The clinical encounter is an increasingly significant
component of the first years of the undergraduate
medical curriculum. A student's clinical experience has
traditionally begun in the third year of the curriculum.
Recently, however, a number of medical schools have
initiated programs that provide students with clinical
experience in each of their four years. Among the initiatives
aimed at increasing the number of graduates
intending to pursue primary care careers, for example,
has been the placement of students in primary care
practices at regular intervals beginning in the first year
of the curriculum. While the clinical encounter is understood
to be a significant educational experience, little
is known about the information needs and information
seeking behaviors of students in response to
clinical problems

Cogdill, K W

Moore, M E

PubMed

Cogdill, Keith W.

Moore, Margaret E.

Carolina Digital Repository

Brief communicationsformation resources are static. Just as health educatorsexperiment with curricula, librarians must continue toseek ways to bring the most advanced-and some-times the most familiar-information resources andtechnologies to faculty and students practicing andlearning in these communities.CONCLUSIONEstablishing a multidisciplinary program is an intri-cate task. Challenges range from the smallest con-cerns, such as differences in the academic calendars ofvarious programs, to the largest, such as how to teachthe same material to both allied health students justout of high school and medical students with doctor-ates in engineering. Adding to this complex mix arethe challenges particular to distance education. Withcooperation and flexibility, two distinct library systemscame together to meet the information needs of ETSU'sunique Kellogg program. This support has helped theuniversity, health care students, and two rural com-munities reap the benefits of a bold experiment.REFERENCES1. RICHARDS RW, HENRY RC. Community partnerships: ed-ucational linkages to increase the number of primary carepractitioners. Acad Med 1993 Aug;68(8):594-6.2. ZUNGOLO E. Interdisciplinary education in primary care:the challenge. Nurs Health Care 1994 Jun;15(6):288-92.3. IBID.Received June 1996; accepted August 1996First-year medical students' informationneeds and resource selection:responses to a clinical scenarioBy Keith W Cogdill, M.L.S.School of Information and Library ScienceMargaret E. Moore, A.M.L.S., M.PH.Health Sciences LibraryThe University of North Carolina at Chapel HillChapel Hill, North Carolina 27599-7585INTRODUCTIONThe clinical encounter is an increasingly significantcomponent of the first years of the undergraduatemedical curriculum. A student's clinical experience hastraditionally begun in the third year of the curriculum.Recently, however, a number of medical schools haveinitiated programs that provide students with clinicalexperience in each of their four years. Among the in-itiatives aimed at increasing the number of graduatesintending to pursue primary care careers, for example,has been the placement of students in primary carepractices at regular intervals beginning in the first yearof the curriculum. While the clinical encounter is un-derstood to be a significant educational experience, lit-tle is known about the information needs and infor-mation seeking behaviors of students in response toclinical problems.Recent studies have investigated the nature of phy-sicians' information needs and how these needs aremanaged. Covell, Uman, and Manning [1] developeda methodology that placed the researchers in ambu-latory care practices for half-day site visits duringwhich physicians indicated any information need rel-ative to each patient encounter. Results of this studysuggest that clinicians articulate an average of two in-formation needs for every three patients seen, but thatonly 30% of questions are resolved at the time of thepatient visit.Gorman and Helfand [2] extended the findings ofCovell, Uman, and Manning by investigating physi-cians' motivations for the pursuit of each informationneed. Two to five days after the formulation of ques-tions, follow-up interviews found that approximately30% of questions had been pursued, corroborating thefindings of Covell, Uman, and Manning. When con-sideration was given to the motivating factors behindeach question, however, Gorman and Helfand foundmuch higher rates of information seeking among cer-tain categories of questions. Physicians pursued 56%of questions they perceived as most likely to have adefinitive answer and 50% of questions they rated asmost urgent for the care of a patient. It is interestingBull Med Libr Assoc 85(1) January 1997 51Brief communicationsthat two factors, the potential benefit to one's generalmedical knowledge and the possibility of applying ananswer to the care of other patients, were significantnegative predictors of information seeking.Wildemuth et al. [3] have studied the informationneeds of first-year medical students by investigatingquestions posed to a hypothetical librarian and phy-sician. Students were presented with clinical scenariosdescribing a patient affected by a toxin. After answer-ing a set of questions about the case, students wereasked to articulate questions to a hypothetical librarianand internist specializing in toxicology. The students'questions were categorized by their form (e.g., identi-fication, explanation, description). Results of this studysuggest that students were more likely to ask the hy-pothetical librarian for help in identifying the toxinand finding references in the medical literature. Thequestions posed to the hypothetical toxicologist weremore likely to involve an explanation of symptomsand descriptions of treatment.Investigations of information needs, such as thosejust described, commonly use an explicit question as asurrogate for the information need. The distinction be-tween information needs and articulated questionsemerges from the early work of Taylor [4], who pro-posed that information needs can be understood ashaving a variety of possible states ranging from avague awareness of need to the articulation of a spe-cific question. As in past studies, the present studyaims at analyzing