Plans for the Development of a Medical Library Network, 1968 [II]
Page  1

the Bulletin of the Cleveland medical Literary Elisabeth Severance (Allen) Prentiss OFFICIAL QUARTERLY JOURNAL OF THE CLEVELAND MEDICAL LIBRARY ASSOCIATION Volume XV, No. 2 April, 1968

Page  2 Plans for the Development of a Medical Library Network by MARTIN M. CUMMINGS, M.D.* Mr. President, officers and members of the Cleveland Library Association, ladies and gentlemen: Several years ago I had the pleasure of addressing a small group here at the Allen Memorial Library. The occasion was, I believe, a pre-marital luncheon meeting when I first learned of your plans to merge your libraries to better serve the needs of your community. At the time I thought of George Bernard Shaw's statement that marriage is popular because it combines the maximum of temptation with the maximum of opportunity. I'm glad you succumbed to both. In his address of dedication for the Allen Memorial Library on November 13, 1926, Dr. Harvey Cushing' related that the fine collection housed here began with a subscription to the London Lancet ordered in 1878 by Dr. Isaac N. Himes. Dr. Himes prevailed upon the authorities of the Case Library to accept this journal and a collection (fenced off in a wire cage as dangerous to the general reader) began to grow. A formal organization, the Cleveland Medical Library Association, soon sprang up to add to the collection and its acquisitions have thrived over the years until, I am told, it quite recently acquired a great university. Seriously, I believe the cooperative venture between the Cleveland Medical Library Association and Western Reserve University to form the Cleveland Health Sciences Library is an exciting one, and augurs well for the development of library resources to better meet the needs of health professionals in the Cleveland area. I would like this evening to describe briefly for you the background of the problems we face nationally today in biomedical communication. Having presented the problems, I plan to suggest our approach to its solution. The so-called "information explosion" has been, in recent years, the subject of much discussion, explication, and dissection. We have reached the point, I believe, where no one can entertain serious doubts concerning the existence or urgency of the problem. In fact, we rarely call it a "problem" nowadays - it is more often referred to as a "crisis." The problem is not a lack of information but rather a lack of organization and access to an abundance of information. The formal mechanisms for disseminating information have always been in disarray. The physician or scientist who is faced with today's bewildering multitude of information sources, any one of which may or may not have the information he seeks, is little better off than his counterpart of 2,000 years ago, who discovered that the material he needed was in the Library at Alexandria, while he was conducting research in Athens. As information needs grew greater, new methods of communication have

Page  3 inevitably been born. The invention of paper, the movable type printing press, and the scientific journal are examples of such advances. In the five centuries since the invention of the printing press, the number of publications has grown to fantastic levels. Tom Masson, American humorist and editor wrote at the turn of the century, "There are 70 million books in American libraries, but the one you want to read is always out." It is estimated that some 30,000,000 books are alive today. According to figures published by Fremont Rider in The Scholar and the Future of the Research Library,[2] major university libraries double their collections every 16 years. The Yale Library, for example, comprised 50,000 volumes in 1849, with 1 1/4 miles of shelving and a card catalog of some 160 drawers. If the growth of the Yale Library continues in the future at the same rate as that of the last century, Rider postulates, by the year 2040 its collection will contain

Page  4 about 200,000,000 volumes occupying a staggering amount of shelf space. If a card catalog were used, it would consist of nearly 3/4 of a million catalog drawers occupying some eight acres of floor space. We must obviously find means to deal with this problem and later I shall address myself to this issue. The scientific journal however, is more appropriate to my discussion here, for it is the phenomenal growth of this medium which presents the greatest problem and challenge to the orderly communication of modern scientific information. Prior to the appearance of the scientific journal in the 17th century, scientists (i.e., men of sufficient means and leisure to pursue their interest in man and nature in systematic fashion) communicated their observations, and discoveries by word of mouth and by letter. The coffee house and the post were, in today's jargon, their primary modalities for information-transfer. The appearance of the Royal Society's Philosophical Transactions in 1665 gave rise to a new form for communicating scientific and technical information. Papers read before the Royal Society, letters, summaries and abstracts of scientific books, in short, the scientific news of the day, was summed up in this journal [3]. Philosophical Transactions was followed rapidly by similar journals published by other national academies in Europe. The rise of the scientific journal has been described[4] by (Fig. 1) Derek de Solla Price, who has estimated that some 100 journals existed by 1800, 1,000 by 1850, 10,000 by 1900, and 100,000 by 1950. He demonstrated that there is an exponential growth of the literature, increasing by a factor of 10 every half century. If this rate of increase remains constant, there will be approximately 1,000,000 journals by the year 2000. This proliferation of scientific journals can be laid directly to the growth and complexity of science itself, and the number of men and women engaged in its pursuit. More physicians and scientists are alive and working today than in the entire recorded history of science. In the health sciences, a breakdown in the transmission of information is more than just an inconvenience to the researcher, more than the wasteful duplication of an experiment previously conducted and reported on. A breakdown in the communication of biomedical research information, technical data, and clinical findings may be a serious disservice to the patient, the ultimate beneficiary of this information. Thus, anything that impedes the flow of biomedical communications can ultimately be reflected in the health statistics of the Nation. New mechanisms for knowledge transfer must therefore be created to make the latest medical findings available as rapidly as possible to scientists, educators, and practitioners. It is to reach this goal that the National Library of Medicine, and the medical library community are now striving. The foundation on which a rapid and efficient system of biomedical communications is today being built was laid about 100 years ago. The idea of a great repository of medical information to serve one day as a truly national

