The National Library of Medicine: Relationships to Medical Education and Research, 1964
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REPRINTED FROM The Journal of MEDICAL EDUCATION VOLUME 40 NUMBER 3 MARCH, 1965 The National Library of Medicine: Relationships to Medical Education and Research* MARJORIE P. WILSON, M.D.,+ AND MARTIN M. CUMMINGS, M.D. National Library of Medicine, Bethesda, Maryland * Presented at the 75th Annual Meeting of the Association of American Medical Colleges, Denver, October 19, 1964. + Associate Director for Extramural Programs. Director. The National Library of Medicine's association with medical education began ninety-nine years ago when Dr. John Shaw Billings was assigned to take charge of the Library of the Office of the Army Surgeon General. Billings developed an interest in the control and access to the medical literature because of the bibliographical difficulties he encountered as a medical student in Cincinnati writing his dissertation. After searching the libraries of Cincinnati, Philadelphia, and New York, he came to the conclusion that nowhere in the world was there a complete medical library and that the indexes of medical books and journals could not be relied upon as a guide to their contents. According to Rogers (1), Billings wrote: It was this experience which led me when a favorable opportunity offered at the close of the war, to try to establish, for the use of American physicians, a fairly complete medical library, and in connection with this to prepare a comprehensive catalog and index which should spare medical teachers and writers the drudgery of consulting ten thousand or more different indexes. Billings began publication of the Index Medicus in 1879 and published the first volume of the Catalogue of the Library of the Surgeon General's Office in 1880. As early as 1876, the same year the Association of American Medical Colleges was founded, he submitted a specimen of a catalog to the Surgeon General and wrote in his letter of transmittal (2): The use which is made of the collection by physicians from every section of this country, and the number of persons who consult it, either in person or by letter, is steadily, and of late, rapidly increasing; and I cannot doubt that if a sufficient number of the catalogue, of which this is a specimen, be printed, and distributed to our medical writers and teachers, so that they may at their leisure learn what aid they can obtain in their researches, no collection of the Government will be more used or be of more practical utility; that it will soon tend to elevate the standard of medical education, literature, and scholarship of the nation, and will thus indirectly be for the benefit of the whole country, since the general knowledge and skill of the medical profession become a matter of personal interest to almost every individual at some time during the course of his life. Now more than 7,000 copies of the Index Medicus are purchased for use in medical libraries throughout the world. This interest in the development of a national medical library for the support of medical education and medical practice has been sustained in the century which followed Billings's original

Page  2 inspiration. In like manner, the relationship of the National Library of Medicine to the development of medical research in this country also stems from the farsighted actions taken by Dr. Billings when he argued that monies appropriated to the National Board of Health be spent for special scientific investigations. In a report to the Honorable John Sherman, Secretary of the Treasury, dated January 1, 1881, there is an account of what we believe to be the first grants for medical research awarded in the United States (3). The awards were made to universities and medical schools, including Johns Hopkins, Harvard, the University of Virginia, and Cornell. The subjects chosen for study included yellow fever, diphtheria, malaria, air pollution, sanitary control of water, and studies of the adulterations of food and drugs. It seems remarkable that it took another sixty years for the research grant to be rediscovered and that many of the problems selected for study in 1880 are still major areas of concern. Today the National Library of Medicine serves the medical community, particularly those concerned with medical education and medical research, through MEDLARS, the Medical Literature Analysis and Retrieval System, which utilizes a high speed digital computer to provide bibliographic control of the biomedical literature. The MEDLARS program has now been successfully operational for ten months. There are 185,000 citations with descriptors stored on magnetic tape. These come from 2,400 biomedical journals published in 40 languages. Demand searches and recurring bibliographies have been produced with success. The next phase will decentralize the output from this system through the establishment of 6 to 8 MEDLARS centers in selected medical schools throughout the country. While acquiring 1,200,000 volumes of medical books and journals, the Library has served as a major information resource for the entire medical community. In the early 1940's, the Library developed the first large-scale photocopying service, which has expanded rapidly to a point where it now provides free more than 4 million pages of medical literature annually to physicians and scientists throughout the world. Last year the Library provided 130,000 interlibrary loans, answered 20,000 reference requests, and filled 83,200 reader requests. More than 25,000, or