|Year : 2007 | Volume
| Issue : 1 | Page : 44-48
Computer-based literature search in medical institutions in India
Jayantee Kalita, Usha K Misra, Gyanendra Kumar
Department of Neurology, Sanjay Gandhi PGIMS, Lucknow, India
Usha K Misra
Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareily Road, Lucknow - 226 014
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: To study the use of computer-based literature search and its application in clinical training and patient care as a surrogate marker of evidence-based medicine. Materials and Methods: A questionnaire comprising of questions on purpose (presentation, patient management, research), realm (site accessed, nature and frequency of search), effect, infrastructure, formal training in computer based literature search and suggestions for further improvement were sent to residents and faculty of a Postgraduate Medical Institute (PGI) and a Medical College. The responses were compared amongst different subgroups of respondents. Results: Out of 300 subjects approached 194 responded; of whom 103 were from PGI and 91 from Medical College. There were 97 specialty residents, 58 super-specialty residents and 39 faculty members. Computer-based literature search was done at least once a month by 89% though there was marked variability in frequency and extent. The motivation for computer-based literature search was for presentation in 90%, research in 65% and patient management in 60.3%. The benefit of search was acknowledged in learning and teaching by 80%, research by 65% and patient care by 64.4% of respondents. Formal training in computer based literature search was received by 41% of whom 80% were residents. Residents from PGI did more frequent and more extensive computer-based literature search, which was attributed to better infrastructure and training. Conclusion: Training and infrastructure both are crucial for computer-based literature search, which may translate into evidence based medicine.
Keywords: Evidence-based medicine, literature search, medical education
|How to cite this article:|
Kalita J, Misra UK, Kumar G. Computer-based literature search in medical institutions in India. Ann Indian Acad Neurol 2007;10:44-8
| Introduction|| |
Medical education in India has been evolving and is supported by medical colleges and postgraduate institutes which impart undergraduate, postgraduate and super-specialty training. Both specialty and super-specialty training take three years each and include residency-training programmes in surgical and medical disciplines, which are supervised by the Medical Council of India (MCI). Lately the evidence-based medicine movement has influenced medical training and practice significantly, especially in teaching hospitals. India has emerged as a power in software and computers, which has also influenced healthcare to some extent. In some medical colleges, especially postgraduate medical colleges and institutes, the use of computers for literature search and reviews has resulted in an easy access to information. In the USA, Canada and UK, the status report has revealed a wide range in knowledge and application of evidence based medicine. A survey of 417 U.S. internal medicine program directors revealed that the most common objectives of literature search were performing critical appraisal (78%), searching for evidence (53%), posing a focused question (44%) and applying the evidence in decision making (35%). EBM teaching and practice vary widely in amount, depth and structure among Canadian postgraduate neurology training programs. Canadian neurology program directors, teaching neurologist and trainees surveyed indicate that EBM is considered highly relevant, valuable and necessary in the training and practice of neurology, however, self-reported proficiency in EBM principles is low and no formal educational EBM neurological curricula exists. In another survey of 122 emergency medicine residency program directors, 80% of programs reported teaching some aspects of EBM. Although respondents believed a median of 10 hours were required to adequately cover this topic, only 22% provided more than five hours per year. Most perceived a lack of trained faculty, time and funding as a barrier to EBM training. A two-week EBM rotation improved EBM skills and reported patient care among faculty and residents. A ten-session EBM workshop increased residents' knowledge and use of EBM constructs during patient care. A brief structured EBM course produced substantial and durable improvements in residents' cognitive and technical EBM skills. Faculty and residents gave high evaluations to all aspects of the EBM journal clubs and statistically significant improvements in understanding of medical literature were observed. A seven-week EBM curriculum in which residents worked through decisions for their own patients improved EBM skills and behaviors. Conversely, emergency medicine residents exposed to EBM journal clubs did not do better on critical appraisal skills compared to residents exposed to traditional journal clubs. PDA (palm diary assisted) EBM course did not alter knowledge test scores although using PDA during tests resulted in higher scores.
