In floods of rancid bile o'erflows: the poetry of medicine

evoted to the mystic practice of healing, the priests of Aesculapius chanted their shamanistic verses long before scientific investigation was introduced into medicine. Over the ages poets good and bad (mostly bad) have communed with their medical muse and set down their deepest sentiments in the special language of symbol and metaphor. However halting or quirky their rhyme and metre, no matter the annihilating banality of their theme or the bottomless bathos of their bavardage, the poets of medicine have left their mark. The magic of poesy has cast its brilliant light on the unfairly neglected subjects of dissection and digestion, sanitation and elimination.

Medical librarians have been alert to these alternative interests of the physicians whose massive clinical texts accumulate on our library shelves. Whatever our own personal feelings may be regarding the poetic or other literary effusions of our patrons, we should not fail to add them to our collections. For example, Jack Coulehan, M.D., M.P.H., has recently published Primary Care (University of Iowa Press), a collection of poems written by physicians who reflect in verse on the uncertainty, pain, anger, sympathy, longing, skepticism, desperation, and love they observe in their patients and often experience themselves. Dr. Coulehan has also edited Blood and Bone: Poems by Physicians.

The thin line between good taste and travesty is easily crossed, however, when medicine is the muse. I have taken a particular interest in those poets, whether medically trained or not, who ostentatiously occupy the other side of that significant divide. In this post I have brought together an evocative collection of my favourites.

John Keats, sweet singer of the English Romantics, studied medicine and died young. In the short time he had to compose some of the greatest poems of the English language, Keats perhaps wisely avoided the daunting task of creating odes or sonnets on the spleen or the perils of gossypiboma. Yet he was no stranger to life's vicissitudes, for he watched his brother die slowly of consumption, and himself succumbed to the same illness a few years later:

Here, where men sit and hear each other groan;
Where palsy shakes a few, sad, last grey hairs,
Where youth grows pale, and spectre-thin, and dies. (Ode to a Nightingale)

For Keats, poetry and medicine could and did share many ideological threads, among them being his theory of "negative capability." It required a certain clinical detachment and strong powers of observation honed by hours of squinting at cadaver dissections to form the basis of that world view. But despite all his concerns about etiolated youth, alone and palely loitering in unhealthy fens and drafty towers, you will find none of Keats' verse below. His negative capability did not extend to meditations on chyle or sexually transmitted diseases. Nor is William Carlos Williams's work represented. Famous for the modernist minimalism so beautifully expressed in his The Red Wheelbarrow, Williams versified little of his experience as a physician. No red gurneys haunt our modern poetic sensibility.

No, the poets here gathered are special. Some were physicians, but most were mere human beings. What brings them together is their intemperate desire to write on medical subjects, an obsession matched only by their want of taste and utter lack of talent. They have experienced the world through the gimlet eye of the surgeon, the peculiar exudations of the funeral parlour, and the horrors of the dentist's chair. They have dropped dripping literary specimens into pails and left ample swatches of gauze after sewing up thoracic cavities. It takes special courage and determination to mount the heights of Parnassus with paeans to ditches, drains, embryos, bloody scalpels, and intestinal flora. Indeed, only the most sensitive of souls could write an elegy on a dissected puppy or a smothered child.

Drawing upon this rich and redolent tradition, the writing of medical poetry continues today. Not content with the themes and visual imagery of traditional English poetry, it challenges our inner eye and nostril with a singular corpus of verse, a very human afflatus that cuts like or can be cut with a knife. As Kathleen Béres Rogers reminds us:

Indeed, one could say that modern-day medical poets and patients repeat the traditionally conceived Romantic project, expressing a “spontaneous overflow” of “powerful emotion, recollected in tranquility”: after the diagnosis, the surgery, the recovery, or the death. Yet by writing their poems, medical poets—now and then—remind us that our bodies also exist as a part of the natural world, defined by both their sublimity and materiality. (Medical poems and the Romantic rise of disciplinarity. Thesis. University of North Carolina at Chapel Hil, 2007, p. 151.)

Each year the human body excretes its own weight in bacteria. Here is an earthy subject of a sublimity and materiality perfectly fitted to the imaginative powers of the poets gathered together in this little anthology. How sad that as yet no English poets have applied themselves to this formidable reality of human existence. We are the lesser for it.

The poems and fragments assembled below, spanning a period of many centuries, are arranged thematically. Readers are encouraged to be moderate in their perusal of the collection, for too rich a diet of this poetry of medicine could require the attentions of a physician.


Anatomy

A MOOD OF MADNESS

Two loves found refuge in my happy heart,
One for my bride, one for the healing art;
Each of my spirit claimed an equal part.