approximately one fifth of the interlibrary loans, were provided to medical schools and their affiliated teaching hospitals. The National Library of Medicine makes no complaint in offering these services, but does have a deep concern that the rapid growth of medical research and medical education has not been accompanied by an equivalent growth of resources of medical libraries. Convinced that our nation's medical library needs are too overwhelming to be met by local funds or resources alone, the National Library of Medicine is developing program plans designed to assist in the rehabilitation of existing libraries and to introduce new resources and technology to help meet the medical information and communication requirements of the modern scientific society. THE EXTRAMURAL PROGRAM A small operating extramural program of the National Library of Medicine actually has been in existence since 1961. Two years ago the preliminary planning for an expanded program was acknowledged by Adams in a paper before this group (4). Again last year, Esterquest (5) mentioned the hopes of the National Library of Medicine for developing a program of support for medical libraries. Our more recent activities have related

Page  3 to the enlargement of original plans, the more detailed analysis of needs, and the prescription of a long-range course of action. On April 2, 1964, the National Advisory Health Council reaffirmed its concern with the urgency and seriousness of the problems facing medical libraries and urged the Surgeon General to utilize existing authority and to seek such additional legislative authority as might be needed to develop a program of assistance for medical libraries. The support for such a program by the Board of Regents of the National Library of Medicine and the Public Health Service has been assured. Employing insofar as possible existing authorities of the Public Health Service, the National Library of Medicine has planned an extramural program for the following 3 general areas: training, research, and secondary publications supported by means of the research grant, the training grant, the fellowship, and the contract. TRAINING PROGRAMS AND SPECIAL LIBRARY FELLOWSHIPS Long-range program development depends upon the quality and quantity of manpower being developed presently. It is clear that there is a serious need for a broad spectrum of individual capabilities in the library-related biomedical communications field and that the resources for providing the necessary range of training experience are at present extremely limited. The solution of pressing problems in the management of the published record requires trained personnel who are capable of providing first-rate service of a highly specialized nature and who are skilled in planning and designing advanced systems and of solving problems in biomedical librarianship through the conduct of their own research. Training is best accomplished in the academic setting where facilities of the university as a whole are available to contribute faculty expertise in modern librarianship, engineering, systems analysis, science, and management so that an extensive interdisciplinary approach to training can be formulated. If the librarian of the future is to assume an appropriate role as a key faculty member in the structuring and coordination of scientific communication networks for the health professions, an appropriate educational background at the graduate level is a prerequisite. The enhancement of a library science career in this manner would undoubtedly have a salutary effect on recruitment of promising young people to the field. At the AAMC's 74th Annual meeting, Esterquest (5) emphasized the significance of the presence of a "leader-librarian" at the head of the library. Bloomquist (6) has suggested that the kind of service which medical school libraries should be providing (and which leader-librarians can provide) has not always been possible and that the lack of achieving this objective has caused scientists to seek other ways by which to satisfy their information needs. Bloomquist (6) further reported that there is not only the need to recruit and teach new librarians, but there is also a need to develop standards for medical librarianship and keep medical librarians already in the field up to date with recent advances through an effective program of continuing education. The Guidelines developed by the Association of American Medical Colleges-Medical Library Association Committee, which describe the skills and traits of the librarian, recommend that the librarian must be open-minded and receptive to changes in dealing with scientific literature problems (7). It is our view that the librarian should not only be receptive, but should himself be

