Context, Uncertainty and Information Needs of Physicians

7/31/2019 Context, Uncertainty and Information Needs of Physicians

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Context, Uncertainty, and Information Needs Within Clinical Practice

Florence M. Paisey


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The real problem is not whether machines think, but whether men do.

B. F. Skinner

Mendels concept of the laws of genetics was lost to the world for a generation

because his publication did not reach the few who were capable of grasping and

extending it; this sort of catastrophe is undoubtedly being repeated all around us,as truly significant attainments become lost in the mass of the inconsequential.

Vannevar Bush


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Information seeking behavior was related to context in the early eighties

when Wilson (1981) asserted that contextual factors precipitated and prompted

information seeking behavior and use. Wilson identified these contextual factors

as environmental aspects such as the social and cultural environment, the

politico-economic environment, and the physical environment. Since the early

eighties, however, little research has been conducted on the effects of context in

information seeking behavior. Other modes of behavior e.g., social, business,

electronic (netiquette, chat), travel, or educational, have commonly been

contextualized and their appropriateness and productiveness understood on the

basis of prescribed expectations or values assigned to behavior in each role. We

often assign measures of normal or deviant, functional or dysfunctional, excellent

or mediocre based on contextual factors, values, and expectations.

We understand how varying contexts and diverse cultures affect behavior

ones values, habits, health, happiness, motivation, attitudes and cultivation. One

can start with Franz Boaz, Ruth Benedict and Margaret Mead; environment and

context have long been understood as key determinants in human development

and behavior, as abundant anthropological, sociological and psychological studies

have demonstrated. Yet, information scientists have spawned a plethora of

information behavior models that attempt to describe information behavior

without placing it in an environment or context until recently.

Times are changing. Investigations of different aspects of context have

been central concerns in studies of information behavior, information seeking


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processes, and information retrieval over the last decade. Currently, it is

recognized that information behavior occurs within multiple, overlapping

contexts that inform, direct, or shape the character of the informational

interaction (Cool & Spink, 2002).

Information seeking, use, and evaluation take place within

multidimensional contexts(ibid). Recent theoretical models of information

behavior (Belkin, 1996) view context as a core variable or level of analysis in

information behavior and information retrieval. This may be news to the

information world, but psychologists have been talking about context since Pavlov

behavior is behavior is behavior. Ones environment, replete with contingencies,

dimensions, and uncertainties, cannot be divorced from ones life or those events

that impact ones life, both overtly and covertly.

Although the value of context has been recognized, it has defied any single,

precise definition or identification of those elements bearing actual or potential

influence on the relationship of context to information seeking and information

retrieval (Cool & Spink, 2002). Several theorists (Vakkari, 1997; Cool, 1991,

Rieh, 2004 ; Allen, 1997; Sonnenwald, 1999) have pointed out the ambiguous,

interchangeable use between the terms context and situation. Dervin (1997)

describes context as an unruly beast due to the difficulty in gaining

methodological control over it. She asserts that her Sense-Making methodology

can provide a framework for studying human behavior contextually,

incorporating time, space, movement, power, gap, constraint, and force, yet


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finds it a slippery concept to define. In 1997, Dervin commented that there is no

term that is more often used, less often defined, and when defined, defined so

variously as context.

Vakkari (1997) contends that situation and context are used

interchangeably without any effort taken to distinguish between the two

conceptually. Cool (2001) simply refers to the distinction between the two

concepts as murky, while Sonnenwald (1999) attempts disambiguation by

characterizing contexts as embedded in situations.

Talja (1999) defines context as:

frames of reference that allow us to choose

the relevant elements for study and concludes[d]

that one way of explaining and understanding

information seeking phenomena is to define

them as patterns of behavior [while] another way is

to understand them as phenomena mediated

by social and cultural meanings and values (p. 762).

Fundamentally, Talja is looking at those factors or variables observed to affect

individuals information seeking behavior: socio-economic conditions, work

roles, tasks, problem situations, communities, and organizations with their

structures and cultures etcetera(Kuhlthau and

Vakkari, 1999). Though Talja approaches the problem of context from two angles,

they intersect at points of observation, behavior, and elements. These points


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characterize her notion of context as something that can be objectified, though

interpreted within the perspectives of cultural and social meaning.

Cool and Spink (2002) broadly define the parameters of context in an

editorial introduction to a group of papers focusing on user needs and addressing

context in information retrieval. This definition views context as information

environments in which information behaviors occur. While Cool and Spink (ibid)

refer to information environments and information behavior, there is no mention

of information need. In a previous paper by Wilson (1999a) information needs are

said to arise out of complex, interrelated contexts and roles prompted by a person's

physiological, cognitive and affective needs any one of which may be the person

himself, or the role demands of the person's work or life, or environments. With

regard to clinical information behavior, particular attention might be placed on the

context of the person himself the clinicians own sense of competency and

capacity to resolve issues of professionally-related uncertainty.

