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gatekeeper for the family practitioner. By Rowena Cullen. Senior Lecturer. School of Communications and Information Management. Victoria University of ...
The medical specialist: information gateway or gatekeeper for the family practitioner By Rowena Cullen Senior Lecturer

School of Communications and Information Management Victoria University of Wellington PO. Box 600 Wellington, New Zealand

The medical specialist emerged as a critical gatekeeper in a study of information sources used by family practitioners in New Zealand. Thirty-four practitioners in the Wellington region were interviewed and their responses examined to ascertain the extent to which five criteria influenced their choice of information sources for clinical decisionmaking. The criteria were availability, searchability, understandability, credibility, and applicability. Of three major information sources investigated (textbooks, colleagues, and medical specialists), textbooks were consulted most frequently but were rated less valuable than colleagues and specialists as a source of information. The medical specialist was identified as the information source that best meets the five criteria. Thus, specialists play an important role in disseminating information to family practitioners. However, female practitioners included in the study were less likely to approach specialists than were their male counterparts. Physicians made little use of medical libraries to support clinical decision-making. The apparent disadvantage of female practitioners in accessing specialists needs to be addressed by professional associations. Medical librarians seeking to improve the access of family practitioners to recent literature should consider the heavy use made of specialists as a source of information. INTRODUCTION

The gatekeeper is a controversial figure in the medical literature, commonly seen as one who screens out the unworthy or least needy from higher levels of medical care [1-3]. However, in the world of information science, as opposed to the world of medicine, a gatekeeper is an individual of standing who both seeks information and disseminates it to a particular cultural or occupational group. Such a person wields considerable power because of the status and authority granted to particular sources and types of information [4]. In this context, gatekeepers may also be perceived as adding value to information by filtering it through their own experience and expertise. There are gatekeepers in the world of medical information. Most individuals prefer to obtain information from other people rather than from more formal sources [5]; this tendency can be seen in studies of the information-seeking behavior of physicians, especially family physicians [6]. However, little research has been conducted on how and why individuals select a par348

ticular informant. Knowledge about the selection process would be helpful to information professionals seeking to provide systems that best meet the needs of clients. The study reported here sought to explore the information-seeking behavior of a group of family physicians in New Zealand, the characteristics of the information sources they select, and the reasons for their choices. Correlations between characteristics of the physicians (i.e., age, years in practice, sex, type of practice, qualifications) and their preference for specific sources or types of information were explored. This article reports the main findings, focusing on the physicians' reliance on consultants or specialist physicians to meet some of their needs for information for clinical decision-making. The study shows that the concept of the gatekeeper as an information broker can be applied to the role of the medical specialist in the dissemination of medical information from point of creation, through the expert literature, to practitioners in the primary care domain. It is hoped that the findings might be of value to medical and health librarians Bull Med Libr Assoc 85(4) October 1997

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seeking to establish information systems and channels that best meet the needs of family physicians. BACKGROUND A number of studies have shown that physicians in family practice make use of professional colleagues, their own textbooks, and to a lesser extent journals as their primary information sources. Most recent studies and two meta-analyses of these and earlier studies have attempted to isolate the characteristics of the main information sources used by family practitioners that are critical to the selection of those sources. Gruppen et al. propose a set of criteria for the assessment of information sources used by primary care

physicians: Information-seeking strategies can be conceptualized as the underlying priorities physicians place on several characteristics of information sources. Some of these characteristics are the availability of the source, its ease of use, its educational value, and its informativeness, which includes relevance and accuracy. The ideal source of information would be highly informative, readily available, easily used, and educational. Actual information sources, however, vary widely on these dimensions [7].

