Knowledge Manager, Ridgeway Primary Care Group, Buckinghamshire.
And Independent Information Specialist

Paper presented at the Qualitative Evidence-based Practice Conference, Coventry University, May 15-17 2000

An exploration of the information needs and information seeking behaviour of General Practitioners is of potential interest to those wishing to diffuse and disseminate both clinical evidence, and examples of good practice, to primary health care teams.

For the past decade I have worked as a ‘freelance’ librarian, providing information support to a handful of practices in the Aylesbury area. The sight of family doctors pursuing information ‘off their own bat’ intrigued me. Hence, this research was driven by two questions :

• What prompts General Practitioners to seek information?

What kinds of factors motivate doctors to look for information, or to request a literature search? Part of the work of an information specialist rests on a presumption of a connection between uncertainty, curiosity and the active pursuit of information. Is this true for GPs – and in what circumstances?

• Does the employment of a Practice Librarian make any difference to their information seeking behaviour?"

I wanted to investigate the impact that a Practice Librarian might have on the attitudes and behaviour of family doctors.

The Research Entry MSc in Information and Library Studies at the University of Central England offered an opportunity to address these questions.

This paper derives from the findings of a case study conducted with the aim of exploring the information needs and information seeking behaviour of a sample of General Practioners.¹

The purpose here is to focus on just two aspects of the research :

• How far GPs perceive a need for information deriving from gaps in their knowledge, from curiosity or uncertainty, or from a desire for evidence on which to base practice.
• To highlight difficulties in the conduct of the qualitative research.

The choice of research methodologies was strongly influenced by the findings of a comprehensive review of the literature on the information needs and information-seeking behaviour of family doctors.²

The value of the body of research available is diminished by the potential bias inherent in the marked preference shown for methodologies reliant upon self-reporting.³ Moreover, it appeared that there was scope for qualitative research to illuminate both the definition of ‘information need,’ and the experience of information seeking, from the perspective of GPs.

The concept of ‘perceived information needs’ is more properly expressed as information ‘wants’. Inevitably, ‘wants’ are limited to those things that an individual knows to be available, or of which he or she has the capacity to imagine. Thus, an understanding of information ‘wants’ will inform but cannot fully define information ‘need’. This research was concerned with information wants.

A case-study of Aylesbury Vale offered an exceptional opportunity to investigate the impact of a Practice Librarian, as well as to explore the broader issues. The strength of the case-study approach, which can "more vividly and sustainedly" engage empathy than techniques that lead to abstract generalizations,⁴ seemed to outweigh the limitations on generalizability inherent in the selection of a small sample of informants.

The intention was to allow doctors to voice their reasons for seeking information, as well as their feelings and thoughts about the process. Three factors governed the final choice :

• The confidentiality of the doctor-patient relationship.
• It would be unacceptable for a librarian to ‘sit in’ on consultations.
• The "sheer volume of documents" ⁵ received in practice.

• The viability of a postal survey was questionable.
• The potential ‘prestige bias’ inherent in self-reporting⁶
• The tendency for individuals to ‘over-claim’ reading behaviours.

Taking these factors into account, and recognizing the value of triangulation, one quantitative and two qualitative techniques were selected :

• Comprehensive records of the use of the Wilfred Stokes Medical Library and Information Service at Stoke Mandeville Hospital, permitted a quantitative study of library use by GPs between April 1996 and September 1998.
• Individual interviews and Group Discussions were used to gain credible insights into the perceived information needs and information seeking behaviour of a group of GPs (both library users and non-users) within the library’s catchment area, as perceived by the GPs themselves.

A full account of the quantitative study is outside the scope of this paper. Sufficient to say, the research was conducted with the co-operation of the Library Services Manager, and in accord with data protection legislation. The study provided a reliable measure of behaviour and identified a sample of ‘Active users.’ Just 11 GPs were recorded as having used the library over a six month period (between April and September 1998).

The study revealed that GPs made very little use of the library and it relied heavily on external sources to meet their demands. The data suggest that involvement in Vocational Training, and the employment of a Practice Librarian, are factors that have a significant impact on increasing use of the library’s document delivery services. Pursuit of the Certificate of Evidence Based Health Care is the single most important factor governing demand for inter-library loans. The activity of just two doctors, both Trainers, dominate the data. Dr. A generated the majority of requests from GPs in 1997, Dr B initiated the majority from April to September 1998.

The doctors came from 16 of the 20 practices across the Vale and almost three quarters of local GPs participated in this study; 19 via individual interviews and a further 39 via the Group Discussions. In all, 11 users and 47 non-users of the Wilfred Stokes Library took part. Eleven doctors from the three practices with a librarian and nine Trainers from Aylesbury Vale participated.