Cool and Spink (2002) facilitate an understanding of the dimensions of

context by succinctly identifying four levels of context:

Information environment level where channels of communication would beexamined.

Information seeking level where a persons goals or problem resolutionand the means by which one satisfies them would be examined given a

problem definition one looks at context in terms of the information seeking

behavior performed.


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The information retrieval context that examines the interaction between theuser and the system within search sessions.

The information query level where the linguistic context or the interactionbetween a query and the system is examined. (Does the system interpretthe query correctly in terms of the context assigned?)

The notion of context is one which could easily occupy this paper, becoming a

bid of a red-herring, if you will. However, human behavior does not occur in a

vacuum, nor are human beings unresponsive to contingencies event, uncertainty,

and information issues being one repertoire. I will satisfice(Simon, 1957) myself

with the definition offered in Penguins Dictionary of Psychology:

Generally those events and processes (physical

and mental) that characterize a particular situation

and have an impact on an individuals behavior

(overt and covert). The specific circumstances

within which an act or event takes place

(Reber, 1995, p.159).

Reber describes context as all those complex events processes, stimuli, and

patterns that circumscribe a situation, distinguishing context as a descriptor of

situation. In other words, a situation occurs within a particular context. This

definition seems to reflect Sonnenwalds (1999) view.

Ive explored an aspect of the concept of information seeking in context

(ISIC). Physicians practice in particularly complex and distinct environments that


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impose rigid contingencies, critical outcomes, and a multidimensional context on

their work. No physician or clinician can practice effectively and safely outside of

his or her medical context tools required to carry out their work are embedded in

the context. There are, of course, extenuating circumstances that may necessitate

clinical treatment outside of a standard medical context. However, these are

exceptions and do not characterize the professional context. In some

circumstances, remote diagnosis and treatment could be managed through

telemedical devices and would be contextualized and defined on its unique

elements and conditions.

The context of information behavior for physicians is fraught with

complications, obstacles, barriers or, as termed, within Wilsons general

framework of information behavior (1999a), intervening variables. These

barriers or intervening variables exist at the start of the patient encounter and

throughout patient treatment to the end, in any medical situation. It is well to

employ the concept of intervening variables as there are many contingencies, some

of which may interact cohesively or randomly, decreasing uncertainty or

escalating it. These contingencies bear on a clinician, where uncertainty presides

and drives the need for information and subsequent information behavior. In the

context of clinical care, uncertainty and a need for information are implicit with

every patient appointment. Studies relating to how the context of a physicians

work affects information behavior, a physicians pursuit or avoidance of


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information, and informationist strategies to support clinical care occupy the

remainder of this paper.

Balsa (2003) maintains that uncertainty is a powerful force in medicine

and supports Wennberg (1985) in viewing uncertainty as the single most

important influence on a physicians [information] behavior (ibid) implying

that the method by which a physician manages uncertainty will determine the level

of expertise a patient will receive as well as the outcomes of that treatment.

Numerous general models of information behavior view uncertainty as the prompt

triggering an information need and ensuing information seeking behaviors

(Wilson, 1981, 1996, 1999a; Belkin, 2005; Dervin, 1983; Krikelas, 1983;

Kuhlthau, 1993, 1996). Wilson and Kuhlthau both employ the term uncertainty,

while Belkin uses anomaly, and Dervin gaps.

Wennberg (1985) identifies several types of clinical uncertainty:

uncertainty about the patients ailment, uncertainty about whether treatment will

be effective, and uncertainty about a patients personality their ethics and

standards. Balsa (2003) identifies several additional roles of uncertainty,

particularly with groups that differ ethnically from the clinician. Some of these

uncertainties are not traditionally viewed as clinical information needs, however

much they may affect the outcome of treatment. The relationship between doctor

and patient has altered notably since the eighties, though traces of this alteration

have been apparent since the seventies.


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Previous to the eighties, physicians played a role in the therapeutic

relationship characterized as authoritarian or paternal. Few patients questioned a

physicians diagnosis; fewer arrived at the medical consultation with professional

information regarding their ailment or known illness. Physicians carried a

mystique(Plutchak, 2000) and were often felt to be unapproachable and

inscrutable. This loftiness has faded as health care policies have changed,

removing some of the privileges as well as preferred treatment and pharmaceutical

courses that physicians once held in full control. Healthcare costs have soared and

health benefits have decreased as a result of health insurance policies and the

limitations placed on physician reimbursement and treatment. Rather than open

ended consultations with ones physician, medical time is now, virtually, regarded

monetarily, resulting in brief appointments that are routinely scheduled, offering

little time to discuss the way one is feeling, the clinical questions a physician has

time to ask, and the health-related questions a patient may need to ask. Though the

physician may still be the source of diagnosis and treatment, the informed, health-

literate patient arrives at the clinic or the physicians office prepared with a series

of questions, often written as a time-saving list. These questions are clinical

questions to which a patient either receives an answer or doesnt.

