The Australian Library Journal

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Evidence-based medicine: an opportunity not to

be missed

Ruth M Sladek

To cite this article: Ruth M Sladek (2000) Evidence-based medicine: an opportunity not to be
missed, The Australian Library Journal, 49:3, 271-277, DOI: 10.1080/00049670.2000.10755926

To link to this article: https://doi.org/10.1080/00049670.2000.10755926

Published online: 28 Oct 2013.

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Evidence-based medicine: an
opportunity not to be missed

EBM (Evidence Based Medicine), is now an unavoidable issue

within healthcare. It is dependent upon accessing'evidence', that
is, both published and unpublished research, and as traditional
suppliers of information services, health librarians now have
excellent opportunities to define and assert their roles in the
health care industry. We need to understand EBM not only in
order to continue to provide relevant services, but so as to explore
current opportunities in extending and promoting our roles. This
article will introduce the concepts of EBM, and identify key areas
for our involvement.

Manuscript received February 2000

This is a refereed article

BM HAS BEE]'; DEFINED AS 'THE INTEGRATJO]'.; OF BEST RESEARCH EVIDENCE with clinical

E expertise and patient values'. 'Evidence' has been defined as 'clinically relevant
research, often from the basic sciences of medicine, but especially from
patient-centred clinical research into ... the efficacy and safety of therapeutic,
rehabilitative and preventative regimens'. (Sackett et al, 2000). Essentially EBM in-
volves incorporating the best available evidence into the decision making process when
Health professionals
need access to
evidence. They need
the technical
capabilities to locate
available evidence
making a decision about health care for a person. from sources such as
Librarians may find these statements unremarkable, and they would not be alone. databases, and
Most people probably assume that healthcare is already based firmly on evidence. The ultimately the full
reality however, is that it has been estimated that only ten-to-twenty per cent of inter- text information ...
ventions are firmly based on solid scientific evidence (Grayson, 1997).
Why does good evidence fail to find its way into clinical practice? Proponents of
EBM are trying to grapple with this question. If evidence suggests better care for pa-
tients, then why don't practices change? There are myriads of potential reasons, too
extensive for this paper, but some of direct relevance to health librarians have recently
been documented in the literature.

THE AUSTRALIAN LIBRARY JOURNAL AUGUST 2000 271

 Evidence-based medicine

It has been noted that except in exceptional circumstances, most GPs do not have
the skills or the facilities to undertake literature searching (Fry et al, 2000). Rubin et al
(2000) said, 'clinicians ... require skills in crystallising clinical questions in a particular
way, searching databases, and appraising research studies or meta-analyses of research'.
Doust & Silagy (2000) reported on a study investigating GPs' application of the
results of a systematic review in general practice. They concluded that 'simply provid-
ing high quality evidence will not be sufficient for such evidence to be translated into
practice'. They further concluded that lack of training in critical appraisal skills is a
barrier to implementation of research.
Such comments are not new. jordens et al (1998) undertook a study on the use of
randomised trials by Australian neonatologists and obstetricians, and concluded that
'better access to digital information technology and training in its use is therefore likely
to enhance uptake of ... reviews'. Young & Ward (1999) identified training GPs in the
use of critical appraisal as a problem contributing to preventing the dissemination of
EBM into clinical practice.
Prescott, Ket al (1997) concluded that GPs need educational and technical support
in order to access research evidence in media other than published clinical effectiveness
sources. Phillips, PA et al (1999) noted that clinicians have not been taught how to
search through medical literature, and efficiently access information.
These comments identify clear needs. Health professionals need access to evidence.
They need the technical capabilities to locate available evidence from sources such as
databases, and ultimately the full-text information. In addition, they need training in
how to access these sources and ultimately in how to appraise the evidence they find.
What is 'good evidence'? The type of evidence required, may depend on the ques-
tion being asked, however the NHMRC (1998) has endorsed a hierarchical list of forms
of evidence, providing Systematic reviews of randomised controlled trials as the strongest
evidence on which to base a decision. However, it is impossible for all healthcare inter-
ventions to be supported with this 'highest level of evidence'. There are circumstances
in which it is impossible to use such research methodology, and in many cases, such
evidence simply will not exist.
EBM, however, involves utilising the best evidence that is available. If no systematic
review exists, then the next highest level of evidence according to the NHMRC levels, is
at least one properly RCT (randomised controlled trial). If no RCT exists, then the next
highest level of evidence is a well-designed pseudo-randomised controlled trial. And so
forth.
It is precisely this requirement which underpins the health librarians role in EBM.
As any experienced database searcher will concur, it is very easy to find something in
most databases, but very difficult to be sure that one has found everything. Without
effective searching skills, health practitioners cannot be confident that they have found
the highest level of evidence available. They need to effectively and comprehensively
search for evidence.
There are two conclusions to be drawn. Put simply, health professionals either need
these skills themselves, or need access to those who do. Either way, health librarians
should be well placed to respond to EBMs information management needs, as trainers
or mediators.

