Change: Pants, PubMed & Patron Expectations

Thank you for your comments and Krafty Librarian's mention about the PubMed Discovery Initiative post. Since then there have been a number of new RSS subscriptions (welcome all!) and a fair amount of web traffic due to that particular entry, so I wanted to mention that I do have a Creative Commons license here. You are welcome to copy, distribute and transmit any of my work here as long as you link back to whatever post it came from in your work. Drop me a comment if you'd like, I love to see what others are thinking. Keep asking so that we may understand, keep sharing so that we may learn.

This blog is still the first Google result for Quizno's I fear change commerical from my April 2008 post. I still love the 'I fear change and will keep my bushes!' reaction to pants, it is often on my mind when I come across resistance to change now. I hadn't reread the post for a while, but my thoughts there are relevant once more when it comes to these current changes in PubMed:

Resistance to change, however, is an undeniable part of human nature that is most successfully overcome through extreme patience, persistence and education in conjunction with assessing user information needs (before, during & after) to determine the proposed changes will/are actually work(ing).

From my very limited time in the field I've observed that many medical librarians have persistence bordering on the obsessive (I'm guilty of this), a very large amount of patience for our patrons, not quite so much patience for one another, and little to no patience when it comes to the electronic tools of our trade not looking or working the way we have come to expect & rely upon them to be. Show of hands for those who pitched a fit when Delicious changed overnight this July, for example? How about the new Facebook profile layout during the same timeframe?

These social bookmarking and networking sites aren't even close to the heart of medical librarianship online tools; PubMed is the core and it has had a number of changes that directly affect our search results and the navigability of the database. No wonder there is so much chatter on MEDLIB-L and other venues about it!

We have come a long way in 11 years though. There once was a cost per query ranging from $2-$4 depending upon the amount of information retrieved and time it took to do so by using Grateful Med to interface with the MEDical Literature Analysis and Retrieval System (MEDLARS) databases. (source) The title (bold mine) of the article reflects the time: Sikorski R, Peters R. Medical literature made easy. Querying databases on the internet. JAMA. 1997 Mar 26;277(12):959-60. I don't think any of us would consider that 'made easy' with our expectations regarding PubMed today, free full text wasn't an option!

What of the role of education in these changes? I already mentioned how, from my perspective, the Discovery Initiative background behind the changes in PubMed wasn't communicated clearly. Medical librarians frequently serve as educators for our users and our webpage tutorials, Camtasia recordings and classes about PubMed have already needed revision regarding the automatic term mapping (ATM), and will again where tabs are concerned per the PubMed Technical Bulletin on November 14, 2008

PubMed Advanced Search will soon no longer be a beta site. It is now the place to go to use features such as field searching and limits. In the near future the tabs for Limits, Preview/Index, History, Clipboard, and Details will be removed from the basic PubMed pages. History, Limits, Index of Fields, and a link to Details are available from the Advanced Search screen.

What about needs assessment? Changes have been and will continue to be made based on the data gathered from over 3 million searches a day, but I don't know the answer to what the results are from PubMed's needs assessment or usability testing studies. Direct feedback from users is a closed loop: web forms and emails are submitted but we as users do not know what happens next from what we send in although we are encouraged to do so. Sometimes we receive a response back that doesn't seem to address what we said, sometimes we receive no response at all.

It may be too radical and soon to cast an eye to some of the Web 2.0 tactics of transparency in change the upcoming administration is utilizing on the web for feedback, such as the first popular Open for Questions. 10,000 questions posted by change.gov visitors were ranked up or down one million times by over 20,000 people and some of the most popular ones received a direct answer for all to see. How could something similar be used to transparently offer a communication and feedback venue about what is important to all PubMed users, not solely medical librarians but all of the multiple populations that use it?

AEA Day 2: Those with authority may fear sharing it

The most frequent searches that unsuccessfully lead people to my blog involve my old Quizno's/EBM post with 'I fear change, I will keep my bushes.'

It was the title statement by the president of the American Evaluation Association during a plenary today that made me think about organization structures. Those in hierarchies both know and execute the flow of authoritative power because it is a controlled factor that also carries an easy amount of blame on 'the system.' I use it myself to describe how things are easily lost in the massive bureaucracies we juggle.

These flows of power don't work the same way in a horizontal organization structure, yet the latter seem to be where most social networking and collaboration occurs. Sharing is not only easy, it thrives here with substantially decreased turnaround expectations compared to the hierarchy. Why is David Rothman apologizing for what really isn't a delay? In my current conference (which is rather un-Web 2.0), the onus is on us to contact presenters via email for copies of presentations. Is part of social networking an acceleration on turnaround time and the expectation that we as creators of knowledge resources will always & immediately share our material online? I'm not certain.