Gorman (1995) identifies four categories of clinical needs, yet relates none

of these needs to the notion of uncertainty, anomaly or gaps. If there were no

stimulus/uncertainty (anomaly, gap) no problem, no clinical question, or

clinical information would exist or be necessary. It seems the issue of uncertainty


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is vital in gaining a full or holistic account of the doctor/patient encounter. The

four categories that Gorman (ibid) identifies include:

Unrecognized needs: inferred by measurement of physicianknowledge or observation of clinical practice.

Recognized needs: those articulated by the physician. Pursued needs: information seeking behavior is either observed or

recalled at a later time.

Satisfied needs: those needs for which information has been neededand for which information as been found and satisfied.

Gormans identification of unrecognized needs serves as a crude gauge of

many uncertainties and problems that critically affect patient care, yet go

unreported as they may not be viewed as clinical in nature. Since the IOM reports,

To Err is Human(1999) and Speaking of Health(2002) policy centers and the

Centers for Disease Control have identified dimensions of the doctor/patient

relationship as of clinical concern, and identified these concerns as issues of health

care. Uncertainty, as it relates to information needs and seeking, may insidiously

cause corrosion in doctor/patient relationships. These unrecognized needs,

activated by uncertainty are discussed briefly.

One obvious, fundamental way in which uncertainty can affect clinical care

is in the physicians own confidence in their skills. This variable or source of

uncertainty results in varying behaviors. Such uncertainty may inhibit the

initiation of information behavior, resulting in a barrier or placebo-like treatment.

It may trigger vital information seeking behaviors that may include consulting


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other physicians, or it may result in a referral to another physician or specialist.

The relationship a physician has with himself/herself will decisively influence

their efficacy as a clinician and incentive to resolve clinical uncertainty through

purposive goal-oriented information behavior.

Uncertainty also arises from the variables inherent in complex subjective,

or discretionary tasks demanded in diagnostic and therapeutic evaluations. This

uncertainty arises from the diagnostic ambiguity of clinical symptoms, laboratory

tests, and unresolved differences of opinion or perspectives regarding the

reliability of diagnostic and laboratory interventions. Numerous other sources of

uncertainty affect a clinicians treatment.

The Institute of Medicine (IOM, 2002) has identified language and cultural

barriers as significant sources of mistrust, misunderstanding, and misdiagnosis.

Various forms of communication barriers significantly affect doctor/patient

relationships and account for considerable noise or uncertainty, and mistrust. A

few communication barriers have been identified and may be briefly discerned as:

Possible (and frequent) miscommunication between clinician andpatient.

Inability of the patient to understand the physicians direction,diagnosis, and/or prescribed treatment.

Doubt about quality and reliability of the clinicians assessment,particularly when cultural barriers exist.

Communication noise between physician and patient may interferewith a patients confidence in the physicians judgment resulting in

non-compliance with prescribed treatment.


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It is clear that a physician faces a multilayered, multidimensional set of

uncertainties during a doctor/patient encounter, particularly with a new patient.

Those behaviors outlined above are sources of uncertainty that arise in a routine

context with ostensibly few complicating clinical variables. Yet, many of these

sources of uncertainty underlie the performance of critical health-related behavior

(IOM, 2002; 1999).

Wilson (1999) maintains that information behavior is relevant to levels of

uncertainty and the solution of a problem or resolution of uncertainty. He argues

that an individual progresses from uncertainty to increasing certainty through

identifiable stages in a problem resolution process. The need to reduce

uncertainty underlies purposive, goal-seeking behavior, identified as information

seeking behavior. Basically, he views information behavior as a problem-solving

process based on the notion of uncertainty reduction.

Wilson et al. (2002) conducted a qualitative study of uncertainty and

information seeking as it relates to Wilsons problem solving model (1999a) and

factors originating in Ellis behavioral model, and Kuhlthaus process model.

Wilson et al. (ibid) found that the uncertainty concept served as a useful variable

in understanding information behavior. This finding supports the long-standing

notion that uncertainty brings about information seeking due to a lack of

understanding, a gap in meaning, or a limited construct (Kuhlthau, 1993a).