A 1990 mail survey conducted by Connelly et al. also examined the factors influencing the choice of knowledge sources used to resolve clinical problems arising from patient care. This study sought to determine how physicians "balance the potential benefits of seeking knowledge with the temporal, cognitive, and monetary costs associated with this search" [8]. The study measured physicians' satisfaction with information sources, using the criteria of credibility, availability, searchability, understandability, and applicability. The authors propose that these criteria be incorporated into any information system designed to meet the information needs of practitioners. Connelly et al. explain the benefits that practitioners gain from interrogating their colleagues:

The interaction with colleagues allows for clarification and questioning so that applicability can be maximized. Hardto-understand information can be repeated and restated. The consulting physicians' ready identification with the inquiring physician's role and concern as a care provider causes the insightful consultant to appropriately tailor the answer so that it is concise and sufficiently complete, with explanations and process information, to allow the requesting physician to implement any suggestion with an appropriate level of confidence [9].

A meta-analysis by Verhoeven et al. of studies published between 1975 and 1992 examines motives and barriers to information seeking among practitioners that are revealed in the eleven studies. The analysis concludes that cost factors, such as the time and enBull Med Libr Assoc 85(4) October 1997

ergy of the practitioner, and characteristics of information sources override quality (Connelly's "credibility" and "applicability") in the information-seeking behavior of most practitioners [10]. The study identifies key characteristics of information sources as physical accessibility (Connelly's "availability"), functional accessibility ("searchability"), and intellectual accessibility ("understandability"). METHOD

Thirty-four general or family practitioners in the Wellington region of New Zealand were given a structured interview by the author. Interviews lasted one to two hours. Questions were asked about a number of information sources used by practitioners, focusing on variables such as frequency and time of use and adequacy of the source. Sample A cross section of practitioners was chosen for the study. Members of the study sample were selected according to criteria that were relevant to the research questions. The sample included recent graduates, experienced practitioners and those nearing retirement, men and women, practitioners in solo and group practices, and practitioners from urban and rural settings. The names were selected from membership files of the Royal New Zealand College of General Practitioners. The college sent a letter to all members whose names had been selected, requesting cooperation with the research, the objectives of which the college fully supported. The mailing was followed by a telephone call from the author seeking an interview time. Ninety-five percent of those asked to participate agreed to do so. Two respondents who agreed to participate eventually dropped out, one because of sickness, and one because an appropriate interview time could not be found. Respondents were interested and cooperative and expressed support for the project and the college's interest in it. Interview questions Questions asked in the structured interview concerned the practitioners' use of the three main information sources as well as medical libraries and continuing medical education (CME) courses. Practitioners were also asked about their attitudes towards electronic delivery of information. The three main information sources were medical textbooks on the practitioners' own shelves (or readily available in the practice), colleagues in their own practice, and specialists or consultants in private practice or based at a local hospital (this category included specialist interns). For each of these three sources, respondents were asked how frequently they turned to that particular 349

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source of information; the purpose for which they sought the information; whether they found the information; and, if so, whether it was adequate to meet their needs. They were also asked at what time the information was sought and how it was used. Demographic information collected included age, sex, qualifications and years since qualifying, size of practice and number of individual patients, type of practice, whether the respondent worked full- or parttime, and the extent to which computers were used in the practice. ANALYSIS Profile of respondents The study sample included fourteen women (nine under forty years of age and five over forty) and twenty men (ten under forty years and nine over forty). The average number of years since first qualifying was 18.6 for women and 19.7 for men.* The median number of years since qualifying was fifteen for both groups: the range was less for women (eight to twenty-two years) than for men (five to forty years). Two of the women and one of the men categorized their practice as urban solo, ten women and twelve men as urban group or sharedt, two women and four men as rural solo, and three men as rural group. Of the women, nine worked part-time and five fulltime. Of the men, two worked part-time and eighteen full-time. Among those who could provide an estimate or precise number of their individual patients, parttime practitioners gave figures ranging from 200 to 2,000 and full-time practitioners gave figures ranging from 800 to 5,500. Part-time practitioners reported twelve to thirty patient visits per day (for a mean of 18.5); full-time practitioners reported twenty to forty visits per day (for a mean of 31)4.

