Health libraries review

The contents of this special issue of Health Information and Libraries Journal highlight the importance of medical history, the growing interest in the subject, the kinds of lessons we can learn from it and the need to preserve the record of medicine today for the historians of tomorrow. The history of medicine, like the history of any discipline, depends on the survival and accessibility of the primary documentation of the subject, in the various forms that may take—books, journals, letters, photographs, electronic files, films, or any other medium. That in turn depends on the libraries and repositories in which the material is stored having the resources to manage it properly, conserve it where necessary, and catalogue it so that it can be made available to researchers. We are fortunate in the UK in having a mature network of libraries and record offices and a well developed awareness of the need to preserve materials for posterity, although the sector is a very fragmented one in terms of funding streams and co-ordinated planning. It is also well known that many libraries struggle with tight budgets and an ongoing financial balancing act to ensure that essential services continue. Many collections are therefore in need of extra assistance if they are to open up the potential of poorly listed resources, to convert old finding aids to electronic formats, or to save fragile and damaged items from destruction. The Wellcome Trust has long been in the forefront of support for medical history, by maintaining the Wellcome Library, by supporting the various Wellcome Units around the country, and by providing a grants scheme that currently disburses around £3.5 million each year to fund new academic research in this area. However, although funding is available for research projects, the existing schemes have no provision to give direct support to the collections upon which the research depends. A survey carried out by Dr Michael Smethurst for the Trust during 1999, looking specifically at resources in the medical historical field, identified well over 400 collections that could clearly be grouped under that heading. The Trust has therefore decided to address these concerns, and has set aside £1 million to establish ‘Research Resources in Medical History’, a new funding scheme that will run for 2 years during 2001 and 2002. It will be open to any type of institution within the UK, seeking to mount specific projects focusing on access to, or preservation of, documentary collections in medical history. In an interesting new departure for the Trust, the scheme will be run in partnership with the British Library; the Trust will provide the main funding, while the British Library will provide the administrative base and support staff. It will be reviewed towards the end of 2002 (by which time, it is hoped, the £1 million will be spent or committed), with the possibility of further funding if the need is demonstrable. The new scheme is a competitive one, and proposals will be assessed by a professional panel including librarians, archivists, conservators and academics. A two-stage application process has been devised, with brief preliminary applications being considered first, after which fuller bids may be invited. Projects will be expected to have a fixed time period, not exceeding 3 years; the size of any awards made must naturally take into account the total funding available to the scheme and it is expected that most grants will be between £10 000 and £100 000, with a minimum application threshold of £5000. The scheme is focused on the history of medicine, and on collections that will demonstrably contribute to the field, but it is not restricted to any particular materials or types of project. Proposals for cataloguing from scratch, retroconverting existing catalogues, or creating new gateways or surveys of collections will all be regarded as eligible, alongside all kinds of conservation work. Projects that comprise or include digitization of original materials will be considered, as long as the purpose and long-term maintenance of the digital media is demonstrable. There is no restriction as to periods or formats; projects based on contemporary records may be submitted as well as ones based on medieval hospital archives. Preference will be given to projects that are likely to have a wide and lasting application for study and research. Funds may be used to pay staff salaries and to purchase necessary equipment, but not to contribute towards major building projects. The scheme cannot be used to cover any kinds of acquisition costs. It is open to institutions, not individuals, but there are no limitations as to types of institution, neither is there a requirement to find any particular proportion of project funding from local or other budgets, although circumstances will be taken into account in each case. The new scheme presents exciting opportunities to open up new research resources in the medical history field, to provide support for the library and archive sector, and to bring lasting benefits to the community of users both today and in the future. Anyone interested in having further information, or wishing to pursue the possibility of making an application, should contact: The Administrator, Research Resources in Medical History, The British Library, Co-operation and Partnership Programme (Floor 4 Zone 6), 96 Euston Road, London NW1 2DB, UK. Tel.: 020 7412 7052; fax: 020 7412 7155; e-mailmedical-history@bl.uk Further particulars can also be found on the Trust website at: and the British Library site at: .

There is now a growing awareness of the difficulties that society faces as it seeks to preserve a record of its own medical history. During the past 10 years there has been a growing wave of interest not only in the wonders of medical science but also in the inadequacies of our own National Health Service and the sensational revelations of scandalous malpractice. The challenge of information technology or medical ‘informatics’ and the widespread concern for adequate data protection of patients has been accompanied by growing recognition within the medical profession that litigation has become part of everyday life in the modern world of health care. Information and records are therefore sensitive pieces of intellectual and physical property for a number of reasons. For the medical historian it is clearly essential that the blemishes and failings as well as the heroic progress of medical practice should be retained warts and all. Since we can never predict with any confidence what the historian of the future would wish to use, the historian makes the unrealistic appeal that everything should be preserved. Above all, the experience of the patient is valued in the social history of medicine. The archivist faced with the plethora of paperwork and electronic databases that has marked the expansion of the National Health Service groans at the calls for mountains of ‘personal instance papers’ (patient records) to be retained. State and county archives provide an index of executive and administrative state power rather than a portrait of its citizens. In the past two or three decades the archives world has struggled, usually with diminishing resources, to respond to the growing demands on the services and to encompass within the public and county record offices at least a meaningful sample of medical and health records of the past two centuries. A major problem that archivists and historians alike confront in their efforts to preserve a record of modern medical records is the relentless drive for space economies within the public health sector and the periodic relocation of health facilities into new buildings. Even a region as richly endowed with medical institutions as the south-west of England was clearly in danger of losing much of its historical documentation as the large mental hospitals closed in the 1980s and the specialist eye, orthopaedic and disability institutions were closing or being transferred at the same period. The rate of destruction of modern (post 1900) medical records provided the stimulus for two large surveys of medical records undertaken at the Centre for Medical History in 1997–99. The first concentrated on updating medical records left by major hospitals in the region and provided further information for the Devon Record Office and via them for the Wellcome Hospital Records survey undertaken at the Wellcome Library. In the process of cataloguing and listing a number of important record deposits in locations ranging from basements of hospitals to remote mortuaries, the archive listing team of Gillian Falla, Robert Turner and Joseph Melling was able to rescue a number of records from almost certain destruction. This initial survey revealed the full extent of the destruction of patient and related treatment records which had occurred in earlier decades, and more particularly (it would appear) from the early 1960s when progressive policies of destruction and weeding were undertaken. Three further studies specifically devoted to examining the survival of mental health records were undertaken as part of research project developments in 1998 and 2000. The first involved an assessment of the historical records which survive in relation to the institutional treatment of mental deficiency in Devon, particularly at the Starcross Hospital, formerly the Western Counties Idiots Asylum. Following a detailed listing, research undertaken by Pamela Dale on these materials revealed the dispersal or destruction of most papers relating to the individual patients. Fragments of correspondence that survive show that these were amongst the most valuable items, which cast light on the largely unexplored relationship between the institution, the families of patients and the remarkable group of voluntary social workers who appear to have played a neglected part in the treatment of this group in the twentieth century. The survey indicated the potential value of a linkage between health records and the files of the social services at both county and borough level, although formidable problems of ethical access remain when scholars seek to use recent materials. More importantly, there seems as yet to be relatively little awareness amongst scholars or archivists of the historical value of such items if the deposits of different county record offices are a reliable guide. The second survey was undertaken with Naomi Doncaster, being particularly concerned with reconstructing the links between hospital and general practice records to evaluate the patient careers of deceased individuals who had been treated in a major psychiatric hospital in the later twentieth century. Here the technique of electronic scanning of key records proved an important tool. The best items were susceptible to optical character recognition or text-reading copying but these formed a small minority of the files and most of the more important documents were scanned as an image, tagged and stored for research analysis on a completely secure (i.e. locked) remote computer system. This exercise suggested the value of general practitioner records, which have sometimes been destroyed within a decade of the death of a patient, although they are generally now retained for approximately 11 years. As yet relatively few of the records left by non-eminent general practitioners are retained for historical use, although their research value is clearly considerable and now increasingly recognized by scholars. The third survey was carried out with Ian Mortimer (formerly at the Centre for Medical History and now Archivist at the University Library, Exeter), with a view to assessing the sources which survive relating to psychiatric treatment of individuals in different institutions within the south-west and other regions of the United Kingdom. This involved a review of the records surviving in a wide range of locations. The survey revealed three basic characteristics in the pattern of retaining mental health and related records in the south-west and two other regions of the United Kingdom. The first is that management, executive and financial records have often been preserved in good order where they formed a consistent run in a major institution, although it would appear that pre 1914 and post 1948 records have a rather better shelf life than those covering the intervening years. The second feature of the deposits and remaining hospital files is that historical patient case notes have rarely survived in any significant number and appear to have been widely weeded for the pre 1960 period once the individual was thought to have died, even where Department of Health circulars advised the retention of records that could have included such case files. The third aspect of these collections is that is that broken and uneven runs of records, as well as the absence of accessible demographic resources (such as census returns), makes the reconstruction of a patient’s career extremely difficult even where ethical access and informed consent can be secured. The position with regard to historical papers which record other kinds of hospital treatment is rather poorer than that relating to mental health records, because the controls on the destruction of, say, accident and emergency or ophthalmic medical files, are much less specific than for mental health care and the treatment of children. A welcome if rare discovery was the existence of good records for community hospitals serving a particular small town. In these instances the ‘angels in marble’ who had preserved the records often included a dedicated matron, sister or doctor with an eye to the historical narrative of their particular patch and the service provided by a charitable or endowed institution. Within the south-west a few of the old Poor Law Infirmary records have also been rescued, although some superb examples in north Devon appear to have been lost without trace. In addition to the institutional records that relate to hospital treatment and the treatment of individuals within the south-west, a survey was undertaken in 1997–98 which attempted a preliminary analysis of those materials covering ‘community health’ services rather than the major hospitals, which have dominated the story of health provision during the twentieth century. This involved a search of record offices, minor hospitals and a detailed survey of general practices across Devon to ascertain the extent and quality of historical medical records that were preserved. The most interesting feature of this trawl was the survival of small knots of patient records in some historically aware surgeries such as that of Sir Denis Pereira-Gray (a colleague at the University), who headed a family practice that extended into the pre-NHS era and where many records of elderly and even deceased patients were retained. Surprisingly few materials relating to school medical services appear to have survived. In general it has to be said that very few records remain of non-hospital treatment and colleagues in the Centre for Complementary Health confirm both the historical abundance of non-hospital and non-classical healing treatments as well as the paucity of historical materials which exist for an analysis of alternative therapies. The most significant deposits once again relate to the ‘community’ care of individuals such as those with mental health and mental disability problems. The next step in the Centre’s archival programme is to consolidate our links with the Devon Record Offices, the County Council, the NHS Trusts and Authorities, and the University Library, who have been our partners throughout the various search and rescue initiatives since 1997. They have proved invaluable contacts and the new Devon Record Office is to have a dedicated medical records suite to sort and evaluate such deposits. We hope to secure funding for this important work whilst also developing Web and other electronic access to the archival collections that have been established within the region. One of the main conclusions of this work has been the need for some level of regional specialization to ensure that different regions which cannot hope to encompass the full range of records that survive for the medical services should be able to focus upon a particular type of institution, medical specialism and practice. Where particular areas have an established network of institutions dedicated to oncology or hip replacement we might expect that a partnership between medical health trustees, managers, archivists and researchers will enable the area to preserve at least some of the most important and interesting chapters in the growth of the health services in the past century.