the information needs experiencedby medical students and recorded as articulated ques-tions. The present study differs from most of the paststudies by focusing on the information needs of stu-dents, rather than those of clinicians.This study seeks to provide a better understandingof students' information needs and their perceptionsof information resources. It analyzes the content ofquestions articulated by medical students in responseto a clinical scenario. In addition, it investigates thetypes of information resources students identified asdesirable for each question.METHODSThis study called for first-year medical students to re-view a clinical scenario [5] and record the informationthey would need to manage the patient's problem. Inaddition, students were asked to identify the resourcesthey would use to pursue each information need. Thedata collection was conducted in the context of a train-ing session on information resources in medicine.Analysis of the data was conducted by using two cod-ing schemes that emerged from the data sets, one forquestions and one for resources identified. Chi-squaretests were conducted to investigate associations amongtypes of questions and information resources.Data collectionParticipants in this study were first-year medical stu-dents at the University of North Carolina at ChapelHill. Recent changes in the curriculum have providedthese students with clinical experience at community-based primary care practice sites during the first yearof the curriculum. Offering first-year medical studentsexperience in a clinical setting has created interest inhow, as novices, first-year students manage the infor-mation needs they experience in response to a clinicalproblem. Therefore all students entering in the fall of1995 attended a set of small-group discussions onmanaging information in medicine and received train-ing by health sciences librarians on a variety of com-puter-based information resources. During the train-ing sessions students were invited to participate in thestudy. In the context of the training session on infor-mation resources, students were presented with a clin-ical scenario developed by a member of the microbi-ology faculty. The case presentation followed a small-group discussion of managing information in medi-cine. Small-group discussion leaders followed a singleagenda developed in advance of the training sessions.After these small-group discussions and at the end ofthe case presentation, students were asked to recordthe information they would need to manage the pa-tient. Students were also asked to identify the infor-mation resources they would use for each of their in-formation needs.Data analysisTwo sets of categories were developed to classify (1)the content of the information needs recorded as ques-tions and (2) the resources identified. Both categorysets emerged from a review of the data. The catego-rization of students' questions was based on the con-tent of each question, such as general disease infor-mation, diagnosis, therapy, general management, pa-tient-specific information, procedures, or psychosocialissues. The categorization of information resources wasbased on the type of resource, such as diagnostic tests,general medical literature, medical textbooks, refer-ence material, a bibliographic retrieval resource, jour-nal articles, human experts, the patient's chart or in-terview, and educational software. Both codingschemes were developed after the data had been col-lected. Inter-rater reliability for the categories was as-sessed by having two judges independently categorizefifty-nine randomly selected questions, with a result-ing kappa coefficient of +0.85. Because the codingscheme for the content of the questions was found tobe highly reliable, the first author coded the remainderof the questions. Little ambiguity was found amongthe types of resources identified, and high reliabilityof the resource classification scheme was assumed. Sta-tistical analysis software (SAS Institute, Cary, NorthBull Med Libr Assoc 85(1) January 199752Brief communicationsFigure 1Types of questionOther 1 2%40% DiagnosisGeneralTable 1Resources identifiedInformation Frequency ofresource identification*tTextbooks 45.4%MEDLINE 16.7%Reference source 12.5%Software 12.1%Human 9.2%Journal articles 7.9%Other 7.1%* Percent of questions associated with each resource.t The combined frequency of identification exceeds 100%, as more than oneinformation resource was identified for 27% of questions.2 9% TreatmentCarolina) was used to identify the frequencies for eachof the types of questions and resources, and the Chi-square statistic was used to test for significant associ-ations among the data.RESULTSData were collected from 88 of the 166 first-year med-ical students. The students recorded a total of 240questions. The majority of questions generated in re-sponse to the case presentation pertained to diagnosis,treatment, and general information about a disease(Figure 1). Forty percent of questions pertained to di-agnosing the patient's problem, and 29% to treatmentissues, such as optimal drug therapy. Requests forgeneral information about a disease accounted for 19%of questions, while the remaining 12% dealt with pro-cedures used in the case, patient-specific informationretrievable from the patient's chart or interview, gen-eral management issues, and psychosocial issues stem-ming from the case.Students did not identify an information resourcefor 52 of the 240 questions. For the remaining 188 ques-tions, students identified 266 information resources.For 124 questions students identified a single infor-mation resource. Two resources were associated withfifty-one of the questions, and three or four resourceswere identified for thirteen of the questions.Resources identified by students included diagnostictests; general medical literature; medical textbooks;reference resources, such as a drug information re-source; bibliographic retrieval resources (MEDLINE);journal literature; human experts; software, such as amicrobiology database; and the patient's chart or in-terview with the patient (Table 1). The most frequentlyidentified information resources included medical text-books (for 45% of