Daily information-seeking arising from patient care All respondents were asked to estimate the number of occasions each day when they required information to make a clinical decision that went beyond routine drug information (such as common prescribing name, dosage, interactions, and contra-indications), specific test results, or the patient's history. Responses ranged from a low of one of forty patient visits (or 2%) during which further information was sought to highs of ten of forty (25%), ten of thirty One respondent did not give age or years of experience. no distinction was made between a group practice and shared rooms because it was the ready availability of medical colleagues that was at issue rather than the business arrangements of the practice. t One respondent who had been seeking a partner or temporary substitute for some time reported seventy visits on some days. *

t For the purpose of the study,

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(33%), and eight of twenty (40%). The average number of visits giving rise to such questions was 4.75 per day. The average percentage of visits giving rise to such a query was 18.75%. Twelve respondents reported a need for further information in as many as 10% of visits, eight reported a need in 11% to 20% of visits, five reported a need in 21% to 30% of visits and six reported a need in 31% to 40% of visits. No respondents reported a need for such information in more than 40% of patient visits per day. The data were examined to determine whether practitioners reporting frequent daily needs for information also reported high use of any of the specific sources included in the survey. Of the fifteen practitioners reporting a need for further information in 20% or more of patient visits, seven sought information from at least one of these sources daily or several times a day, four used at least two sources daily or several times a day, and the other three used all these sources daily or several times a day. One respondent who seldom needed information nevertheless reported frequent (daily or several times a day) use of one source, and six other respondents reporting information needs in fewer than 20% of patient visits still reported frequent use of textbooks. Textbooks were the information source most used by respondents. The seven respondents who reported daily or more frequent textbook use also reported daily or more frequent use of at least one other source; that is, they appeared to be heavy information users generally. Respondents reporting infrequent textbook use did not necessarily prefer human sources of information. Of this group (fifteen or 45% of respondents), only two indicated a clear preference for another source (in both cases for specialists, who were called several times a day), and five indicated little information-seeking behavior overall. Given the high level of textbook use, questions must be raised about the nature and publication dates of these texts. Most respondents maintained texts that were in regular use. Recent but very general manuals such as the Merck Manual were in general use, as were older editions of Harrisons Principles of Internal Medicine. Most respondents also regularly referred to at least one other recent text covering a specialized area such as skin diseases, fractures, or obstetrics. Beyond these observations, no consistent pattern was evident among textbooks held. Despite the slight inconsistencies already noted and the difficulty of getting respondents to distinguish between routine drug information and other information, by and large the practitioners reporting frequent daily information-seeking also reported high daily use of specific information sources, and vice versa. There were no apparent relationships, however, between patterns of information-seeking and practitioner age, sex, Bull Med Libr Assoc 85(4) October 1997

The medical specialist Table 1 Frequency of use of the three main sources

Textbooks

Colleagues Specialists

Several times/ day 9 1 6

Table 2 Responses regarding information found and its adequacy

Daily

Several times/ week

Once a week

10 6 4

8 10 10

7 13 13

No reNever sponse 2 2 0

0 2 1

qualifications, or other attributes, such as number of patient visits per day. Nor were there significant patterns in the overall information-seeking behavior of full-time or part-time practitioners. In both groups there was a virtually equal division between those who reported seeking information in fewer than 20% of patient visits and those who reported seeking it in 20% or more of patient visits. Use of and satisfaction with information sources Table 1 shows the frequency of use of the three main information sources. Responses were examined to determine whether the more frequent use of textbooks relative to use of the other sources was reflected in practitioners' satisfaction with the information found there. This correlation was measured by asking whether the information sought was found, and whether it was adequate. Responses are shown in Table 2, which demonstrates clearly that while greater use is made of textbooks, respondents were more likely to find the information sought by asking colleagues and specialists, and were most satisfied with the information provided by specialists. Possible reasons for this pattern emerge in the explanation given by some respondents that specialists are able to apply their greater expertise to the particulars of a patient case, including age, previous history, and current medication. A further reason emerges in one comment: "You can rephrase your question if necessary, unlike a book, where if you are looking in the wrong place, you can't find the answer." Satisfaction levels with each of the sources do not appear related to the level of use of that source. Comments made during interviews suggest that satisfaction, or the adequacy of the information supplied, stems primarily from the degree of certainty in the answer that results from consulting the information source. When a conflict arose between the practitioner's initial determination and the information provided by a textbook or a colleague, a third information source would be sought. This might be a specialist, or in some cases a medical library. Factors affecting the use of textbooks were ready availability within the practitioner's own office, familiarity with the layout and indexing system of the Bull Med Libr Assoc 85(4) October 1997