This article looks at the work of Elizabeth Blackwell (1707-1758), by all accounts the first British female herbalist. To raise funds to free her husband from debtors prison, she produced her hand drawn, engraved and coloured 'Curious Herbal' in 1735. Using the copies of the herbal in the British Library, the article will look at the circumstances surrounding production of the herbal, her influences and sources used, including the people who recommended production of the book to the Society of Apothecaries and some of the current projects to put her name back on the map.

Clinical medical journals have not been effective in meeting the information needs of practitioners and bridging the gap between clinical research and practice. The slow adoption of results of clinical research is at least partly due to the failure of clinical journals to disseminate information in a way that would motivate practitioners to change practice. Although implementation is primarily a local process, medical journals are in a unique position to advance implementation by modifying their focus and adjusting their contents. Strategies that may be useful include publication of pre-appraised evidence summaries and 'clinical bottom-lines' and giving importance to systematic reviews and large evaluative research articles as they represent higher levels of evidence and have greater potential to change practice. Clinical journals should encourage researchers to consider how and by whom the findings will be used and provide information on implications for implementation such as possible strategies that may work, cost-effectiveness, side-effects and potential barriers to implementation. Medical journal publishers should explore ways to cooperate so that findings of landmark clinical trials could be shared thus reducing the 'scatter' of medical information. Electronic media offers numerous advantages such as quick accessibility and linking of information, and medical journals should capitalize on such innovations. There is a paradigm shift in health care practice as evidence is consciously and explicitly incorporated into individual patient care. Medical journals need to change to reflect this change in practice and provide practitioners with valid and relevant information.

There are many challenges, developments and successes surrounding the delivery of information to healthcare practitioners and consumers in a fast-changing world. A special issue on medical history may seem incongruous, or even irrelevant, in that context. Why bother about all that old stuff when surely, what we need to know more about is greater efficiency and cost-effectiveness in managing the information of today? Not only is history a hugely popular concern, but most people will readily agree that it matters. In health care, history can teach and inform in many ways. Quite apart from its obvious ability to warn us against repeating the mistakes of the past, history abounds with subtler messages about the dangers of assuming too much by way of scientific knowledge. Treatments are new, illnesses are not, and the ways in which both practitioners and patients of the past have coped with the psychological and physiological traumas of disease can inspire or help us today. A historical perspective is often necessary in order to understand present practices—the recent foot and mouth crisis being a case in point. For all kinds of reasons, people want to know about medical history, whether they are completing a PhD on the development of the NHS, whether they are researching social attitudes to some particular disease or whether their grandfather was a doctor and they wish to know more about him. Medical librarians have a key role to play in preserving the record of today for the historians of tomorrow. The point is succinctly but eloquently made by Roy Porter in his opening piece, and amplified by David Pearson who highlights the difficulties of controlling the ever more diverse contemporary record of medicine, and the need for a collaborative professional approach. Bruce Madge opens up for us the remarkable story of Elizabeth Blackwell—whose Curious Herbal is now automated as one of the British Library’s Turning the Pages projects—and Lucretia McClure teases out the need for ‘experimental doubt’ and the importance of studying the medical past in her paper on ‘Giants’, originally given at last year’s 8ICML Conference in London. The brief communications highlight a range of initiatives and issues that are currently taking place in the medical historical field. A growing interest in the subject, and in the interface between medical training and history, is generating two new CD-ROM products, one sponsored by the Open University and one by The Wellcome Trust. Wellcome are also supplementing their existing support for medical history with an important new funding scheme for libraries and archives. This will be administered in partnership with the British Library and will provide a million pounds during 2001–2 for projects that focus on easing access to, or preservation of documentary collections in medical history. The management and preservation of contemporary medical records also pose many problems; Jo Melling describes his local experiences in the south-west. Many people wish to develop their interest in medical history—Robin Price describes the flourishing diploma course run by The Society of Apothecaries. To quote from Roy Porter, ‘future historians will bless or blame us, depending upon how wisely we act now’. Most medical libraries see their primary responsibility as being towards the present but we have a responsibility to the future too. It is in that spirit that this special number of HILJ is offered, and we hope that readers will be inspired by the challenge.

This paper addresses the need to recognize the importance, and the challenges, of preserving the hugely expanding record of medicine today for historians of the future. We are faced not only with an increase in traditional publishing formats, but also with the rapid growth in electronic communications. Two celebrated medical cases, one from the late seventeenth century and one from the late twentieth, are used to illustrate the differences and the difficulties. The need for active and effective professional collaboration is stressed; libraries should work together to address these issues.

In 2004, the Open University will launch a new second-level survey course in the social history of European medicine—its first ever offering in this area. The team behind this new venture hope to make the course distinctively different from similar courses taught in conventional universities through the inclusion of a strong visual element. This will be delivered via an interactive CD-ROM, which will be integrated with the more traditional print and video material. This decision reflects the increasing interest in images as resources for the study of the history of medicine, and the university’s wider Learning and Teaching Strategy which aims to include an ICT component in all courses by 2005. The CD-ROM will give students the opportunity to explore the wealth of visual material associated with medicine—anatomical drawings, hospital plans, fever maps, portraits of eminent practitioners. It will provide material that offers particular insights into aspects of medical history: hospital plans, for example, convey a sense of the spatial organization of care that texts simply cannot replicate. Visual images can also provide alternative perspectives on events: early nineteenth century cartoons poking fun at practitioners provide a vivid contrast to doctors’ presentation of themselves as honest, caring and gentlemanly. The new course will use the CD-ROM’s unique facilities to present material in an accessible and interesting way. It will include animations of still images, such as the illustrations of Harvey’s experiments on the circulation. It will also present combinations of different types of image, such as plans of hospitals linked to photographs of the interior of wards. However, images will not be used simply as illustrations to supplement texts. By combining images with text, students will be taught to use images as important primary sources, to analyse the information conveyed by images and to think of how the content of pictures related to their intended audience. The interactive element of ICT is especially helpful for Open University students working at a distance, whose interaction with tutors and other students is somewhat limited. Traditionally, OU course books have included exercises that encourage the reader to think through ideas, to apply concepts presented in one historical context to different sets of circumstances and to draw together information from different parts of any course. These exercises encourage the students to engage with the material and provide some of the experience of a dialogue between student and teacher, allowing students to articulate the new knowledge and ideas they have acquired and thus develop a deeper understanding of concepts. These objectives can be replicated on CD-ROM, with the advantage of interactive feedback geared to the student’s responses. This allows students not only to test their grasp of new information and ideas but to identify and receive guidance on how to improve weak areas in their knowledge. Although the CD-ROM is designed specifically for the OU course, it is hoped that it will be copublished and thus available to be purchased ‘off-the-shelf’ for use by students in other universities studying the history of medicine. Library staff will play a central role in the development of this CD-ROM and of other new ICT material. The Library has already produced ROUTES—a database of links to Web materials tailored to specific courses—which Library staff actively manage and maintain. CD-ROM adds another element to resource provision: the CD-ROM requires written and image resources, linked to Web resources. Library staff supporting the history of medicine course team will be assessing the range of image databases available and ensuring that course teams are aware of what is on the market. The Library had already begun to expand the collection of visual resources available to academic staff by subscribing to SCRAN, a massive resource base designed especially for education, and will be building on this further. This article was written by Debbie Brunton who is devising the course. If you are interested in knowing more then please contact Tricia Heffernan at e-mail:P.A.Heffernan@open.ac.uk