Page  4 an innovator, designer, investigator, and developer. The needs for personnel for direct library service are of such magnitude as to demand early and vigorous action. It is estimated that more than 3,000 additional professionally qualified biomedical librarians are needed to provide one such person for each existing medical library. Presently, many medical libraries outside the medical school are staffed by individuals lacking adequate background to meet the needs of scientists and practitioners using their resources, and less than 50 new medical librarians are being trained annually. The National Library of Medicine is interested also in the support of training of information specialists and scientists and personnel of varying backgrounds to serve as indexers, programmers, searchers, and abstractors. Also, the production of manpower capable of the editorial work and scientific writing necessary for the compilation of biomedical information is a necessary adjunct to the medical library field. Training programs in the history of the life sciences also will be supported. An additional aim is to further scholarship in the development of monographs, critical reviews, bibliographies, and historical studies. A program of special library fellowships has been developed so that university scholars may be in residence at the National Library of Medicine to work on problems of medical history or in the preparation of critical reviews. RESEARCH PROGRAMS The experience of the National Library of Medicine in making its holdings of the scientific literature available indicates the extent of interlibrary activity that is taking place. While it is essential that a sufficient number of individual medical libraries be brought to at least a minimum standard, the phenomenon of completely uncoordinated development of conventional libraries is approaching obsolescence. However, the role which a regional library can fulfill in the structuring of optimal systems for providing extensive coverage and easy accessibility to the literature by the user has not been adequately assessed. The relationship of the local to the regional resources also requires careful study. There is need for experimentation in the use of modern techniques available to facilitate the storage and retrieval of information and for research and demonstration projects on conventional and nonconventional systems for providing basic library services. Various other categories of the NLM extramural research program may be identified with problems of immediate or potential interest to the operation of the National Library of Medicine and biomedical libraries in general. The program is aimed at the solution of problems encountered in the development or functioning of library-related information handling systems with particular attention to the major areas of access, storage and retrieval, and transmission of information to the user. PUBLICATIONS AND TRANSLATIONS In November, 1962, the Surgeon General invited a number of special consultants to meet with him and members of the Public Health Service for a working conference on health communications (8). In October, 1963, the National Academy of Sciences-National Research Council was asked by the Director of the National Institutes of Health (9) for a "broad examination and assessment of the problem of communication among working scientists in the biomedical area." Both of these endeavors resulted in a number of recommendations, including a call for increased support of activities such as those presently conducted by the National Library of Medicine in

Page  5 support of publications. Because of its particular interest in the bibliographic control of the literature, the NLM has chosen to emphasize support of secondary publications, including indexes, abstracts, bibliographies, and critical reviews. So far the Library has sponsored the translation, publication, and distribution of Soviet, Polish, Japanese, and Serbo-Croatian literature of interest to the U.S. scientific community. It has also supported the publication of directories of research institutions and individuals in such countries as Poland, Yugoslavia, and Russia. UNMET NEEDS The activities just described will bring an effective force to bear on many problems of medical libraries. Our present authorities, however, do not permit us to make grants for construction. This is a major deficiency, since the need for space and modern facilities is one of the more urgent problems of medical libraries. Hopefully, new legislation to meet these needs will be forthcoming in the near future. Deitrick and Berson reported in 1953 in Medical Schools in the United States at Mid-Century (10), that in 27 of the 41 schools visited during their survey, the most urgent need was for space, both for storage and processing of literature and for the use of students and faculty. They indicated that a factor leading to the need for more space was the increase in the number of periodicals the library should make available. Other factors included the marked increase in the number of medical students, interns and residents, graduate students, and students in other health fields, and in the size of faculties as well as in the number of research projects carried on in the schools. The report (10) further stated that demands placed upon the libraries by research projects had not been recognized by the administrative officers of medical schools or by agencies granting funds to support such projects. Little evidence was found of attempts to meet the libraries' increased needs during a period of tremendous expansion in the research and other activities of the schools. The conclusions and recommendations of the Deitrick-Berson report are not new to this group. They are as true today as they were in 1953 and we find the echo of these conclusions and recommendations in the Guidelines (7). What is astonishing and disappointing is that ten years later the same recommendations are being made and apparently little has been done to implement them. The Bloomquist report (6), published in 1963, indicated that the median library operating expenditure was only 1.7 per cent of the total institutional expenditure for educational and general purposes. The Keenan report (11), published this year, indicated medical school library budgets still in this same depressed range. The New York