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Rivers of knowledge
9th Specials, Health and Law Libraries Conference
A new breed of doctor? Lessons learned and changes made to library services for the mbbs program at the University of Queensland
K Joc, and K Lasserre
November 2000 saw the graduation of the first cohort from the new MBBS Program at The University of Queensland. The fully integrated problem-based curriculum has provided many challenges and opportunities for The University of Queensland Library such as servicing an extensive remote student population, information technology issues and customer demand. In October 2000 all four years of the MBBS Program completed a survey on related issues such as the library's collection, web-based resources, information skills and evidence-based medicine. This paper focuses on the results of the survey, and the future directions of the library to ensure that the new doctors graduating from this program gain the essential attributes of life-long learning, information management and evidence-based principles.
The University of Queensland Library
The University of Queensland Library comprises:
The library's clients include more than 29 000 students, approximately twenty per cent of whom are postgraduates and 4500 academic and general staff. In addition, the library services staff of major teaching hospitals, staff and students from other Institutions with which special agreements have been negotiated as well as the wider community.
The library's collection consists of over two million volumes, 19 000 videos, 18 000 journal titles of which more than 8000 are electronic, over 120 000 e-books and 450 networked databases as well as microform, manuscripts and pictorial materials. A single interface to all library collections and services is provided by the library's website (http://www.library.uq.edu.au). The library's award-winning Cybrary represents the integration of physical space and cyberspace in the delivery of library and information services. The provision of customer-focussed quality services is the library's driving force articulated in its mission statement as:
We link people with information, enabling The University of Queensland to achieve excellence in teaching, learning and research.
The three hospital libraries related to the University of Queensland Library are the:
Funded jointly, but not equally by the hospitals and the University, these libraries, together with the Biological Sciences Library on the St Lucia campus, play a major role in servicing the information needs of the staff and students of the School of Medicine, as well as the other schools operating in the Faculty of Health Sciences.
School of Medicine
The School operates at centres throughout Queensland and in Brunei. Its Clinical Divisions carry out the School's teaching and research activities. The Central Clinical Division is located at RBH and the Southern Clinical Division is located at PAH. Some staff are also based in rural hospitals.
The School of Medicine offers a four-year Bachelor of Medicine/Surgery (MBBS) graduate entry program. The program began in January 1997 and reflected the worldwide move towards graduate entry medical courses. There are approximately 835 students currently enrolled over the four years of the course. The problem-based learning (PBL) curriculum is designed to produce doctors able to meet the challenges of the 21st century.
The structure of the MBBS Program is shown in table 1:
Table 1. MBBS Program structure
The curriculum for years 1 and 2 focuses on set weekly problems. Small groups of students meet with a tutor, twice a week for a PBL session. The students' own learning objectives drive the process. Students are encouraged to use a variety of resources including lectures, expert tutorials, computer assisted learning packages (CAL) and library resources.
In years 3 and 4 the teaching focus changes. Students undertake clinical placements in hospitals and other health care settings such as general practices. Instead of the set problems students are encouraged to base their learning on patients.
Prior to the introduction of the MBBS Program, library resources and services supported a six-year undergraduate medical course. The first three years of this course were taught at the St Lucia campus. Students were based at the Mayne Medical School, Herston. The current MBBS Program is decentralised with students throughout Queensland and Brunei. Teaching of the course has changed from the didactic or lecturer-student format to problem-based learning. These changes have had implications for the library in providing resources and services. The library has altered its resources and services to meet the needs of the MBBS Program by:
Prior to the course commencing in 1997, both the Queensland Medical Education Centre (QMEC) and the University of Queensland Library recognised that a librarian would need to be appointed to facilitate the flow of information between the Library and QMEC. The appointment of a librarian was made in 1995, and was jointly funded by the library and QMEC. The librarian was actively involved in both the design phase of the curriculum and in identifying key resources to support the problem-based learning program. The emphasis on electronic delivery of the course reflected the library's practice of flexible delivery of information resources.