But, as my talent rose and waxed mature,
Love for my bride became more insecure,
Love for anatomy more deep and pure.

She was a subject to my eyes alone;
Not woman, forsooth, but so much flesh and bone,
Sinew, and blood, and skin, which were my own.

And I had lawful right, with foul intent,
I who for progress on this sphere was sent,
To use her body for experiment.

So in her wine I dropped consuming blight,
One moaning, shadow-haunted winter night,
And, watching, clutched my scalpel's handle tight.

Then, ere her eyes, that agony expressed,
Had closed forever, with impatient zest,
My hands were red dissecting her white breast.

Francis Saltus Saltus (1849-1889)



AN ELEGY TO A DISSECTED PUPPY

Sweet Dog! now cold and stiff in death,
What cruel hand enticed thee here?
Did toothsome crust of juicy bone
Allure to stretch on thy bier?

... ruthless hands of alien race
Are opening up thy quiet breast,
With prying eyes they peer within,
Explore the contents of thy chest.

Georgia Bailey Parrington (fl. 1907)



from THE COURSE OF TIME, Bk. VII

And as the anatomist, with all his band
Of rude disciples, o'er the subject hung,
And impolitely hewed his way, through bones
And muscles of the sacred human form,
Exposing barbarously to wanton gaze
The mysteries of nature, joint embraced
His kindred joint, the wounded flesh grew up,
And suddenly the injured man awoke
Among their hands, and stood arrayed complete
In immortality—forgiving scarce
The insult offered to his clay in death.

Robert Pollock (1798-1827)


MRI

In this image

Of your brain
I see each curve
In the corpus callosum,
Curlicues of gyri,
Folding of fissures,
Sinuous sulci,
Mammillary bodies,
Arcuate fasciculus,
Angular gyrus,
Tracts and nuclei,
Eyes and ears,
Tongue and phalanx.

But not even
A single syllable
Of one
Tiny
Poem

Vernon Rowe. In: Angela Belli and Jack Coulehan, eds. Blood and Bone: Poems by Physicians (Iowa City: University of Iowa Press, 1998), p. 102.



Dentistry

Stranger! Approach this spot with gravity!
John Brown is filling his last cavity.

Anonymous


MY LAST TOOTH

You have gone, old tooth,
Though hard to yield,
You have long stood alone,
Like a stub in the field.

Farewell, old tooth
That tainted my breath,
And tasted as smells
A woodpecker's nest


from THE DENTIAD

... her lips disclosed to view,
Those ruined arches, veiled in ebon hue,
Where love had thought to feast the ravished sight
On orient gems reflecting snowy light,
Hope, disappointed, silently retired,
Disgust triumphant came, and love expired!

When'er along the ivory disks, are seen,
The filthy footsteps of the dark gangrene;
When caries come, with stealthy pace to throw
Corrosive ink spots on those banks of snow—
Brook no delay, ye trembling, suffering Fair,
But fly for refuge to the Dentist's care.

Solyman Brown (1790-1876)



Dermatology

A PRETTY GIRL

On her beautiful face there are smiles of grace
That linger in beauty serene,
And there are no pimples encircling her dimples,
As ever, as yet, I have seen.

J. Gordon Coogler (1865-1901)



Emergency Medicine

from A TALE OF THE SEA

'Twas on the 8th April, on the afternoon of that day,
That the little village of Louisberg was thrown into a wild state of dismay,
And the villagers flew to the beach in a state of wild uproar,
And in a dory they found four men were cast ashore.

Then the villagers, in surprise, assembled about the dory,
And they found that the bottom of the boat was gory;
Then their hearts were seized with sudden dread,
When they discovered that two of the men were dead.

And the two survivors were exhausted from exposure, hunger, and cold,
Which caused the spectators to shudder when them they did behold ...

They were carried to a boarding-house without delay,
But those that were looking on were stricken with dismay,
When the remains of James and Angus M'Donald were found in the boat,
Likewise three pieces of flesh in a pool of blood afloat.

Angus M'Donald's right arm was missing from the elbow,
And the throat was cut in a sickening manner, which filled the villagers' hearts with woe,
Especially when they saw two pieces of flesh had been cut from each thigh,
'Twas then the kind-hearted villagers did murmur and sigh.

William McGonagall (1830-1902)



Epidemiology

ODE TO A DITCH

Oh, ditch of all ditches,
Death's store-house of riches,
Where wan disease slumbers mid festoons of slime!
Oh, dark foetid sewer
Where death is the brewer
And ail is the liquor he brews all the time!

Oh, hot-bed of fever,
That fatal bereaver
Whose fiery breath blights the blossom of life!
Oh, palace of miasm
Whose hall is a chasm
Where pestilence revels and poison is rife!
...