While walking around Paris one day, I came upon the laboratory of Claude Bernard. It was an exciting moment for me, as exciting as anything I saw in that city of beautiful and exciting things. Father of experimental physiology and medicine, Bernard is one of those individuals whose writings so impress me. The aim of Bernard’s work was to give medicine the decisive push along the road of its transformation into an experimental and conquering science. M. D. Grmek, a Bernard biographer, says he confirmed the primordial role of feeling or intuition as the ‘point of departure for creative experimental research’. Convinced that method by itself produced nothing, Bernard set forth a series of precautions for the experimental biologist. His principal advice concerned the ‘experimental doubt’ and the necessity to avoid fixed ideas. Bernard is quoted as saying: ‘A good experimenter must be simultaneously theoretician and practitioner: a skilled hand without the head to direct it is a blind instrument; the head without the hand to carry out an idea remains impotent’.1 Experimental doubt is exactly what we need today. We need scientists and physicians who doubt and question, who continue to ask why and what if. It has become very difficult to do this in a world that has become a race—an excursion in a fast car, a faster plane, a demand to beat the competition, a cry for instant information. It is easy to say that scientists build on the work of others and it is an accepted standard in the development of new ideas and advances. It is based, however, on the understanding that the scientists will study the past and review the progress, the controversies, the failures that led to the knowledge we appreciate today. Students in science and medicine are used to obtaining information instantly. They are used to quick and easy access to databases and current articles. It is my observation over the past 20 years that a student is often unwilling to spend hours searching and reading the print literature. The practice of earlier years when professors outlined the developments of a discipline and insisted that the students identify and read the classic publications, learn to read journals critically, and use a variety of indexes/resources seems to be out of fashion. It does take time to doubt! Of course there are many advantages to knowing the computer and using the extensive variety of technological wonders available today. Skill in searching for current information and for covering great quantities of material is a true asset to any practitioner or student. The speed with which one can achieve a bibliography on a pertinent and limited topic is nothing short of remarkable. But having that skill at one’s fingertips is not a guarantee of either education or learning. Charles Sedgwick Minot said: ‘Methods of obtaining knowledge are the means of progress. Remember how much anatomy owes to the method of human dissection; how much pathology owes to the method of staining microscopical preparations; how much surgery owes to the method of antisepsis; how much bacteriology owes to the method of artificial cultures’.2 One of my friends was in hospital and asked the resident in attendance if he had enjoyed reading Osler. ‘Oh’, he replied ‘I never bothered with that old stuff’. Here is Osler the physician, adored above all others during his lifetime, held in great esteem yet today. His medical writings portray disease with such clarity and understanding that his works are well worth reading even now. In an address at the opening of the Wistar Institute of Anatomy and Biology in 1894, he asks if we have lost our sense of continuity. ‘We are even impatient of those who would recall the past, and who would insist upon the importance of its recognition as a factor in our lives, impatient as we are of everything save the present with its prospects, the future with its possibilities.’3 Would you not want to know what happened before anaesthesia? Could you even contemplate the role of the surgeon whose most needed attribute was speed in operating? The impact of ether, the changes it brought about in surgery, the developments that resulted, allowing the surgeon to operate on the most delicate areas of the heart and the brain. We did not leap from ether to heart transplantation, but there is a connection. Studying the past is essential to understanding the present and for building the future. Reading history reveals the trends, outlines the progress, points to the errors as well as the successes. We need to know more than how to solve today’s problems; we need the perspective that comes from seeing the broad picture. Reading history helps show how illness affects patients and how society copes with the impact of an epidemic. If you think back to Harvey and his understanding of how blood circulated and follow that thread to this day when blood can be redirected to allow heart surgery, you will find the connections. Medicine did not begin with the CAT scan and medical literature did not begin with medline. When you read that the only remnants of small pox are stored in a vault and may soon be destroyed, do you think of Jenner and his milkmaids? Consider the mind that recognized the immunity they received from cowpox. This thread runs through the present with the struggle to find vaccines to treat polio, diphtheria, AIDS. Medicine has traveled a bumpy and winding road. Each false step may lead to a future breakthrough, each mistake to a new train of thought. How do we impart this value of the past to new generations of students who come into medicine with a computer as a learning companion? It is a serious question. This is how Dr Richard V. Lee expresses it: ‘My concern is with history: beginnings and becomings and endings. History has, like books and the weather, become something of an anachronism. Instantaneous and contemporaneous news makes history out of date. Being up to date has become more desirable than being well read in history. Computers have extracted from the scholar’s life the joy of savoring, cataloging and retrieving facts, of reviewing the literature. Efficiency has eliminated serendipity. So much happens in a twinkling that we have come to expect everything to happen in a trice’.4 It is here that librarians can play a role. For we are educators with a special opportunity and a special knowledge. We know the materials that describe and define our history—the rare book, early periodicals, the student notes from centuries past, the artifacts, essays, pictures, manuscripts. We know and value the collection of these resources, with the ultimate goal of making them available to students, practitioners, scholars. These materials are among the best for stimulating ideas, opening new areas of scholarship, for enhancing an author’s writing. In addition to knowledge of the resources, we know how to search and ferret out the details that make history so interesting to read, so fascinating to study. For example, reading the story of Marie and Pierre Curie is dramatic in itself, but what happened with their discovery of plutonium/radium is even more compelling. Using atomic energy changed the war and has continued to be a factor in the ways nations interact, has been a major factor in the struggle for world peace. How many students know about the Curies? How many see how their work led to the development of nuclear medicine and many of the practices in medicine today? Our opportunities to teach are endless. Each time we help an individual construct a database search, seek information on a topic or receive a question that needs an answer, we can talk about the literature and how important it is to understand the background of the author, to look for clues about how the research was developed, and where it stands in the history of the subject. Peter Medawar makes this statement: ‘A scientist must be resolutely critical, seeking reasons to disbelieve hypotheses, perhaps especially those which he has thought of himself and thinks rather brilliant’.5 Students often hesitate to question what they read. They are willing to accept whatever the computer spues forth, whatever is printed in a formidable looking journal. Reading widely, tracing the thread of a discovery, learning how a scientist came to his ideas and beliefs, how the physician found a clue while treating a patient are all ways that help students see the broad stroke rather than the isolated piece. Some of the best reading in medicine is in the realm of history. Some of the best writing is to be found in the history section. Our faculty, the residents, the scientists can be of immense help in encouraging their students to think about and seek out the answers to questions that lead to historical study. One cannot imagine a medical student failing to be impressed by the beauty and strength of the work of Vesalius. One cannot imagine that educators would fail to ensure that students have the opportunity to read and examine the works of the giants of the past. Arthur M. Silverstein, in the preface to his History of Immunology, relates that the single event that ‘triggererd’ his serious entry into the study of history was his receipt of a manuscript for review from a leading journal. The paper was an elegant study of an important problem, but ‘one that Paul Ehrlich had reported on 80 years earlier! Not only was the author unaware of Ehrlich’s work, but he was also unaware that his data and conclusions differed little from Ehrlich’s, despite the marvels of our newer technologies’.6 To me there is no more fascinating literature than that of medicine. It has the poetic, the clinical, and the basic science, all mixed with controversy, quackery, and the foolish. The richness of medical literature is available for all to peruse and enjoy. Our purpose must be to make this known to all who would be in this special world of medicine. And with it all we must keep our doubt!

Health Information & Libraries JournalVolume 18, Issue 4 p. 238-240 Free Access Column Editors Andrew Booth, Andrew Booth School of Health and Related Research (ScHARR), University of SheffieldSearch for more papers by this author Andrew Booth, Andrew Booth School of Health and Related Research (ScHARR), University of SheffieldSearch for more papers by this author First published: 18 July 2008 https://doi.org/10.1111/j.1478-0542.2004.00110.x-i1Citations: 2AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume18, Issue4December 2001Pages 238-240 RelatedInformation

The Wellcome Trust through its Medicine, Society and History programme is sponsoring an exciting new project in the history of medicine that brings together several wings of the Trust’s scholarly staff. The plan is to create a highly visual self-directed learning module for medical students that will explain key concepts in the history of medicine by using examples drawn from English literature and literature in translation. George Eliot’s Dr Lydgate will join Dr Zhivago, Sherlock Holmes and Dr Watson, Mr Rochester’s mad wife in the attic and others from European, Russian, Indian and American literature, old and new, western and non-western, to provide a lively, richly illustrated and authoritative teaching product. The course will be supplied on CD-ROM suitable for loading onto an intranet, with future provision for online distribution, and is designed to fit into University College London’s medical curriculum as a special study module. Written by historians at the new Centre for the History of Medicine at UCL, it will showcase the world-famous resources of the Wellcome Library for the History and Understanding of Medicine and draw extensively on a wide range of stunning images from the Iconographic collections, Medical Photographic Library and Medical Film and Video Library. Electronic experts from the Wellcome Trust’s Tropical Medical Resource are masterminding design and production, using their experience from creating similar teaching resources on tropical diseases. The course will be ready for trials in 2001 and (with luck) released to students at the start of the academic year 2002. If successful, it is hoped to make it available to other bodies. The impetus for this collaboration has come from the introduction of the new medical curriculum in London’s medical schools, in keeping with recommendations from the General Medical Council. The curriculum provides several opportunities for prospective doctors to broaden their education, especially in the humanities. These special study modules are, in part, intended to help students understand the diversity of backgrounds and the cultural variety of the patients they will eventually meet, as well as putting their own participation in modern medicine in a wider social context. It was thought that a short course on the relations between literature and medicine would usefully introduce a range of issues and approaches to the history of health and illness which would encourage the student to acquire a sense of the chronological development of medicine and build a basic framework into which modern medical science can fit. It aims to be as inclusive as possible, touching on nonwestern medical systems as well as gender, professionalization, war and social issues. There are ulterior motives too. Creative literature involves the personal, the intimate, feelings of pain and joy. While the course is necessarily selective, we hope it will stimulate medical students to think about their patients as people and of the health professional’s place in a long, fascinating, constantly changing tradition. It aims to supply six teaching sessions broadly covering themes such as Doctors and Nurses in Literature, Medicine in Shakespeare’s Time, Diseases in Literature, Medicine and the Mind, Medical Utopias and Dystopias, and Medicine in Cultural Context. Each session will be prefaced by an introductory essay that sets out the theme. Summaries of the novels, and commentaries on the extracts are also included, although for reasons of space not in the examples below. Each extract will be illustrated with appropriate historical images, perhaps some snatches of film for the First World War poets, for example. Supporting materials will supply the authors’ biographical details, a pictorial timeline, self-test questions, details of the texts and visual sources, further reading in the history of medicine, and so on. The two examples given below offer opportunities to explore perceptions of medicine, hospitals, monsters and madness in the nineteenth century via the literary extracts and the accompanying images. We can only produce a glimpse here of the kind of multimedia resource that will eventually be produced, but it is hoped that it will at least convey a flavour of what should prove to be an innovative new learning aid. ‘She was a fat old woman, this Mrs Gamp (Fig. 1), with a husky voice and a moist eye, which she had a remarkable power of turning up, and only showing the white of. Having very little neck, it cost her some trouble to look over herself, if one may say so, at those to whom she talked. She wore a very rusty black gown, rather the worse for snuff, and a shawl and bonnet to correspond. In these dilapidated articles of dress she had, on principle, arrayed herself, time out of mind, on such occasions as the present; for they at once expressed a decent amount of veneration for the deceased, and invited the next of kin to present her with a fresher suit of weeds: an appeal so frequently successful, that the very fetch and ghost of Mrs Gamp, bonnet and all, might be seen hanging up, any hour in the day, in at least a dozen of the second-hand clothes shops about Holborn. The face of Mrs Gamp—the nose in particular—was somewhat red and swollen, and it was difficult to enjoy her society without becoming conscious of a smell of spirits (Fig. 2). Like most persons who have attained to great eminence in their profession, she took to hers very kindly; insomuch, that setting aside her natural predilections as a woman, she went to a lying-in or a lying-out with zest and relish. “Ah!” repeated Mrs Gamp; for it was always a safe sentiment in cases of mourning. “Ah dear! When Gamp was summonsed to his long home, and I see him a lying in Guy’s Hospital with a penny-piece on each eye, and his wooden leg under his left arm, I thought I should have fainted away. But I bore up”.’ A convalescent woman trying in vain to rouse her hired nurse. Etching by Nicolaus I. W. C. von Heideloff, 1807, after Thomas Rowlandson A caricature of a drunken nurse. Wood engraving, artist unknown. With a red nose and a hand that gestures towards an almost empty brandy bottle, it is clear that the only thing this mid. 19th century nurse cares for is a tipple ‘Now, the hand of Henry Jekyll (as you have often remarked) was professional in shape and size; it was large, firm, white and comely. But the hand which I now saw, clearly enough in the yellow light of a mid-London morning, lying half shut on the bed-clothes, was lean, corded, knuckly, of a dusky pallor, and thickly shaded with a swart growth of hair. It was the hand of Edward Hyde (Fig. 3). I must have stared upon it for near half a minute, sunk as I was in the mere stupidity of wonder, before terror woke up in my breast as sudden and startling as the crash of cymbals; and bounding from my bed, I rushed to the mirror (Fig. 4). At the sight that met my eyes, my blood was changed into something exquisitely thin and icy. Yes, I had gone to bed Henry Jekyll, I had awakened Edward Hyde.’ Head of a man, composed of nude figures. Oil painting, artist unknown. An image that vividly presents 19th century notions of the conflicting emotions that coexist in the human mind A man asleep dreaming of monsters. Etching by Fransisco Goya, 1796/98. In English, the caption reads, ‘The sleep of reason induces monstrous thoughts’. This ghoulish scene bears witness to the concept that the monster we fear is in fact the externalization of the monster from within. Stevenson said that The Strange Case of Dr Jekyll and Mr Hyde was conceived after a nightmare