Yes

Usually

SomeNot times usually

No

No response

Interview question: Is required information found with this source? 0 2 4 19 9 Textbooks 4 4 1 17 8 Colleagues 1 2 0 21 10 Specialists Interview question: Is information supplied by this source adequate? 8 1 2 7 14 2 Textbooks 1 1 3 12 3 9 Colleagues 4 1 1 5 0 13 Specialists

books, and the suitability of some information in textbooks for use as patient information. Other issues were explored in the interviews through follow-up questions. A number of respondents commented that a colleague's lack of knowledge could be helpful in building the practitioner's confidence because it suggested that lack of knowledge was common in the profession rather than a personal failing. Further information would then be sought. When the view of a specialist was significantly different from that of the practitioner making the inquiry, most respondents implied that they would accept the specialist's advice. When asked to explain how the information found changed the clinical situation, most respondents made statements such as "confirms me in my choice of treatment," "gave me the confidence to proceed," or "offers me some options." One described using a specialist as "a shortcut to the library." This type of response-which can be categorized as expressing relief of uncertainty-is common across all sources. It also reflects the gateway or gatekeeper role of the specialist. Purposes for which information was sought The respondents were asked the purposes for which information was sought from each of the three main sources. They were also invited to categorize the purpose as related to diagnosis, treatment, or management of the patient's condition, or other issues such as confirming the need for a referral or giving information to the patient. In several cases, the diagnosis category included checking diagnostic criteria and the inTable 3 Purpose for seeking information from three major sources Diagnosis Treatment Textbooks

Colleagues Specialists

6 6 2

2 5 13

Both

Other

No response

16 16 17

9 3 1

0 3 0

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Cullen Table 4 Use of information sources by sex Men

Women

11 (11.8) 9 (8.8)

8 (7.8) 6 (6.2)

5 (4.2) 13 (13.8)

2 (2.8) 10 (9.2)

9 (6.2) 11 (13.9)

1 (3.9) 12 (9.1)

Textbooks* High use Low use

Colleaguest High use Low use

Specialistst High use Low use

Note: First number in each cell is actual use; numbers in parentheses represent expected use if no sex differences. "High use" is daily or more often. "Low use" is less than once daily. * Chi-square = .899 with Yates correction; p = .05; 1 df. t Chi-square = .69 with Yates correction; p = .05; 1 df. t Chi-square = 5.064 with Yates correction; p = .05; 1 df.

terpretation of diagnostic test results. Responses to this question are shown in Table 3. For each of the three information sources, the largest group of respondents identified both diagnosis and treatment as driving the search. Some respondents thought of the problem as diagnosis, saying, "Diagnosis is the big problem-once you know what the complaint is you can usually define the treatment," and "It is very hard if you don't know the diagnosis to know what to look up." Most described the problem as one of confirming the diagnosis in difficult cases

and confirming recent treatment and management ap-

proaches. Greater use, however, is made of information from textbooks for patient information (especially visual), and correspondingly greater use of specialists for up-to-date advice on management. Influence of sex No relationships were apparent between practitioner age or sex and satisfaction levels with a particular information source, but sex differences seemed to be apparent in the extent of practitioners' use of the three major information sources. A chi-square test was therefore performed to determine whether there were any sex differences in the use of these sources. Table 4 shows the actual use of each source compared with the expected use if there were no differences by sex. High use is defined as daily or more often, and low use as less than once a day. The data on use of textbooks and colleagues have been adjusted by using the Yates correction§ or one degree of free§ In a table with one degree of freedom, a small sample which gives cell sizes of five or less can result in an overestimation of the true value of the chi-square. This calls for the application of a Yates correction, in which .5 is subtracted from the difference between observed and expected frequency in each cell of the table. 352

