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    Friday, October 20, 2006
    MHSLA06: Closing Keynote Speaker
    The closing keynote speaker is Mary Joan (M.J.) Tooey, immediate past president of MLA. Her topic is Investment strategies for medical librarians. M.J. is a very fun, dynamic speaker.

    Invest in:

    Politics
    -Find out who the opinion leaders, influencers and heat seekers are.
    -Learn to speak their language.
    -Now your advocates and your enemies.
    -Be a good listener.

    Service
    -Get out. Be visible. Don't be afraid to promote yourself ande your services.
    -Find out what keeps your users awake at night. What is the problem they are
    trying to solve? How can you help?
    -Make yourself and your expertise invaluable NOW. Advocate.
    -Find areas for future opportunities. Try new things. Be aware of trends from
    other industries that may have an impact on your work.
    -Find partners and collaborators.
    -Don't rely on entitlements for survival.

    New MLA resource - Vital Pathways page.

    Research
    -So, what does keep your users awake at night?
    *Research dollars?
    *Length of stay?
    *Outcomes?
    *Patient safety?
    *Time savings?
    -Do you have an effect on any of these?
    -Become familiar with the language of research.
    -Research does not have to be complicated and long - sometimes it just involves a
    simple question.
    -Acquaint yourself with the literature of research.
    -Take classes.
    -Ask colleagues what questions they want answered.
    -Don't be afraid.

    Evaluation tool - NNLM

    Education
    -Be curious
    -Learn new things
    -Partake in continuing education
    -Read outside the profession
    -Broaden your horizons
    -Be a lifelong learner

    Now
    -Network
    -Join and get professionally involved - locally, statewide, regionally,
    nationally.
    -Reach out, teach, think of the community and community organizations - "think
    globally, act locally".
    -Apply for grants, contracts, awards, scholarships.

    Future
    -Go to K-12 career daya.
    -Go to career fairs or exhibits.
    -Teach library school classes.
    -Mentor a new professional.

    Why she thinks the future is bright...

    -By making investments - knowledge, viability, validity, new perspectives,
    support.
    -New roles, opportunities emerging - but don't expect them to be "given" to us.
    -Increased energy, enthusiasm, ideas.

    Last thought... invest in yourself

    -Work to live, don't live to work. Get your priorities right
    -Your health (mental aned physical)
    -Be kind to yourself and others - "Civility costs nothing and buys everything."
    (Lady Mary Wortley Montagu, 1689-1782)

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    Posted by Alexia Estabrook @ 9:17 AM   0 comments
    Thursday, October 19, 2006
    MHSLA06: MSHLA's Strategic Plan
    Jennifer Barlow reviewed MHSLA's new strategic plan.

    Three themes:

    1. Communication / Marketing / Outreach & Advocacy.
    -Help members to articulate the value of their libraries
    -Actively recruit new members
    -Communicate effectively with existing members

    2. Adapt to the changing information landscape.
    -Employ technology to operate efficiently
    -Educate members about new technologies
    -Educate members about basic tools of the trade

    3. Build Coalitions to promote health literacy.
    -Educate members about low health literacy
    -Help members educate clinicians
    -Encourage members to promote literacy work
    -Help ensure access to appropriate patient education materials

    Outcomes to avoid:
    *Letting traditional strengths slip
    *Trying to be all things to all members
    *Trying once and giving up

    Discussion -

    Has there been a question or point of interst for the research paper? What would we measure? LOS? Adverse effects?

    Suggestion - focus groups with hospital administrators to get a handle on what matters to them.

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    Posted by Alexia Estabrook @ 4:20 PM   0 comments
    MHSLA06: Keynote Address
    Dr. David Slawson is the keynote speaker, and is taking on "Flawed Transmission of tghe Best Evidence: What Should Clinicians Know About the Treatment of Diabetes. Dr. Slawson is the B. Lewis Barnet, Jr. Professor of Family Medicine at the Univeristy of Virginia, Charlottesville.