The Society has a very splendid title, but it is far more than that. Unlike many of the older Livery Companies of the city of London it has remained highly active within its original craft of healing. In 1815, some 200 years after its grant of a Royal Charter, it acquired the duty to examine and license in medicine. As a natural development of that duty it has also continued to promote some 10 diplomas in medicine and related fields, such as those in medical jurisprudence, genito-urinary medicine and, most recently, medicine for catastrophes. All of these are areas of medicine that require proper examination and authentication, but which no other body so covers. The Society’s Faculty for the History and Philosophy of Medicine and Pharmacy (‘the History Faculty’) has taught and examined in the history of medicine since 1969, and in the associated field of the Philosophy of Medicine (ethics of healthcare) since 1974. These Diploma courses, covering one academic year, are well respected within medicine, and are much sought after and well attended. The history diploma course (‘DHMSA course’), open to all those who can prove a genuine interest in the field together with commensurate qualifications, attracts some 30 students year on year, and the philosophy course (‘DPMSA course’) regularly attracts some 12 students each year. Candidates for examination—perhaps a symptom of our more serious continuing medical education times—rise each year; and in the history course there is regularly an absolutely even age-profile from 22 to 72—that is, from students to the retired. Participants are primarily medical or medically related, but a sprinkling come from other professions such as the law, medical journalism, and adult and school education. Their comment at the end of the course is that it is mind-expanding and that they have had their perceptions and even their practice considerably widened. The history course has recently acquired CME and PGEA status, not always easy to attain in the medical humanities. To date, some 200 candidates have successfully qualified as history diplomates, some of whom have carried the message of the history of medicine forward into other spheres either by teaching or by research. The History Faculty has remained explorative and experimental. More particularly, it has on the suggestion and with the generous financial support of the Wellcome Trust, organized for 10 years a very successful 3-day course for 30–40 medical students, primarily from the University of London. This takes place annually in the Easter vacation. It is entirely free to the students; and it is at pains to engage the interest of the student—to brush him/her lightly with the idea of history—by talks rather than lectures, by videos, and by visits in the afternoons to places of medico-historical interest in London. Students hugely enjoy the course, and they often return for more, either to the DHMSA course (and some even make time and energy for the examination), or to the Wellcome Academic Unit’s intercalated BSc course. The course has had, and continues to have, a powerful catalytic effect, and other such courses are now on offer to students elsewhere in Britain. The Faculty had early in its life appointed Apothecaries’ Lecturers in the History of Medicine to the London medical schools. These appointments continue, and comfortably interdigitate with Wellcome Award Lecturers carrying out a similar activity in other medical schools. In brief, the remit of the Apothecaries’ Lecturers is to introduce students to the history of medicine by whatever means are available and best adjusted to the traditional style and facilities of their medical school. This may be by way of a series of introductory lectures, or the founding of student medical history societies (which can have a quite extraordinary do-it-yourself effect), or increasingly and most valuably by Special Study Modules (SSMs), which are now available in an increasing number of medical schools whether by way of Apothecaries’ Lecturers or Wellcome Award Lecturers. These are an assessed part of the medical course, and thus doubly attractive to students. The increased interest in the history of medicine, and particularly when history is presented within an SSM, has been enormously enhanced by the new undergraduate medical curriculum agreed by the medical schools and outlined by the GMC in Tomorrow’s Doctors (1993),1 whose major reform was to divide the core curriculum from the ‘intellectual space’ to be devoted to explorations of unfamiliar territory through special studies, not least in the medical humanities, in which history of medicine is a prime focus. In London there are Apothecaries’ Lecturers at the Royal Free, the Royal London, St George’s and at Guy’s King’s and St Thomas’ medical schools. Elsewhere in the UK, the Faculty has appointed lecturers to the medical schools of Birmingham, Bristol, Leeds, Newcastle, St Andrews, and the University College of Wales. Some funding from the Faculty has been made available to Apothecaries’ Lecturers to enable them to carry out their task. As part of its wider outreach, the History Faculty holds six evening lectures, known as the Eponymous Lectures, throughout the academic year. These are followed by a seated buffet supper, also in the Hall. The occasions, which agreeably mix formality with informality, attract large attendances. Past lecturers have included the Viscount Hailsham, Dr Jonathan Miller, Professor Roy Porter, Marcel Marceau, Dame Cecily Wedgwood, and Professor Hugh Trevor-Roper (Lord Dacre). Membership is drawn widely across medicine, the professions, and academia. To join the Faculty (in order to receive notices of lectures) costs only £15.00 per year on application to the Clerk of the Society, and is open to all those interested. To secure provision of the history of medicine for medical students—and to ensure co-operation and co-ordination across the board—the History Faculty, together with the History Section of the Royal Society of Medicine, and the then Wellcome Institute for the History of Medicine held a 100-strong meeting in the Royal Society of Medicine in 1996, following which a National Action Group was set up. Then in its turn it set up three regional English and Welsh groups and recognized a free-standing Scottish group, in order to share expertise within those regions for the all-round provision of the history of medicine for medical students. Address lists of lecturers and skill lists have been created for information and co-ordination. In accordance with the tradition of the Society of Apothecaries, the role of its History Faculty has been a creative and catalytic one. Before any other body in the UK it began to draw together the strands of the history of medicine and to teach and to authenticate the subject by examination. It has continued to do so, and it continues to seek novel ways of bringing the history of medicine well within the natural domain of the medical student, as to the medical practitioner, to professions related to medicine, and to the general public. The existence of a private body, not funded by the taxpayer, which is free to move on its own account, and above all free to seize the creative moment before it passes, acting in accordance with its own acute sense of medical, cultural and public need, undeniably confers a considerable advantage to the whole of society. For further details of the Society of Apothecaries History of Medicine course, and its other activities in this area, see the Society’s Website at: , or contact the Course Administrator, Miss Kim Edmunds, Apothecaries’ Hall, Blackfriars Lane, London EC4V 6EJ, UK.

There has been an explosion of mental health literature available on the Internet over the past 5 years, with current estimates placing the number of health related Websites at over 100,000. The scope and depth of each site is unique and this serves to contribute to the difficulty of finding reliable, high-quality literature. This paper details efforts being made within the UK to provide high quality, evidence-based mental health literature for patients, clinicians and health policy makers as part of the National electronic Library for Health project.