questions), and MEDLINE (for 17%of questions).Chi-square tests revealed significant associations be-tween the most frequently identified resources, MED-LINE and textbooks, and the types of questions asked.Of particular interest was the observed frequency ofMEDLINE identifications being significantly greaterthan expected for questions pertaining to treatment.Among questions for which students identified MED-LINE as a resource, 43% pertained to treatment. Incontrast, among those questions for which medicaltextbooks were identified as a resource, 23% pertainedto treatment (Figure 2). While the overall frequency oftextbook identifications was more than twice the fre-quency of identifications of MEDLINE, questions per-taining to treatment accounted for more MEDLINEidentifications than any other question category.DISCUSSIONThe results of this study provide a better understand-ing of first-year medical students' information needsand their perceptions of appropriate resources. Likethose of experienced clinicians, students' informationneeds most often pertain to diagnosing a problem orchoosing a treatment. Unlike experienced clinicians,however, first-year medical students can be expectedto request general disease information frequently inFigure 2Figtources identified and question types50%40%30%| Textbooks| MEDLINE20%Diagnosis General Treatment OtherDiseaseBull Med Libr Assoc 85(1) January 1997 53Brief communicationssupport of their management of a problem (19% ofquestions). While colleagues are an important resourcefor experienced clinicians, students in this study sel-dom reported a preference for human sources of in-formation (for fewer than 10% of questions). This lowpreference for human sources of information shouldbe interpreted with caution, however, since it mayhave been a result of the data collection methods, asstudents reported their preferences for information re-sources in the context of having participated in small-group discussions about information management inmedicine led by librarians.Textbooks were the information resource most fre-quently suggested by students. Among questions per-taining to treatment, however, MEDLINE was identi-fied substantially more frequently than medical text-books as an appropriate information resource. Thisfinding suggests that students perceive questionsabout treatment as needing a frequently updated in-formation resource, such as MEDLINE. It is importantto note that the classification of information needsused in this analysis was developed after the data hadbeen collected. Students had not been introduced to aclassification of their information needs prior to thedata collection.CONCLUSIONThis study's findings underscore the importance oftextbooks within the collections of academic health sci-ences libraries. It is now common for libraries to pro-vide remote access to the journal literature throughMEDLINE and other indexes as well as full-text da-tabases. Results of this study suggest that librariansserving the information needs of medical students can-not overlook the importance of textbooks, increasinglyavailable in both print and electronic formats.Implications of this study also extend to referenceservice and educational programs for medical stu-dents. In both reference service and educational pro-grams, an important role of the library is to provide abridge between information needs and appropriate in-formation resources either at the time of need or inanticipation of future needs. This study's findings de-scribe the information needs students are likely tohave in response to a clinical encounter as well as theirperceptions of which resources are appropriate forspecific types of needs. A thorough understanding ofthese factors is increasingly important, as many med-ical schools develop curricula that rely on problem-centered learning.Finally, it may be concluded that at an early stagein their medical training, students perceive specific in-formation resources as appropriate for particular typesof information needs. While textbooks are the mostcommonly preferred general resource, MEDLINEemerges as the preferred resource for questions per-taining to treatment.Future studies that include multiple clinical scenar-ios are needed. Wildemuth et al. [6] have observed thatwhen subjects are presented with multiple clinical sce-narios the types of questions stemming from each sce-nario vary substantially. While the types of questionsexpressed for different clinical scenarios can be ex-pected to be at least partially dependent on the contentof the scenario, consistent associations of types of re-sources with types of questions may again emerge.ACKNOWLEDGMENTSThe authors are very grateful for the assistance of Bar-bara M. Wildemuth in all stages of this study. Theauthors also gratefully acknowledge the assistance ofBrynn Mays, Phyllis Ruscella, Julia Shaw-Kokot andother Reference and Education Programs librarians atthe University of North Carolina's Health Sciences Li-brary. Suggestions from the anonymous reviewers onthis journal's editorial board were of great benefit tothis paper.REFERENCES1. COVELL DG, UMAN GC, MANNING PR. Information needsin office practice: are they being met? Ann Int Med Oct1985;103(4):596-9.2. GORMAN PN, HELFAND M. Information seeking in primarycare: how physicians choose which clinical questions to pur-sue and which to leave unanswered. Med Decis Making Apr-Jun 1995;15(2):113-19.3. WILDEMUTH BM, DEBLIEK R, FRIEDMAN CP, MIYA TS. In-formation-seeking behaviors of medical students: classifica-tion of questions asked of librarians and physicians. BullMed Libr Assoc Jul 1994;82(3):295-304.4. TAYLOR RS. Question-negotiation and information seekingin libraries. Coll Res Libr 1968;29:178-94.5. GILLIGAN PH. American Joumal of Clinical Pathology. Inpress.6. WILDEMUTH, op. cit., 300.Received June 1996; accepted August 1996Bull Med Libr Assoc 85(1) January 199754

First-year medical students' information needs and resource selection: responses to a clinical scenario.

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First-year medical students' information needs and resource selection: responses to a clinical scenario.

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