30 men and 28 women GPs participated. As the profession is 69% male and 31% female)⁷ some gender bias may be present.

Almost a quarter of local GPs) were interviewed, a total of 19 doctors. Some difficulty in arranging interviews was anticipated; the scale of the challenge was underestimated.

The Consent Form sent out to the sample of 11 users, by the Library Services Manager, invited respondents to indicate if they did not wish to be interviewed. This device worked well although it proved impossible to interview the whole sample. Non-users were easily recruited from Surgeries with a librarian but insufficient thought had been given to the recruitment of the majority of users. Fortunately, the Group Discussions proved useful in recruiting further interviewees.

The emphasis was on "purposively selecting information-rich cases."⁸ Ten of the interviewees were known to have external responsibilities eg. within the fledgling PCGs or related to Vocational Training.

Core elements of the ethnographic interview were introduced, specifically the expression of explicit purpose and the use of ethnographic questions, posed to discover the concepts which informants used to describe and classify their understanding of their information needs, and their experience of information seeking.⁹

Most informants appeared to welcome an opportunity to express their own point of view and raised issues spontaneously. An aide memoire was used to ensure that all the topics thought to be central to the study were raised.¹⁰ A pilot interview, with a GP working outside the area, emphasized the need to schedule adequate time. The majority of interviews lasted 45 minutes. It also revealed a tendency for informants to volunteer significant observations towards the close of the interview (mirroring the experience of the doctor-patient consultation). Progressive focusing was used to shape successive interviews.

The Aylesbury Trainers’ Group hosted a half-hour Discussion that was characterised by genuine verbal, intellectual, emotional and attitudinal interplay. Of the 12 doctors present, only one had already been interviewed individually. A twenty-minute Discussion conducted during a Half Day Study Day for local GPs, gave voice to many more non-users of the Medical Library than the interviews. About 20 different doctors spoke."¹¹

These Discussions confirmed that all the issues identified within the groups were being raised spontaneously, or with prompting, within the interviews.

The interviews were recorded, with consent, and subsequently transcribed using Idealist software, which offers full-text searching. They occupy 12 hours of taped recording, resulting in 104 pages of data.

Emergent themes were identified during the process of transcription so that data was inserted into the appropriate field from a potential selection. A process of progressive analysis was applied, so that as the relevance of ‘new’ aspects became apparent (eg. Clinical Governance), another field was created, data previously transcribed was reviewed, and relevant data transferred into the new field.

The records of the Group Discussions were analysed in the same way, and were examined for both corroboration and exceptions from the data gathered in the interviews.

In answer to the first research question, "What prompts GPs to seek information?" the data illustrate that the family doctors of Aylesbury Vale are prompted to seek information by needs arising from a combination of professional responsibilities and personal characteristics. The data suggest an overall ranking of these ‘information wants’, as they perceive them :

1. Patient care

ie. problem-orientated information arising from the care of individuals.

2. Keeping up-to-date.

3. Patient Information.

4. Sharing fourth place :

Pharmacological information

Gaps in knowledge

5.Curiosity

6. Evidence in response to uncertainty.

For some Trainers, information needs arising from their role in Vocational Training take precedence over patient care, thus displacing their ranking of all the other needs in turn.

It is significant that informants commonly placed descriptions of their information needs in the context of feelings of anxiety about ‘Information overload’ and about time.

A more full account of the data on knowledge, curiosity, uncertainty and evidence is of interest to those concerned with extending the boundaries of evidence-based practice.

Gaps in knowledge identified during the doctor-patient consultation, motivate GPs to make the effort to seek information. Several examples were given of ‘new’ diagnoses and therapies, news items, and topics more pertinent in primary than secondary care, on which information might be needed.

There have been one or two new things since I qualified. AIDS, of course, is the whopper and Lyme Disease …What has changed is, of course, the prognosis and the therapeutics and this is really the area where I know I need the help.¹²

I can remember doing quite an extensive bit, thing, when Viagra first hit the headlines.¹³

When I was at medical school I knew nothing about Evening Primrose oil and now I know quite a lot about it … It is those kinds of things that you then look up or ask for more information about.¹⁴

More than half of the interviewees identified a personal bete noir, typically "the anatomy, and all the gubbins"¹⁵ and "Some skins. Piccies of skins."¹⁶

A few informants adopted the stance that "My style is, I don’t like not knowing. … I get irritated if I don’t know."¹⁷

Information seeking is driven by "personal interest and inclination to a large extent".¹⁸ Almost half of the interviewees and participants in the Trainers Group identified natural inquisitiveness as a factor which prompts information seeking.