dom. There was no evident difference between men and women in the use of textbooks or colleagues as sources of information. However, for the data on the use of specialists, the value of chi-square was greater than 3.84 (the critical level for one degree of freedom at the 5% level of significance), indicating an observable difference between men and women in their use of this evidently valued source of information. The difference is discussed later in this article. Use of a medical library Among questions asked of respondents were some related to their use of the local medical library. Of the twenty-two respondents who reported using a medical library, seven estimated that they used it only once a year or less, seven used the library once every six months, and eight used it more than once every six months. Respondents used the library for the following purposes: "update information in own textbooks" (nine responses), "seek recent research information" (eight responses), "seek overviews of recent research or summaries of treatment" (thirteen responses), and "other" (twelve responses). "Other" included looking up specific references, seeking patient information, and seeking information to share with a peer-review group or journal club. The primary reason given by the twelve library nonusers for not using the library was the problem of access, expressed in terms of either time or parking (nine responses). Among other reasons, the next most common was lack of need (six responses). These respondents judged the information in the medical library to be irrelevant to general practice; they felt they had adequate information sources on hand.

Greatest information need and type of information that meets it Respondents were also asked to categorize their greatest need for information and the type of information that fulfilled this need. Most (91%) of the practitioners surveyed gave reasons that included but went beyond immediate patient management, suggesting that it is a complex sequence of events, rather than one patient case, thatprompts information seeking, and that there is a general need for information related to these other areas that is unmet. The need for information for patient management appears to be routinely met through the three major sources discussed earlier. To meet more general needs, only two respondents said they would read original research; six identified reviews of research as their preferred source of information; and twenty-five preferred to read summaries of the most-recommended treatments, which nine of these respondents read in combination with reviews of recent research. Bull Med Libr Assoc 85(4) October 1997

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Attendance at CME courses Continuing medical education (CME) was acknowledged as a valuable source of up-to-date clinical information, and attendance levels at CME courses were high. Regular attendance is encouraged by the requirements for a minimum number of hours per year of some form of approved CME for continued registration as a medical practitioner. Twenty-six respondents attended evening CME seminars at least monthly, six did so about once every six months, and two respondents attended only once a year. (One practitioner did not answer the question.) Attendance was much lower at day-long and halfday sessions. Two respondents attended such sessions monthly (both also attended evening sessions monthly), twelve did so every six months, seven once a year, and thirteen either did not attend any such sessions or did not respond. For sessions longer than one day, only one respondent attended monthly, twelve attended every six months, and fifteen attended once a year (five did not respond). The usual pattem of attendance at CME courses was evening sessions once a month and one-, two-, or three-day sessions every six months to a year. However, those who attended evening courses only once every six months or year did not attend longer sessions (half a day or longer) any more frequently than other respondents. Attendance at CME courses did not appear to be related in any way to practitioner age, sex, or type of practice. Many practitioners commented on their preference for CME as a source of information because it gave them ready access to specialists and experts; was available at times when they had no patient appointments or could schedule blocks of free time; and provided information in a verbal, interactive mode, a clear preference for many respondents.

Information-seeking styles The study made it possible to examine the way in which practitioners saw their own information-seeking behavior. For example, some respondents characterized themselves as print-oriented whereas others preferred oral sources. These characteristics may influence source selection as much as the features of the sources do. A number of respondents made explicit unprompted statements defining themselves as "print-based" or preferring "print-based learning." In all, seventeen respondents (50%) made comments that put them clearly in this category. Yet only three respondents in this group made any significant use of a medical library (i.e., approximately monthly), with the rest using a library only once every six months to a year. On the other hand, nine of this group were also heavy users Bull Med Libr Assoc 85(4) October 1997

of oral sources of information (colleagues, consultants, or both). A smaller number of respondents categorized themselves as preferring informal or oral sources, making statements such as "I prefer colleagues over books. I like an interactive style of learning." Only one respondent indicated a conscious selection of sources according to how well the source met the sorts of criteria identified in the literature: "I will target the source I think can supply the information immediately and most efficiently. I target colleagues or specialists according to who is likely to know the answer." DISCUSSION