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In a case study where one subject was a medical resident, Kuhlthau (1996)

looked at the relationship between uncertainty and the complexity of a task. The

medical resident reported that the complexity of the task affected her approach to

information seeking. Complex tasks were identified by the participant as those

needing substantial searching to acquire adequate information to meet her

information goals.

Kuhlthaus (ibid) findings support the notion of redefining roles and tasks

associated with providing information service in the workplace. The medical

resident in this study identified four levels of informational assistance she had

encountered during her medical training. Three informational encounters with

librarians were ineffectual; the first was described as just a room of journals;

the second was described as just a person who sits behind the desk and has the

job of filing things; the third was described as a real library where the librarian

does searches for you; the fourth was described as quite apart from the others.

When asked about the fourth librarian the resident described her as

collaborative and interactive. The resident explained that when she gave the fourth

librarian some keywords she would respond with what about this, and what about

that, and let me see what I come up with. She regarded her as helpful to have her

there and be able to interact. This fourth librarian was engaged with the

researcher and associated information needs. The characteristics of the effective

librarian advised on resources and process in addition to interpreting and

connecting disparate pieces of information. This interactive librarian differs


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from the traditional librarian whose role or relation to the patron has been more

passive, providing access to references and sources on a particular topic.

While the medical resident in Kuhlthaus (1996) study understood that the

complexity of the task influenced her information behavior, she provided only a

general statement about how she dealt with the complexity of a task complex

tasks required substantial searching to acquire adequate information to meet her

information goals. In this case an intermediary, the librarian, performed her

substantial searching. For whatever reason, she did not manage the task herself.

Kuhlthau (ibid) supported her notion of redefining roles and tasks in the

workplace by illustrating the difficulty a medical resident experienced in seeking

information that would address a complex task or problem. The context of this

study involved research that a medical resident was conducting, either to resolve a

clinical problem that arose in a clinical context or a research problem that an

instructor or professor had assigned.

In either context, the task for which the resident required intervention was

perceived as a complex task, a task that the resident could not perform herself and

required information to meet her goal. In this scenario the librarian (either in a

hospital or university) intervened by locating sources and assisting with the

interpretation and integration of information, reducing the residents uncertainty,

or anomalous state of knowledge.

The more complex the task the greater the potential uncertainty and need

for information. The complexity of a task is a central feature in determining


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consequent information needs (Vakkari, 1999). The concept of

predeterminability and structuredness are both features of task complexity, or

perhaps task architecture. If one has prior knowledge of a task, one can determine

its structure and consequently the information required for its accomplishment,

reducing uncertainty. The more one knows about the dimensions or structure of a

task, the less complex it becomes. Complex tasks are new and genuine decision

tasks where the information required for accomplishment can not be determined in

advance (Vakkari, 1999). Such tasks, particularly of a critical nature, in a time

constrained context, require intervention.

Clinical medicine is a fertile source of scenarios that illustrate the

complexity of tasks where the information need may be unexpressed or

imperfectly understood. The strategy one employs in approaching complex tasks

in the context of clinical medicine may also differ as one extracts, synthesizes, and

applies knowledge to a clinical problem complicated by all those elements that

individual personalities bring as patients.

It is well to understand information behavior as a form of human activity in

an attempt to understand human lifehow individuals and groups behave in

varying cultures, what is of significance and meaning, what we can do to improve

conditions, ensuring quality life. Over the last two decades, scientific and

technological developments have led to the means of producing and distributing

information in exponentially greater quantities. Electronic communication has

impacted and transformed the tools we employ to communicate and interact in


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society and culture. It has added yet another tool that socio-economic affluence

will offer to those who have it, yet deny the tool to those who havent. New

expressions to communicate this impact have emerged: the digital divide, the

global South, the World Information Society Day (sponsored by the U.N.).

As information has become more and more profuse, the process of finding

needed information has also changed. Quality sources are buried among tiers of

sources, some relevant, some disreputable, all requiring the skill of discernment.

This process of identifying required sources amid abundance is a sophisticated

skill, but of enormous importance. Within the an incomprehensible quantity of

information, is a slim slice of knowledge or piece of information that can save a

life, forecast disaster, manufacture fuel. The problem information professionals

face is developing interactive indexing and retrieval systems that provide efficient,

accurate access when we need it, where we need it, and how we need it with

efficiency and ease. These systems can be designed and built, but first, it is

necessary to understand the information behavior characteristics of specific user

populations, and build systems that complement and meet their needs.

No profession is in greater need of possessing such technology and skill

than medicine. The proliferation of information in medicine is endemicmore

information is produced, more research is conducted, more papers are published.

How does one keep up, and if not keep up, simply gain accurate, efficient access?