In India, though some institutes are using computers for storing information, patient care and hospital management, computerization of healthcare is still in its infancy.,, Computer training is a part of school curricula. Medical students now a days are generally well-versed with general knowledge about computers. There is no published information on the use of computers and its influence on medical and surgical training, patient care and teaching. We, therefore, have conducted a survey on the use of computer based electronic literature search and its application in clinical training and patient care. This information is likely to provide insight into the use of computers and its application as a surrogate marker of evidence based medicine in India.
| Materials and Methods|| |
The subjects for this study were recruited from two medical institutions: a) Postgraduate Medical Institute (PGI) and b) Medical College (MC). Postgraduate Medical Institute is a tertiary care referral hospital and mainly imparts super-specialty training in medical and surgical disciplines (DM, Mch), which are a three-year program after postgraduation in general medicine or surgery. Some departments also provide specialty postgraduate training such as pathology, microbiology, radiotherapy, radio diagnosis, thus training MD students as well.
Medical college includes undergraduate, postgraduate and some super-specialty students. This study has included only the specialty and super-specialty residents. We have also included some faculty members from both the institutions representing both specialty and super-specialty; surgical and medical fields.
The subjects were required to complete a questionnaire comprising 10 questions about electronic literature search aimed at evaluating its purpose (presentation, patient care, research), realm (sites accessed, frequency of search, nature of articles searched), effect on diagnosis and patient care, support in the form of training and infrastructure available and suggestions for further improvement [Table - 1]. Some answers were to be given a yes/no response and others had to be marked on a scale of 1 to 10 depending upon the frequency of use of the item in question, with 1 indicating the least often used and 10 the most frequent. Subjects were reminded telephonically to send the responses.
The responses were computed and compared between the two institutions, super-specialty and specialty residents using nonparametric (Chi square, Fisher's exact test) and parametric tests ( t -test and ANOVA). The factors determining the extent of electronic literature search were analyzed using logistic regression. For logistic regression analysis, the following independent variables were categorized into: Institution (MC=1; PGI=2), field (nonsurgical=1; surgery=2), motive for search (research=1; presentations=2; patient care=3), gender (female=1; male=2), course (specialty=1; super-specialty=2) and prior training (present=1; absent=2). The dependent variable frequency of search was categorized into: at least once a week=1 and < once per week=2). Statistical analysis was performed using the SPSS software (version 10).
| Results|| |
We received 194 responses out of 300 approached; 103 of whom were from PGI and 91 from Medical College (see [Table - 2]). The responders included 97 specialty residents, 58 super-specialty residents and 39 faculty members. The majority of responders (89%) used computer-based literature search at least once a month; though there was marked variation in the frequency and duration of search. The most important reasons for search were making presentations (175; 90.2%), research (126; 65%) and patient-related problems (117; 60.3%). The search was most frequently performed at home (123; 63.4%) although internet facility was available in the work place of 149 (76.8%) subjects. The benefit of computer-based electronic search was acknowledged in patient care (125; 64.4%), research (126; 64.9%) and learning or teaching (156; 80.4%). Formal training in computer-based literature search was received by 80 (41.2%) subjects of whom 64 (80%) were residents mostly from PGI (8 hours stand alone programme in 2 weeks). The type of search included review articles (143; 73.7%), clinical trials (113; 58.2%), practice guidelines (108; 55.7%) and meta-analysis (95; 49%). Google and Pubmed were the most frequently accessed sites followed by MD Consult and Science Direct.
On comparing the characteristics of computer-based literature search in PGI and MC it was found that responders from PGI performed more frequent electronic searches for all three purposes- research, patient care and presentations compared to MC. Responders from PGI most frequently accessed Pubmed, MD Consult and Science Direct. On comparing the type of articles searched, responders from PGI more frequently accessed review articles, meta-analysis and clinical trials compared to MC. The majority of responders from PGI made their literature search at their work place whereas responders from MC at cyber cafιs. The comparison of details of computer-based electronic literature search in PGI and Medical College is presented in [Table - 3].