As the course progressed over the years the involvement of the library also developed and increased. The library not only provided both print and electronic resources, but also information skills classes. The number of branch libraries supporting the course grew from two to five and the number of librarians supporting the course grew from one to four.
Given the number of libraries and librarians included in providing services to the MBBS Program it was decided to form an MBBS action group to co-ordinate and improve resources and services to support the teaching, learning and research needs of the program. Reflective practice theories influence the group in facilitating regular reflection, self-evaluation and in providing the opportunity to learn from colleagues. The group has led to more effective liaison with the school as librarians meet regularly with academic staff.
In late 2000 the action group felt that it would be valuable to survey MBBS Program students to determine if the changes made to Library resources and services met the needs of the new course and to determine if further changes were needed.
The purpose of the survey was to obtain qualitative and quantitative data about the library's role in supporting the program and to identify new resources and potential new value-added services. The survey was the first formal feedback opportunity for the library as the school had previously suggested waiting for the first cohort to graduate, as it was a new program and the school had extensively surveyed the students throughout the course. The survey covered the print and electronic collection, remote student access to services, information skills classes and evidence-based medicine (EBM) needs of the program.
The survey was distributed in October 2000. The survey for years 1 and 2 was different from the year 3 and 4 students' survey. The structure of the program affects the information needs of the students and this was reflected in the survey questions. Year 1 and 2 students' learning is based on weekly problems and is a set course of study. Students tend to use the same range of library resources. Year 3 and 4 students are more geographically dispersed. Their learning is based on patients they see while on clinical rotation and therefore their information needs are more diverse.
The survey was distributed by hand to year 1 and 2 students during their last week of problem based learning tutorials. As the year 3 and 4 students are dispersed with many located outside Brisbane, they received their surveys by e-mail. The response rate is detailed in figure 1.
The response rate for years 1 (65 per cent) and 2 (35 per cent) was reasonable. The poor response rate for years 3 (seven per cent) and 4 (six per cent) may be due to the delivery method and survey fatigue. Overall, the survey revealed:
The print collection: overview
The students responses to the adequacy and distribution of the collections, varied for each year. Overall, there is a strong reliance on textbooks. Green (2000, p.219) in an article on medical information needs, supports textbooks as key resources in medical education programs as they answer 'background' clinical questions. Background questions look at general presentation such as the description of a disease, the general approach to evaluation, basic therapeutic options or possible causes of a condition - which is typical textbook information. As students advance in their learning they ask more 'foreground' questions which look at an explicit or implied outcome resulting from a particular intervention in a patient. Original research found in journal articles or evidence-based summaries may better answer these questions.
The print collection: survey results
The survey revealed that sixty per cent of year 1 students wanted improved access to textbooks including more copies as well as shorter loan period such as three days and seven days, rather than the standard two week loan. The year 1 students stated that those who attended PBL tutorials later on Mondays had an advantage over those who started PBL first thing as they can borrow the textbooks first. Students agreed that by the library placing one copy of each textbook for that week's problem in the High-Use collection of the Biological Sciences Library would increase equitable access. High-Use material is only available for two hours in the library or overnight loan.
Year 2, 3 and 4 students were unaware that copies of textbooks and journal articles were held in each branch library. Overall students were satisfied with the Biological Sciences Library's collection but felt that there were insufficient numbers of textbooks in the three hospital libraries.
The library provides resources to students who are located outside Brisbane for their clinical placements. Following suggestions by students about the lack of resources available to them on these rotations, the library contacted several Queensland Health Libraries to arrange housing some resources for the MBBS Program. Selected resources (including twelve core textbooks and photocopied journal articles) are now housed in several Queensland Health and other libraries. Feedback from the survey suggests that these resources have not been heavily used due to many of the students being unaware that these materials were available. In addition, by year 3 students are encouraged to identify their problems from patients they see on clinical rotation rather than use the set examples, therefore, these students rely less on the recommended readings. The students also suggested that the journal articles were too specific for their needs. One comment summarises the survey results: "I didn't actually use these at all because I wasn't aware they were there. Even if I had known though, I may not have used them. I only used the photocopied articles in years one and two occasionally, as they often seemed to be fairly detailed, specific topics for the week, and with the large number of learning objectives to cover, I was often looking for broader summaries."