Right now, most clinicians dont; a scant few who research and practice in


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bleeding-edge research and teaching hospitals do, but how many patients reach

those few?

Practicing medicine well, and applying current research findings, requires

expert management as well as innovative information systems, finely organized

with ground-breaking retrieval features. Information overload requires

professionals trained in information management as well as expert knowledge

managers who can search these systems once theyre built. Ultimately, one would

want an information system so intuitive, so efficient, that any literate search,

within context, could satisfy a question put to it. Evidence-based, point-of-care

medicine will drive this effort, but, these systems have yet to be built, and

information behavior has yet to be adequately understood to design such systems.

Many systems have already been built, but few have come systems are still too

inefficient, too imprecise, too crude to be effective for general practitioners.

To illustrate the proliferation of medical literature and the urgent need for

advanced retrieval systems, one might consider that about two million biomedical

articles are publishedeach year. A physician would have to read six thousand

articles a day to keep up with all possible relevant biomedical literature

(Verhoeven, 1999). And if that isnt sufficiently staggering, consider that

biomedical literature has grown 267% in ten years (ibid) and the rate of

publication is still climbing. In view of this quantity of biomedical literature, when

practicing clinicians are uncertain and perceive an information need, they need to

engage in effective information searching behavior.


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Leckie et al. (1996) performed a meta-review of information seeking

characteristics of physicians and healthcare workers (among other professionals).

They found that the range of information behavior among physicians in the role of

clinician varied significantly and organized their reported findings as variable-

related differences relating to context, demographics, and complexity. Variables in

reported specialties included: the focus of patient care, and those who looked at

psychological aspects of illness. Variables in information behavior were widely

scattered and identified as:

The specialty or discipline Experience, Age Type of practice Location or work site The number of questions posed.

The number of questions answered. The size of the primary hospital.

In terms of patient care surgeons focused on routine monitoring,

While pediatricians looked at what psychological effects may be influencing the

illness. Recent graduates were contrasted with the variable of age use of library

resources, and books increased with recency of training, and consultation with

colleagues decreased as physicians grew older. This demographic of age as a

descriptor of information behavior may be questionable. Does age predict

information behavior or some other variable? A more recent study by Ely (1992)


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refuted age as a descriptor, finding no significant difference between those

demographics. It seems that looking at age as a demographic variable has some

inherent bias. Recent clinicians may have been researchers during early years,

changing to practice later. Those who choose to practice when young or as recent

graduates, may re-tread as researchers and lecturers. Often, particularly in higher

end practices, clinicians do both, practice a few days while teaching and

researching others. As stereotypical notions regarding any population, in this

caseage, fade, a more accurate notion of what drives professionals to scholarly

literature may surface.

Type of practice or specialty were found to influence information behavior

or methods of research. General practitioners used unsolicited medical literature

and consulted colleagues. Ob/Gyns preferred consultations with colleagues, rather

than research professional literature or other sources. Internists were found to

prefer journals and textbooks, while family practitioners consulted colleagues.

Those clinicians working in an urban setting were found to use colleagues more

than in other locations and clinicians in institutional practice informally consulted

colleagues.

A significant area of concern that Leckie et al. did not deliberate regards

questions and time. Those physicians practicing in urban areas asked more

questions given time, but pressured by a heavy case load, tended to ask the fewest.

The statistics reported on answering questions were particularly disconcerting.

Covell (1985) as cited by Leckie et al. (1996) reported that only 30% of perceived


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and recognized physician information needs were met; this finding was

corroborated by Murrays (1992) finding that only 1 out of 4 questions arising

from a patient visit was met. Given that statistic, 75% of physician information

needs are unsatisfied.

Leckies research on the information seeking of professionals was

published in 1996, a decade ago. Her findings were based on literature researched

and published prior to that, some back to the eighties. It would be interesting if she

conducted the same study now, comparing data. Much more information on types

or categories of clinical questions are available Ely et al. (2000) have developed

a taxonomy of clinical questions in order to better understand the information

needs of clinicians.

Verhoeven (1999) conducted an extensive study on the information needs of

general practitioners, offering a rich source of information on their clinical

uncertainties, information needs, and information seeking behaviors.

Leckie et al. (1995) produced a general model of information seeking for

professionals, based on their literature review. The model identifies work roles

and tasks as fundamental to understanding a professionals (in this case, clinicians)

practical information needs. Context was not included in their model, although it is

implicit that contextual elements and structure will impact work performed in

varied sites. According to their model of information seeking, the user is identified

as seeking information with the objective of outcomes. No behavioral strategies,

such as Ellis model or Kuhlthaus are included in this model. It seems that such


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strategies are assumed in the seeking process. Outcomes, in a clinical sense could

be interpreted as laboratory results, or any diagnostic technology employed to

provide clinical information, aiding in a diagnosis. It seems that if outcomes

suggest some ambiguity or uncertainty, the model depicts the user seeking

information from sources. Sources, in the model, remain unidentified.