    Dr. Slawson will talk about how the information flow is not as good as it should be. Clinicians are part of the "Information Business" even though most do not think they are. Good information + learning = better patient care. Who is responsible? In part, we all are (all being vendors, librarians and clinicians).

    Typical flow of information in medicine:

    Medical research is published --> Results summarized by experts --> review articles OR CME --> Clinicians --> Patient Care

    Dr. Slawson co-authored an article on which the keynote is based:


    What happened to the valid POEMs? A survey of review articles on the treatment of type 2 diabetes. [Review] [19 refs] [Journal Article. Review] BMJ. 327(7409):266, 2003 Aug 2.


    Purpose of article was to find out what went wrong and give ideas on how to fix it.

    Gimenez-Perez G, et al. Diabetic Medicine 2005;22:688-92 - Random sample of 66 sites. Web basically useless but your best bet is non-comerical sites.

    "Still a man sees what he wants to see and disregards the rest." - Paul Simon.

    Who should write reviews?

    Oxman AD, Guyatt GH. The science of reviewing research. Ann NY Acad Sci 1993;703:125-33

    Study of 36 review articles using 10 criteria for determining rigor. The overall rating of rigor: expert correlation was 0.23, non-expert correlation = 0.78. The greater the expertise of the writer = stronger prior opinion --> less time spent on review --> lower quality. Their conclusion: the epxerts should do the research, the non-experts should write reviews due to less bias.

    There is quality and then there is the perception of quality. The perception of quality (i.e., marketing) always wins in the end.

    Is our information system working, or is it flawed and broken? Need to grade for bogth validity and relevance. He spoke about SORT (see notes from CE class).

    Information Mastery Method

    Medical Research publishes -> Results evaluated by Information Masters --> Publish in EBM sources (Cochrane, valid POEMs, InfoRetriever, etc.) --> clinicians --> highest quality patient care.

    Cannot have a solution until there is a recognition of the problem. There is no recognition of a problem here in the United States.

    Wisdom is the individual application of knowledge.

    Dr. Slawson has done a great job explaining what the problem is. Our job now is to figure out how medical librarians can be part of the solution. We could drop our traditional passive role vs. active, assertive role. Change agents of American medicine are NOT going to be doctors. It probably won't be the political arena. It's up to us to determine where we will fit in.

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    Posted by Alexia Estabrook @ 8:58 AM   0 comments
    Wednesday, October 18, 2006
    The Librarian and Work - Navigating the Maze
    PubMed Clinical Queries - forces you to step through PICO.

    P(opulation or Problem)
    I(ntervention)
    C(omparison)
    O(utcome)

    EBM Heirarchy

    1. Systematic Reviews (Cochrane, DARE)
    2. Critically Appraised Topics (Clinical Evidence, DynaMed, FPIN Clinical Inquiries)
    3. Specialty spefic POEMS (Daily InfoPOEMS)
    4. Critically appraised individual articles (ACP Journal Club)
    5. Textbooks (UpToDate, Harrison's Online (expert opinion))
    6. Journals articles (Original research found with MEDLINE & other databases)

    Librarians will play a significan role in evaluating the ever increasing EBM resources and guiding clinicians through the pyramid

    You can have information free or uncensored but you can never have both.

    Physicians aren't going to look something up if they don't think it's going to be there.

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    Posted by Alexia Estabrook @ 2:26 PM   2 comments
    Using Expert-Based Information Delivery Systems
    Information mastery measures BOTH the validity AND relevance. There is NO tool that incorporates both.

    Using an expert / being an expert

    Expert is anything or anyone you go to for an answer to a question.