Page  5 library of medicine, and of an all-embracing index-catalogue of such a library, came to John Shaw Billings, a 22 year-old medical student at the Medical College of Ohio, in the middle of the nineteenth century. Planning a thesis to satisfy requirements for the doctorate, he took as his subject, "Surgical Treatment of Epilepsy," but found himself handicapped by the lack of both a good medical library and a reliable, comprehensive index to the medical literature. Remembering this need years later when Billings became librarian of the Library of the Surgeon-General's Office, the forerunner of the National Library of Medicine, he compiled an Index-Catalogue for this library which has been described by Dr. William H. Welch as America's most important contribution to medicine. Index Medicus, a periodically issued listing of references to journal articles in the field of medicine was also initiated by Billings. The Royal Society of Medicine described Index Medicus as America's greatest contribution to medicine on the occasion of our 100th anniversary in 1965. It is clear, however, that published catalogues and indices are not sufficient to serve today's medical information requirements. To Billings' concept we must add another, one made possible by the application of the enormous capability of the electronic computer to store, process and retrieve scientific and technical information. The new concept is that of a closely-integrated network of health-science libraries and specialized information centers that use modern communications technologies to deliver information directely to the user. The first large-scale application of computers to the handling of biomedical information came through the National Library of Medicine's Medical Literature Analysis and Retrieval System (MEDLARS) which became operational in 1964. Articles from about 2,300 biomedical journals in some 40 languages are regularly indexed at the Library, and the citations transferred to magnetic tape for storage in the computer's memory bank. As of this date, there are some 750,000 augmented bibliographic citations in this store. The manipulative skills of the computer are most impressive when the vast store of references is rapidly searched and a bibliography tailored to the preciselystated needs of a requestor is produced. As many as 30 reference searches can be processed simultaneously. In 1967 more than 5,000 demand bibliographies were produced by the system. Certain of these bibliographies are chosen as being of interest to a wide audience and reproduced in quantity. These bibliographies are called "Literature Searches" and more than 24,000 were distributed on request last year. An evaluation of the quality of the demand bibliography, made by an objective outside user group reveals that the system has 70% recall and 65% relevance, a most satisfactory performance. Affording health professionals greater access to MEDLARS, six decentralized MEDLARS stations have become operational in the United States. They are located at Harvard, UCLA, Ohio State University, and the Universities of

Page  6 Colorado, Alabama, and Michigan. Two overseas stations are also operational at the Karolinska Institut in Stockholm, Sweden, and at the University of Newcastle-upon-Tyne in England. I have described in some detail the products and services performed by MEDLARS as one example of how the introduction of modern technology can extend the traditional role of the health-sciences library. Much remains to be done in furthering the application of the new technology in such areas as graphic image storage and retrieval, and the rapid facsimile transmission of documents, If sophisticated technology, such as MEDLARS, offers us one system to combat the problems of medical communications, the much larger question of how to develop other systems to serve national information needs remains. For the past two years, we at the National Library of Medicine have been planning the design and logistical support for a national biomedical communications network. Because of the great difference in the resources of medical libraries, ranging from those of small hospital collections with, perhaps, a few hundred volumes, through the extensive collection of the Cleveland Health Sciences Library, to the approximately 1,500,000 items at NLM, we came naturally to the conclusion that the National Library of Medicine should continue to serve as the backstop for all other medical libraries in the United States, a central source to which they could turn for material not in their collections, and for assistance in improving services to their users. Fig. 2. Network concept (information flow)