The print collection: lessons learned and changes made
The survey highlighted several issues which the Library has since addressed. Funds for textbooks have been redistributed to reflect the decentralised student population. The PAH Library will serve more students with the transfer of year 2 students from the Mayne Medical School at Herston. Each branch library has reviewed their collections and items have been culled or redistributed.
To facilitate collection development, textbooks from the MBBS Program textbook list and from the recommended readings for weekly problems, have been entered into an Endnote database. The distribution and currency of the collection is continually monitored as all branches have access to this database and librarians advise each other of later editions.
A library guide will be produced to raise students' awareness of resources. This guide will include: resources held at each branch Library which supports the MBBS Program; contact details for liaison librarians for each year; details of borrowing rights; and remote students' library contacts. We envisage that this guide will eventually become a web-based tailored package for 'my' generation.
Electronic/Web-based resources: an overview
The majority of the MBBS Program is delivered via the MBBS intranet. Each week for years 1 and 2 the Library contributes to the MBBS Intranet by providing e-access to library resources such as textbooks, photocopied articles, videocassettes, and websites relevant to each week's problem. Years 3 and 4 are also provided with set information resources such as articles, websites and textbooks relevant to each of the rotations. As these resources take a lot of time to maintain, create and update so it was important for the library to determine if these resources were utilised.
In 2000 the Library digitised the MBBS photocopied article collection and made the articles available via the Cybrary for years 1 and 2 and via the MBBS intranet for years 3 and 4. The articles have been linked using PURLs (Persistent Uniform Resource Locators) or scanned, then transferred into portable document format (pdf). Web resources have been included to support the problems. These resources are particularly valuable to 3 and 4 students because they may have limited access to other information resources when on clinical placement. The Library wanted to know the usage of these resources to determine if it was necessary to maintain print and electronic versions.
Electronic/Web-based resources: survey results
In year 1, ninety-three per cent of the students found the resources useful and sixty-six per cent used them daily or weekly and thirty-three per cent monthly or bimonthly. Students' comments from year 1 included "...the introduction of on-line resources was excellent.." also "...they were a valuable resource...". In year 2, fifty-nine per cent found these resources useful and fifty-five per cent used them either daily or weekly and twenty-five per cent used them monthly or bimonthly. One year 2 student commented, "The resources that are posted are good...." Due to the limited response rate of years 3 and 4 no percentage is available, however, the consensus from those that responded was that the resources were useful.
The library also wanted to determine whether students preferred electronic or hard copies of journal articles. Figure 2 details the responses. One of the reasons why electronic formats were supported is clear from this student's comment "I can download onto my computer and read at my leisure, delete if I don't want and do not have to pay for photocopying." One of the advocates of the print version said "I can high-light important bits and prefer to look at paper rather than a computer screen."
While textbooks are heavily used by all years, year 1 and 2 students' use photocopied and digitised journal articles more than years 3 and 4. Overall, although students were not aware of the availability of resources, e-books were popular. The challenge for the library is to continue providing access to information resources, especially electronic resources within a limited budget.
Electronic/Web-based resources: lessons learned and changes made
Based on the survey results, the Library has decided to maintain both electronic and print resources, but has reduced the number of print copies. Since the survey, the photocopied article collections for all four years have been rationalized, following discussion with academic staff. Year 2 articles have been redistributed throughout the three hospital libraries to support the dispersed student population.
The library questioned whether providing these problem-based learning resources conflicted with the development of self-reliance in learning which is an aim of the MBBS Program. The learning objectives of the Program are organised into four sections called domains. The development of self-reliance in learning is an aspect of professional development in the ethics, personal and professional development (EPPD) domain. Students are required to increase their own abilities to acquire information in a meaningful and relevant context. However, there was no mention of the concept of the students being spoon-fed in the results of the survey.