    Person as an expert

    Type 1: Content expert
    Type 2: Clinical scientist
    Don't have to be content experts
    Good at evaluating evidence
    separation of therapeutics
    YODA: Your Own Data Analyzer
    Relies on POEMs first, even if this information conflicts with DOEs or clinical experience
    When POEMs not available, YODAs use the best DOE
    Demonstrate appropriate validity assessments

    YUCK - Your Unsubstantiated Clinical Know-it-all.

    POEM isn't a POEM if it's not Patient oriented. A valid DOE is NOT a POEM.

    EBM - absence of proof is not proof of absence

    Are CME's beneficial. Traditional lecure format (passive) - no. Hands on (active) learning - Maybe.

    Validity - depends on speaker
    Relevancy - depends on POEM:DOE ration

    Type 3: Review articles

    McMasters - worksheet to evaluate review articles

    The expertise of the author vaires inversely with the quality of the review - Oxman / Guyatt

    Cochrane - Excellent source for hunting and foraging. Top of the EBM pyramid.

    Our (medical librarians') job - how to tell quality from the PERCEPTION of quality.

    Be careful of the term Evidence-based Guidelines. What is important is how the evidence is USED.

    Better - Evidence-Linked Guidelines
    -Brief summary statement
    -Detailed discussion of the evidence
    -long reference section point to original research
    -Methods section showing how evidence was obtained and evaluated.

    SORT (Strength of Recommendation Taxonomy) classification - only system that takes Validity AND Relevance into consideration.

    Rating:
    A = Consistent and good quality POE
    - Standard LOEs for validity, POE for revelance
    B = Inconsistent or limited-quality POE
    C = Consensus, usual care, opinion, DOE, case series

    No hunting tool uses SORT.

    PDR - compendium of drug advertising without peer review. hmmm, I'm looking at PDR differently now.

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    Posted by Alexia Estabrook @ 1:08 PM   0 comments
    Random thoughts on information mastery...
    I'd like to send a big Thank You out to Sheila B., who coordinated the food for the conference. The salmon was to die for appartently (I didn't have it, being the good Russian I am I opted for the stroganoff) and the cheesecake was amazing. Great job Sheila.

    Random thoughts on the class while I'm waiting for it to start up again...

    I think I'm finally becoming comfortable with the what evidence based medicine really is.

    It's scary how much research out there isn't really valid.

    It's even scarier how much that is out there is influenced by "special interests".

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    Posted by Alexia Estabrook @ 1:02 PM   0 comments
    Random thoughts on information mastery...
    I'd like to send a big Thank You out to Sheila B., who coordinated the food for the conference. The salmon was to die for appartently (I didn't have it, being the good Russian I am I opted for the stroganoff) and the cheesecake was amazing. Great job Sheila.

    Random thoughts on the class while I'm waiting for it to start up again...

    I think I'm finally becoming comfortable with the what evidence based medicine really is.

    It's scary how much research out there isn't really valid.

    It's even scarier how much that is out there is influenced by "special interests".

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    Posted by Alexia Estabrook @ 1:02 PM   0 comments
    The hard part of information mastery
    Evaluating information:

    particpant allocation - one of 7 types of blinding, one of two absolute types of blinding.

    Why is allocation concealment important?

    Could change the outcome of the results.

    Mamography screening
    Lancet Jan 8, 2000; Oct 20, 2001

    "Mundus Vult Decipi"
    "The world wished to be deceived"
    People would rather be deceived than have the truth cause anxiety

    Caleb Carr, "Killing Time"

    Second absolute type of blinding - judicial assessor blind.

    Also look for intention to treat

    Levels of Evidence:

    SR with homogeneity = 1a
    RCT: LOE = 1b
    Cohort: LOE = 2b
    Case Control: LOE = 3b
    Case Series: LOE = 4
    Expert Opinion: LOE = 5

    Statistics you need to understand to evaluate research:

    Probability Level (P-Value) - likelihood that the deifference observed between two interventions could have arisen by chance.