Oh, wonderful sewer,
Each year brings a newer
And ghostlier charm to they cavernous deeps!
More puppies and cats,
To say nothing of rats,
And offal and filth of all manner in heaps.

Anonymous. Originally appeared in the Fayetteville North Carolinian on February 21, 1857.



Gastroenterology

from THE ART OF PRESERVING HEALTH, BOOK II

The languid stomach curses e'en the pure
Delicious fat, and all the race of oil:
For more the oily aliments relax
Its feeble tone; and with the eager lymph
(Fond to incorporate with all it meets)
Coyly they mix, and shun with slipp'ry wiles
The woo'd embrace. Th'irresoluble oil,
So gentle late and blandishing, in floods
Of rancid bile o'erflows: what tumults hence,
What horrors rise, were nauseous to relate.
Choose leaner viands, ye whose jovial make
Too fast the gummy nutriment imbibes.

...

Half subtilis'd to chyle, the liquid food
Readiest obeys th'assimilating powers;
And soon the tender vegetable mass
Relents . . . .
The stomach, urged beyond its active tone,
Hardly to nutrimental chyle subdues
The softest food: unfinished and depraved,
The chyle, in all its future wand'rings, owns
Its turbid fountain; not by purer streams
So to be cleared, but foulness will remain.

John Armstrong (1709-1779)



Infectious Disease

from POOR LITTLE HEARTS

Poor little Ada Queetie has departed this life,
Never to be here no more,
No more to love, no more to speak.

Poor little Ada Queetie's last sickness and death,
Destroyed my health at an unknown rate,
With my heart breaking and weeping,
I kept the fire going night after night, to keep poor little dear warm,
Poor little heart, she was sick one week
With froth in her throat,
Then 10 days and grew worse, with dropsy in her stomach,
I kept getting up nights to see how she was.

She was coming 9 years of age, when she was taken away,
By all I found out, very certain true
Poor Sissy hatched her out her egg in Chilmark,
The reason she was taken away before poor Sissy,
Her constitution was as weak as weak could be.

Her complaint that caused her death,
Was just such a complaint as poor Sissy had
Only poor Sissy's complaint ended with dropsy in her stomach.

Nancy Luce (fl. 1860s)



Internal Medicine

from THE SPLEEN

I always choose the plainest food
To mend viscidity of blood.
Hail! water gruel, healing power,
Of easy access to the poor;
Thy help love's confessors implore,
And doctors secretly adore:
To thee I fly, by thee dilute—
Through veins my blood doth quicker shoot;
And by swift current throws off clean
Prolific particles of spleen.

Matthew Green (1697-1737)



Obstetrics

Gooing babies, helpless pygmies,
Who shall solve your Fate's enigmas?

from The Light-Bearer of Liberty, by J.W. Scholl (A pathetic attempt at rhyme by a very bad poet)


BETWEEN OUR FOLDING LIPS

Between our folding lips
God slips
An embryon life, and goes;
And this becomes your rose.
We love, God makes: in our sweet mirth
God spies occasion for a birth.
Then is it his, or is it ours?
I know not—He is fond of flowers.

T.E. Brown (1830-1897)



Ophthalmology

ONLY ONE EYE

Oh! she was a lovely girl,
So pretty and so fair,
With gentle, lovelit eyes,
And wavy, dark-brown hair.

I loved the gentle girl,
But oh! I heaved a sigh,
When first she told me she could see
Out of only one eye.

But soon I thought within myself,
I'd better save my tear and sigh,
To bestow upon some I know,
Who has more than one eye.

She is brave and intelligent,
Too she is witty and wise,
She'll accomplish more now, than many,
Who have two eyes.

Ah! you need not pity her,
She needs not your tear and sigh,
She makes good use, I tell you,
Of her one remaining eye.

Lillian E. Curtis (fl. 1870s)



Orthopedics

WOODEN LEG

Misfortune sometimes is a prize,
And is a blessing in disguise;
A man with a stout wooden leg,
Through town and country he can beg.
...

And when he only has one foot,
He needs to brush only one boot;
Through world he does jolly peg,
So cheerful with his wooden leg.

In mud or water he can stand
With his foot on the firm dry land,
For wet he doth not care a fig,
It never hurts his wooden leg.

No aches he has but on the toes
Of one foot, and but one gets froze;
He has many a jolly rig,
And oft enjoys his wooden leg.

James Macintyre (1827-1906). A Canadian noted for another immortal poem, Ode on the Mammoth Cheese.



Pediatrics (Psychiatry?)

HIS MOTHER DRINKS

Within a London hospital there lies,
Tucked in his cot,
A child with golden curls and big blue eyes.
The night is hot,
And though the windows in the long low ward
Are open wide,
No breath of air comes from the sun-baked yard
That lies outside.