The strength of Leckies model lies in her contextualization of information

needs and the connection of context to a professionals role and consequent tasks.

There are a few weaknesses: the lack of identifiable behaviors in seeking

information in sources and the lack of reference to who will do the information

seeking. In view of the vast sources of clinical research findings and publications,

it seems unrealistic to expect physicians to conduct information seeking as a

matter of routine. Clearly there are some issues that are best handled through ready

reference or possibly a simple search. However, if 75% of clinical questions go

unsatisfied, it is clear that not only do systems require greater efficiency, but a

professional skilled in dealing with clinical questions and biomedical literature

would be of great service.

This paper has only skirted over the issues that the medical professional is

facing with regard to clinical context, uncertainty, information needs, and

searching. It is clear that research findings are not being used optimally, and

cannot be use optimally, given the amount of biomedical literature available and

the time it takes to search, filter the search and identify studies of direct relevance

to the immediate clinical information need. Davidoff and Florance (2000)


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proposed that a clinical librarian, an informationist, as they have termed the

specialization, take on a clinical role as an integral member of a clinical group

with a specialized expertise that can contribute vitally to clinical situations. The

clinical librarian would read the full text of pertinent articles, extract relevant

findings, write up a synopsis and present the research findings on rounds.

With evidence-based medicine at the door, information overload, patient

overload, and research findings that are lying in waste, unread, and unknown to

the general practitioner in all specializations, the concept of a clinical librarian, an

informationist, standing tall on a medical team and ready to pick up on any clinical

uncertainties expressed or unperceived is a rescue conscientious clinicians would

welcome with open arms. How will such a librarian be trained? Who will pay?

These are the issues on the table. But, as Scott Plutchak, President of the Medical

Library Association has said, If you think the information profession has changed

over the last few years, you aint seen nothing yet. (Plutchak, 2000)

References


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Agosto, D. E., & Hughes-Hassell, S. (2005). People, places, and questions:

An investigation of the everyday life information-seeking behaviors of urban

young adults. Library & Information Science Research, 27(2), 141-163.

Belkin, N. J. (2005). Anomalous state of knowledge. In K. Fisher (Ed.),

Theories of Information Behavior. New Jersey: ASIS&T.

Booth, A. (2005). The body in questions. Health Information and Libraries

Journal, 22(2), 150-155.

Bystrm, K. (2002). Information and information sources in tasks of

varying complexity. Journal of the American Society for Information Science and

Technology, 53(7), 581-591.

Cool, C. (2001). The concept of situation in information science. In M. E.

Williams (Ed.), Annual review of information science and technology (Vol. 5).Medford, NJ: Learned Information.

Cool, C., & Spink, A. (2002). Issues of context in information retrieval

(IR): an introduction to the special issue Journal or Information Processing

Management, 38(5), 605-611.

Coumou, H. C. H., & Meijman, F. J. (2006). How do primary care

physicians seek answers to clinical questions? A literature review. Journal of the

Medical Library Association, 94(1), 55-60.

Covell, D., Uman, G., & Manning, P. (1985). Information needs in office

practice: are they being met? Annals of Internal Medicine, 103, 596-599.

Davidoff, F., & Florance, V. (2000). The informationist: a new health

profession? Annals of Internal Medicine, 132(12):996-8.(12), 996-998.

Dervin, B. (1997). Given a context by any other name: methodological

tools for taming an unruly beast. In P. Vakkari, R. Savolainen & B. Dervin (Eds.),

Information seeking in context: proceedings from an international conference in

information needs, seeking, and use in different contexts (pp. 13-38). London:

Taylor.

Dervin, B. (2005). What methodology does to theory: Sense-making

methodology as exemplar. In K. Fisher (Ed.), Theories of Information Behavior

(pp. 25-29). New Jersey: ASIS&T.

Edwards, E. (1964). Information Transmission. London: Chapman & Hall.


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25

Elfreda, A. C. (1991). Life in a small world: Applicability of gratification

theory to information-seeking behavior. Journal of the American Society for

Information Science, 42(6), 438-449.

Ellis, D. (2005). Ellis' model of information seeking behavior. In K. Fisher

(Ed.), Theories of Information Behavior. New Jersey: ASIS&T.

Ely, J. W., Osheroff, J. A., Ebell, M. H., Bergus, G. R., Levy, B. T.,

Chambliss, M. L., et al. (1999). Analysis of questions asked by family doctors

regarding patient care. BMJ, 319(7206), 358-361.

