraging to report adverse drug reactions. As a part of the Peripheral National Pharmacovigilance center, we have a complete list of adverse reactions reported from our hospital. We have already published articles regarding the same.
The State Pharmacy Councils are also working on the issue for providing reliable and evidence based approach on drug information. Kindly see the websites of the State Pharmacy Councils and some of the councils have established online system too.
Another factor that the author has rightly pointed out is too much information overload. We totally agree, it takes not less than an hour to gather all possible evidence for a single drug information query. Sometimes it takes almost a day to fetch the right answer. This mainly because of too much information and most of it is garbled. In many situations we have felt that doctors do need reports on RCT's and case controlled studies. We end up to give them a handful of case reports or Cochrane reviews. Still lot many studies have to be published to gather the evidence based approach.
The lack of awareness is the main factor behind such issues and being a pharmacist it is hard to digest that we are underutilized.
We say give us the chance and needed resource we will try to help you to tackle critical situations.
Competing interests: None declared
Drug Information Center, Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences
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27 December 2010
My thanks to Richard Smith for this much needed Edtiorial!
Apart from the fact that there IS an information overload, in countries like ours (I am from India), we have additional issues
1. Practically no training in how to handle information, whether it is about searching or organizing (forget managing overload). 2. Lack of adequate promotion of the resources that ARE available
My observations based on over 50 workshops on literature searching are:
a) Participants know barely 10% of the features in PubMed and are wasting colossal amounts of time by doing a bad search and wading through tons of irrelevant references
b) Large numbers of people do not know that the Cochrane Systematic Reviews are freely accessible in India for the last almost four years, thanks to a country-subscription. Even if they do, they are not aware of how exactly to use it and how to differentiate these from other journal articles
c) The National Medical Library initiated a project called ERMED - by which they gave access to around 400 titles (electronic) and around 1300 titles (for photocopies of articles) to several Govt Medical Colleges and ICMR institutions across the country (nearly 100 institutions) - See http://www.nmlermed.in/members.htm
As I checked with a few participating institutions, the usage of this has been abysmal. It is a shame to see Crores of Rupees spent, and miserably underutilized due to lack of awareness and training. Yes, even after all this training, there will still be a problem of Overload - as you have mentioned. But what we are facing here is a problem of much larger magnitude, where there is a "System issue"
Our Foundation is now out to work with medical colleges to tackle these issues. We plan to first help each institution create PubMed LinkOuts for their holdings and train students and faculty to use these. We also plan to train trainers within each institution to help others on a continuous basis
I sometimes feel that the System - in many parts of the world - has the "Ostrich approach" that you mentioned, to recognize that "searching" requires a systematic approach. Many higher authorities in medical schools have told me "youngsters know everything about computers - they manage to find it all"! They just don't seem to understand that "knowing computers" does not mean knowing how to search. Just like knowing how to bind or print a book does not mean you know everything about the contents of a book. As a trained librarian, I think it is time that Clinical Librarianship and Medical Librarianship became a (super?) specialty and is recognized as a need to help health professionals tackle the problem of Information Overload. And considering that Davidoff and Florance  recognized the need in 2000, are we procrastinating?
Disclaimer - I know there are pockets where good work is happening with training, LinkOut, use of Cochrane and other resources - but it is not enough
I would like to highlight one more issue
There is an article of 2008 - Poor reporting and inadequate searches were apparent in systematic reviews of adverse effects. http://www.ncbi.nlm.nih.gov/pubmed/18394536
The results and the conclusion highlight something that I find scary, and also feel are rarely highlighted. If so many Cochrane Reviews as well as DARE Reviews have shown an inadequacy both in the search strategies as well as number of databases searched, then the "Foundations" of the reviews are weak. It could actually indicate flawed meta-analyses and conclusions.
When health professionals search the literature for clinical practice, if they get systematic reviews that are "inadequate", then what do they look for?
Overall the point I would like to emphasize is that Literature Searching is a specialty that needs to be recognized as just that "A Specialty". And Clinical Librarians and Trial Search Coordinators need to be super-specialty professions. Clinicians, Researchers and Search Specialists need to work in a very closely knit team - when Search specialists work to understand exactly what the other two need and the other two teams know enough about searching, to communicate correctly with the Search Specialists.
Reference 1. Davidoff F, Florance V. The Informationist: a new health profession? Ann Intern Med. 2000;132:996-998.
Competing interests: Three years ago I set up QMed Knowledge Foundation.
QMed Knowledge Foundation
25 December 2010
Richard Smith makes some very good points, especially the suggestion to sign up at hifa2015.org (I've done so, thanks!)
It's ironic that so many NHS Trusts block Twitter when organisations such as the Department of Health, the BMJ and the Royal College of Obstetricians & Gynaecologists are using this service.