A kindly nurse who sees his wistful smile,
To cheer him cries;
"The doctor says that in a little while
He'll let you rise,
And send you home again!" His eyes grow dim.
She little thinks
What since his father died home means to him—
His mother drinks!


TWO SMOTHERED CHILDREN

Theirs was not the peaceful death-bed,
Where affection's silent tears,
O'er the couch of pain fast falling,
Blend with deep responsive prayers;

Nay, their death was strangely fearful!
No fond parent closed their eyes,
And no voice of pity answer'd
To their feebly moaning cries!

Mrs. Marion Albina Bigelow (fl. 1850s)



Public Health

COME BACK CLEAN

This is the song for a soldier
To sing as he rides from home
To the fields afar where the battles are
Or over the ocean's foam:
"Whatever the dangers waiting
In the lands I have not seen,
If I do not fall—if I come back at all,
Then I will come back clean.

"I may lie in the mud of the trenches,
I may reek with blood and mire,
But I will control, by the God in my soul,
The might of my man's desire.
I will fight my foe in the open,
But my sword shall be sharp and keen
For the foe within who would lure me to sin,
And I will come back clean."

Ella Wheeler Wilcox (1850-1919)


LONDON

Magnificent, too, is the system of drains,
Exceeding the far-spoken wonders of old:
So lengthen'd and vast in its branches and chains,
That labyrinths pass like a tale that is told:
The sewers gigantic, like multiplied veins,
Beneath the whole city their windings unfold,
Disgorging the source of plagues, scourges, and pains,
Which visit those cities to cleanliness cold.
Well did the ancient proverb lay down this important text,
That cleanliness for human weal to godliness is next.

Samuel Carter (fl. 1848-1851)



Surgery

from THE SURGEON'S KNIFE

There are hearts—stout hearts,—that own no fear
At the whirling sword or the darting spear,—
that are ready alike to bleed in the dust,
'Neath the sabre's cut or the bayonet's thrust;
They heed not the blows that Fate may deal,
From the murderer's dirk or the soldier's steel:
But lips that laugh at the dagger of strife
Turn silent and white from the surgeon's knife.

It shines in the grasp—'tis no weapon for play,
A shudder betrays it is speeding its way;
While the quivering muscle and severing joint
Are gashed by the keen edge and probed by the point.
Dripping it comes from the cells of life,
While glazing eyes turn from the surgeon's knife.

Eliza Cook (1818-1889)


from THE AVENGER

[A brigand is overpowered in the act of attempting to molest a lady and requires medical care:]

So stunned, surrounded and beset,
The surgeon struggled hard to see
His patient, or at least to get
Some signs of his proximity:
At length they opened up a way
To where a man extended, lay,
Presenting an appalling sight
Seen dimly through the chequered light...
For swelling, high amid the clothes,
The body, like a mountain rose
That scarce the head was seen;
While from below the feet protrude
(Like Satan "stretching many a rood"
So giant-like I ween.) —
And on those large and naked feet
A pair of antique spurs were placed,
Which fastened o'er the instep meet,
With many-coloured latchets graced.

[The surgeon enquires later:]

"Since when he has," (replied the nurse,)
"Been going on from bad to worse."


Samuel Carter (fl. 1848-1851)



Physicians

ON DR. ISAAC LETSOME

When people's ill they comes to I,
I physics, bleeds, and sweats 'em.
Sometimes they live, sometimes they die;
What's that to I? I Letsome.


ON SIR JOHN HILL, M.D., PLAYWRIGHT

For physic and farces his equal there scarce is;
His farces are physic; his physic a farce is.

David Garrick


from ODE UPON DR. HARVEY

Coy Nature (which remain'd, though aged grown,
A beauteous virgin still, enjoy'd by none,
Nor seen unveil'd by any one),
When Harvey's violent passion she did see,
Began to tremble and to flee,
Took sanctuary, like Daphne, in a tree:
There Daphne's lover stopt, and thought it much
The very leaves of her to touch,
But Harvey, our Apollo, stopt not so,
Into the bark and root he after her did go.

Abraham Cowley (1618-1667)



In closing

And now, kind friends, what I have wrote,
I hope you will pass o'er,
And not criticize as some have done,
Hitherto herebefore.

Julia A. Moore (1847-1920) "The Sweet Singer of Michigan."