Page  7 (Fig 2) The flow of information within this network is self-perpetuating. Information disseminated to users ultimately returns to the libraries and information centers in the form of new publications. I think your Director, Mr. Robert Cheshier, identified the key to the network concept when he wrote in the January 1967 issue of The Bulletin of the Cleveland Medical Library.[5] "Regardless of whether we look at those who use us or those we use, we see a hierarchy of library resources. This is an exciting view, because if we can see the hierarchy we can explain it to our users and others." Fig. 3. Overall network plan (organizational) Although the next slide may seem a page straight out of Mr. Cheshier's "hierarchy thesis," I assure you we reached our conclusions independently. (Fig 3) In order to maintain and control the flow of information, we envision a network stratified according to the resources of the libraries and the services they would be able to provide. Activities within such a network would be designed to be compatible with a future national information system and the practices and plans of the Library of Congress and the National Agricultural Library. The network would work closely with organizations and groups in specialized fields within the biomedical sciences to meet their information needs, and would provide assistance as needed to the specialized information centers which have been established by mission-oriented groups.

Page  8 Fig. 4. Network Plan (NLM and CBC). (Fig 4) Segmenting the hierarchical system presented in the previous slide, we must first examine the apical functions. Although other network configurations may be possible for other information systems, we believe that a medical library network cannot be, if I may use the expression, topless. The resources of the National Library of Medicine, the world's largest biomedical library, we believe, make its choice as the central element in the network a logical one. In addition, a Center for Biomedical communications is a planned element of NLM whose primary function would be research and development leading to improved systems and modes of biomedical communications. (No. 1 on chart) The Library strives to acquire all new literature of direct concern to medicine and all applicable literature from the allied sciences. (No. 2 on chart) This literature is cataloged and indexed at NLM and the resulting citations published in the NLM Current Catalog and Index Medicus. (No. 3 on chart) I have already described the bibliographic services made available through MEDLARS. Items four and five would be a part of the functions of the Center for Biomedical Communications. Number 6 was made a reality on October 22, 1965 when President Johnson signed the Medical Library Assistance Act. I would like to go back to the first item for a moment, for audiovisuals are especially worthy of note here. On last July 1, the Public Health Service

Page  9 Audiovisual Facility at the Communicable Disease Center in Atlanta was transferred organizationally to the National Library of Medicine. The Facility has been renamed the National Medical Audiovisual Center and its placement under NLM will result in the Library's being able to serve better as a truly comprehensive repository and distributor of biomedical information in all forms. Fig. 5. Network plan (regional and academic libraries). (Fig 5) The center slice of our triangle is composed of regional and academic medical libraries. The latter would include substantial university health science and medical school libraries. It is at this level that regional medical programs will transmit and receive medical information and data. The establishment of what we call "Regional Medical Libraries" is provided for in the Medical Library Assistance Act. We are now in the process of reviewing grant applications from existing institutions in defined geographic areas of the country to enable these libraries to expand their collections and provide increased and more efficient servics to local medical libraries. In June 1967 the Board of Regents of the National Library of Medicine reviewed and approved a grant establishing the first Regional Medical Library at the Francis A. Countway Library of Medicine in Boston. The Countway Library, which began its regional services on October 1, serves the New England states of Maine, Vermont, New Hampshire, Rhode Island, and Connecticut. Countway will expand and improve its inter-library and reference services to readers served by local medical and hospital libraries, thus

Page  10 providing health professionals in the region with faster access to biomedical information. The second regional library will be in Seattle, Washington to serve the northwest Pacific area including Alaska. There will be six or seven such libraries operating by 1970 and, ultimately, if they are successful, some 25-30 regional libraries serving their respective geographic areas may be supported. These libraries will have MEDLARS capability via electronic linkage to the central facility at NLM. Fig. 6. Network plan (local libraries). (Fig 6) The local medical library is the base of the triangle, and indeed, the base of the whole system. It is to the local library that most health professionals will turn for information. This is the underdeveloped base for continuing education. Consequently, it is the type of library that most needs strengthening to enable it adequately to meet its users' needs. If we view this network as an inverted sieve of increasing fineness, it is desirable to have the gaps at the local level as small as possible to preclude a torrent of requests to the academic and regional libraries. I would like to return for a moment to the concept of a Center for Biomedical Communications that I mentioned earlier. Basic research is modernizing and improving the techniques of transferring knowledge is still largely limited to non-library functions. New developments in communications technology which which could be applied with great profit to the area of biomedicine have been sadly neglected. Most librarians have had all they could do merely to cope with