Another library concern was that references for year 1 had become dated and the original writers of the problems (in some cases) were no longer associated with the MBBS Program. To provide current references to fulltext quality journal articles for year 1 "canned searches" have been written for such databases as Infotrac and Proquest. Canned searches allow you to provide a dynamic link to a particular title, article, journal issue, or set of records relevant to your query.
E-books have assisted in making the delivery of medical information resources more flexible for the MBBS Program. The University of Queensland Library has purchased the electronic version of several medical texts such as Harrison's Online and Scientific American Medicine. Students from the four years were asked which e-books they found the most useful. Seventy-one per cent of year 1 students and sixty-three per cent of year 2 students reported that they used Harrison's Online. Years 3 and 4 students also regularly accessed Harrison's Online. Students' usage of Harrison's Online increased from 76158 in 1999 to 131711 in 2000 which is a 100 per cent increase. Other e-books used were Scientific American Medicine Online, Merck Manual and textbooks incorporated into the Virtual Hospital, (a digital health sciences library created in 1992 at the University of Iowa.) Some e-books were available via the library intranet, such as the thirty-one titles on STAT!Ref. The library purchased the web version of STAT!Ref when it became available in this format. Other e-book packages, such as Up-To-Date, are currently being evaluated.
Information skills: overview
The library has a strong commitment to information skills instruction and invests considerable resources in developing and delivering classes. The commitment of the Library to information skills reflects the educational priorities of the School of Medicine. Computer literacy and information management are included in the set of graduate attributes The University aims to give its students. MBBS graduates, as 'new' doctors will need to collect, analyse and organise information efficiently to answer clinical questions. These skills will help them be effective practitioners of evidence-based medicine.
The personal development component of the MBBS Program involves the development of a commitment to life-long continuing education and evaluation. Part of this component is a recognition by students that the ability to effectively manage information is an essential component of self-reliance in learning and that the dynamic nature of information resources obliges regular knowledge and skill updates.
The library plays a key role in developing the skills of information management and computer literacy in the students and aims to integrate information skills classes into the MBBS Program. It is a Library policy that librarians work collaboratively with academic staff in the delivery of information instruction. The founding MBBS librarian identified the formal integration of information skills instruction into the program as the major challenge in her work with the School (Foxlee and Todd 1997). The literature (Brahmi et al. 1999; Murphy 2000; Green and Ellis, 1997) supports this view and indicates that for training to be effective and well attended it needs to be integrated into the curriculum and explicitly supported by the teaching staff. Training needs to be clearly linked to the clinical setting with real examples drawn from contact with patients. Information skills classes should be:
Adequate training and computing facilities are essential to support these goals. When interviewed in 1998 on the impact of the new medical curricula on information skills, London Medical School librarians cited restrictions such as poor computing facilities and the design and layout of their libraries (Murphy 2000). Continual improvement of facilities has been a priority for The University of Queensland Library with each branch library having a state-of-the-art training room.
The Library actively markets its expertise in information management to academic staff and students. Involvement in curriculum planning and development is a goal. The Library is represented on the School of Medicine's Teaching and Learning Committee and Board of Studies, and the Faculty Board of Health Sciences. A sound knowledge of the curriculum assists the Library in identifying opportunities for the integration of information skills into teaching programs such as training in EBM tools.
Information skills: survey results
At the beginning of each year an overview of library resources and services is offered in orientation week to year 1 students, followed by classes on searching databases and the World Wide Web. In 2000, the sessions were well attended as detailed in Figure 3.
Ninety-two per cent of the students responding to the survey found the sessions useful. One student commented: "Excellent - if only I had used the databases more I wouldn't forget how to use them!". The five per cent of students who did not find the classes useful had previously studied at The University of Queensland and therefore were already familiar with the library's information skills classes.
Because the students are dispersed, it has not been possible to successfully integrate information skills classes into the curriculum for years 2, 3 and 4. Few students attended the information skills classes offered to all library customers during the year. Information skills classes were promoted to year 3 students and some students attended and found the training useful. All MBBS students are regularly advised of information skills classes by e-mail and via the Cybrary's training calendar.