Missing the obvious, Part 2: slapdash database grocery lists masquerading as articles in medical journals

Six months after a "research letter" entitled World Databases of Summaries of Articles in the Biomedical Fields was published by Falagas et al. in the Archives of Internal Medicine, a politely-worded demolition of that pretentious excresence has appeared in the same journal's issue of 14 Jan 2008. I vented much less diplomatically about Falagas et al. last July, shortly after it had been published. What was it that raised my hackles and got my goat? Without even nodding in the direction of a library, Dr. Falagas and his team (it actually took more than one person?) sat around a computer one day, scribbled a straggly list of a few databases "based on our previous knowledge" and a few they happened to come across in Google, and by some unattested miracle got their sophomoric effort published in one of the world's most important medical journals. Imagine Will Ferrell and Jon Heder doffing their figure skates and heading for the Moulin Rouge.

I groused at some length about how this inept and unscientific approach not only missed the obvious but apparently escaped any intelligent peer review. I made reference to the well-known Murphy's Law definition of an expert as a person who avoids the small errors while sweeping on to the grand fallacy. Unfortunately, in Falagas' farrago even the small errors were hopelessly compounded, and he swept irreversibly on to something approaching Grand Guignol.

With their letter subtitled "Getting the whole picture," Dr. Isobel C. Hoskins of CAB International and her two co-authors shine some welcome light on this Carnaval des spectres. With laudable courtesy and restraint — something I wouldn't be capable of under any circumstances — they list "some important omissions" from Falagas' shabby compendium of health databases: Global Health, CINAHL and PsycINFO, to name a few. They tactfully correct one of the grossest errors: "Readers should also be aware that the published list of additional databases includes hosts for databases such as Dialog and EBSCO rather than the databases themselves." As if his dilettantish approach wasn't bad enough, even Falagas' mistakes have errors. His misbegotten enumeration of database hosts omits OVID, for example. Hoskins et al. conclude by finally attempting the right thing and pointing to a health library website. They could have done better than supply a list of public health databases (CINAHL is not included), but in this weak suggestion Hoskins et al. are at least providing a hint to the readers of the Archives that it's all right to go beyond the input of colleagues and the Google prompt when looking for medical resources on the web.

In his two-paragraph reply, festooned with no less than four self-referential footnotes, Dr. Falagas welcomes the valuable input of "our colleagues." In a tone approaching that of a pronouncement from the Holy See he asserts his strong belief "that the availability of lists of databases ... is useful to researchers, clinicians, and other health care professionals." And he's not just whistling Gaieté parisienne. He goes on to puff more of his grocery lists, all of them published in major medical journals. And there are others he hasn't cited. This bloke pumps out more research than kicks at a cancan show (I count 298 PubMed citations to date). An extraordinary accomplishment considering that he seems not to have do-si-doed across the threshold of a library in his entire career. My question is: why doesn't he leave the choreography of knowledge-based information resources to those who know how to dance?

Before I get my petticoats into a real knot, I will briefly mention another of Falagas et al's forays into the world of databases and search engines — this time in a paper unaccountably published in FASEB Journal — comparing PubMed, Scopus, Web of Science, and Google Scholar. Did anyone at FASEB edit this article or even look at the contents? A reading of the first clause of its first sentence is not encouraging: "The development along with the spread of the World Wide Web (WWW) represents an informational [sic] revolution ..." There is much more where this comes from as the article develops and spreads. "In conclusion, scientific databases of biomedical information are frequently used by both clinicians and researches [sic]. In this article, we compared the content and various practical aspects in [sic] the utility of the main databases of biomedical scientific information. We found that PubMed remains an important source for clinicians and researchers ..." And on they go in this manner for five densely printed pages without a single original thought, spinning in all directions, legs lifted and twirling. Zoot alors! Kick. Kick. Kick.

Another modest proposal

How not to answer clinical questions

No sooner had I put the final touches on my last post about physicians' overconfidence when trawling the web, than my colleague Michael Tennenhouse alerted me to an article in this month's Canadian family physician that should give patients pause (1). It's like what they say about ketchup: if you do not shake the bottle, none'll come and then a lot'll. Somebody please stop the flow.

Here is yet another example of what can go wrong when physicians set out to conquer the proverbial ocean of information without compass and sextant. Our Canadian crew, all family medicine residents at various Canadian universities, show more nautical expertise than the hapless landlubber in the Australian family physician (2). Unfortunately, they all could use some more lessons in navigation.

The Canadian article cites PICO also as the authors attempt to phrase an appropriate clinical question — although in my opinion their question leaves much to be desired. The Canadians then go on to complete a questionable search. On the surface things look reasonable. Yahoo! is not even on the map, and the authors are at least aware that "'Googling' your question does not necessarily lead to the best evidence-based answer" (p. 1535). PubMed is visited, "the obvious starting point." We then turn the rudder towards SUMsearch and TRIP.