272 AUGUST 2000 THE AUSTRALIAN LIBRARY JOURNAL

 Evidence-based medicine

Sackett et al (2000) identified five stages of the EBM process. Stage 1 involves con-
verting a clinical need for information into an answerable question that can be searched
in a database.
Stage 2 has been identified as 'finding the evidence'. This involves using technical
skills to search databases, including not only an understanding of boolean logic, but
truncation symbols, proximity searching and the use of formal thesauri headings along
with textwords. In addition, 'finding the evidence' requires an understanding of poten-
tial sources of evidence, their coverage and limitations.
Medline is still highly regarded as a premier source of medical information, but it is
often searched in isolation from other databases. This is still true in a hospital environ-
ment, even if access to other databases is made available through a dedicated library
service. Private practitioners have even less access to library services, and are therefore
even more likely to be depending solely on Medline (via PubMed).
Medline however, only indexes approximately 3900 journal titles out of an esti-
mated 30 000 health titles which are published annually (Bastion, 2000). If Medline
alone was searched, all articles in the remaining 26 100 journals would be missed. The
point is that finding evidence requires identifying a range of databases likely to contain
the information sought. In addition to Medline, searchers in my context should now
automatically search the Cochrane Library, and at least consider Embase, Cinahl, AMED,
Psychinfo, and other relevant databases. How can health professionals search these
databases or ask for them to be searched, if they do not know they exist?
The third stage of EBM is appraising the evidence. Systematic reviews, cited earlier
as the strongest form of evidence should represent 'a summary of the best available
evidence on a given topic' (Doust &: Silagy, 2000). Chalmers&: Altman (1996) say
'systematic reviews, with their explicit methods, will limit bias and improve the reliabil-
ity and accuracy of recommendation'.
However Oxman &: Guyatt (1988) warn: 'If one doesn't have some guidelines for
assessing the reviews ... deciding which review to believe is like deciding which tooth-
paste to use. It is a question of taste rather than a question of science'. It is therefore not
surprising that the need for critical appraisal skills has been identified in the literature.
A poorly done systematic review of randomised controlled trials may simply compound
the biases of the trials it includes. Critical appraisal skills help one to assess the trust-
worthiness (validity) and relevance of research.
Applying the results to practice and finally reviewing performance are the final stages
of the EBM process, however these are not explored here. The first three stages, it is
argued, warrant the full consideration of health librarians.

Roles for health librarians.

Librarians are skilled in information retrieval, storage and management, and it is argued
that our profession can become a useful collaborator with health professionals in mak-
ing healthcare more evidence-based. The three initial stages of EBM outlined by Sackett
et al (2000), of
• convening an information need into an answerable question
• finding the evidence and
• appraising the evidence,

THE AUSTRALIAN LIBRARY JOURNAL AUGUST 2000 273

 Evidence-based medicine

all suggest ways in which we can significantly contribute to improved health out-
comes.
1. Librarians know how to construct sound search strategies. We train individuals
in these skills every time we assist a searcher. We have the opportunity now to
develop more formal training sessions in these skills, and perhaps extend our
target market to those outside of our home institutions. We have the opportu-
nity to teach these skills within a problem-based learning approach (Stage 1).
2. Librarians know about databases. We are aware of their range, coverage and
limitations. We have a responsibility to increase awareness of these and to max-
imise access to these sources of information within our institutions (Stage 2).
3. Librarians have experience searching databases. We can develop tailored pack-
ages to train health professionals in searching not only traditionally used data-
bases, but also new sources such as the Cochrane Library and the internet. We
can educate users about the strengths and limitations of databases (Stage 2).
4. journals and publications are primary tools for the librarian. We can subscribe
to, and promote new journals such as Evidence Based Medicine, and Evidence
Based Nursing and explain their significance as new sources of information (Stage
2).
5. Librarians are expert mediator searchers for their users. We can become involved
in the appraisal process ourselves, and present information in terms of the 'best
available' evidence. We can promote our expertise as mediator searchers. As
Dawson (1999) argues, we have the experience and expertise to provide infor-
mation services to health professionals, and it remains neither necessary nor cost
effective for them to undertake searching themselves (Stage 2/3).
6. Librarians can undertake workshops to develop critical appraisal skills in their
own workplace communities (Stage 3).
7. Librarians can pursue 'strong managerial commitment to information systems',
a factor identified by Rubin (2000) as a precondition for implementing new
evidence (Stage 2). There is a need to become more instrumental in developing
information systems to support health workers, not only at an organisational
level, but also at a state level. Ritchie &: Sowter (2000) summarise state-wide
projects currently underway in New South Wales, Queensland and South Aus-
tralia, which health librarians have been involved in developing.
8. Librarians can collaborate with other partners to develop a national library strat-
egy to support EBM. While Ahmed&: Silagy (1995) argued for an infrastructure
for the dissemination of EBM into clinical practice, there is as yet no docu-
mented national strategy for developing services and staff in the health library
profession to ensure we can adequately support health professionals (Stage 2).
Discussions have begun however, with the recent advent of the ALIA National
Health Section Working Party on Continuing Professional Development for Evi-
dence Based Health Care, currently chaired by Greg Fowler
(fowler.greg@saugov.sa.gov.au).
There are certain to be other possibilities, but it is argued that the above are all
within the legitimate expertise of our profession. Many of the identified roles are un-

