The NLM and Medical Education, 1969
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The National Library of Medicine and Medical Education Martin M. Cummings, M.D.* [*Director, National Library of Medicine, Bethesda, Maryland.] Technology should always be a servant of social purpose. Despite the explosion of contemporary communications technology - television, computers, and satellites - we at the National Library of Medicine believe in this principle. The tool must fit the hand, and not the hand the tool. Taking full advantage of communications research and development supported by others, we have acquired at NLM instrumentation which can be fashioned to the purposes of health education at all levels. We believe its potential for medical education has far-reaching consequences, and we are soliciting the participation and guidance of the Council of Academic Societies in order to realize this potential. Several years ago the NLM began a modest program of research and development with the stated goal of providing assistance to the informational needs of medical education, research, and practice. Despite a war which has drawn very heavily on the nation's manpower and funds, the National Library of Medicine has succeeded in gaining the statutory authority, organizational base, and modest funding to begin the development of a biomedical communications network. The Library's aim is to develop a national health communications resource which can be shared freely on a dedicated basis not only in terms of human purposes, but also in terms of competition for available means of communication, a problem which must be anticipated. A joint resolution passed by the House and Senate (P.L. 90-456) called for the establishment of a National Center for Biomedical Communications to be named after retiring Senator Lister Hill, who has given so much of his time and energy to the cause of health and medicine. Strong representation on the part of the scientific community led to the passage of this legislation and the preliminary funding to help mount the planning effort. Under present planning the Lister Hill National Center for Biomedical Communications will adjoin the National Library of Medicine. Hopefully, it will possess resources not designed solely for our use but also for use by the medical community on a nationwide basis. Projection for completion of the facility is between three to five years after funding by the Congress. The design of the Biomedical Communications Network is a principal function of the Lister Hill Center. The network is based on a tenet that educational processes must be coupled with information resources if the following specific objectives of the medical community are

Page  2 to be realized: (a) improved research, (b) improved service, (c) improved education, (d) conscious decisions on applications of technology, and (e) larger wellinformed citizen population. The Biomedical Communications Network is being designed with the following objectives: (a) to facilitate the development of new knowledge; (b) to speed the flow of this new knowledge to application, and hopefully through this, to improve the care that attends the patient population; (c) to improve the teaching of medical students and graduate students; and (d) to offer new communication modalities for continuing education of all health professionals. An important corollary objective is to improve the understanding of the public in preventive medicine and healthful living. If advances in public education parallel the advances in medical education, the task of the medical professional will be made easier. A network was chosen as the vehicle for meeting these objectives, since it epitomizes a complex process heavily dependent upon communication, control, and feedback. Networks also exhibit the appropriate structure for the necessary management activities. Fortunately, the state of the technology is sufficiently advanced for us to employ a network structure. Components of Network The framework of the network is based on an interrelating complex of 5 components, all of which exist in one form or another as national resources. The challenge is to develop the necessary linkages to make these function coherently and efficiently. The components of the network are: (a) a library, (b). specialized information services, (c) specialized education services, (d) audio and audiovisual facilities, and (e) data processing and data transmission. The preliminary network design has been formulated so as to treat each individual component separately while still preserving the necessary interlinkage to yield a coherent engineering and managerial entity. The phasing, or the pacing design of the network, is dictated by the fact that its components are already in varying stages of advancement. The library component is most advanced, both with respect to planning and with respect to actual services provided. On the other hand, the specialized information and the specialized education services components are in very early planning stages due to the lack of involvement, professional assistance, and guidance of those who will ultimately use the system. In these areas we shall need your help. At the intermediate level of development are the audio and audiovisual component, situated at the National Medical Audiovisual Center in Atlanta, and the data processing and data transmission component. The latter is evident in most universities in one form or another as a data processing or a data handling center as well as in many government agencies which possess management and information data banks of a disparate and nonstandardized nature. It is important to insure that there is a proper match between the capabilities or needs of potential users on the one hand and network resources and equipment requirements on the other. It would be poor planning, for example, to let users assume that they could tap network data banks when they are financially unable to afford the necessary terminal equipment and the communication tariffs to receive or transfer this information.