To ensure information skills remain relevant, students were asked if they would like to receive additional training and if so in what areas. Only thirty-three per cent of year 1 and seventeen per cent of year 2 students wanted additional training. Table 2 shows the areas suggested.
Table 2. Year 1 and 2 training needs
Year 2 students highlighted the importance of ready access to user names and passwords for resources. Easy access is now possible via the Cybrary using an authentication program. Overall, the years 3 and 4 respondents were not interested in information skills classes. As one year 4 student stated he needed "...not so much training as an update as to what new resources had become available".
As most students did not request further training, it is reasonable to suggest that they are confident in their ability to find information. Fifty-one per cent of year 1 and forty-two per cent of year 2 students indicated having only some confidence in searching databases. Most year 3 and 4 respondents were confident in their ability to search databases. The low response rates of years 3 and 4 make it difficult to draw any firm conclusions, however, a gradual increase in confidence over the four-year course would not be surprising. Davidoff (2000, p996) in an article on clinical librarianship stated that eighty per cent of American medical school students reported that their literature searching skills were adequate by the time they graduated.
Information skills: lessons learned and changes made
The library is responsive to the needs of students located outside Brisbane. In 2001 the first group of MBBS Program students undertook a clinical rotation in Brunei. Students are given an overview of Library resources and services during their orientation programs in Brisbane and updates are e-mailed regularly. An information session with a focus on accessing electronic resources was offered to students who went to Brunei. Flexible learning resources such as the library guides, Use-its (basic guides on how to use resources) and Find-its (guides on how to find information in subject areas) are promoted. Assistance is available via the library's two virtual reference services, Ask a Cybrarian (for library and information help) and AskIT (information technology help and training) services. Ask a Cybrarian, a virtual reference desk service, was introduced in 2000 and has been extensively used by the MBBS Program students.
The challenge of servicing a remote student population was exemplified by a student who asked if the training was available in Cairns. The library is investigating visits to rural and regional centres to deliver information skills classes. The development of the rural clinical schools in Toowoomba and Rockhampton where there will be a permanent student population will further progress this goal.
Overall, year 1 students attend more information skills classes than other years and are generally more interested in training opportunities. Year 3 and 4 students are more confident in their ability to search databases. The survey revealed that students do not prioritise information skills classes. The challenge for the library is to continue to attract students to classes and to find ways to satisfy the information skills training needs of remote students.
Evidence-based medicine: overview
The library recognises the importance of evidence-based medicine to the MBBS Program. This is reflected in the following initiatives:
EBM: survey results
In the survey, year 1 and 2 students were presented with a list of potential information skills classes and resources designed to enhance their EBM knowledge and skills. Overall students indicated that they want training in EBM as indicated in figure 4.
When asked if it would be useful for a librarian to advise on how to find the best evidence and formulate the clinical question for the week's problem during PBL sessions, seventy-five per cent of year 1 students indicated yes. The preferred frequency was twice a year. Year 2 students were less enthusiastic with fifty-nine per cent indicated no.
The library asked year 3 and 4 students if they had developed the ability to use a range of information resources to support evidence-based medicine with most responding that they had. One made the connection between EBM, ready access to information and the Library saying: "Yes, though I can perceive a need for ongoing access to a service like UQ Library to enable this to continue." A year 3 student who responded negatively blamed restricted access to resources. Ready access to resources is central to EBM.
In order to assist collection management and better target information skills training the library wanted to know the particular EBM resources used by the students. Students cited a wide variety of resources including Medline, Cochrane, PubMed, Cliniweb, Medscape, Biosciences database, journal articles, full text articles, websites and books. One student described his use of information resources to support EBM as "Searching databases after finding our information in the texts". A student mentioned difficulty accessing the Cochrane Library. "Access from own computer at home would mean I would use it a lot more". Since the survey, the Cochrane Library has been made more accessible as a new supplier with a more inclusive license agreement has been found.