274 AUGUST 2000 THE AUSTRALIAN LIBRARY JOURNAL

 Evidence-based medicine

controversial and already assumed to be pan of our historical and current professional
practices. What has changed however, is the framework in which we operate. Health
professionals need 'evidence' rather than 'information', and the practice ofEBM empha-
sises evidence as an essential rather than an elective component of the decision making
process about an individuals health care.
In many ways these changes have both legitimised and mandated our expertise.
They have, however, also revealed gaps in our knowledge: about EBM, research meth-
odology and the clinical decision making process. Either as trainers or mediators, we
need to ensure we understand and are knowledgeable in these areas.
Our potential role in delivering critical appraisal skills training may be controversial.
Possibly some librarians will not feel comfortable with this, or might argue that it is not
within their area of expertise. If, however, health librarians need to acquire this knowl-
edge themselves to continue to provide effective services with the increasing impor-
tance of EBM, then it is argued that health librarians should be equally as well placed as
other professions to deliver this training. This is especially true when combined with
our existing knowledge of published information. It presents an opportunity to pursue
a role as educators in what could be seen as a logical extension of our current practices.
The concept of educator was identified by Reid (1999) who summarises her article
on the information needs for EBM by saying 'educational changes are needed to help
health care professionals and the public to use information effectively. Organisations
need staff with specialised skills to help them cope with the information age'. Our
profession needs to explore the depth and breadth of our potential as educators, and
transcend our traditional approach. As Dorsch et al (1990) said, 'traditional biblio-
graphic instruction is no longer an adequate response to the needs of future physicians
faced with todays complex information needs'.
It is encouraging to see that new graduates and medical students now search the
Cochrane Library as matter of course, or in certain circumstances in preference to
Medline. However there are many practising professionals who do not have the benefit
of a changed or changing curriculum. Dorsch et al (1990) were quite succinct and
prophetic. Ten years later the literature continues to document the more complex infor-
mation needs of physicians, identifying them as significant factors in making practices
more evidence-based.
Health professionals need evidence, but without understanding what it is, why it is
necessary, knowing how to identify and locate it, knowing the downfalls of reliance on
traditional sources, and ultimately interpreting what the evidence might actually be
saying ... how will they select the best available evidence on which to base a decision?
How will we help them find the best available evidence?
As the chair of the ALIA Working Party recently succinctly summarised, 'EBM is
here to stay, is unavoidable, and is important'. We can rightfully assen our importance
to the health industry by seizing the opportunities of EBM. By ignoring EBM, we can by
default refuse to go down the path of lifelong learning within our own profession. This
would be a tragedy. There may be issues for us to address, such as new training needs
and competency issues, but these are not beyond us.
EBM is a fact of life in the health industry. As skilled professionals we can fill a
myriad of potential roles which can ultimately support better health outcomes. We

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 Evidence-based medicine

must, however, identify and pursue our own training needs in order to do so. Reid
(1999) concluded that this is an exciting time for health information. It is an exciting
time for health information professionals because we are facing an excellent opportu-
nity to develop and extend our roles. The health profession has clear training needs in
many areas within our field of expertise. We have opportunities not to be missed.

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Ruth Sladek is chief librarian, Repatriation General Hospital, SA and deputy chair of the SA
Department of Human Services Libraries Consortium, holds a BA in Library Studies (1986), with an
additional undergraduate major in Psychology. She has developed a successful institutional-based
program of EBM training, covering the basic tenets of EBM, the Cochrane Library and critical appraisal
skills.

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