State Education Department recommends 5 per cent of the total general and educational cost for minimum support of college library services. This coincides with American Library Association recommendations. It is apparent from past and more recent surveys that one of the most prominent unmet needs is a program for assistance in the construction of new library buildings, the renovation and rehabilitation of existing structures, and the provision of equipment, resources, and personnel necessary to operate these facilities. The needs of the biomedical libraries of the nation are not solely the result of the neglect which they have suffered in the past, but are magnified by the role which they will be required to fulfill in the future. The library should assume increased importance as a center for education, not only in the traditional sense, but in

Page  6 the expanded function attributed to the role of the library as a learning resource center. This function imposes the further necessity for space more specialized than has been needed in the past. Most biomedical libraries as they exist today would not be capable of assuming effective roles because of the limitation placed on them by inadequate and antiquated physical plants. In June, 1964, the Association of American Medical Colleges conducted a survey of the need for medical library facilities and resources. All but 2 schools replied to the AAMC questionnaire. It was learned from this survey that the present average size of the medical school library is 18,100 square feet. An estimate was made for an average need of almost 32,900 square feet for established schools. The developing schools reported an average need for 38,000 square feet. Most schools indicated a need to develop new library facilities rather than renovate existing space. Only 5 of the schools indicated that they plan solely for renovation of facilities. Another 10 planned renovation in addition to new facilities; 62 schools require entirely new facilities. The schools desiring new construction require a total of $96,000,000. Another issue of great interest to the Association and the library is the need for the development of library resources. The medical schools indicated a need for an additional 1,352,000 volumes at a cost of approximately $13,000,000. They estimated their other resource needs at about $12,500,000 for a total cost of approximately $26,000,000. Bloomquist (6) indicated in 1963 that only 25 per cent of the medical schools approached the suggested standard for a working medical school library of 100,000 volumes. To be sure, this is a standard which has come into being perhaps primarily because it has been quoted so often, and the AAMC-MLA Committee on Guidelines probably wisely avoided using a quantitative standard for holdings, since such standards have significance only if the scope, quality, and other characteristics are also specified. But it is interesting to note that the estimates for resources returned on the questionnaire indicated maintenance of the average medical school collection still far below the 100,000 volume level. Clearly, a federal program should not subsidize the total cost of such resources. But whatever is the exact nature of support for resources which is eventually provided, and this still requires a great deal of thought and planning, there will undoubtedly be a matching provision in any new legislation. It has been suggested that a formula be developed on the basis of a provision of federal support for a percentage of the average budget for the library for a preceding period of time, with a diminishing percentage applied to the federal contribution over a five-year period. Such a formula is clearly suggested to encourage the university's own contribution to its library. We referred previously to the need for the further study of the interdependence of major resource libraries with each other and with their local library users. Under our existing authorities for the conduct of research, it will be possible, if funds are forthcoming, to study the potentials of these existing service patterns as a substructure for an integrated network of medical library services working cooperatively with the National Library of Medicine. The implications of advanced patterns of electronic technology for improving the intercommunication of libraries locally, as well as nationally, must be reviewed. Also, the nature of resources to be acquired for the library of the

Page  7 future must be determined. However, once certain questions are answered about the economic feasibility and desirability of the further development of the interlibrary network which actually exists informally today, financial aid will have to be provided to support continuing acquisition of resources and the activity of repository or regional libraries on a continuing basis. If regional complexes are fully developed, it seems prudent to place such resources wherever possible in existing private, university, or free-standing libraries of excellence. THE CHALLENGES What, then, are the challenges? There are challenges to the medical schools, to the librarians, and to the Federal Government. First, it appears important that the schools themselves analyze why so little action has been taken with regard to their medical libraries in view of the Deitrick-Berson study (10) of 1953, as well as more recent studies which reveal the deplorable state of our nation's medical libraries. The work of the AAMC-MLA Committee on Guidelines defines the basic ingredients of a satisfactory medical