Health Libraries ReviewVolume 17, Issue 1 p. 22-25 Free Access Revolutionizing how we generate new knowledge: a challenge for librarians, health professionals, service users and researchers Sandy Oliver, Corresponding Author Sandy Oliver Research Officer, Social Science Research Unit, University of London Institute of Education, 18 Woburn Square, London WC1H 0NS, UK E-mail: sandy@cix.co.ukSearch for more papers by this author Sandy Oliver, Corresponding Author Sandy Oliver Research Officer, Social Science Research Unit, University of London Institute of Education, 18 Woburn Square, London WC1H 0NS, UK E-mail: sandy@cix.co.ukSearch for more papers by this author First published: 21 April 2009 https://doi.org/10.1046/j.1365-2532.2000.00256.xCitations: 5AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Librarians support both health professionals and their patients by finding information about health and healthcare. As research-based information and patients' involvement in decision-making escalates, so does the workload for librarians. It is not only the demand for librarians that is changing, but also the nature of the information that is sought and the skills required to find it. Two major movements in healthcare, evidence-based health and patient partnership, are influencing the content of information sought and its format of presentation. This paper discusses the combined impact of these changes on our needs and expectations for information and how we generate new knowledge. It also proposes that librarians may facilitate a quiet, but far-reaching, revolution in our knowledge-based society. Evidence-based healthcare Evidence-based healthcare is the 'emerging discipline that brings the best evidence from clinical and healthcare research to the bedside, to the surgery or clinic, and to the community'. 1 Librarians are key players in this process. They work both with clinicians who need quick and accurate responses to requests for research evidence relevant to the care of their patients, and with researchers wishing to examine comprehensive collections of research reports systematically for evidence of the effects of care. Whether seeking information about diagnosis, prognosis or therapy, the practice of evidence-based healthcare starts with converting these information needs into answerable questions and tracking down the best evidence with which to answer them. 1 There is a risk that both clinicians and researchers may be misled by the findings of studies that are insufficiently rigorous, or by missing findings that are more elusive because they are negative and less likely to be published in English (or at all), or because they are kept out of the public arena as the property of commercial enterprises. In trying to meet the information needs of clinicians and researchers, librarians have tried to minimize these biases by improving search strategies for electronic bibliographic databases and by subscribing to The Cochrane Library, which provides a short cut to controlled trials (published or not) and systematic reviews of effects of care. 2 Despite these advances, there remain gaps in the answers and this problem has already been recognized by librarians themselves. 'Sufficient thought has perhaps not been given to the information that is missing: the information which does not get published (even as grey literature), which cannot be acquired, organized and used by patrons of medical libraries…. The problem of missing information is something librarians should keep in mind and transmitting as they develop collections and catalogues, give reference services, and train students, doctors, research and other patrons to use information resources.'3 I propose that some of this missing information can be identified by approaching the subject from the perspective of patients. Evidence-based patient choice Patients are increasingly sharing clinical decisions about their care with health professionals. The growth in health information for patients to support this trend has kept librarians and information specialists busier in public libraries, patient support groups, drop-in health information centres and consumer health information helplines. Resources such as Help Box 4 a database of information services and publications for patients and the public, are the tools of the trade for providing patient information. This type of service is following a similar trend as that of medical libraries serving clinicians. Meeting the needs for 'informed choice' by patients, a relatively new development in healthcare, is already being superseded by the challenge of meeting the information needs for evidence-based patient decision-making. This places a greater emphasis on evidence of the effects of care to inform personal decisions. It has been given a boost by the Centre for Health Information Quality, which is funded by the NHS Executive to improve the capacity of the NHS to provide high-quality information about services, treatment options and outcomes. 5 The Centre works directly with NHS and patient representative groups to raise awareness of key issues in the development of consumer health information. A key product in this area is the DISCERN instrument, which helps people appraise patient information about treatment options. 6 These developments will increase the materials for librarians to catalogue and make available, but also provide routes and methods for librarians to identify high-quality materials to recommend directly to patients or to clinicians to support the decision-making they share with patients during consultations. Consumers' ideas Together, evidence-based healthcare and shared clinical decision-making set up a strong flow of information, from science to clinician to patient, which is facilitated by librarians in universities, post-graduate medical centres, charitable and consumer organizations and the public libraries of cities, towns and villages. Important as it is for the education of clinicians and patients, this flow of information depends primarily on scientific theories about health and disease, and does not do justice to the ideas and beliefs of patients themselves; their lay theories about health and disease. Scientific theories and lay theories about health differ in a number of respects. 7 Scientific theories tend to be strong in that they are based on the findings of careful observation, experimentation and analysis by different people, and are set out in a logical, internally consistent manner, and appear in research and clinical publications to provide much of the foundation for clinical practice. Lay theories, on the other hand, do not share these characteristics. They tend to be informal, descriptive conjectures that are implicit rather than explicit, based on tacit, nonspecified assumptions and are less likely to be published. Rather than discounting lay theories for their lack of clarity, I propose that these differences make lay theories particularly valuable for health research, albeit difficult to access. They are rarely presented formally, thus lay theories may be ambiguous, incoherent and inconsistent, but nonetheless useful in appropriate circumstances. Lay theories should provide the raw material for scientific investigation; they should inform and shape research questions. Some consumer groups have recognized such opportunities themselves, and undertaken their own research. For instance, it was women's requests for help that motivated the National Childbirth Trust to investigate women's experiences of epidural anaesthesia 8 and induction of labour, 9 and it was responses to an earlier questionnaire that prompted the Royal National Institute for the Blind to investigate parents' experiences at the time they were told their child was blind or partially sighted. 10 These reports do not appear on bibliographic databases because they are only available as in-house publications. This is some of the 'missing information' that librarians are encouraged to bear in mind. If what is missing merely cuts the quantity of reports to be read on a topic, the reduction in workload could be a relief. However, this missing information differs qualitatively from the information more readily available. These research reports, like others prepared by other consumer groups, give greater emphasis to the social, emotional and functional aspects of health. 11 Consumer critiques suggest that information about social and emotional aspects of health is frequently missing from professionally led research. 12 For professionals' research to address consumers' concerns, the usual flow of information from scientist to clinician to patient needs to be reversed. One example of this happening is when mothers of hyperactive children surveyed their experiences of nutrition and behaviour and proposed an explanation, 13 which was subsequently formally investigated by biochemists. 14 This was possible because the mothers had developed their lay theory from their original hunch to a formal theory, backed by data they collected themselves and published in a research journal. More typically, in-house publications of consumers' research are less likely to attract attention within mainstream research. Indeed, judging by the systematic reviews of care during pregnancy and childbirth published in The Cochrane Library, few of the recommendations made in the two National Childbirth Trust reports mentioned above 8,9 to investigate social and emotional issues have been incorporated into subsequent research in maternity care. Here again the 'missing information' is qualitatively different from the information readily available. In order for lay theories to bear fruit in health research, there is a need for information to flow in the reverse direction also, from patients to clinicians and scientists. The NHS Health Technology Assessment (HTA) programme does this without relying on consumers publishing their ideas. The consultation inviting suggestions for research topics is open to all, and a system is being developed for calling on consumers to play an active role in defining and prioritizing research questions (S. Oliver et al., manuscript in preparation). Consumer groups (not their reports) with an interest in topics under consideration are sought and invited to comment on plans even before the research is commissioned. A similar innovative approach is taken to prepare 'Clinical Evidence: a Compendium of the Best Available Evidence for Effective Healthcare'. 15 The publishers talked to patient groups even before embarking on production and the questions that are addressed are 'selected for their relevance to clinical practice … in collaboration with primary care physicians and patient groups', to ensure an 'emphasis on outcomes that matter to patients'. By contacting people rather than retrieving (or not) reports, those managing the HTA programme or producing Clinical Effectiveness are able to capture and draw on elusive and informal lay theories. This is lay knowledge that would otherwise be missed. Whereas advances in evidence-based health developed explicit and comprehensive searches for the retrieval of information about the effects of care, the time has come to develop explicit and comprehensive searches for ideas to direct research and generate new knowledge. Different cultures Evidence-based patient choice spans different cultures. Clinicians and researchers publish their work primarily in professional journals while consumers publish theirs primarily in leaflets and newsletters. Clinicians have access to bibliographic databases of research literature, while consumers are targeted with adverts for health information services listing support groups and patient literature. Clinicians use professional language while patients and consumers use lay language. Bringing lay questions in lay language to professionals' resources can lead to confusion. For instance, patients value being listened to, but an intuitive search of The Cochrane Library for supportive listening skills in clinicians unearths references for the therapeutic value of music and the technical skills for taking clinical histories, a far cry from having a supportive listener. It takes a trained librarian to identify keywords such as 'Professional-Patient-Relations' and text words such as 'patient* interact*' or 'interact* patient*' to interrogate a database in order to know whether any relevant literature exists (thanks are due to Fay Bower. Cochrane Consumers and Communication Review Group). Clinicians and professional researchers often avoid such confusion by not even considering lay resources to inform their work. They can easily miss issues that raise important questions in the minds of patients without even noticing. Librarians who work with clinicians, researchers, patients and consumer groups are ideally placed to build the necessary bridges. To do this they need to be familiar with bibliographic databases of research reports and registers of consumer groups and their publications; clinical language and lay language. Then, not only can they highlight gaps in the answers provided by research (an important feature of evidence-based health) but they could also warn of gaps in the questions addressed by research. Librarians as revolutionaries Librarianship which focuses on people rather than publications as sources of ideas, is a long way from its origins. While I can only outline some of the challenges we now face I hope that librarians will develop some of the solutions. How can consumer groups access the research literature to answer their own questions? How can they make the best use of electronic searches and journal collections? Where are the resources to come from to give librarians the time to support patients as well as clinicians to find their way around a wealth of research based information? How can professionals be encouraged to access consumer resources to support clinical consultations or shape research questions? How can they make best use of databases such as Help Box and the Internet, which is a growing attraction for patients? Librarians need to develop and access new resources, or use existing resources in new ways. For instance, Help Box can be a route to consumer groups only if users can distinguish between the information sources provided by NHS services, charities led by clinicians and consumer self-help and campaigning groups. This echoes the experiences of systematic reviewers who found that medline could only be a reliable source of evidence of effects of care if controlled trials were accurately keyworded. Investment in keywording medline references and collecting trials in the Cochrane Collaboration Trials Register has paid dividends for evidence-based healthcare. A parallel investment in adapting or developing de novo databases for finding consumers and their work could facilitate healthcare research that embraces consumers' questions as well as those of clinicians. Searching strategies for people need to be as advanced as searching strategies for published information. This requires librarians to explore different cultures, to be innovative and take others with them—acting as translators and introduction agencies—and be enthusiasts for sharing cultures. In this way, librarians would no longer simply provide access to research, but provide the inspiration for new research and be a catalyst for new knowledge. For the new millennium, librarians are challenged to develop new skills and resources, nurture new partnerships and establish new networks in order for the public and patients to inform the written word, rather than the conventional expectation of the written word informing patients and the public. Enriching the research agenda in this way is a revolution, and librarians could be important revolutionaries. References 1 Sackett, D. L. & Haynes, R. B. On the need for evidence-based medicine. Evidence-Based Medicine 1995, 1(1), 5 6. 2 The Cochrane Library, Issue 2, 1999. Oxford: Update Software. 3 Aronson, B. & Bertrand, I. Missing Information: Some Issues Medical Librarians Should Be Thinking About as They Bridge Between Published Information and Delivery of Care. Paper presented at the 5th European Conference of Medical and Health Libraries, Coimbra, Portugal, 1996. 4 Help Box, Help for Health Trust, Highcroft, Romsey Road, Winchester. 5 The National Health Service: a service with ambitions. Leeds: Department of Health. 6 Shepperd, S. DISCERN: An Instrument for Judging the Quality of Written Consumer Health Information on Treatment Choices. Funded by the British Library, 1997. 7 Furnham, A. Lay Theories: Everyday Understanding of Problems in the Social Sciences. London: Whurr Publishers Ltd., 1988. 8 Some Women's Experiences of Epidurals: a Descriptive Study. London: National Childbirth Trust, 1987. 9 Kitzinger, S. Some Mothers' Experiences of Induced Labour. London: National Childbirth Trust, 1978. 10 Cole-Hamilton, I. & McBride, S. Taking the Time: Telling Parents Their Child is Blind or Partially Sighted. London: Royal National Institute for the Blind, 1996. 11 Oliver, S. Users of health services: following their agenda. In: S. Hood, B. Mayall, S. Oliver (eds). Critical Issues in Social Research: Power and Prejudice. Buckingham: Open University Press, 1999. 12 Oliver, S. Exploring lay perspectives on questions of effectiveness. In: A. Maynard, I. Chalmers (eds). Non-Random Reflections on Health Services Research. London: BMJ Publishing Group, 1997: 272 291. 13 Colquhoun, I. & Bunday, S. A lack of essential fatty acids as a possible cause of hyperactivity in children. Medical Hypotheses 1981, 7, 673 679. 14 Stevens, L., Zentall, S. S., Deck, J. L., Abate, M. L., Watkins, B. A., Lipp, S. Essential fatty acid metabolism in boys with attention-deficit hyperactivity disorder. American Journal of Clinical Nutrition 1995, 62, 751 758. 15 Clinical Evidence: a Compendium of the Best Available Evidence for Effective Health Care. BMJ Publishing Group and the American College of Physicians- American Society of Internal Medicine, 1999. Citing Literature Volume17, Issue1March 2000Pages 22-25 ReferencesRelatedInformation