The library sought expressions of interest from years 3 and 4 on a range of EBM information skills classes. Students were generally enthusiastic. Year 3 students mentioned as most valuable the classes on the Cochrane Library and the best databases to use when searching the evidence. Year 3 students complete an EBM project for the General Practice and Community component of their course. EBM classes are planned for these students in 2001. From the results, it appears that year 4 students have mastered these skills and were ready for the next step: critical appraisal.
EBM: lessons learned and changes made
In response to year 1 students' feedback, a new programme of information skills classes has been developed and trialled. Information skills classes have been incorporated into the introductory block (six weeks of basic subjects) which was established in 2001. These classes are:
In the class 'Searching for best evidence using databases' students use the PICO (Patient, Intervention, Comparison, Outcome) framework to formulate a clinical question and Medline clinical queries filters to retrieve evidence-based information. It is co-taught by the Liaison Librarian with a member of the academic staff.
Follow-up or drop-in sessions by a librarian are integrated into the students' PBL tutorials. In a fifteen minute session, students use PICO to formulate a clinical question based on the weekly problem and then choose a clinical queries filter or devise a search strategy to obtain relevant information. Critical appraisal of the literature follows. Up to fifty visits are planned from June to October 2001.
Evidence-based medicine is an opportunity for the library to collaborate with academic staff from the School of Medicine and other experts in training the students. The library markets its expertise in finding the evidence and librarians undertake professional development activities to increase their skills in other facets of EBM such as critical appraisal of the literature, research methodologies and biostatistics. Librarians have completed the Evidence Based Medicine and the Medical Librarian course offered by Duke University, USA and Cochrane Library training presented by the Australasian Cochrane Centre.
The library maintains an awareness of literature and information resources in the area of EBM and aims to have a well-balanced collection with the limited resources available. The library is investigating additional resources such as Up-To-Date and Evidence Based Medicine Reviews. Improved access to key resources has been achieved and the library has an EBM Find-it as a jumping point to resources.
Overall, students are interested in EBM tools and further training in this area and this reflects the School's emphasis on EBM and its integration into the curriculum. Life-long learning is also seen as the key to being a successful evidence-based practitioner. The challenge for the library is to satisfy these information and training needs within a geographically dispersed population.
Priorities for the library
The library will continue to focus on the areas highlighted by the students. Trialling different strategies and monitoring resources and services will continue in the branch libraries to ensure staff and students of the School of Medicine are well supported. The following areas have been identified as priorities:
The survey provided valuable feedback on the changes made to Library resources and services to accommodate the different needs of the MBBS Program in comparison to the previous course. Information is available for the Library to determine future directions in the areas of collection development and management, electronic resources, information skills and evidence-based medicine. The Library looks forward to the results of the survey it will conduct in 2001 and to further contributing to the teaching, learning and research needs of the MBBS Program.
Brahmi, F A, London, S K, Emmett, T W, Barclay, A R and Kaneshiro, K N 1999, 'Teaching lifelong learning skills in a fourth-year medical curriculum', Medical References Services Quarterly, 18, 1-11.
Faraino, R 1998 'Teaching medical information a la carte: a curriculum for the professional palate', Medical References Services Quarterly, 17, 69-77.
Foxlee, N and Todd, H 1997, 'Challenges and realities of the Graduate Medical Course for The University of Queensland', In 7th Annual Special, Health and Law Librarian's Conference ALIA, Adelaide, SA.
Green, M L 2000, 'Evidence-based medicine training in internal medicine residency programs', Journal of General Internal Medicine, 15, 129-133.
Green, M L, Ciampi, M A and Ellis, P J 2000, 'Residents' medical information needs in clinic: are they being met?', The American Journal of Medicine, 109, 218-223.
Green, M L and Ellis, P J 1997, 'Impact of an evidence-based medicine curriculum based on adult learning theory', Journal of General Internal Medicine, 12, 742-750.
Murphy, J 2000, 'The role of health science librarians in preparing tomorrow's doctors to manage information', Health Libraries Review, 17, 7-13.
School of Medicine, The University of Queensland Graduate Medical Course, Available at: http://gsm.herston.uq.edu.au/gmc/p01.html (accessed 18 April 2001)