library. What importance does the medical school administration attach to recommendations that have been made over the years about the role of the library? How important is a good working library to the faculty, and what place does it have in the continuing education of the physicians of your medical community? Are students learning to use the literature properly and to develop taste and discrimination? Is there active attention on the part of the faculty to this aspect of the student's education? Are medical school faculties different from those in other fields who find the library important to a community of scholars? Is there any real conception of the needs and wants (which, incidentally, may be quite different) of the users of medical libraries? Has the medical school developed a plan of action to meet these needs? An equally great challenge faces the librarian. A mechanism of support for the training of "leader-librarians" in greater numbers and in greater depth will be offered through the National Library of Medicine extramural program. Will the librarians accept and welcome this opportunity? Will they be courageous enough to speak out on those things which they know well with regard to information management and handling? Will they be willing to take on new assignments and to prepare themselves to incorporate modern technologies as integral segments of highly developed communications networks? What of the role of the Federal Government? The Federal Government should not assume sole responsibility for the revitalization of the nation's biomedical libraries. There is need for the comprehension, constructive suggestion and criticism of the medical community and the library community, as well as their support. There must be a clear understanding on the part of both the federal administrators and the university administrators of the implication for the university of another federal program of assistance. It should be kept in mind that the basic mission of the Federal Government in this endeavor is the improvement of medical communications with the ultimate goal of securing the health of the people of this nation. The basic mission of the medical school or university may be different from this, but there is not necessarily incompatibility in the means toward our various goals. However, compatibility will not just happen. It will require the close attention of both

Page  8 parties. Care must be taken to preserve the fundamental freedoms of all components of our society and at the same time develop efficient and economical systems, particularly in the sensitive area of the development of communications systems. Hopefully, the program under consideration will not be limited to one particular segment of the medical community but will make its resources available for research, for education, and for the practicing physician. It was gratifying that the AAMC took seriously its responsibility toward the medical library problem in the establishment of the Committee on Guidelines. It is hoped that this is not the end but that the Association will respond to this problem on a continuing basis. We invite your consideration in selecting representatives of this Association and of the Medical Library Association, and possibly others, to work with the National Library of Medicine staff to develop further planning guidelines with particular attention to the requirements for the medical library of the future, so that when new facilities are constructed, they are useful not only today, but truly represent the library of tomorrow. In conclusion, a reflection of Sir William Osler (12) still seems pertinent: In the recent history of the profession there is nothing more encouraging than the increase in the number of medical libraries. The organization of a library means effort, it means union, it means progress. It does good to men who start it, who help with money, with time and with the gifts of books. It does good to the young men, with whom our hopes rest, and a library gradually and insensibly moulds the profession of a town to a better and higher status. REFERENCES 1. Rooms, F. B. John Shaw Billings: 1838-1913. Libr. J., 88:2622-2624, 1963. 2. U. S. Surgeon General's Office. Library. Specimen Fasciculus of a Catalogue of the National Medical Library. Washington, D.C.: U. S. Government Printing Office, 1876, p. V. 3. U. S. National Board of Health. Annual Report, 1880. Washington, D.C.: U. S. Government Printing Office, 1882. 4. Adams, S. Medical Library Resources and Their Development. J. Med. Educ., 38:20-27,1963. 5. ESTERQUEST, R. T. Improving the Quality of the Medical School Library. J. Med. Educ., 39:451-458, 1964. 6. BLOOMQUIST, H. The Status and Need of Medical School Libraries in the United States. J. Med. Educ., 38:145163, 1963. 7. Guidelines for Medical School Libraries. J. Med. Edue., 39: January, Special Issue, 1965. 8. U. S. Public Health Service. Office of the Surgeon General. Surgeon General's Conference on Health Communications, Nov. 5-8, 1962. Washington, D.C.: Public Health Service Publication No. 998, 1963. 9. National Research Council. Division of Medical Sciences. Communication Problems in Biomedical Research. Washington, D.C., 1963, p. 2. 10. Deitrick, J. E., and Berson, R. C. Survey of Medical Education. Medical Schools in the United States at Midcentury. New York: McGraw-Hill, 1953. 11. Keenan, E. L. Medical School Library Statistics. Bull Med. Libr. Assn., 52: 386-419, 1964. 12. Osler, W. Aequanimitas with Other Addresses. Third Edition. Philadelphia: Blakiston, 1943, Pp. 293-294.