Information Overload, the Index Medicus, and PubMed

Image by Nuevo Anden via Flickr

The growth of medical knowledge is difficult to visualize. One classic representation is the Index Medicus — a comprehensive index of medical journal articles — whose bound copies filled the shelves of medical libraries for 125 years. In 2004, however, the National Library of Medicine decided to stop publishing the Index. The first reason was practical: the Index Medicus had grown from 82 pounds in 1985 to an estimated 152 pounds in 2004. The second and more important reason was the widespread availability of the search engine PubMed — an electronic database of medical literature available for free via the Internet — which made the printed index obsolete. Compared to the Index Medicus, PubMed was more convenient, could be searched more easily, could be updated more quickly, and certainly weighed less. Copies of the Index Medicus are now a historical curiosity; many physicians now search the medical literature exclusively through PubMed.

The story of the Index Medicus and its successor, PubMed, illustrates three ideas.

First, the quantity of new medical information is more than any single physician can absorb, and keeping up to date with this expanding body of knowledge is challenging. As of April 2009, for example, PubMed contained information on 18,782,970 citations in the medical literature and was adding over 670,000 new entries per year. Doctors must not only absorb this flood of new ideas about treating, diagnosing, preventing, and understanding disease — deciding which information is relevant and which is not — but also learn how to apply and explain this knowledge to the patient sitting with them in the exam room or laying ill in a hospital bed.

Second, in parallel with this unprecedented expansion in medical knowledge, new media and technologies have emerged — of which PubMed is one example — which has made the task of searching, organizing, and retrieving relevant information easier. Potential sources of information for physicians include not only printed journal articles like those indexed in PubMed, but lectures, case conferences, and newer Internet resources such as reference tools (e.g., UpToDate), discussion groups, online expert systems, clinical resource tools, and podcasts.

Third, the expansion of medical information and proliferation of new technologies has required physicians to develop new skills and strategies to keep their knowledge current. Often, the availability of new knowledge overwhelms physicians’ ability to process it, a condition known as information overload. In physician’s offices, one symptom of information overload is the common spectacle of unread piles of medical journals stacked up on every available horizontal space.

While many medical schools now require classes on searching the medical literature and evidence-based medicine, few resources have been available designed to teach physicians how to learn and practice medicine more efficiently. That's why, over two years ago, I started writing The Efficient MD blog.

Since then, I'm glad to report that online resources for physicians have proliferated. Ways of improving efficiency and reducing information overload are now common topics on medical blogs. For example, see recents posts in Life in the Fast Lane, Clinical Cases and Images, and Musings of a Distractible Mind. (For more great ideas, see the list in the sidebar.)

Thanks for reading!

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(Much appreciation to Jacque-Lynne Schulman, Stephen Greenberg, Margaret Vugrin, and Dean Giustini for helping me with an updated estimate of the weight of the Index Medicus. Any inaccuracies in this post are, of course, my own.)

The New Hello Health Video

Via Hello Health, Jay Parkinson's brainchild.

When Doctors Make Mistakes by Pauline Chen

Dr. Pauline Chen writes in the New York Times:

"I called Dr. Colin P. West recently, a practicing general internist and the associate director of the internal medicine residency training program at the Mayo Clinic in Rochester, Minn. About three years ago, Dr. West and his colleagues published an article in The Journal of the American Medical Association on the effect of errors on physicians-in-training and on the outcomes of their future patients. The researchers found that self-perceived errors not only increased the risk of burnout and depression but also adversely affected subsequent patient care. Over time, young doctors who believed they had made errors in the past felt less and less empathy toward their patients, which then led to an even greater risk of subsequent errors."

Medical Bloggers go to Washington

Via Dr. Wes:

Dr. Wes will stop blogging briefly to participate in a press conference next week entitled "Putting Patients First", to be held at the National Press Club in Washington on 17 July 2009 from 9AM-12 noon EST.

Dr. Val Jones (of the blog "Better Health") has graciously invited me to participate along with other nurse, nurse practitioner and physician bloggers to discuss issues of health care reform that directly affect doctor/patient relationship from an "Outside the Beltway" perspective. The keynote speaker for the event will be Congressman Paul Ryan, (R-Wisconsin), ranking member, House Budget Committee and the moderator will be Rea Blakey, Emmy award-winning health reporter and news anchor, previously with ABC, CNN, and now with Discovery Health.