RSS (Really Simple Syndication) newsfeeds are also worth a mention. There is a handy News & RSS section at http://www.library.nhs.uk/rss/default.aspx that gives lists of feeds and information on what RSS is and how to use it.
The Cochrane Library and the BMJ have been making podcasts available for a long time; NHS Evidence and various commercial information services are providing access via mobile apps. These are also good ways of keeping up to date.
Regarding the machinery, I would like to see really effective "push" technology at the point of care. However, there are so many hospital IT systems that do not talk to each other. Joined-up medical computing will only be practical when standardised sets of medical data can be passed automatically from one specialised system to another.
 The Electronic Encyclopaedia of Perinatal Data volume 15. S.IN.B.A.D.s http://fawdry.info/index.php?&id=35 (accessed 24 December 2010)
Competing interests: I am a volunteer co-editor of the Electronic Encyclopaedia of Perinatal Data cited in reference .
University Hospitals Coventry & Warwickshire NHS Trust
24 December 2010
Richard Smith observed that, "we have what Muir Gray...calls an information paradox--we are overwhelmed by new information yet have many unanswered questions"(1).
Shannon, when examining the loss of information during transmission down telephone lines, famously concluded that information exhibits what he termed negentropy in that it decreases with the passage of time and as such defies the second law of thermodynamics, which states that entropy, or disorder, increases with the passage of time. The concept is similar to that of negative entropy proposed in 1942 by Schrodinger to account for what he concluded was the essence of life, an ability to reverse the direction of entropy by extracting energy from the oxygen and nutrients within our environment. This gave rise to what is known as the entropy paradox.
Might Muir Gray's information paradox be considered analogous to the entropy paradox in that it defies the essence of information theory, negentropy? More importantly does Muir Gray's information paradox reveal a flaw in information theory, the failure to distinguish between useful and redundant and useless information?
If we consider the information continuously generated by the metabolic events within our own bodies chaos is averted by the suppression of all that information not needed for executive decision making. That is to say evolution has blessed us with a very effective filter and, most importantly, an intelligent one even though it is subconscious. Cochrane reviews and the like are intended to act as a filter and promote the evolution of better and better care of patients. Whilst they have clearly been of benefit in so far as they have identified treatments that do not work or do harm might they have been an impediment to the evolution of better and better care in so far as they, and especially the current measures of the quality of information derived from clinical practices, is concerned?
The traditional filter of new medical information has been reviews in articles and especially books by the leading clinicians and clinical investigators of the day. In my opinion this is still the best filter especially as the true value of any new development may not be appreciated for years or even decades. The need to examine source material is a refining process and one essential to the evolution of even newer innovations but one rarely of practical value to busy clinicians. I have been made acutely aware of this in my attempt to get my arms around quantum mechanics. In particular Sir Roger Penrose's Road to Reality and his latest book, Cycles of Time, have made me acutely aware of these issues for, had I tried to learn from source material I would never have been able to begin distinguishing head from tail. Why Sir Roger in preference to others, many of whom are far better known and might be considered better qualified? Because I am familiar with the environments in which he has worked and have come to appreciate his informed, objective and disarmingly critical management of old and new information.
Much of Cycles of Time is devoted to the most critical analysis of the second law of thermodynamics and entropy I have ever read, a simpler account being the "The Laws of Thermodynamics: A Very Short Introduction by Peter Atkins, also of Oxford. Sir Arthur Eddington of Cambridge, who was responsible for making Einstein famous when he observed the bending of starlight during a solar eclipse, famously said of the second law:
"If someone points out to you that your pet theory of the universe is in disagreement with Maxwell's equations--then so much the worse for Maxwell's equations. If it is found to be contradicted by observation-- well these experimentalists do bungle things sometimes. But if your theory is found to be against the second law of thermodynamics I can give you no hope; there is nothing for it but to collapse in deepest humiliation".
1. Strategies for coping with information overload Richard Smith BMJ 2010 341:c7126doi:10.1136/bmj.c7126
Competing interests: None declared
22 December 2010
Helga Perry responds to my article by saying that machines alone are not the answer, but I should perhaps have made clearer that I was talking about machines that push information--that are primed with the latest knowledge and prompt the clinician.
But I should have included the use of libarians as another strategy for dealing with information overload.
This point has been made to me in a very spirited and global discussion of my article that has been proceeding on the Health Information for All 2015 listserve. I would urge BMJ readers to visit its site and think about joining.
Another strategy, a very bad one, that I might have discussed is increasing specialisation. The British Journal of Ophthalmology, which I was once responisble for, had a specialist editor for each layer of the eye, and I always remember a discussion with an orthopaedic surgeon who told me he knew only about the elbow and no other joint. "Knowing more and more about less and less" leads to doctors who know a lot about one part of the body or a disease but little about human beings. Patients mostly don't like their humanity to be ignored.