    Number Needed to Treat - 1) the number of patients that need to be treated for one additional patient to receive benefit, 2) the number of paitents that need to be treated to prevent one additional outcome, 3) takes into account the relative risk as well as the absulte risk of not treatment.

    NNT = 100 / % in treatment group - % in control group

    Relative risk - risk of harm (or benefit) of one treatment as compared with another. Does not take into account the risk of NO treatment (absolute risk).

    relative risk tells part, but not all of the story; NNT does better

    confidence interval - upper and lower possibilities of our statistical estimates. If CI crosses 1.0, the difference is not significant.

    Statistical signiificance is a requirement for determining clinical significance, but is not enough to signify a clinical difference.

    Confidence Intervals helop us to understand how close our answer is to the truth.

    What to look for in validity:
    randomization
    allocation concealment
    blinded judicial assessors
    intention to treat
    follow-up > 80%
    Narrow confidence intervals

    Time for lunch...

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    Posted by Alexia Estabrook @ 10:54 AM   0 comments
    Information Mastery continued...
    Relevancy - how do we determine what is relevant?

    1. Patient-Oriented Evidence
    - mortality, morbitiy, quality of life
    - live longer and/or better

    2. DOE: Disease-Oriented Evidence
    - Pathophysiology, pharmacology, etiology

    3. Patient-Oriented Evidence that Matters (POEM)
    - It matters to you and the clinician, because if valid, it will require a change in practice.

    Validity always comes down to probability. How many studies does it take? There is no absolute truth in the world of information. What is the level of probability that will cause people to change their behavior.

    Traffic light anology - most of the information in medicine today is in the yellow light (benefit / harm uncertain). Doctor's need to keep an open mind.

    "I know a lot, therefor I am"
    - Replaceable by a computer.

    "I think, therefore I am"
    - Never replaceable by computer.
    - People are going to start not trusting a doctor who won't use computer.

    Hand held computer = stethoscop of the future.

    Levels of information mastery -

    Level 0 - making decisions by guessing or being influenced by drug reps.
    Level 1 - hunting and foraging tools.
    Level 2 - people who create foraging tools for level 1.
    Level 3 - people who do the original research or do systematic review.

    We really only need to get most people to Level 1.

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    Posted by Alexia Estabrook @ 9:32 AM   0 comments
    MHSLA06: Librarian's Role in Information Mastery
    This should be a very interesting class. Instructors are David Slawson, MD and Mike Simmons. I am eager to hear how a physician will teach a class of librarians. It will be an intersting dichotomy.

    A link to the course outline with speaker notes can be found at http://www.healthsystem.virginia.edu/internet/familymed/information_mastery/information_mastery_course.cfm

    Mike started out with introductory information. He makes an interesting point that when he did a search in PubMed on EBM he got far fewer hits than when he searched "Evidence Based Medicine". Apparently, PubMed does NOT map EBM to evidence based medicine. We need to keep in mind the terminology that the physicians use.

    "Incorporating the best evidence into the real world of the busy practitioner requires the applied science of information management."

    What is our role in this? Apparently not as much as we'd like to think. The number one influence of physicians in the United States is drug reps. Whether or not they push a drug or stop pushing a drug has more influence than the medical literature. On average, it can take up to 13 years for a change to occur in medical practice strictly on the literature alone. People don't change unless they have a reason to change.

    Limitations to the practice of high-quality medicine at the bedside:

    1. Shortage of coherent, consistent scientific evidence.
    2. Difficulties in finding what evidence does exist due to searching and access limitations.
    3. Difficulties in applying evidence to the care of individual patients.

    There will never be information to answer all of the questions all of the time.

    EBM has taken medical practice from inductive to deductive. Doctors don't have time to read the literature - we need to come up with secondary sources.

    Usefulness of any source = relevance x validity / work.

    Doctors won't look for something if it takes them more than a minute to find. They won't look if they don't know it's going to be there.

    Break time...

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    Posted by Alexia Estabrook @ 9:16 AM   0 comments