National Library of Medicine and Continuing Education, 1970
Page  1

NATIONAL LIBRARY OF MEDICINE AND CONTINUING EDUCATION Martin M. Cummings, M. D.* [... top file (can't read)] [(1) Osler, William, Brit. Med. J., 2:925-928, 1909 *Director, National Library of Medicine Presented at the Association of American Medical Colleges Conference on Continuing Medical Education. Los Angeles , California, Oct. 29, 1970] "So far as the library is a factor, the greater part of a man's postgraduate education must be at home. In this country no man practices very far from a country town in which there is a medical society or a general hospital with a library attached." (1) This was written by William Osler in 1909 when he was in England during the most mature period of his professional career. You are all familiar with his love of books and journals, but I believe many have forgotten that this derived from his intense interest in continuing education rather than his interest in bibliography and scholarship. Your National Library of Medicine was founded in 1836 to provide an opportunity for continuing education of the medical officers of the Army and has since grown to the world's largest medical library to serve the same important purpose.

Page  2 The California survey of physician opinions about continuing education programs (1969) revealed that short symposia and reading ranked as the highest modalities of medical information transfer. Among surgeons reading ranked first. (2) [(2) A Socio-economic Report of the Bureau of Research and Planning, California Medical Association, Cal. Med. 0 111:132-139, Aug. 1969.] To assist in this process, NLM publishes the Index Medicus, a Current Catalog of all books and monographs, and issues 17 recurring bibliographies in specialized clinical fields. These are designed to serve the reference needs of the medical community. In addition, there are approximately 300 other indexing and abstracting services which deal with health and medicine in part. This flood of secondary information services is nearly as complex and overwhelming as the primary literature itself. The past decade brought forth a new type of information service known as information analysis centers. There are about a dozen such activities which are federally funded which are available to health practitioners as well as scientists. Importantly, NLM has developed programs to upgrade 400 local medical libraries ($2 million per year), established a network of ten regional medical

Page  3 libraries ($2 million per year), as well as streamlining its own interlibrary loan, reference and bibliographic services. These all serve to assist the physician find medical information for his continuing education. Specifically designed for the practitioner and small community hospital we now produce an Abridged Index Medicus which contains citations from the 100 leading English language clinical journals. This heavily used bibliographic tool has now been computerized so that the file can be interrogated by on-line access to the data base for the price to the customer of the telephone or telegraph line charges. This averages about $7 per search and will be reduced when the data base is decentralized to several other regional centers. A demonstration of these services by the Lister Hill Center can be viewed in the exhibit area of this conference. We have also supported the important development of the Medical Education Jukebox which Frank Woolsey and his associates at Albany Medical School have pioneered. Its use at NLM and in several community hospitals provides convincing evidence that physicians like and use information in small audiovisual packages.

Page  4 We are now engaged in a significiant experiment with Dartmouth Medical School and the University of Vermont where two-way television and data linkages between the medical schools and some fifteen surrounding community hospitals are being designed. The failure of one-way TV systems to satisfy continuing education needs of physicians should not be used as a basis to predict failure for a two-way interactive system. In fact, limited experience to date suggests that the dialog made possible by two-way interactive audio-video systems is what physicians want. They do not wish to be lectured to but rather prefer to participate in the problem solving exercise by close involvement with the faculties and their teaching materials. NMAC--new policy to collaborate with universities and professional societies to produce A-V materials. A group is meeting here to select subject matter for A-V production for medical education at all levels. We are working with Stanford, the University of Wisconsin, the University of Alaska at Fairbanks, and the University of Washington in experiments using satellites for medical communications. Early tests, although primitive, have successfully tested EKC transmission, computer-to-terminal linkage, color facsimile transmission and voice dialogue. These linkages will soon include

Page  5 several sites in Alaska where it is hoped that the skills of our participants may be used for postgraduate education as well as for patient care assistance. Although there are more individuals involved in postgraduate medical education than undergraduate medical education (a ratio of 4:3), I believe that there is a considerably larger investment of funds in the latter. The largest number of health professionals exist in medical and allied health practice, yet an undefined but relatively modest amount of money is spent for their continuing education. Admittedly inadequate funds exist for support of medical education at all levels. Nevertheless it is my belief that the most effective use of available dollars can be made through the use of better communications between these three levels of medical education. Information concerning diagnosis and treatment of most diseases should be the same at any given point in time for those who are learning as medical students, those who are learning as they assume patient care responsibilities as house staff, and by the community practitioner. Thus information available to one group should be equally accessible to the others. Resource sharing through new technologies of communications represents a logical approach to this problem.

Page  6 Holding these views, I was obviously most attracted to the plan for continuing medical education described recently by-Brown and Uh1 in the September 7, 1970, issue of J.A. M.A. Their concept of tying the physician and his patient to information sources through modern communications systems is both realistic and achievable. The establishment of a communications network which brings the medical center to the physician and his patient provides a means of resources sharing which in my view offers continuing education along with the opportunity for improved health care through the problem solving mechanism. In summary, we believe that, in a small way, your National Library of Medicine has demonstrated the advantages of a medical library network for information transfer. Its principal thrust has been to bring informational materials to his home, clinic or hospital where he spends most of his time. The time has come when the larger dimensions of continuing education be tested through the development of a more comprehensive communications system.

Page  7 Finally, I make a plea for more involvement of the medical community with its National Library. The AAMC and its Council of Academic Societies are working with us to develop the blueprint for substantive content production for medical education at the undergraduate and graduate levels. We need a similar mechanism to obtain advice and counsel in the development of learning materials and resources for continuing education of health professionals. "It cannot be denied that many men practise, and do so successfully, with few journals and still fewer books.... medicine is now a rapidly progressive science, as well as an exceedingly complicated art, of which, at qualification, a man has only laid the foundation; and if he is to develop his intelligence - that is, get an education - it must be by systematic post-graduate study. Out of leading-strings he must himself be at once teacher and pupil, and make and keep certain self-made laws. Whether he will get this education, whether, indeed, he will be able to keep what he has, will depend in part upon the type of mind with which he has been endowed.... After a few years such a man gives up in despair, and without mental exercise grows stale and is fit to do only the ordinary reflex practise, in which cough means an expectorant

Page  8 mixture, and heart disease digitalis, just as surely as a tap on the patellar tendon brings out the knee-jerk. A glance at the consulting-room suffices for the diagnosis of this type: the British Medical Journal or Lancet lies uncut in heaps on the table, and not a book in sight! Some of the men of this type play a good game of tennis, others shoot and ride well, more play a good game of bridge, but they are lost souls, usually very dissatisfied with the profession - the kickers, the knockers, the grumblers, without a glimmer of consciousness that the fault is in themselves." (1) [{1} Osler, William, Brit. Med. J., 2:925-928, 1909]