There are clear parallels between the behaviors and preferences of the practitioners in the present study and earlier findings reported in the literature. The same needs for immediate, reliable, and usable information are evident, and the same main sources of information are used for clinical decision-making-textbooks, colleagues, and specialists, in much the same proportions. As in the Connelly study [11], the present group of practitioners made little use of research literature and the formal systems of bibliographic access to research literature. A few minor differences with earlier studies were noted. There seemed to be greater "uptake of new information," as Gruppen [12] describes it, through CME courses attended by this group compared with that reported in earlier studies. There is little evidence that practice setting affects information seeking, and no indication that the nature of the problem-therapeutic or diagnostic-has any impact. Indeed, practitioners seem divided over which type of question usually leads to a search for information. A more interesting issue is the extent to which the attributes of each information source affect a physician's choice of source. Mapping Connelly's five criteria for information source selection among family physicians against those proposed by Gruppen and Verhoeven, one can identify a comprehensive set of attributes derived from the most significant studies in the area. The five criteria are credibility, availability, searchability, understandability, and applicability. Did these attributes influence physicians' choice of information sources in the New Zealand study? Does it seem, as Verhoeven posits, that cost factors (i.e., the time and energy of the practitioners) and the accessibility of the information source (i.e., its availability, searchability, and understandability) were more important than quality (Connelly's "credibility" and "applicability") for this group of practitioners? Do these attributes contribute to an understanding of practitioners' use of specialists as one of their most valued sources of information? 353

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Accessibility: availability, searchability, understandability

The results reported here and the comments recorded during the interviews clearly indicate that among this group of practitioners, accessibility was a strong factor in the selection of information source-the book on the shelf, the colleague in the next office, the specialist who is willing to be telephoned. Weekly use was roughly equal across the three main sources, indicating little difference in physical availability. These results represent higher use of specialists than was found in some other studies, perhaps because of the relatively small medical community in New Zealand: There are only two comprehensive medical schools, supplemented by two clinical schools covering the last three years of the basic six-year training program. Practitioners in family practice are likely to have attended medical school with specialists in their community and to attend CME courses conducted by the same specialists. The three sources also seem fairly equal in terms of searchability. Textbooks, for example, are easy to search. Familiarity with the layout, context, and indexing system of their most frequently used text-based source appeared to be a clear factor among most respondents in their use of the source. Colleagues and specialists are also highly searchable. This element of searchability in interpersonal interactions was also noted by both Gruppen and Connelly [13, 14]. It was emphasized by many observations made by participants in the present study, whether or not they declared themselves to have a print orientation.

Specialists and colleagues may also have a higher quotient of understandability than does a textbook. As noted previously, the practitioner can repeat or rephrase a question and ask for further explanation of parts of the answer not fully understood. On this aspect of accessibility, oral sources rate higher than do textbooks. Quality: credibility, applicability Credibility and applicability are equally important in practitioner responses. Specialists are most favored with respect to these criteria because they have perceived expertise (credibility) and are able to customize this expert knowledge to the specific circumstances of the practitioner's individual patient (applicability). Specialists are more trusted than textbooks, which allows the practitioner to proceed with an increased level of confidence. This explanation was given by several respondents when asked why they valued the information provided by specialists. 354