Participants will include:

Primary Care Panelists:
Kevin Pho, M.D., Internist and author of the popular KevinMD.com blog

Rob Lamberts, M.D., Med/Peds specialist and author of Musings of a Distractible Mind

Alan Dappen, M.D., Family Physician and Better Health contributor

Valerie Tinley, N.P., Nurse Practitioner and Better Health contributor

Specialty Care Panelists:

Kim McAllister, R.N., Emergency Medicine nurse and author of Emergiblog

Westby Fisher, M.D., Cardiac Electrophysiologist and author of Dr. Wes

Rich Fogoros, M.D., Cardiologist (and yes, another Cardiac Electrophysiologist) and author of The Covert Rationing Blog And Fixing American Healthcare

Jim Herndon, M.D., past president of the American Academy of Orthopaedic Surgeons and Better Health contributor

Screenshot of Medical Apps for the iPhone

Case Study of a Physician's Use of the iPhone 3GS (Part 1)

I recently upgraded my original iPhone, which I purchased two years ago, to the iPhone 3GS. Truthfully, I wasn't expecting much of a change. Sure, I read the marketing hype — faster processor! 3G speed! GPS! voice control! better camera! — but I didn't expect the new model to make much of a difference in my daily clinical practice as a nephrologist.

Boy, was I wrong. I've been using the 3GS so much that by the end of the day, I've not only burned through the iPhone's battery, but I often burn through the external battery in my Mophie Juice Pack Air case as well. (I highly recommend the Mophie, by the way, which removes a subtle disincentive to using the device because you're worried you may run out of battery life.)

The following is a multi-part description of my own use of the iPhone 3GS. In my experience, the best way to learn to use a new gadget is to look over the shoulders of others, watch how they use it, ask lots of questions, and experiment constantly. (Most iPhone owners are familiar with the phenomenon of having someone grab their phone, scroll through the applications they have installed and ask, "What's that one do?")

So if you have an iPhone, and are a health care professional or patient, this will hopefully be helpful. Even if you don't have an iPhone, some of the applications I describe are available for other PDAs — or they soon will be, since the iPhone has significantly raised the bar for what a mobile device can accomplish.

(Original drafts of these posts were written on the iPhone app BlogPress.)

Advice for New Interns

Edwin Leap provides advice for new interns:

1) It’s going to be hard. Deal with it. The less you whine, the more you will be loved and trusted. Learn to be strong, learn to power through your fatigue. And remember that it often takes more energy to avoid work than to just do it.

2) Do the right thing. Ethically, professionally, morally. Be the one everyone can count on to do the right thing; however hard it may be.

3) Humans, to paraphrase Blaise Pascal, are glorious and wretched. Capable of nearly angelic goodness and demonic evil, they will both thrill and disappoint you. Be neither too judgmental nor too naive. And remember that you, dear ones, are human as well.

Via Dr. Wes.

Steve Jobs and Hospital Employees

The Secret Diary of Steve Jobs:

Steve, while hospitalized in Tennessee, fired several hospital employees who could not satisfactorily answer the question, "What do you do here?"

The iPhone as Mobile Computer

John Gruber from Daring Fireball recently wrote on the iPhone as mobile computer. Gruber, one of my favorite technology commentators, convinced me that blogging from the iPhone can actually work well. (This post, for example, was written entirely on the 3GS.)

Gina Trapani asked her Twitter followers if they were planning to buy a 3GS, and she compiled the 175 answers into a single post for her weblog. I love the first one, from Meg Hourihan:

Yes, iPhone = my computer, and $399 is worth it. Haven’t bought new laptop since late 06 and don’t plan to for long time.

The Reading List

Alert readers will notice a new addition to The Efficient MD blog's sidebar — a continually updated "reading list" of posts from other websites I enjoy, most of which have information on new technologies and advice on improving the practice of medicine. (Of course, it goes without saying that this list is a small selection of the many great medical blogs out there.)