Ely, J. W., Osheroff, J. A., Gorman, P. N., Ebell, M. H., Chambliss, M. L.,

Pifer, E. A., et al. (2000). A taxonomy of generic clinical questions: classification

study. BMJ, 321(7258), 429-432.

Fisher, K., Erdelez, S., & McKechie, L. (Eds.). (2005). Theories ofinformation behavior. Medford: ASIS&T.

Florance, V., Guise, N., & Ketchell, D. (2002). Information in context:

integrating information specialists into practice settings. Journal of the American


Ford, N. (1999). IR and creativity: towards support for the original thinker.

Journal of Documentation, 55(5), 528-542.

Foxlee, R. (2003). The information specialist in the clinical team: buildingexpertise in evidence-based healthcare. Paper presented at the 10th Asia Pacific

Special Health and Law Librarians Conference, Adelaide, Australia.

Fuller, S., Ketchell, D., Tarczy-Hornoch, P., & Masuda, D. (1999).

Integrating knowledge resources at the point of care: opportunities for librarians.

Bull Med Libr Assoc. , 87(4), 393-403.

Gaslikova, I. (1999). Information seeking in context and the development

of information systems. Information Research: an international electronic journal,

5(1).

Glimcher, P. W. (2005). Indeterminacy in brain and behavior. Annual

Review of Psychology, 56(1), 25-56.

Gorman, P. (1995). Information needs of physicians. Journal of the

American Society for Information Science, 46(10), 729-736.


26/29

26

Inglis, I. (2000). Review: the central role of uncertainty reduction in

determining behavior. Behavior, 137(12), 1567-1599.

IOM. (1999). To err is human: building a safer health system. Washington,

D.C.: The National Academies Press.

IOM. (2002). Speaking of health: assessing health communication

strategies on diverse populations. Washington, D.C.: The National Academies

Press.

IOM. (2004). Health literacy: a prescription to end confusion. Washington,

D.C.: The National Academies Press.

Jarvelin, K., & Wilson, T. (2003). On conceptual models for information

seeking and retrieval. IRinformationresearch, 9(1).

Keeling, C., & Lambert, S. (2000). Knowledge Management in the NHS:

positioning the healthcare librarian at the knowledge intersection. Health Libraries

Review, 17(3), 136-143.

Ketchell, D. S., St. Anna, L., Kauff, D., Gaster, B., & Timberlake, D.

(2005). PrimeAnswers: A Practical Interface for Answering Primary Care

Questions. J Am Med Inform Assoc, 12(5), 537-545.

Klein, M., & Ross, F. (1997). End-user searching: impetus for an

expanding information management and technology role for the hospital librarian.Bulletin of the Medical Library Association, 85(3), 260-268.

Kuhlthau, C. (1996). The concept of a zone of intervention for identifying

the role of intermediaries in the information search process. Paper presented at the

ASIS 1996 Annual Conference Proceedings, Baltimore, Maryland.

Kuhlthau, C. (2006). The information process: a search for meaning rather

than answers. 2006, from

http://www.scils.rutgers.edu/~kuhlthau/Search%20Process.htm

Kuhlthau, C., & Vakkari, P. (1999). Information seeking in context (ISIC).

Information Processing and Management, 35, 723-725.

Leckie, G., & Pettigrew, K. (1997). A general model of the information-

seeking of professionals: role theory through the back door? . Paper presented at

the Information Seeking in Context: Proceedings of an International Conference


27/29

27

on Research in Information Needs, Seeking, and Use in Different Contexts,

Tampere, Finland.

Leckie, G., Pettigrew, K., & Sylvain, C. (1996). Modeling the information

seeking of professionals: a general model derived from research on engineers,

health care professionals, and lawyers. Library Quarterly, 66(2), 161(133).

Marchionini, G. (1998). Information seeking in electronic environments.

Cambridge: Cambridge University Press.

Maviglia, S. M., Yoon, C. S., Bates, D. W., & Kuperman, G. (2006).

KnowledgeLink: Impact of Context-Sensitive Information Retrieval on Clinicians'

Information Needs. J Am Med Inform Assoc, 13(1), 67-73.

Miller, G. (1968). Psychology and Information. American Documentation.

Plutchak, S. (2000). Informationists and librarians. Bulletin of the Medical

Library Association, 88(4), 1-3.

Richardson, J. V. (1999). Understanding the reference transaction: A

systems analysis perspective. College & Research Libraries, 60(3), 211-222.