‘Providing access to reliable information for healthcare workers in developing countries is potentially the most cost-effective strategy for improving the quality of healthcare delivery.’1 Yet there are many gaps in our understanding of information needs, and the international community has hardly begun to build a coherent cross-sectoral approach to meeting those needs. The current article will look briefly at the challenge, from an international perspective, of improving access to the practical information needed to deliver the safest, most effective healthcare possible with available resources. It will argue that the international community needs to clarify its approaches to different target audiences. Looking particularly at national ministries of health (MoH) and ministries of education (MoEd) as being the primary holders of responsibility at national level, the article will conclude that a coherent international co-operative approach is needed to complement and strengthen national programmes. In many developing countries, healthcare workers often have little or no access to basic practical information. Indeed, many have come to rely on observation, advice from colleagues and building experience empirically through their own treatment successes and failures. Information is important not only for effective healthcare, but also to support the generation of new knowledge and solutions from the South, and to allow critical interpretation of the relevance and quality of the highly variable new information that is increasingly accessible, particularly through increased access to information and communications technologies (ICT). What information support do healthcare workers need to deliver the best quality of care with the available resources? Needs assessments are limited by difficulty in differentiating ‘wants’ from ‘needs’. All who have undertaken such assessments are familiar with respondents recommending texts published ‘when I was a student’, perhaps 30 years beforehand. Many have little knowledge of appropriate, affordable products that might be currently available—even those produced within their own country. However, there are a few consistent messages from trainers and students alike. All practical information should be clear, simple and appropriate to the target audience. The ability to write plainly and simply is a rare skill that requires a combination of abilities in communication and language, as well as an understanding of the language level of the target audience. Equally importantly, it must be locally relevant —much of the information currently available to healthcare workers in the South is irrelevant to local needs. It must be in a language that is accessible, preferably the first language of the reader. And it must be reliable. Too many health workers in developing countries have to rely on biased information from pharmaceutical companies, out-of-date or irrelevant information from unselective donors in the North, or materials produced without adequate source materials or editorial resources. Information needs to be easy to use and accessible at the point of care. As stated by the Shaughnessy equation ‘The usefulness of any source of information is equal to its relevance multiplied by its validity, divided by the work required to extract the information.’2 A further consistent message is that the introduction of information alone is seldom effective unless it is integrated with training and learning activities. Access to information is not enough in itself for that information to be used and applied effectively, particularly in situations where health workers have previously ‘got by’ without it. There is an important role for trainers to encourage use of materials in libraries or ‘resource centres’, and such resources and collections are currently the only cost-effective way to provide help in finding information and access to relatively large numbers of books, whether through reference or lending systems—the latter often being restricted to the older, less useful texts. (The following is based largely on experience in Africa, but may be applicable to other areas of the developing world.) At national level, and particularly in sub-Saharan Africa, the responsibility for meeting the information needs of healthcare workers generally lies with the MoH and MoEd. Typically it is the training unit of the human resource division within the MoH that is responsible for meeting the needs of in-service healthcare workers plus all pre-service healthcare workers in nursing, midwifery, environmental health and laboratory technology. The current model for the ministry of health to carry out its function is through a dual system of (1) libraries or ‘resource centres’ in training colleges, hospitals, etc. and (2) local production of health learning materials (HLMs), often in partnership with local commercial publishers. Local production needs an increased skills base, particularly in writing and editing, and better access to quality source information. Also, given the need for highly selective prioritization of new publications, commissioners of health learning materials programmes need clear information about what is already available, appropriate and affordable—locally, regionally or internationally. Such information is currently unavailable or highly dispersed. A recent study by Healthlink Worldwide of the National Health Learning Materials Programme (NHLMP) in Ghana illustrates the above. The NHLMP is part of the Human Resources Division of the Ministry of Health and has the responsibility, with very limited resources, of meeting the information needs of some 30 000 preservice and in-service healthcare workers throughout the country. It is meeting this challenge through a dual strategy: support and advice for resource centre staff in hospitals and training colleges across the country, and its own modest publications programme. The main target audience (namely, responsibility) of the NHLMP’s own resource centre in Kumasi is health information workers throughout Ghana—not the local health workers who happen to live near the centre (although the latter would of course be welcome and would probably find the collection at least as useful as an ad hoc collection for health workers). To meet the needs of health information workers—and the commissioning staff of its own publications programme—the NHLMP in Ghana would like to be able to develop (or at least have access to) a unique collection of single reference copies of internationally recognized, appropriate and affordable HLMs for district healthcare workers, published both internationally and within Ghana. In international terms, such an approach would have minimal cost (involving a single selective collection for each country) but would require access to something that does not yet exist: a single authoritative source of information on recommended international publications that is reliable, affordable and appropriate for use by district healthcare workers. The MoEd in most countries is responsible for medical students, dental students and pharmacy students. It is the MoEd that is responsible, for example, for university and medical school libraries. Such libraries are usually the national reference point for medical texts in general, and specialist texts and journals in particular. Their priorities are clearly highly diverse depending on their level of resources, and correspond closely with those of university libraries in general. A detailed analysis of several university libraries in sub-Saharan Africa, including the Muhimbili University College of Health Sciences Library and the University of Zimbabwe Medical Library, can be found in Rosenberg’s University Libraries in Africa. 3 A healthy local publishing industry is essential for sustainable access to relevant health information, not least because there will always be gaps between what is correctly available and affordable internationally, and what is needed locally. Key areas to address include production, dissemination and access to locally or regionally produced materials, and co-publishing of low-cost standard texts. Better access to information on currently available titles might be useful to help plan publications programmes in response to emerging gaps and needs in the market rather than ad hoc contacts and approaches by authors. Local publishers are perhaps particularly important in meeting the needs (in co-operation with ministries of health) of healthcare workers at district and community level, as well as the production of practical manuals and textbooks for training colleges and in-service training. In both cases, personal ownership of appropriate core materials is probably at least as important as access to a resource centre. In the context of the present article, the term ‘international health information community’ refers to all persons with a professional interest in improving access to reliable information for healthcare workers. The field is diverse, and includes representatives of non-governmental organizations and international agencies, publishers, librarians, healthcare worker representatives, educationalists, health information professionals, and communications technologists, among others. The community is a complex web of individuals and organizations, North and South. In 1994 the British Medical Association and INASP (International Network for the Availability of Scientific Publications) hosted a meeting to look at a question that had not previously been addressed in a multisectoral context: How can the international health information community work together more effectively to meet the information needs of healthcare workers in developing countries? 4 The meeting showed that individual organizations were doing excellent work, and professional associations existed to provide sectoral support at global and regional level. However, there was little if any cross-sectoral co-ordination, despite the common objectives of the various players. Partnerships, where present, had formed in an ad hoc fashion, with gaps in coverage and duplication of effort. It could be argued that some approaches had created parallel systems of access bypassing rather than building on national capacity. In general no-one knew who was doing what. The conference called for a complementary cross-sectoral approach to create a shared understanding of needs and priorities, and ways of meeting those needs. To help develop such an approach a neutral focal point was needed, to foster mutual support, to share ideas and to build a foundation of information about health information activities, for the benefit of present and future players. INASP accepted the challenge and developed plans for the INASP-Health programme in consultation with some of the leading players in the UK. With seed money from the UK Department for International Development, INASP-Health was launched in 1996, and continues to be supported by Danida, the British Medical Association and the International Council for Science. The approach is to provide a neutral focal point to build co-operation, analysis and advocacy among organizations involved in health information access. INASP-Health has developed an advisory and referral service with an international network of over 600 organizations and individuals, and is mapping the activities of health information organizations world-wide, as described in the biennial INASP-Health Directory. 5 In 1998, in response to demands from INASP-Health network participants, INASP-Health launched the Health Information Forum (HIF), which shares the objectives of INASP and provides a ‘blank canvas’ to build a picture of information needs and priorities through debate and exchange of ideas, through meetings and e-mail. In line with the principles of INASP-Health, HIF seeks to be transparent, inclusive and neutral, and its remit specifically excludes activities that might compete with existing organizations. It is not in itself a provider of health information, but serves to facilitate interaction among organizations to develop more effective ways of working, both individually and collectively. In future HIF seeks to internationalize its participation and to act more effectively as a platform for healthcare worker representatives and health information workers in the South. It also seeks to strengthen debate and exchange of ideas with related sectors and networks, including educationalists, health communications experts and information professionals. Further information about INASP-Health’s activities, including reports of all Health information Forum workshops, are available on the INASP Website < http://www.inasp.org.uk>. Mapping of activities is one thing. An even greater challenge is to promote the co-operative development of a coherent cross-sectoral approach. The World Health Organization has recently taken up the challenge to work with the ‘health information community’—using INASP-Health services and the Health Information Forum as a tool—to build such a framework for co-operation between WHO and health information organizations. The aim is to develop a strategic framework to clarify priorities and the respective roles of WHO vis-à-vis other organizations, laying the foundation for a more coherent, co-operative approach in the future. The framework will draw on as wide a range of perspectives as possible and will be built co-operatively in open consultation with healthcare worker representatives, health information workers and other sectors concerned with improving access to health information. In conclusion, there is massive potential for international development co-operation in supporting national and local programmes to improve access to reliable information for healthcare workers in developing countries. The international organizations should be clear and informed in their responsibilities and roles relative to one another. And their activities should be demand-led and based on a shared understanding of needs and priorities from national and local perspectives. The author would like to thank Irene Bertrand (Library and Information Networks for Knowledge, World Health Organization), Ana María Cetto (National Autonomous University of Mexico), Francis Devadason (Asian Institute of Technology), Carol Priestley (Director, INASP) and Diana Rosenberg (consultant, INASP) for their valuable comments on the draft of this article.