Why specialists are favored Reviewing the study results in light of all five criteria, it would seem that of the three major sources of information used by respondents in this study, only specialists met all five criteria, and that they are a favored source for this reason. However, if specialists are the one source that appears to meet all five criteria, then it is a matter of considerable concem that most female respondents appeared to be disadvantaged in their ability to benefit from this source. One can only speculate about the reason. Of the other main sources to which practitioners have access, journals, even when freely provided, lack a certain aspect of accessibility because of practitioners' documented lack of use of indexing systems. Journals also may lack applicability because they focus primarily on research literature, which continues to be of little interest to practitioners, and they do not always provide the preferred broad overviews of recent treatments. Journals may also lack credibility if they are associated with drug companies. Libraries as sources of information fall short not only in terms of accessibility (practitioners lack time, parking, skill levels, etc.), but also in terms of applicability (they contain mainly research material that has not been filtered or customized for immediate application to patient management) either individual or general. The other major source of up-to-date clinical information accessed regularly by most respondents was CME. In their comments concerning CME courses, several respondents observed that sessions featuring consultants or specialists and a panel of family practitioners were especially useful because they combined expert knowledge with the more practical aspects of patient management within family practice. Although CME courses do not rate as high on the criterion of immediate availability of information as do the three major sources, such courses may have an advantage with respect to credibility and applicability. CONCLUSION

The findings of this study suggest that specialists play a major role in the provision of information to family practitioners through personal and telephone conversations, letters, and CME courses. Thus, specialists can be characterized as significant information gateways or gatekeepers through whom a high proportion of family practitioners obtain much of their up-to-date knowledge of patient management. Practitioners seek the expertise of specialists to interpret the medical literature and research findings, and apply this information to general and individual case management. Specialists have considerable influence on the parameters of treatment within a particBull Med Libr Assoc 85(4) October 1997

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ular medical community. They can effectively deprive the family practitioner community of new information as well as provide it. They function therefore as a second system of peer review in the communications link between research and medical practice in the primary care environment. Two key points therefore arise. It is critical that specialists have recent and reliable research information, awareness of their gatekeeper role, and the skills to interpret data and pass it on to practitioners working in the community. A key role for medical librarians emerges here. New initiatives may be needed to ensure that quality information is brought to the attention of medical specialists in public and private practice, and that they understand their role as disseminators of information to the wider medical community. It is also critical that women physicians in family practice be encouraged to contact specialists as often as their male counterparts do and that barriers to this communication be identified and removed. Further research is necessary to determine whether there are widespread sex differences in the willingness of family practitioners to seek information from specialists. If so, then the apparent disadvantage of female practitioners in accessing a valuable source of information could be addressed by both family practice associations and specialist medical associations. Specialist medical associations also need to be aware of the gatekeeper role played by their members and work with medical libraries to ensure that

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the information they impart is supported by quality information systems. REFERENCES 1. GEYMAN JP. Family practice and the gatekeeper role. J Fam Pract 1983 Oct;17(4):587-8. 2. REAGAN MD. Physicians as gatekeepers: a complex challenge. New Engl J Med 1987;317:1731-4. 3. GLASGOW N. The gatekeeper controversy: why it exists and how it can be resolved. New Zealand Med J 1996;

109(1021):168-70. 4. METOYER-DURAN C. Gatekeepers in ethno-linguistic communities. Norwood, NJ: Ablex, 1993. 5. CHEN C, HERNON P. Information seeking: assessing and anticipating user needs. New York, NY: Neal-Schuman Publishers, 1982. 6. VERHOEVEN AH, BOERMA EJ, MEYBooM-DEJONG B. Use of information sources by family physicians: a literature survey. Bull Med Libr Assoc 1995 Jan 83(1):85-90. 7. GRUPPEN LD, WOLF FM, VAN VOORHEES C, STROSS JK. Information-seeking strategies and differences among primary care physicans. Mobius 1987;7(3):18-26. 8. CONNELLY DP, RICH EC, CURLEY SP, KELLY JT. Knowledge resource preferences of family physicians. J Fam Pract 1990

Mar;30(3):353-9. 9. CONNELLY, op. ct. 10. VERHOEVEN, op. ct., 85-90. 11. CONNELLY, op. Cit. 12. GRUPPEN, op. Cit. 13. GRUPPEN, op. ct. 14. CONNELLY, op. ct.

Received December 1996; accepted May 1997

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