Sackett, D., William Rosenberg, J. A. Muir Gray, Haynes, R. B., &

Richardson, S. (1996). Evidence based medicine: what it is and what it isn't British

Medical Journal, 312, 71-72.

Schulz, A., & Luckmann, T. (1974). The structures of the life-world.

London: Heinemann.

Schwartz, K., Northrup, J., Israel, N., Crowell, K., Lauder, N., & Neale, A.

V. (2003). Use of on-line evidence-based resources at the point of care. Family

Medicine, 35(4), 251-256.

Shershneva, M. B., Slotnick, H. B., & Mejicano, G. C. (2005). Learning to

use learning resources during medical school and residency. Journal of the


Shipman, J., Cunningham, D., Holst, R., & Watson, L. (2002). The

Informationist Conference: report [special report]. Journal of the American


Simon, H. (1957). Models of man -- social and rational. New York: Wiley

& Sons.


28/29

28

Sonnenwald, D. (1999). Evolving perspectives of human behavior:

contexts, situation, social networks and information horizons. Information

Processing and Management, 36(3), 461-479.

Soo Young, R. (2004). On the web at home: information seeking and websearching in the home environment. J. Am. Soc. Inf. Sci. Technol., 55(8), 743-753.

Spink, A., Wilson, T. D., Ford, N., Foster, A., & Ellis, D. (2002).

Information-seeking and mediated searching: theoretical framework and research

design. Journal of the American Society for Information Science and Technology,

53(9).

Sundin, O. (2000). Brief Communication. Qualitative research in health

information user studies a methodological comment. Health Libraries

Review, 17(4), 215-218.

Swinglehurst, D. A. (2005). Information needs of United Kingdom primary

care clinicians. Health Information and Libraries Journal, 22(3), 196-204.

Talja, S., Keso, H., & Pietilainen, T. (1999). The production of "context" in

information seeking research: a metatheoretical view. Information Processing and

Management, 35, 751-763.

Tarczy-Hornoch, P., Kwan-Gett, T., Fouche, L., Hoath, J., Fuller, S.,

Ibrahim, K., et al. (1997). Meeting clinician information needs by integratingaccess to the medical record and knowledge resources via the Web. Paper

presented at the Proceedings of the AMIA Annual Symposium.

Taylor, R. S. (1985). Citation Classic - Question-Negotiation and

Information Seeking in Libraries. Current Contents/Social & Behavioral

Sciences(47), 24-24.

Vakkari, P. (1997). Information seeking in context: a challenging

metatheory. In P. Vakkari, R. Savolainen & B. Dervin (Eds.), Information seeking

in context: proceedings from an international conference in information needs,

seeking, and use in different contexts (pp. 451-464). London: Taylor Graham.

Vakkari, P. (1999). Task complexity, problem structure and information

actions integrating studies on information seeking and retrieval. Information

Processing and Management, 35, 819-837.


29/29

29

Verhoeven, A. (1999). Information seeking by general practioners.

University of Groningen, Groningen.

Vygotsky, L. (1978). Mind in society: the development of higher

psychological processes. Cambridge, MA: Harvard University Press.

Webb, R. E. (1995). Platform for change: the Medical Library Association's

response to the professional development challenge. Health Libraries Review,

12(1), 23-27.

Wilson, T. (1999). Exploring models of information behavior: the

uncertainty project. Information Processing and Management, 35, 839-849.

Wilson, T. (2000). Human Information Behavior. Information Science

Research [special issue], 3(2), 48-55.

Wilson, T. (2000). Models in information behavior research. Journal of

Documentation, 55(3), 249-271.

Wilson, T., Ellis, D., & Ford, N. (2000). Uncertainty in information

seeking. InformationR.Net.

Wilson, T., Ford, N., Ellis, D., Foster, A., & Spink, A. (2002). Information

seeking and mediated searching. Part 2: uncertainty and its correlates Journal of

the American Society of Information Science and Technology, 53(9), 704-715.

Wilson, T. D. (1981). On user studies and information needs. Journal of

Librarianship, 37(1), 3-15.

Wilson, T. D. (1999). Models in information behaviour research. Journal of

Documentation, 55(3), 249-270.

Wilson, T. D. (2005). Evolution in information behavior modeling:

Wilson's model. In K. Fisher (Ed.), Theories of Information Behavior. New Jersey:

ASIS&T.

Wilson, T. D., & Walsh, C. (1996). Information behaviour: an inter-

disciplinary perspective (a report on a review of the literature): British Library

Research and Innovation Report.

Yoon, S., Kaufman, D., Mendonca, E., Cimino, J., & Johnson, S. (2004).

Scenario-based assessment of information needs. International Medical

Informatics Association

Documents

Context, Uncertainty and Information Needs of Physicians