A Quebec resource called InfoClinique is described as "excellent," but we are immediately told that it is available only to Laval University members. I tried it. It works slowly, searching a limited list of EBM sources (curiously, neither TRIP nor SUMsearch appears among its sources indéxées). When the results finally appear, the links are hidden behind lots of little x's. Recommending the unhelpful InfoClinique looks more like a well-meant attempt at Canadian two-solitudes inclusivism than a contribution to the authors' task.

Having steered around these shoals the authors glance briefly at textbooks, among which they include eMedicine, UpToDate, Dynamed and the resources to be found in MD Consult. They then sum things up by proudly describing how they answered their own question in under 10 minutes. Land ho!

While the general approach of the authors is acceptable, there are serious problems with their method. As my colleague pointed out to me, they choose mostly appropriate limits, but the actual search term selection, resulting from the poorly worked out question, is problematical. Their article nicely demonstrates some common mistakes made by many of our students and residents:

1. Poor question building, especially with respect to identifying the problem and the intervention.
2. The use of "red-herring" or unnecessary terms in the search strategy which artificially limit the results (in this case it's the term "expectant").
3. Uncritical review of the search strategy and results.
4. No use of MeSH in PubMed, or how to easily seek out the best MeSH from the most relevant retrieval, or how to use Related Article searching.
   

The authors argue in their second paragraph (p. 1535) that they have merely reproduced what most physicians would do given the case under consideration (premature rupture of membranes). They choose to use "the Internet alone" (i.e., free resources, except for InfoClinique). They choose to look at only "articles available without subscription, as we do not always have time to ask the library for an article when a patient is in front of us." Using a "variety of key words" their goal is "to mimic what is often done in practice." In other words, they are quite prepared to shortchange a patient, to flounder about on the web's treacherous expanse with poor preparation and ill-chosen search strategies, in order to save time and perhaps some expense. If this is truly mimicking what is done in practice, more's the pity.

In a recent post, T. Scott reiterates the point that physicians are drowning in information. Like most of us, he is "worrying about the health of the patients that are being served by physicians who have only the faintest notion of how to construct even the simplest search." As health sciences librarians it is "our responsibility to get [students] out of med school with a decent set of information management skills."

I couldn't agree more. So here is my other modest proposal. Let the aspiring family physician pass both these articles by. The Canadians and Australians have shown you how perilous the voyage can be in search of the best evidence. Seeing the library as little more than an obstacle in their way, they try to make the best of it on their own without capsizing. Sometimes they're lucky, in the same way that contestants in a bathtub race sometimes reach the finish line. But what furious paddling, what desperate flailing about all the while.

So pass these articles by. If you keep looking, however, surely something will, as they say, turn up.

"Precisely. It is evident to me that Australia is the legitimate sphere of action for Mr. Micawber! I entertain the conviction, my dear madam," said Mr. Micawber, "that it is, under existing circumstances, the land, the only land, for myself and family; and that something of an extraordinary nature will turn up on that shore."

References

1. Lacasse M, Lafortune V, Bartlett L, Guimond J. Answering clinical questions: What is the best way to search the Web? Can Fam.Physician 2007 Sep;53(9):1535-8. http://www.cfp.ca/cgi/content/full/53/9/1535

2. Qureshi F. How I use the internet. Aust.Fam.Physician 2007;36(7):538. http://www.racgp.org.au/afp/200707/17421

A modest proposal

Would this post sound more authoritative if I entitled it: "Predictive value of information literacy (IL) levels for recurrent mediocre search results (RMSR)?"

Last July I commented on a review article by Karen Davies on the information-seeking behaviour of physicians. The article appeared in the June 2007 issue of Health information and libraries journal. There were no real surprises in Davies' review. It's the old problem. Things are still in statu quo. Doctors have information needs and they have a wealth of resources to find the answers to their questions; but they do not have the time or the skills to get the best results from the tools at hand. Librarians have the time and training to provide the best resources and to meet physicians' information needs by using these resources in an expert manner; but we are often left waiting by the phone.

There are many physicians who are using the Internet intelligently to answer clinical questions and who have made the effort to get training in its proper use. And then there are the others who conform to all the bleak analyses of Karen Davies' article. What mystifies me is that not only are there physicians who don't get beyond "quick and dirty" searching or who simply don't know what they are doing, some even go so far as to hang that dirty laundry in public — even in the pages of prestigious medical journals. In an earlier post I discussed one such disaster, and now I must regretfully point out another.