Yet another strategy, which will seem counterintuitive to many, is to use Twitter. With Twitter you chose whom to follow and you receive Tweets only from them. If you identify people or institutions (like the BMJ or Fiona Godlee, the BMJ editor) who are good at pointing you towards something important or interesting information then it's a fine way of navigating through the jungle of information. Most Tweeets include a URL that takes you to a full blog, article, or report.
Another issue that emerged from the discussion on the HIFA listserve is that just as important as the information problem, and possibly more important, is the curiosity problem. We heard about an expensive project mounted in India to give people access to some 1700 journals that was hardly used at all . There are, as we know to our cost, huge amounts of information about almost everything, but many people simply don't have the curiosity to go and find it.
Competing interests: I'm the author of the article to which I'm responding.
Patients Know best
21 December 2010
In order to get up to date information on medical care, I subscribe to table of contents from journals that give free access to the full text of the article. Beside that I also subscribe for several mailing list that provide update on new publish article or guideline from trusted national or international health organization (such as World Health Organization, Central for Disease Control). For other guidelines usually I subscribe for update from several medical sites.
Using reviews site such as Cochrane, Clinical Evidence or Best Practice, is not affordable for me. Searching in PubMed needs extra time, because I have to try several good key words. Usually the people who have enough time for that, such as researchers, librarians, who use them as medical information sources. I just using PubMed during my master.
Competing interests: None declared
RSUD dr. H. Soemarno Sosroatmodjo
20 December 2010
Dear Doctor Smith,
As a scientist I am involved in knowledge management of public health experts based in low income countries. I am spending one day a week selecting and reading articles of interest for my potential readers and still feel I struggle with time to do the job properly. My readers regularly send me feedback that our selection process is very precious as it saves them lots of time. We do not pretend we are doing evidence based policy review and reckon our work is probably biased. The amount of information produced in our field, like in the narrow example you raise of cardiac imagery is really appealing. Personally, I feel completely unable to cope with the amount of research published on child survival in low income settings, my preferred field of research.
Couldn't we suggest researchers produce less papers and of better quality instead? The actual incentives structure often described as "publish or perish" and the number of PhD scholars, professors and researchers engaged in a research career all over the world makes it obvious that the amount of information produced will remain inaccessible for individuals if nothing is done. I support the idea of having machines doing the synthesis for us but can't we think of a system where less information is produced and of better quality? Or that only filtered information gets to the mass of health professionals?
The system of impact factor and peer review are supposedly doing so but many factors exist that hinders the efficacy of the system. Many people are better placed than I am to discuss this. Nevertheless, my main ideas are that for the former, journals want to survive and researchers wants to be published, for the later peer reviewer and editors are volunteers in most cases. Hence, they do not spend much time putting the papers they assess in perspective even less are they compiling databases.
There are two options I see ahead of the strategies you suggest to cope with the amount of information. Firstly the scientific community could agree on new incentives for research where researchers are not anymore assessed to the amount of papers published but on the contribution of the papers to the improvement in health and wealth of patients. Secondly the information produced could be assessed and summarised first hand by panels in every field ahead of publication. We could think of a new institutional arrangement that would allow the people doing this task to do it properly. Defining a system that would upfront grade the value of a paper could increase the quality of papers submitted if the pressure to publish is reduced or redesigned. Obviously this is an enormous task but an idea one might want to explore. firstname.lastname@example.org http://www.itm.eu/ihp
Competing interests: None declared
Institute of Tropical Medicine, Antwerp, Belgium
20 December 2010
Keeping up to date is a challenge which requires innovative strategies so as to take the element of conscious effort out of it. The strategy that I used to recommend to my juniors, and one that I continue to follow seven years post retirement, is to attend grand rounds in a spirit of intellectual curiosity and inquiry intending, if need be, to ask searching questions on all related problematic issues, even if this is at the risk of ridicule or loss of face. Thereafter, in order to complete the exercise while the grand round is still in recent memory, it should become a routine to undertake a literature search based on the topics raised in the grand round so as to anchor the information so gained more firmly in one's mind. Given the fact that never in the entire history of medicine has so much high quality medical knowledge been so readily accessible, we must never cease to marvel at the fact that we are the recipients of a rich and continuing legacy of scientific wisdom. Indeed, our illustrious medical forbears, arguably even those of the calibre of Sir William Osler, would be incredulous of the fact that it has now become a badge of honour, tantamount to an ASBO, to level indiscriminate mockery and denigration, not only at clinical stigmata of disease(including life- threatening diseases), but also at potentially life-saving evidence-based factual knowledge. I would wager that their response would be to say that, instead of taking refuge in flippancy and mockery(all in the name of irony), we should individualise not only the interperetation of clinical signs and symptoms, but also the interpretation of evidence-based knowledge, and put both in the context of our own experiential knowledge.
Competing interests: None declared
manchestre medical society