Using logistic regression analysis, the best predictors of computer-based electronic literature search included the institution of the responders and prior training in electronic literature search. The details of the model are provided in [Table - 4].
| Discussion|| |
Our study revealed that 89% of responders made electronic literature searches although there was marked variation in the frequency and extent of literature search. We have used two medical institutions- Postgraduate Institute and Medical College for studying the pattern of computer based electronic literature search. The responders from PGI did more frequent and more extensive literature search for various purposes such as presentation, research and patient related management problems. On multivariate logistic regression analysis organization and training were most significant predictors of electronic literature search.
Organization encompasses the type of curriculum, infrastructure and training, which contribute to computer based electronic literature search. PGI offers mainly super-specialty training (DM, MCh), manages complicated referred patients and high standard of curriculum requires frequent literature search by both residents and faculty. These courses have in-built research demands which necessitates greater degree of electronic literature search in PGI compared to Medical College.
The other contributing factor determining the difference in the organization was the infrastructure. Infrastructure in PGI, with a hospital information system (HIS), intranet and a dedicated lease-line providing access to high speed internet in OPD, laboratories, library and bedside desktop workstations in wards, was superior to medical college. It was however interesting that 20% of PGI and 66% of medical college responders made their computer-based literature search at their residence. Moreover, inadequacy of infrastructure did not seriously jeopardize literature search in Medical College where 66% responders did their literature search in Cyber Cafιs (which need payment) and 65% at their residence. It is well known that availability of computers at work place improves the access, appraisal and application of information. Access to valid and relevant evidence on a portable computing device improves learning in EBM and boosts confidence in clinical decision-making.
Training in computers and computer-based literature search was an important determinant of computer-based literature search in our study. In PGI, the residents are exposed to five weeks of formal training curriculum in EBM, which includes literature search as well. At the end of the course the students' performance is assessed. The importance of training EBM skills is well known to improve knowledge in medical students and residents. The benefit of training in critical appraisal and computer-based literature search has been confirmed in a controlled trial. Even a short course of EBM improved the knowledge and skills by 57%. The most frequently accessed sites were Google and MEDLINE; however at PGI, additional sites such as MD consult, Science Direct, Oxford Database were also available as the institute library subscribed to these. Responders from Medical College were restricted to MEDLINE and some other free websites. Cochrane database was not accessed by either institute, because of the cost. MEDLINE, though popular, has certain limitations such as predominance of basic science articles and complex search requirements. Busy clinicians may find it difficult to practically identify, read and appraise the entire literature, which necessitates the use of alternate resources that evaluate, assess and succinctly present the available scientific information.
The most important reasons for electronic literature search were presentation of seminars and lectures (90.2%), research (64.9%) and patient care (60.3%). In all these areas, responders from PGI performed significantly better than Medical College. We, however, did not find any difference between males and females; faculty and residents; medical and surgical groups. The super-specialty residents did more frequent and extensive search than specialty residents in our study. These results are in contrast to another study in which residents had lower skill than the contemporary first year medical students in 1998. 79% residents and 86% of first year medical students owned a computer. We have not been able to get this information in our study, but would be of interest. It is consistent with increasing computer training in school and premedical levels even in India.
Our study highlights that residents at PGI performed more frequent and extensive computer-based literature search than those in Medical College and it seems to be related to curricular demand, infrastructure and training in computer-based electronic literature search at PGI.
There are two important limitations of our study. PGI and Medical College did not represent super-specialty and specialty residents only; there was some overlap in the curriculum in these two institutions, which could blur the conclusion of our study. Secondly we got only 65% response to our questionnaire; drop out of 35% makes our conclusion less emphatic. Ours is the first study of its kind from a developing country, but as the computer application in rapidly increasing, more information from different regions needs to be collected so that proper comparison and planning for future can be done.