When I came across the one-page "How I use the internet" in the Australian family physician, my first thought was, "Lucky patient you were. The first item that popped up in your doctor's web search was only a four-year-old article. Things could have been worse." The target of my scorn is a brief "practice tip" which, minus the illustrations, takes up half of page 538 in volume 36. Written by a general practitioner in Adelaide, it is an unintentionally humorous description of using the Internet to find information about discontinuing warfarin for a female patient who had suffered an episode of deep vein thrombosis. The author decides to conduct a "quick, computerised literature search using the Yahoo! search engine." He picks Yahoo! because the patient, a hockey player, is familiar with it, and he wants to allow her to be involved with her treatment.

In Yahoo! he enters the query, "Can d-dimer levels predict recurrent venous thromboembolism?" He justifies using this form of query by citing The well-built clinical question (an online tutorial developed by librarians Connie Schardt, Duke University Medical Center Library and Jill Mayer, University of North Carolina at Chapel Hill Health Science Library). "Entering key words would not help to construct a question and phrase it in such a way as to facilitate an answer," he writes. I had to read this sentence a few times, but its author seems to be claiming that entering a syntactically correct English-language question into a web search engine is preferable to a key word search. Cue Twilight Zone theme.

Our physician does not understand the difference between proper use of a web search engine and constructing a well built clinical question according to the principles of EBM. Like Captain Kirk consulting the ship's computer, he dutifully asks his question. And a fine one it is; but sticking to only this formulation of the question radically limits the possibilities for retrieval. It is an approach free of empirical duty. Had he consulted a librarian, our physician would have found that the skilled employment of key words in a Yahoo! search produces more recent articles on this topic, like one published just last year in the NEJM, which in turn cites a clinical trial that concludes: "The optimal duration of oral anticoagulant treatment in patients with idiopathic venous thromboembolism is still uncertain."

What our physician's quick and dirty method does produce as its first item is a JAMA article from 2003. Without further ado, he uses the information from this article to advise the patient, who — trusting soul — is "happy with the outcome of the search result." Aside from the problematic acceptance of Yahoo!'s ranking algorithm, why use only Yahoo! in the first place? Surely he must be aware of Google Scholar. A search that plugs the same question into that search engine turns up relevant articles from Circulation and Archives of internal medicine in the top ten. More importantly, why has he ignored PubMed, ClinicalTrials.gov, and other free EBM resources? And surely his young patient would have benefited more from being directed to something like the MedlinePlus article on thrombophlebitis or JAMA's own patient page on the same topic, which cites a 2006 JAMA article with new information on other measures for identifying patients at low risk for recurrent venous thromboembolism.

In his book The trouble with medical journals, Richard Smith quotes an aphorism that he valued highly as editor of BMJ: "Anybody is free to make a fool of himself in my journal" (p. 64). This was in the context of a discussion of BMJ's policy of allowing rapid, sometimes egregious, responses by email to published articles (a practice that was later tightened up by the editorial board). But in the case of the "practice tip" under review here, the editors must have read it and approved it. What were they thinking? This is a tip the way Swift's A modest proposal is social planning.

"The time constraints of a consultation" are cited as the excuse for this travesty of medical information retrieval. Our physician would have required less time to email the question to his local health sciences library and have them send the information. "How I use the internet" looks to me like a perfect demonstration of the dire need for improved information literacy for health care providers. Here is my modest proposal. If they truly wish patients to continue, as Mr. Micawber would say, in the enjoyment of salubrity, medical people and medical journal editors should view such amateurish squibs with greater suspicion. In short, they should not be published. Or next time, the patient may not be so lucky.

Missing the obvious

I have the greatest respect for the Archives of internal medicine. It is a venerable institution, which, according to Journal Citation Reports, ranks eighth amongst general medicine journals with an impact factor of 7.920. To get published in the Archives is a mark of distinction, to be sure. Now, I'm certainly not privy to the editors' rationale for selecting articles, but I do have a bone to pick with one I read recently.

In the issue of 11 June 2007 a "research letter" was published with the imposing title: World Databases of Summaries of Articles in the Biomedical Fields. A Greek MD and a group of collaborators report on their hunt for databases from around the world which "archive information regarding scientific publications in biomedical and life sciences." The fruit of their research is a page-long list, a diverse collection of resources such as the ArabPsyNet (Arabic, French, English, described only as covering 23 psychology and psychiatry journals), and Media Sphere (Russian, 14 searchable medical journals from a single publisher). The list ranges from the vast and expanding EBSCOHost to the 11 journals covered by the Greek-language Iatrotek.org.

Much labour must have been spent in doing the research for this brief article. But as I looked it over it struck me that the way the authors had gone about their work was entirely wrongheaded. Not only had they missed the obvious, I should think it hardly possible to come a cropper with more precision.

I read the entire article carefully, analyzing the methodology, looking for that familiar word starting with the letter 'l' which would indicate that they had perhaps not totally wasted their time. Nowhere was it to be found. Not once in the entire text of this article do the authors mention that they consulted a librarian or even used a library's online resources.

