Informationists and librarians

Perhaps it's an omen.

While in Vancouver for MLA/CHLA/ABSC 2000, Carolyn Lipscomb and I talked about possible themes for her history column in this issue of the Bulletin of the Medical Library Association. We settled on clinical medical librarianship (CML), a topic that has been the subject of numerous papers over the last thirty years and would, therefore, provide a suitable subject for the column. We had no idea that Frank Davidoff and Valerie Florance were putting the finishing touches to an editorial for the Annals of Internal Medicine that will almost certainly bring discussions of clinical librarianship to a new level of intensity [1]. You need to read it.

Librarians will quibble over the term “informationist.” It has an awkward and contrived sound, but as a rhetorical device, designed to get our attention, it certainly does the trick. Some have been quick to reply that what Davidoff and Florance describe is what librarians already do; we do not need another bit of jargon to make it glitzy. The fact is, the work they are describing is not what librarians already do.

It should be.

The singular addition that Davidoff and Florance make to the development of clinical librarianship is to insist on more specialized clinical training than health sciences librarians typically have, even those who participate in clinical librarian programs. Shortly after the editorial appeared, Patricia Fortin, who works as a clinical librarian in Canada, made this comment on MEDLIB-L;

although I could do summaries of the literature for some of the questions I receive and/or identify, I would not feel entirely comfortable doing this without more of a clinical background, statistical knowledge, and/or very well-honed critical appraisal skills. This is because what I write could greatly impact patient care. [2]

This is the crux of the matter. Clinical librarianship programs have attempted to extend the helping role of the librarian to the patient's bedside, but they have not essentially altered that role. The librarian's sphere remains that of understanding the question, searching the literature, providing targeted information—clinical judgments are left to the physicians. Perhaps this is as it should be.

But Davidoff and Florance think something more is necessary. They are suggesting that the relationship between the information-management expert and the other members of the health care team needs a significant shift. They point out that CML programs “have remained largely outside the mainstream of clinical practice.” They argue that now is the time to move them into the mainstream.

What is required to do this? Davidoff and Florance advance two primary causes for the failure of clinical librarianship to “take root and flourish.” Money is always a problem, of course. Clinical librarianship programs have always been viewed as ancillary, as extras, as things to be done if we can find the funding—not as critical services that should be funded first. Davidoff and Florance also point to the “physician's ambivalence about needing help,” and they argue that “it's time to face up to the fact that physicians can't, and shouldn't, try to do all or even most medical information retrieval themselves.”

Perhaps there is another reason—an ambivalence on the part of librarians to take on the outlined role. I am reminded of the controversy that still accompanies the notion of quality filtering. While many of our colleagues have adopted and adapted quality filtering as an integral part of the work that they do, many others are repelled by the notion, believing that to make the sorts of required judgments takes one beyond the boundaries of good librarianship. I imagine that the notion of taking an even more active filtering role would be that much more appalling to those who take this view. Perhaps they will agree that whatever these informationists are, they should not be called librarians.

But librarians are exactly what they are. Librarians playing a role that very few of us have played so far, to be sure, but fundamentally, librarians doing the core work that librarians have always done: making sure that people have the information they need, where they need it, when they need it, and in the format in which they find it most useful.

Twelve issues ago, in the October 1997 issue of the Bulletin, Nunzia Giuse prefigured Davidoff and Florance, arguing in an editorial that the future of medical librarianship lay in moving into the clinical realm [3]. She identified the lack of adequate preparation for librarians as the most important element limiting the success of CML programs. She identified a number of specific things that should be done. Librarians should “assimilate the culture,” “seek instruction in the techniques of clinical trials,” “study … evidence-based medicine,” and receive “mentored instruction and practice in searching, retrieving, filtering, and summarizing information.” These elements, and the others mentioned in her editorial are, indeed, absolutely critical. But in the end, Giuse's better-prepared (and more successful) clinical librarian is still a library-based librarian. The program is developed in the library; the training is managed through the library; the funding is provided by the library. Davidoff and Florance take the concept a very substantial step further.

In their view, the informationist takes part in a nationally recognized standard curriculum, has appropriate training and accreditation, and will “answer directly to clinical directors and chiefs of staff, and their services [will] be paid for directly, as is done for other health care providers.” This model is clinic driven, not library driven.

Nine months after her editorial appeared, Giuse and her colleagues published an article describing the Vanderbilt CML program [4]. In comparing it with the informationist piece, I am struck by the fact that it lists “caseworkers, nutritionists[, and] pharmacists” as models for the role that clinical librarians can play, while Davidoff and Florance point out that physicians do not “perform their own clinical chemistries, electrocardiography, computed tomography and the like.” The former models are still one step removed from the patient, providing services that support the caregivers. The latter models are hands-on. This difference may just be a coincidence, an accident in the writing of the two pieces, but it does serve to emphasize that the informationist described by Davidoff and Florance is not a librarian with additional training in or exposure to clinical situations. This informationist is a true hybrid—still a librarian, but one steeped in the clinic in a substantially new way.

There is something else that strikes me when I look at the literature. Almost all of the articles that have been written about clinical librarianship over the years stress that good clinical librarian programs are essential for the survival and growth of librarianship. Davidoff and Florance's piece is not concerned with the survival of our profession. It is concerned with the survival of patients.

I do not know if the development of informationists is good or bad for our profession; but as a librarian, I know that doing something that will enable clinicians to make better judgments based on better use of published information is definitely going to be good for patients. And when I get to the heart of it, I seem to recall that is why I became a medical librarian.

What should our association be doing about this? We should be right out in front in responding to Davidoff and Florance's challenge. They call for the development of a “national program, modeled on the experience of clinical librarianship, to train, credential, and pay for the services of information specialists.” Clearly, we need to play a central role in this development. Obvious partners include the Association of American Medical Colleges, the American Hospital Association, the library schools, and the National Library of Medicine. The Medical Library Association has an opportunity to take the lead in reaching out to potential partners to begin the discussions and the planning that are necessary to see what sort of beneficial reality can be made out of the informationist concept.

Three years have passed since Giuse sounded the call in these pages that to avoid moving into the clinical realm “is to deny our future in the information age.” Davidoff and Florance have now issued a challenge to “everyone involved in health care.” We should not let one more year go by before we respond to that challenge.