| References|| |
|1.||Green ML. Evidence-based medicine training in internal medicine residency programs a national survey. J Gen Intern Med 2000;15:129-33. [PUBMED] [FULLTEXT]|
|2.||Demaerschalk B, Wiebe S. Evaluating the relevance of evidence based medicine in a neurology residency programme. Can J Neurol Sci 1998;25:S79-80. |
|3.||Kuhn GJ, Wyer PC, Cordell WH, Rowe BH; Society for Academic Emergency Medicine Evidence-based Medicine Interest Group. A survey to determine the prevalence and characteristics of training in evidence-based Medicine in emergency medicine residency programs. J Emerg Med 2005;28:353-9. [PUBMED] [FULLTEXT]|
|4.||Thom DH, Haugen J, Sommers PS, Lovett P. Description and evaluation of an EBM curriculum using a block rotation. BMC Med Educ 2004;4:19. [PUBMED] [FULLTEXT]|
|5.||Ross R, Verdieck A. Introducing an evidence-based medicine curriculum into a family practice residency-is it effective? Acad Med 2003;78:412-7. [PUBMED] [FULLTEXT]|
|6.||Smith CA, Ganschow PS, Reilly BM, Evans AT, McNutt RA, Osei A, et al . Teaching residents evidence-based medicine skills: A controlled trial of effectiveness and assessment of durability. J Gen Intern Med 2000;15:710-5. [PUBMED] [FULLTEXT]|
|7.||Elnicki DM, Halperin AK, Shockcor WT, Aronoff SC. Multidisciplinary evidence-based medicine journal clubs: Curriculum design and participants' reactions. Am J Med Sci 1999;317:243-6. [PUBMED] [FULLTEXT]|
|8.||Green ML, Ellis PJ. Impact of an evidence-based medicine curriculum based on adult learning theory. J Gen Intern Med 1997;12:742-50. |
|9.||Bazarian JJ, Davis CO, Spillane LL, Blumstein H, Schneider SM. Teaching emergency medicine residents evidence-based critical appraisal skills: A controlled trial. Ann Emerg Med 1999;34: 148-54. |
|10.||Grad RM, Meng Y, Bartlett G, Dawes M, Pluye P, Boillat M, et al . Effect of a PDA-assisted evidence based medicine course on knowledge of common clinical problems. Fam Med 2005;37: 734-40. |
|11.||Kapoor L, Mishra SK, Singh K. Telemedicine: Experience at SGPGIMS, Lucknow. J Postgrad Med 2005;51:312-5. |
|12.||Sarbadhikari SN. The state of medical informatics in India: A roadmap for optimal organization. J Med Syst 2005;29:125-41. |
|13.||Misra UK, Kalita J, Mishra SK, Yadav RK. Telemedicine for distance education in neurology: Preliminary experience in India. J Telemed Telecare 2004;10:363-5. |
|14.||Leung GM, Johnston JM, Tin KY, Wong IO, Ho LM, Lam WW, et al . Randomized Controlled trial of clinical decision support tools to improve learning of evidence based medicine in medical students. BMJ 2003;327:1090. |
|15.||Norman GR, Shannon SI. Effectiveness of instruction in critical appraisal (evidence-based medicine) skills: A critical appraisal. Can Med Assoc J (CMAJ) 1998;158:177-81. |
|16.||Bennett NL, Casebeer LL, Kristofco RE, Strasser SM. Physicians' internet information seeking behaviour. J Contin Educ Health Prof 2004;24:31-8. |
|17.||Fritsche L, Greenhalgh T, Falck-Ytter Y, Neumayer HH, Kunz R. Do short courses in evidence based medicine improve knowledge and skills? Validation of Berlin questionnaire and before and after study of courses in evidence based medicine. BMJ 2002;325:1338-41. |
|18.||Cook DJ, Mulrow CD, Haynes RB. Systematic reviews: Synthesis of best evidence for clinical decisions. Ann Intern Med 1997;126:376-80. |
|19.||Jerant AF, Lloyd AJ. Applied medical informatics and computing skills of students, residents and faculty. Fam Med 2000;32:267-72. |
[Table - 1], [Table - 2], [Table - 3], [Table - 4]
|This article has been cited by|
||E-learning in medical education in resource constrained low- and middle-income countries
| ||Seble Frehywot,Yianna Vovides,Zohray Talib,Nadia Mikhail,Heather Ross,Hannah Wohltjen,Selam Bedada,Kristine Korhumel,Abdel Karim Koumare,James Scott |
| ||Human Resources for Health. 2013; 11(1): 4 |
|[Pubmed] | [DOI]|
||Barriers to evidence based medicine practice in South Asia and possible solutions
| ||Agarwal, R. and Kalita, J. and Misra, UK |
| ||Neurology Asia. 2008; 13(2): 87-94 |