We are told that at the onset of their investigations the authors "made an initial list of relevant databases based on our previous knowledge." Naturally one has to begin somewhere. But this kind of exercise is to research methodology what Chopsticks is to Chopin.

With their initial list drawn up, the authors proceed to part two of their methodology. They "looked in popular World Wide Web search engines (specifically, Google, AltaVista, and Yahoo)." They used "several keywords including medical, biomedical, medicine, biomedicine, databases, library, archive, and online." Acknowledging that they were not trying to produce an exhaustive compilation, they assert that their aim was "to generate an initial list of such databases that may gradually be expanded by the input of the scientific community."

There is a peculiar blindness and ingenuousness in their approach, and one can't help squirming slightly, as one would at a sophomore’s half-page explanation of the Hegelian dialectic.There is a well-known definition of an expert as a person who avoids the small errors while sweeping on to the grand fallacy. (Arthur Bloch, Murphy's law and other reasons why things go wrong, 1977). Well, in our research letter even the small errors seem to be compounded, sweeping on to something approaching Grand Guignol.

I will refrain from going into any further detail. Read the article for yourselves, and weep. Had the authors ignored Google for a moment and gone to any self-respecting health library’s website, anywhere in the world, they would have found that most of their work had already been done for them. Instead they have the distinction of having published an article in the Archives of internal medicine that is at best a curiosity. Although some little-known resources are brought out of obscurity, this effort does nothing to enhance medical research, but succeeds wonderfully at raising librarians' hackles.

Off The Shelf: Still waiting for a breakthrough with physicians

Davies K. The information-seeking behaviour of doctors: a review of the evidence. Health Info Libr J 2007 Jun;24(2):78-94

The Author's Abstract: This paper provides a narrative review of the available literature from the past 10 years (1996-2006) that focus [sic] on the information seeking behaviour of doctors. The review considers the literature in three sub-themes:

• Theme 1: the Information Needs of Doctors includes information need, frequency of doctors' questions and types of information needs;
• Theme 2: Information Seeking by Doctors embraces pattern of information resource use, time spent searching, barriers to information searching and information searching skills;
• Theme 3: Information Sources Utilized by Doctors comprises the number of sources utilized, comparison of information sources consulted, computer usage, ranking of information resources, printed resource use, personal digital assistant (PDA) use, electronic database use and the Internet.

The review is wide ranging. It would seem that the traditional methods of face-to-face communication and use of hard-copy evidence still prevail amongst qualified medical staff in the clinical setting. The use of new technologies embracing the new digital age in information provision may influence this in the future. However, for now, it would seem that there is still research to be undertaken to uncover the most effective methods of encouraging clinicians to use the best evidence in everyday practice.

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No real surprises in this welcome review of recent literature. I have seen this problem in my own practice: doctors have information needs and they have a wealth of resources to find the answers to their questions. But they do not have the time or the skills to get the best results from the tools at hand. Librarians have the time and training but have trouble communicating to clinicians the benefits of information literacy.

As I remarked in my post of July 14, even increasing computer use by physicians and their improved knowledge of health resources does not necessarily lead to a good search when it comes to the crunch. I would argue that we are still a long way from the AI killer app that will answer more complex clinical questions quickly and accurately. And we all know how hard it is to come up with innovative, truly effective instructional techniques, while every study of this kind enjoins us to do so, and to do more research to find out how to do it better.

Although roughly 60% of physicians' questions are simple, according to Davies' evaluation of the literature, that leaves a considerable number of complex queries being brought to Google or PubMed with a few key words typed into the search box. Not an encouraging prospect. Specialized EBM resources, such as the Cochrane Library and UpToDate, helpful as they are, have not done all that well in filling the gap. In a study in which librarians searched these resources for answers to complex questions, no answers were found 40% of the time. How would less skilled searchers have fared?

Among physicians, who are the only objects of this study, time has long been recognized as the key barrier to information searching, and Davies finds it worrying that clinicians are only able to complete "quick and dirty" searches because of time constraints, some spending as little as two minutes on average pursuing an answer. This obviously affects the efficiency of their searching. One study found that 82% of doctors' searches were merely fair (52%) or poor (30%).

Davies' bleak conclusion is that "doctors are not yet embracing the use of computerized resources." They still rely on text sources and the advice of colleagues. When they do search online, they encounter difficulties. Ineffective search strategies do not produce results. If information is not located, it is often assumed not to exist. This can lead to mistaken opinions concerning the contents and coverage of a database. Combine that with the traditional barriers we medical librarians face in making our skills known, and you end up with health professionals who harbour a false perception of their information literacy skill levels.

Time to renew my efforts to get the message out there.