Up to 83% of the population is employed in service industries in developed countries. Typical service professions are government, finance, commerce, transport, education, medicine, law, religion, libraries, hairdressers and IT. Manufacturers of products from cars to furniture are increasingly concerned about service. A car purchaser may find that the vendor’s service history and facilities are as important as design and engine power. In researching the book Service, it became increasingly clear that service workers, the first-line of communication between customer and corporation, are well aware of both the demands and the importance of service. Managers and politicians, however, often pay lip service to customer service, but to date it has seldom had top priority. Users of services, whether they approach them as customers or, in the case of state-provided services, as citizens, thus encounter obstacles and aggravations such as queues, delays, uninformed personnel, lengthy decision processes, missing goods, errors, lack of information, lack of documentation, and goods or services that are difficult to use. One means of improving this situation is by the adoption of service declarations or agreements. The supplier of the service (government or private) either makes promises regarding service quality to the buyer (citizen, customer, patient, traveller...), or develops an agreement in cooperation with the buyer. The United Kindom, through the Citizens’ Charter programme, has developed more than 10 000 service declarations, with success it seems. However, in response to criticism, a development adjusting the declarations more in the direction of agreements has commenced. A common criticism of many service programmes is that the buyer encounters a rigid and apparently impervious hierarchy when trying to get something done. This is especially so in government, whether at the local or national level. To make things worse, the number of government regulations is increasing in all OECD countries, with inevitable implications for the delivery of services. Figure 1 shows the Norwegian Government task structure. It can be seen to be complex, partly unstructured and ambitious, perhaps over-ambitious. Analysing the figure in terms of service, shows that different citizen needs are addressed—but service was probably not the main reason for organizing Government as it is. One general criticism of government in industrialized countries is that information is difficult to find, and consequently in some cases getting things done is a major undertaking. As an example, written and oral complaints about the UK’s Citizens’s Charter were handled differently (this has changed). In Denmark ‘service offices’ have been established for local government in response to this complaint. Citizens can now turn to a service office that is supposed to take care of their needs. The Danish Government service office located a requested publication 2 hours after a call, and telephoned only to say that the book was in the post. Even service offices are criticised, for creating new hierarchies and handling things differently from case to case. This is where a defined methodology comes in. Service offices resemble IT Help Desks, where a standard has been established for IT service management (BSI Code of Practice PD0005). The IT service management code of practice stipulates for instance that all requests (incidents) should be recorded, and that the person first receiving the request is also in charge of resolving it (even if the actual work is done by others). This ensures that the citizen calling has someone in Government working for her or him on this task, and that it is not ‘forgotten’. NHS Direct was established in Britain on 23 March 1998, and by 1999 is extended to cover more than 40% of the country. The speed of this enterprise is possibly unprecedented in public management, and has been achieved due to enthusiasm among both providers and users, according to feedback. A user of NHS Direct can call a certain telephone number at any time, and talk to a qualified nurse. In more than one-third of the cases, the nurse will help the caller to ‘self-help’, i.e. do things at home that do not require external assistance. In June 1998 ambulances were called for 99 people who did not think beforehand that they required emergency assistance; probably lives were saved. Futhermore in June 1998 only a limited pilot version of NHS Direct was running. Combining the experience from service offices and NHS Direct, we suggest that perhaps all government should be fronted by a Service Office. Citizens can use this facility by telephone, Fax, Internet, letter or meeting personally. The Service Office operates like a huge Help Desk: it records incidents/requests, transfer tasks, follow up, create statistics, etc. Figure 2 shows how the Norwegian Government information could be reorganized. For smooth operation a problem/request handling structure is established, ensuring that no problem or request is lost. Modern technology is used to transfer requests, including all documentation. Existing IT applications can be employed to track problems and requests. Most of this requires only existing technology. A Norwegian local government is implementing a service office, and will man it only with personnel transferred from other functions. NHS Direct was established primarily to save money. The service enables people to do more health work at home, addressing what may be this century’s major problem: how to provide resources to care for the increasing number of elderly and dependent people. Other technology may help, for instance self-testing, and what the book Service calls a ‘Service Home’. This is a variant of the ‘Intelligent Home’, but focuses primarily on service rather than automation. The service home includes full wiring for computer equipment and entertainment. At the same time it features special devices for different handicaps: large reading screens, Braille readers, remotely operated doors and other equipment, scanners that transfer text to speech, etc. Different alarm types are natural components. External services can vary from shopping to chat groups and power checks. If this is established when the house is built, and if the equipment follows national or international standards, researchers estimate that the total cost of the initial wiring will be as low as £1000 (not including special devices). Even for a private family this may be a smart investment. For instance they get one central PC that can be used by everybody in the house—cheaper than giving the children their own. Besides, the central PC may easily be replaced by a more modern model. This is only one instance of the service philosophy. The starting point is the agreement between supplier and buyer. Typically they start out with differing views of what service is, but by working together on the agreement, in modern service terminology they solve problems before they occur (i.e. they avoid problems). Already in the name service agreement, the prime focus is placed on service, not on financial or judicial matters (although they may be part of the agreement). When trying to arrive at a common definition of service, the supplier and buyer typically have to shift their original view, and the end result is often more complex than either imagined at the outset. Components of service include for instance accessibility, responsiveness, reliability, security, information provision, documentation and price. Even aesthetics, empathy, politeness and environmental factors may be important. Most of these components are not interchangeable, even though price may be a common denominator. Often the buyer is also a supplier, to a buyer who can in turn be a supplier. We talk about a service chain, and a bad link in this chain will negatively affect service of all links following it. Having defined what service should be delivered, conclusions follow: for instance to reduce customer queuing, improve information, design for easy use, design for service availability and so forth. The ultimate goal is ‘design for service’. First-line service workers play an important role in this concept. They are the buyer’s first contact and due to this unique position often know his or her needs better than anyone else in the supplier organization. The first-line must be given the ability and the authority to carry out this function well, and an important aspect of authority is information, mostly in form of training or education. Buyer needs may also necessitate a reorganization, for instance to establish ‘closeness’. For example, if ambulance services are to reach a patient 14 min after a call in urban areas, one big head office is hardly the best solution. In general, service principles can be at odds with several modern tendencies, such as centralization, mergers, re-engineering and profit centres. The biggest concern is that service seldom seems to be addressed when such reorganizations are discussed, and at least one American writer suggests that service normally is sacrificed. If customer (or citizen) service is most important for the organization, the conclusions presented above follow. If service is not most important for the organization, perhaps the organization should try to establish what its own role really is. Tore Høie is an IT service consultant and author of the book Service, and can be contacted on fringilla@ah.telia.no. Service—metodikk og ledelse by Tore Audun Høie. Tano-Aschehoug 1999 (Oslo). ISBN 82–518–3812–6.