Page  3 Similarly, it is essential immediately to enlist as members of the network those professional organizations which have the information resources and educational processes of greatest benefit to the largest audiences within the medical community. The network should also have certain characteristics which are vital to a cooperative venture between the federal and nonfederal sectors. Understandings must be reached with respect to (a) the regulation and management of growth and (b) responsiveness to the highest priority needs since all needs cannot be satisfied concurrently. Any network, be it a telephone or a railroad system, requires certain operating standards. Compliance with standards is essential to providing adequate and efficient services. For economic reasons, there must be some overview of the research and development which attends the building of such a complex system to avoid redundancy and incompatibility. Library component.-The objectives of the library component are to provide (a) bibliographic citations to biomedical literature, (b) the necessary complementary access to the document itself, and (c) a guarantee that somewhere in this nation there exists a total acquisition of the world's medical literature, and centralized cataloging, indexing, and announcing of the availability of these materials to user groups. A set of regional medical libraries has been established to provide more equitable geographic access to this reservoir of published material. A number of decentralized computer-based MEDLARS (Medical Literature Analysis and Retrieval System) Centers have also been established in this country. The medical schools and freestanding libraries which are already part of this network blanket every portion of the United States. Specialized information services component.-The specialized information services component has the objective of communicating information related to specific subject areas to customers in the medical community. It has as a nucleus the Toxicology Information Program requested by the President's Science Advisory Committee. The National Library of Medicine is beginning to develop this program as a national resource in an attempt to learn the technology of integrating a specialized information center within such a national network as well as to provide services to those who need such information. One of the constituents of the specialized information services component is a central referral center. Through it one will have access by direct dial services to information promptly by referral to the most appropriate source of the information requested. This source might be a single individual, a group of individuals such as a department in a medical school, or a complex system such as a poison control system. Specialized educational services component.-Very little can be said about the specialized educational services component until the medical education community is committed to joining the National Library of Medicine in early planning. It is here precisely that we appeal for your help. New communication and information science technology should have applications in undergraduate, graduate, and postgraduate medical education. This is evidenced in part by the current existence of approximately 50 established medical school departments, sections, or other organizational entities relating to audio and audiovisual communications. Through regional medical programs, of course, a significant amount of activity

Page  4 is being generated in this same field. However, these efforts have resulted in somewhat disparate programs. Materials now being generated in one locale may have little utility in another area because of the difference in size, format, and types of equipment. As a result, a large investment may be jeopardized because materials produced in one environment cannot be used easily in another without costly conversion. As we are frank in expressing our concerns with total decentralization of communications systems, we are aware that others may be suspicious of a national effort. It is hoped, therefore, that through discussion and dialogue in the spirit of meeting national needs, some resolution of this important problem can be reached. This is necessary if for no other reason than that neither group now has sufficient funds to do significant work under the present conditions. The specialized education services component has several stated objectives. They are to provide assistance to: (a) continuing medical education for the medical profession; (b) education for the medical professional in relevant technology, such as new devices, new communications media, and new procedures; and (c) education of the medically uninformed. Because the problem of technical obsolescence is such an enormous one, an especial attempt will be made to reach the health practitioner through these new technologies. In this area substantive input will be sought from medical schools, professional societies, and specialty groups. It is assumed that education for the medically uninformed should be within the area of interest of those responsible for this component. By transmitting simple health facts to people in the ghetto, in Appalachia, and in other underprivileged parts of the country, they may help themselves in some cases and be helped by the medical community more effectively by knowing when to seek medical assistance. The objective of education in related technology is based on the belief that it is productive to teach young medical undergraduate and graduate students how to use the new technologies. For example, physicians of the future must be readily adaptable to using terminals to reach data banks at distant sites and to use any other types of new equipment which will assist them in their practice. Audio and audiovisual facilities component.-The National Medical Audiovisual Center is an integral part of the National Library of Medicine. The primary mission of this instrumentality should be to advance health education rather than to produce materials for less directed purposes. This can be done only with the involvement of the educational community which will determine what materials are needed for production and will set the standards for these materials. Data transmission component.-The data transmission component is perhaps the one that needs least discussion here. There are many highly sophisticated data banks, some of which are of a very personalized nature. Stored in these data banks are enormous amounts of data of variable quality. We should be most interested in the most sophisticated, evaluated information. Conclusions Finally, medicine may be able to harness the technology available to it as a spinoff of space research for use in our communication problems. The cost involved in the use of satellites for communications is conservatively estimated to be half the cost of landline transmission to