Page  11 the rising flood of published material and to satisfy the increasing demands of their users. The few systems which have been placed into operation are not being tested under controlled conditions and, as a result, many new ideas for improving and extending these systems have had to be rejected for lack of adequate data. We also envision establishing a national biomedical Clearinghouse and Referral Unit within the Center for Biomedical Communications. Fig. 7. Center for Biomedical Communications. (Fig 7) This activity would quickly guide the user through the maze of units which collect, process, and disseminate biomedical information. Emphasis would be placed on identifying data of interest to user groups, directing users to information contained in the specialized information centers, and collecting forms of data that might otherwise be lost, such as unpublished reports, negative reports of scientific investigations, and translations. The Referral Center would be a thread to guide the user through the labryinth of biomedical information sources - a single point of entry into the network. For those materials not contained at the Center, the message will be switched to a specialized information resource. Much planning has gone into developing the concept of a national system of

Page  12 biomedical communications. We must now commit ourselves to the implementation of the system. The technology already exists to accelerate radically the flow of biomedical information from the researcher to the hospital, classroom, laboratory, and physician's office and even his home. What has happened here in Cleveland is a step in the right direction. You have pinpointed, on a local level, the problems which face the biomedical community on a nationwide scale. And you have taken constructive, intelligent steps to rectify these problems by inter-library cooperation. The development of a national network of medical libraries depends on just such cooperation, but on a larger scale. Although the Federal Government can assist in providing resources, advice, and direction, the success of a biomedical communications system depends ultimately on institutions such as yours. I hope others will follow your splendid example. Finally, I would be remiss if I didn't acknowledge the indebtedness of the National Library of Medicine to the Cleveland Medical Library which accepted the responsibility for housing our historical treasures during World War II. You not only protected the world's greatest collection of medical books but added to its strength and beauty by the efforts of your bindery which restored many of our volumes during their 20-year tenure here. Your own esteemed Dr. Robert Stecher also deserves recognition tonight for his service as a member of our Presidentially approved Board of Regents. I doubt that any city claims a physician who has done more for the development of local and national library resources than your own. Thus, it was with a sense of great humility that I accepted your invitation to speak here tonight - I feel like the man who lived through the great Johnstown flood - on every occasion thereafter when given an opportunity to speak, he recounted his experiences during the flood. When he finally came to his resting place in heaven he was given an opportunity by St. Peter to say a few words about his life on earth. He immediately beamed as he was being introduced but-as he stepped up to speak he was reminded that Noah was in the audience. I close with a quotation from your own Bob Stecher who wrote in 1945: "The first obligation of the library is to care for the needs of the practising doctor, the interns, and the medical and dental students. These are the men who need the services most, being less able to provide for their necessities independently. The alert librarian senses their needs, anticipates their requirements and explores the possibilities for greater aid. Upon his ability to recognize such opportunities depend the librarian's and the library's success. The usefulness and availability of the library's resources are greatly enhanced by the free delivery system ... "The administration of this great library is a serious public trust. Such an accumulation of the world's recorded experience, available today very largely because of the generosity and provident foresight of a former generation, must be

Page  13 offered for study to all who are competent to profit from association with it. Restrictions in its use are only those which seem proper for resonable protection and eventual preservation." This is the same spirit which must pervade all elements of a national medical library network. References *Presented to the Cleveland Medical Library Association, February 16, 1968. Based on a presentation to the Association of College and Research Libraries Subject Specialists Section, American Library Association. Published in part previously at Ciba Foundation Symposium on Communication in Science: Documentation and Automation, 1967, pp. 110-122, London. 1. Cushing, Harvey. Consecratio Medici. Boston, Little, Brown and Company, 1940. p. 250. 2. Rider, Fremont. The Scholar and the Future of the Research Library. New York, Hadham Press, 1944. p. 8-10. 3. Stimson, Dorothy. Scientists and Amateurs. New York, Henry Schuman, 1948. 4. Price, Derek John de Solla. Science Since Babylon. New Haven, Yale University Press, 1961. p. 93,98 5. Cheshier, Robert G. The librarian and cooperation (from the Librarian's Desk) Bull. Cleveland Medical Library 14 (1): 23-24, January 1967. CLEVELAND MEDICAL LIBRARY ASSOCIATION 11000 Euclid Avenue, Cleveland, Ohio 44106 Telephone: 231-4402 OFFICERS RUTH R. RAUSCHKOLB, M.D ...................President DONALD M. GLOVER, M.D ............................... Vice-President ROBERT E. HOLMBERG, M.D .........................Secretary-Treasurer EXECUTIVE COMMITTEE DONALD M. GLOVER, M.D., Chairman JOHN R. HASERICK, M.D. JOHN B. HAZARD, M.D. ROBERT E. HOLMBERG, M.D. HARRY HAUSER, M.D., ex-orio RUTH R. RAUSCHKOLB, M.D.