For much of this century medical schools tended to be rather closed institutions, defending their isolation from social changes on the grounds that the content and methods of education could only be determined by biomedical scientists and clinicians. 1 In the closing years of the 20th century, this position seems less defensible as professional bodies and associations seek to reassure the public that doctors are accountable and responsive to the needs of society. 2, 3 Following the publication of the General Medical Council (GMC) Report ‘Tomorrow’s Doctors’4 in 1993, medical schools across the UK have been reviewing their curricula, their learning resources and their teaching methods to ensure that they are providing the type of education the GMC demands. By the year 2000, all UK medical schools will have implemented a new curriculum with explicit aims and learning objectives, new assessment methods, new forms of delivering the curriculum and new approaches to teaching and learning. In parallel with these changes aimed at producing more independent, life-long learners, there has been major investment in IT infrastructure to support new methods of teaching and learning. 5 Developments in the National Health Service (NHS) have created additional reasons for rethinking and reforming medical education. From the point of view of those responsible for health informatics programmes, the 1990 and 1998 NHS information strategies have provided a vision as to how information can contribute to better patient care and a more effective health service. To achieve the outcomes specified in Information for Health6 educational providers must examine the opportunities and incentives students have to develop knowledge, skills and positive attitudes in relation to the information component of their profession. It was against this backdrop of change that the Council of Heads of Medical Schools, in consultation with the Education and Training Programme in IM&T, commissioned a survey of informatics teaching in UK medical schools to provide evidence as to what medical schools are doing to implement the GMC recommendations in the area of health informatics. The purpose of the survey was to provide baseline data as to what medical schools are doing to prepare students to collect, share and use information, for research, education and patient care. The expectation was that these findings could be used in the future to monitor the impact of the new medical curricula on the teaching of informatics skills. For reasons of time and resources, it was decided to restrict the data collection to the medical schools in London (n = 7) and Scotland (n = 4). Following the recent reorganization of London medical schools, there are now 25 medical schools in the UK, so the survey encompassed 44% of all schools. Approval was sought from the undergraduate deans and postgraduate tutors of all the schools to conduct interviews with librarians, tutors, clinicians and preregistration house officers (PRHOs). All schools agreed to participate on the understanding that the results would be reported in an anonymous fashion and the research protocol would be made available in advance of the site visits. In all, 71 people were interviewed, seven of whom were librarians. Table 1 indicates the roles of the respondents and the numbers in each category. All the recent GMC documents 4, 7, 8 and the 1996 Informatics Report 9 were analysed by the project team to identify statements with an informatics dimension. This exercise generated a set of 17 requirements, which were scrutinized to construct a set of four meta-themes. Table 2 shows the themes. A proforma was constructed for each of the four themes, which provided the focus for the interviews. Table 3 gives details of the proforma relating to education and research. Given the different roles of the respondents, the focus of the interviews was negotiated at the outset of each meeting. Some respondents chose to focus on one or two of the four areas, whilst others were in a position to comment on all four topics. Although most of the interviews were one-to-one, there were some group interviews. Most librarians directed their comments towards the area of education and training. Table 4 shows the number of respondents who made comments about education and research. The interviews were carried out over a 6-month period (January–June 1998). Not surprisingly, in view of the open-ended nature of the interviews, the study yielded a wealth of qualitative data. The interview transcripts were given to an independent statistician who entered the data into a database, looked for common themes and prepared high level summaries. Her analysis was returned to the interviewers to validate. In this report, attention will focus exclusively on what our respondents told us about what they were doing to help students become independent, life-long learners, able to find, evaluate and apply evidence. (For details on the other findings see Murphy et al.10) In view of the qualitative nature of the data, it would be inappropriate to present the findings in a numerical or tabular format. What I have done is adopt the technique of discourse analysis, 11 reading through the narratives and reviewing the database to identify the themes that emerged in our discussions. Quotes or paraphrases are provided to give examples of the comments made by our respondents. What follows is mainly derived from the interviews with the seven librarians in the London schools, but the views of other respondents are included where relevant. Although the numbers of librarians interviewed was small, it is important to bear in mind that we spoke to librarians in all but one of the London medical schools and all held senior posts (Heads or Deputies). As service providers, this group are collectively responsible for more than 4500 undergraduate medical students. Respondents made a distinction between three modes of teaching: formal, timetabled sessions with groups of students; scheduled drop-in sessions (participants self-selected); and more informal, unstructured teaching (ad hoc, on-demand). Medical librarians’ main involvement in the curriculum comes early in the first term/first year of the degree and is quite brief. Most schools run some type of induction course, scheduled in the first weeks of term, aimed at acquainting students with the library facilities and introducing them to information sources. Respondents stressed that it was important to have protected time with students. In some schools it appears that students are expected to turn up to these sessions, while in other schools attendance is more voluntary. Librarians generally organize and run these sessions with no involvement from academic staff. Some schools timetable small groups, but in others students are seen in large groups. Most students are introduced to medline in their induction session. In most of the schools the learning is not assessed (either by formative or summative methods), although one school has introduced worksheets to enable staff to assess students’ competence at the end of the session and to identify those who need additional help. With schools that have a preclinical campus, responsibility for initial training rests with the preclinical (Life Sciences) library staff. This can lead to quite separate, uncoordinated approaches being adopted. ‘The librarians do an introductory session. After that the development of information skills depends on what students are required to do.’ (Senior clinician, with a key role in the new curriculum) Some academics and librarians expressed concerns or doubts about whether the present system adequately prepares students for self-directed learning. ‘… very little effort is made to prepare students for SDL. Students are told about medline and other resources, but after that there is nothing.’ (Medical Educationalist referring to the curriculum that is about to be changed) ‘End users are only capable of doing very basic searches.’ (Medical librarian) Much of the formal teaching about information sources takes place in the early part of the course, therefore clinicians are never involved. Consequently, students may get the impression that what they are being taught is academic, and not really of value to the practising clinician. This interpretation of how students experience the old curricula was reinforced by a comment made by a young PRHO student. When asked whether she uses medline she replied that medline was strictly for students and that she did not have the time to look up articles. Given the restricted time librarians have with students, the main electronic tool to which students are introduced is medline. Although Cochrane may be mentioned, there is often no time for hands-on work. (Some respondents were doubtful as to whether students needed to know how to search electronic databases at the very start of the course.) We encountered dissatisfaction on the part of some curriculum leaders with the current way of introducing students to information sources. The critics thought there was a need for earlier, more structured learning opportunities. They acknowledged that this problem could not be remedied by the librarians; it was up to curriculum planners and module convenors to see that students were given reasons and incentives to become proficient in information retrieval. From what we were told, academics are starting to see that there is a need for more continuous training instead of a one-off introduction to the library. Consequently, many libraries are working to develop and implement a formal programme of training. After the initial introductory session, librarians’ formal contact with students is limited and very much determined by the students themselves and by the nature of the curriculum. ‘Students seek help on an ad hoc basis if they have problems’, was a typical comment. In modules with some type of project work, students are more likely to seek help because they have more focused information needs. Two librarians explained how what they provide in the way of medline training mirrors the curriculum. One school has introduced scheduled ‘drop-in’ sessions for year one students who required additional help. Another school lays on a follow-up session for students before their first special study module. One respondent was very keen on the prospect of more involvement in the curriculum, but felt that current staffing levels would make this difficult. In schools with a preclinical campus, the clinical library provides further training when students transfer as part of the induction programme. Although all the librarians we spoke to expressed an interest in EBM, none was involved in formal teaching for medical students. (Even though some of the respondents were running workshops for other audiences.) According to one of our respondents, the library’s role at present is more to do with the acquisition of materials to support evidence-based practice than with direct teaching of medical students. Teaching about evidence-based medicine (including critical appraisal skills) tended to be the province of statisticians. The view of some academics is that the library is responsible for teaching students the basic skills of accessing and using information, whereas the academic tutors are the ones who deal with critical appraisal skills. One respondent thought that EBM was not having any impact on the way in which undergraduate students search for information. He maintained that interest is much more evident at the postgraduate level. Another person was convinced that EBM is pushing librarians in new directions. He felt that growing interest in evidence-based medicine would help to build bridges between the basic medical sciences and the clinical school. None of the librarians we spoke to was involved in teaching information skills in clinical settings. Many commented on the fact that medline and other electronic resources are rarely available on the wards. At the same time, our respondents thought that if courses were to be offered to clinical students, to succeed they would need to be sponsored by enthusiastic clinical tutors. Some librarians had tried offering courses to third year students but had discontinued the practice because of the very poor attendance. Not all librarians are convinced of the benefit of library involvement in ward-based teaching, fearing that it might be too intrusive. However, those who held this view were still in favour of getting information services to the wards. The trend seems to be for schools to produce their own local, in-house training materials. We were shown a wide range of attractively produced documents. Examples included notes on using medline which students could access on-line, handouts to support sessions on ‘How to find information to solve a problem’, and various worksheets. Several people told us that they were in the process of making their handouts available on the Internet. All the libraries provided multimedia resources (usually CD-ROMs on a stand-alone machine), but there were doubts as to whether students were actually using these resources. Our respondents were convinced that CAL will not be used by students unless it is supported by tutors. Medical Curriculum Groups need to understand that it is not sufficient for librarians to purchase packages and advertise them. Tutors need to be aware of what CAL is available and to actively promote its use. Some felt strongly that only when use of such resources is a compulsory part of a module will students go out of their way to use the materials. A recurrent complaint voiced by our respondents was the lack of academic leadership with respect to electronic learning resources and the absence of an acquisitions’ policy. One librarian had a slightly different view about the provision of multimedia learning resources, in that she felt it appropriate for the library to take the lead in acquiring materials which reinforce and supplement the main teaching. It was clear from what our respondents said that the attitudes and behaviour of students is shaped by their curriculum and the expectations of tutors. With traditional curricula, medical students tend to restrict their reading to textbooks. As one respondent (in a school that had yet to implement a new curriculum) explained: ‘Students are quite instrumental in how they seek for and use information. They do not read around the subject; they do not do much background reading.’ The reason he gave for students’ reliance on very restricted information sources is the fact they are under so much pressure, as a result of a very heavy timetable and many different subjects. Study habits are formed early in the basic medical science phase of the course when students come to expect they will find everything they need in textbooks. This view on information retrieval persists into the clinical years. Another significant influence on students’ approach to information sources is the fact that these skills are not explicitly assessed. One respondent was adamant that what drives students are examinations and their pattern of use of the library mirrors the assessment scheme. To put it bluntly, ‘Medical students are not driven by curiosity but by examinations’. As well as telling us what they were currently doing and their plans for the future, our respondents used the interview to share ideas about their role and the changes that they would like to see in years to come. As one would expect, medical librarians do not necessarily speak with one voice. Their different circumstances and different experiences produce different perceptions about their role. Nevertheless, despite these differences, some common views did emerge. The recurrent messages are summarized below using headers that best seem to capture the meanings of the various conversations. Librarians are critical of the way in which students on the old curricula are prepared for the information management part of their role. There is a general feeling that information management skills need to be part of the formal, explicit curriculum, with adequate time and resources made available to support such programmes. Librarians feel a need for better liaison, closer co-operation and improved communications between themselves, academic tutors, clinicians and curriculum leaders. In the absence of partnerships with their curriculum leaders and teachers, librarians feel their professional expertise may not be recognized and appreciated. When academics emphasize the importance of knowing how to find information, students are more likely to attend workshops and other events run by librarians. Improved liaison is also essential from the point of view of managing library and information services. Those medical schools that have already implemented a new curriculum with significant amounts of self-directed learning, have discovered how important it is for tutors to keep librarians informed about the sorts of activities planned for students so that the library can plan ahead. With the very large cohorts in the newly merged London medical schools (up to 340 per cohort), attention needs to be paid to staggering groups so that not all students are trying to access the same information at the same time. Librarians would welcome the chance to be more involved in curriculum planning and development. This topic came up in nearly all the interviews. Librarians have sometimes felt marginalized from the process of curriculum change by virtue of the fact that in some schools they have not been invited to sit on relevant committees. Although this is starting to happen as schools change their curricula, there is a considerable variation across schools. If librarians are not consulted and made to feel part of the academic community, an ‘us’ and ‘them’ mentality emerges. Under these circumstances librarians expressed dissatisfaction and frustration. They may see how things could be improved but feel powerless to initiate change. Information retrieval skills must be assessed and monitored. One respondent pointed out that an absence of assessment means there is no way of measuring the benefits of the work done by librarians. If students know that assessment criteria for essays will include the ability to locate, cite and reference evidence, these skills will be valued and students will make an effort to develop them. Librarians need to ‘sell’ or market their expertise—to both staff and students. Librarians accept that the onus is on them to change the perception of users as to what they have to offer to ‘customers’. Most students, for example, on arriving at medical school feel that they already know how to find a book in the library. To attract them to a training session, the activity needs a more compelling title, for example ‘How to find information to solve a problem’. Librarians can see where students need help but they need to be able to transform this insight into training sessions, which are targeted to the right groups and linked to the curriculum. Librarians have often been constrained by the design and layout of their premises and poor computing facilities. In London, some libraries have been housed in old buildings, which has made it difficult to create a modern, attractive environment for training. Librarians who were struggling to provide a service in out-of-date buildings spoke of feeling constrained by the architecture. The good news, however, is that considerable investment is taking place—in buildings, networks, hardware and software. The London–Scotland survey suggests that librarians have much to offer medical students, but faculty and students may not fully recognize their expertise. With the introduction of new medical curricula, there is evidence that medical librarians are becoming more involved in both the planning and the teaching process. Up until now most libraries have tended to respond to training needs ‘on demand’, but in future this may no longer be feasible. More structured, assessed training may be inevitable because the pressures on libraries is increasing as they endeavour to serve many more user groups. The two challenges that are likely to have the greatest impact on the role of academic librarians in the next few years will be the growing need to prepare future doctors to search for, appraise and use the best available evidence and the expansion of Internet-based information sources. Once the NHS implements the National Electronic Library for Health (NeLH), health science librarians will have new roles as they become involved in identifying appropriate material for NeLH and training end users to make use of the virtual library. The Institute of Health and Care Development (Education & Training Programme for Clinicians in IM&T) and the Council of Heads of Medical Schools sponsored this research. The other members of the research team were: Stuart Watson, Richard Gordon, Dean Phillips, Neil Hamilton, Jacqueline Furnace, Ivy Cheung, John Williams, Chris Pearson and Alex Lewis. We are grateful to the many academic staff, librarians, clinicians and junior doctors who allowed us to interview them.