In the nature of sharing, (I saw others with laptops today, yay!) today's conference notes are here containing mostly unedited raw material that I'll turn into at least one lengthy blog post in the future and possibly two. I'm too pooped to put all 5 proper session titles, all the presenter names & affiliations and will edit them later. I need sleep because I have 6 sessions on tap for tomorrow!

I fear change, I will keep my bushes: EBM, email & human nature

My husband just made fun of me for trying to find a Quizno's commercial from the turn of the century without success.

(May 12, 2009 edit: Bless you Xyc0, you have FOUND THE VIDEO!!)

Perhaps you remember it. The opening dialog is between two three primitively dressed British actors (and another standing around) at a ranch on the outskirts of Los Angeles (no, really), one wearing pants with the others holding on to what looks like a tumbleweed for apparel, and they meet and greet one another...

Primitive Brit 1: Aah! You are cursed with the legs of a goat!

Primitive Brit 2: Nay, these are pants! No more thorns and bugs!

Primitive Brit 1: I'd like to wear pants!

Primitive Brit 3: I fear change, and I will keep my bushes.

The part about hanging on to the tumbleweed because of fearing change has been on my mind today. I have read, re-read and am still pondering a blog entry from yesterday that caught my attention via Kevin MD about evidence-based medicine (EBM) and the difficulty in persuading physicians to change their practice. I cannot summarize the historical background quickly so please give it a read if you're curious about how long it took between the first randomized control trial (RCT) & setting best practice standards (hint: 1 century is about halfway there) and while we may promote EBM to resistant audiences, we're unlikely to die in a 19th century insane asylum in part due to physician resistance to installing plumbing for handwashing (RIP Dr. Semmelweis, we're still fighting ventilator-associated pneumonia (VAP) and Methicillin-resistant Staphylococcus aureus (MRSA) over the same thing).

What really got my attention was this section, based in part on Asch SM, Kerr EA, Keesy J et al., Who is at greatest risk for receiving poor quality health care? New England Journal of Medicine, 2006 Mar 16;354(11):1147-56.

"The gap between what we know works and what is actually done is substantial enough to warrant attention," the NEJM study concluded.

"What can we do to break through this impasse?" the researchers asked. "Given the complexity and diversity of the health care system, there will be no simple solution. A key component of any solution, however, is...to make information available...with a focus on automating the entry and retrieval of key data for clinical decision making and for the measurement and reporting of quality." In other words, we desperately need electronic medical records, and the data from those records needs to be consolidated in order to establish benchmarks for performance and best practice guidelines.

But even the best healthcare information technology will not help if physicians resist the fact that medical knowledge is constantly changing, Lalvani points out. Too often, physicians stick to the treatments they have always used, declaring that if tens of thousands of physicians do it this way, it must work.

I'm not certain I would agree with the author's inclusion of "we desperately need electronic medical records" (EMRs) because without careful user needs assessment, research, integration & training EMRs can backfire just as easily as whatever the latest 'ooh!' technology toy du jour does. There is not currently and I doubt there can be a one-size-fits-all EMR (we won't even touch the hot potato clinical decision support systems (CDSS) part of the equation!) as long as we have so many different key players in the health care industry.

Resistance to change, however, is an undeniable part of human nature that is most successfully overcome through extreme patience, persistence and education in conjunction with assessing user information needs (before, during & after) to determine the proposed changes will/are actually work(ing). In our MLA class we had an episode last week where, despite being instructed to post blog entries or contact our online instructors via chat with gentle reminders along the way, there was an outbreak of using an email listserv to communicate participant thoughts regarding the class. The listserv manager finally limited postings to instructors because the emails were becoming way too numerous.

I find this fascinating: we, as medical librarians and agents of change (I need a badge), in a class specifically for learning about new online communication technologies... went straight back to the familiar standard email listserv without hesitation even when we were told not to do so from the beginning.

Wow. Talk about fearing those goat legs and hanging onto the tumbleweeds in the face of change! I hope the class remembers this listserv stint when we experience difficulty in reaching/teaching our users regarding EBM (and other changes) though. We have great curriculum sources such as the EBM Librarian Wiki, but it takes time and knowledge of your users to teach new ways of practice. I think this is especially true when it comes to students who are learning from clinicians who have 'always done it this way.' If there's too much, too fast or any semblance 'you're doing it wrong' as part of the instruction to a group of people who are given a high level of societal power... well, it's not exactly surprising that hospital libraries are closing because they aren't perceived as valuable, is it? At least they haven't carted the librarians off to the insane asylum (yet)!