Page  5 blanket this nation. Hopefully these costs will decrease further in the near future. For example, the National Library of Medicine has been told that the technology in the next three to four years will provide antennas for reception of direct satellite communications at reasonable cost in every physician's home, office, clinic, and hospital. It is proposed that we start with the community hospital and the medical schools as the first sites on which to place antennas. The choice of who transmits information and particularly what needs to be transmitted is more difficult. This requires involvement of those represented in this conference. This planned network is a complex system, yet all of the technical elements now exist. Its success will ultimately depend on the willingness of the student or the physician to use his eyes and ears which are attached to his brain. Without intelligent use, the network will have little value. Man has a finite cranial capacity and therefore cannot be expected to remember everything that he has been taught. Any network must have the capability to recall and retrieve those things that he has forgotten. This belief is a very important element in the planning to date. One cannot be complacent any longer about the continued exponential growth of knowledge. A plan, such as has been presented, we believe offers some hope of transmitting new knowledge to those who wish to apply it to meet society's needs and aspirations. DISCUSSION Dr. Price: When will a satellite be available? Dr. Cummings: We have already been offered the use of time on satellites and have declined because we did not have the necessary substantive program support. Its capability was offered to the Department of Health, Education, and Welfare and to the National Library of Medicine specifically for a test and demonstration. Because the state of our program planning in terms of what should be transmitted was so meager, we declined. We are going to have parking problems in space as we have them on earth. There already is competition for the finite number of parking spaces for synchronous satellites. There is going to be a shortage of frequencies in the near future. There is a long list of potential user groups. I hope, of course, that the health industry will plan to reserve a parking space up there for its needs. Dr. Smythe: Could you illustrate how such a system might be used in either undergraduate or graduate medical education? Dr. Cummings: With respect to undergraduate medical education, I think of sharing of faculty resources on a national basis through the use of these communication modalities, particularly through the use of two-way television. Also, sharing of audiovisual materials carefully selected for content and quality is possible among the nation's medical schools. This may be important to those schools which may be deficient in a particular phase of medical education. The analogy of a debate that took place when the telephone was being invented might be useful. When the telephone was invented, nobody really did a user study or market survey. Few persons had any idea that the telephone would be as beneficial as history has shown. It proved to be a useful form of communication only after it was made available at low cost. If we make communication channels available at a reasonable cost, we believe that educators will find use for them. Just as Western Union was organized to shorten the relay delays from point to point as a technical measure and went on to exercise a profound

Page  6 influence on the nation's communication efforts in many fields, we may find the same will be true of yet another method of communication. Dr. Tosteson: To be somewhat more specific about sharing the faculty, do you envisage that a faculty member from one university would tape something which would be transmitted from Bethesda, or do you envisage two-way communication being transmitted from elsewhere in the country? Dr. Cummings: I envisage televising, for example, an unusual conference in one institution so that it might be shared nationally without the necessity of having people move about geographically. Sharing an unusual strength in one institution with another institution, such as in the field of neurophysiology, is another example. Dr. Price: When do you think such a national medical television network might be possible? Dr. Cummings: The technical development plan for the network calls for complete implementation in seven years under an assumed funding plan. Although this is the time schedule we are working against, we believe a significant element of the total plan can be a reality in five years. We could be on the air with many of the planned services in less than five years, but we think waiting for space-satellite technology is going to reduce costs substantially. It takes an audience of a million to make economic use of a satellite for communications. Medicine might represent one third of the capability of that satellite. If we assume that 300,000 physicians and students might be users of a system that will cost $15 million a year, the cost would be $50 per person per year. It is my hope that private and federal cost sharing will develop for such a system. I believe that the federal government has a responsibility to pay some of the costs of research and development to engineer such a system. Not all of these costs should be transmitted to the user. But if the user is to pay full costs once the satellite capability exists and is made available on a dedicated basis, it is estimated that it would amount to $50 per physician per year.