I suppose it could sometimes be just my own curiosity¹⁹ I think of myself as being very curious and not accepting of conventional medical wisdom … but I think, for others, being curious runs the risk of finding out stuff you might be uncomfortable with, or not like to know about, so you just don’t do it.²⁰

A third of the interviewees offered insights into the subject of uncertainty. The majority of these appear to regard uncertainty as the norm.

Commenting upon the experience of anxiety during a consultation, one GP commented :

Most of it clearly will be, at the time, acute – during the consultation. The trouble is, that falls off the longer you can leave it before doing something about it … Once the anxiety wears down, reflect upon … find other ways through, patterns, ways of managing uncertainty. And the interesting thing about evidence is that, as General Practitioners, we are trained to manage uncertainty, and to live with responsibility and uncertainty. It’s an interesting sea-change.²¹

Some GPs are prompted to seek information by a sense of discomfort :

If I feel uncomfortable about something, I make it become an interest, so if I don’t know, I’ll go and find out.²²

When I get in a stew about things at four o’clock in the morning … that’s anxiety-led, and more, anxiety about your own ability-led. … It’s also about the uncertainties that sometimes you’re happy to live with and sometimes you’re not - and sometimes you’re better at living with those uncertainties and sometimes you just think you can’t cope with them.²³

argue the case" against new Government guidelines.²⁴

It’s also when somebody has said something … This person has been seen by another doctor … and it just doesn’t sit right! … then it’s the right time for a new search. … Somebody else’s bullshit! … You start thinking "Well, maybe they’ve got a point."²⁵

Probing about the issue of uncertainty led to the expression of attitudes towards the emergent philosophy of evidence-based medicine.

I am fairly tolerant of uncertainty. … Although I know that there’s a lot of good evidence out there, and I will actively search it out, I understand that a lot of medical evidence is imperfect and that we never know the answers to everything, and that often what was the answer last year is no longer the answer this year - and that’s just a fact of life and I can tolerate that. Interesting! And I think that’s why I am quite happy to question and change my practice because I don’t feel that I’m no good as a doctor, just because what I was doing last year is not what is considered right this year, just because things have changed.²⁶

Several doctors expressed practical difficulties in seeking clinical evidence.

The idea that you could form a clinical question and tap a button and pull the answer out in a minute … yes, that’s fine but by the time you’ve, if it’s there and then, and you can do it there and then - without it being very disturbing. But if you have to close down … fiddle around, even kind of getting started takes 5 minutes, even if it’s only a minute and a half then. And there isn’t time to do that after every patient or even after every fifth patient. … It needs to be sitting there so that it isn’t a bother.²⁷

Many of the problems that we come across are just unanswerable. Sometimes we come across one that’s easily translatable into a question that we think could be answerable – and some of those questions are still unanswerable. So it’s all getting whittled down, and occasionally we get a sensible answer to a question.²⁸

I don’t … My own personal vision is that I don’t see ordinary GPs, in their day- to- day clinical practice, trying to practice evidence-based medicine; doing what I would call ‘a proper search’. They need to be able to access proper sort of evidence-based guidelines, if you like. We need a proper service to do it with, because we can’t.²⁹

Practice protocols generate relatively little demand for information. A fifth of the interviewees, and some participants in the Half Study Day, expressed a need for information about the ‘evidence base’ to support the development of practice guidelines and protocols.

Members of the Trainers Group, and just two interviewees, wanted information about existing, externally produced protocols. One doctor wanted to be able to access evidence to support clinical governance that is categorized along the lines "of the old AA Hotel Guides." ³⁰ Another observed that the predominant need that led her to look "at the literature" derived from training activities.³¹

The qualitative research indicates the order in which GPs are most likely to select from a range of information seeking behaviours.

Convenience and availability take precedence over other criteria for selecting information sources. Reference to written information within the practice is the most common approach; accessing electronic information sources is the second preferred behaviour. Contacting local specialists and colleagues features third except for practitioners at the Surgeries with a Librarian, where a preference for using the Practice Library displaces the use of personal contacts.

All the GPs scan current medical journals on an ad hoc basis. A Current Contents service at practices with a librarian is popular with recipients.

The second question that the case-study sought to address was : "Does the employment of a Practice Librarian make any difference to the information seeking behaviour of General Practitioners?"

The qualitative data reveals interesting differences in emphasis between GPs at practices with a librarian and their peers. By comparison, doctors from the Surgeries with a librarian identify a broader range of information ‘wants’, place more emphasis on the need to keep up-to-date, describe making more use of electronic sources and regard their Practice Library as a valuable resource, identifying its use as a means of obtaining information more frequently than they discuss approaching other individuals.

The qualitative data makes fascinating reading, presenting a vivid account of the perceptions of the informants. The richness of the qualitative data gathered derives from the candour with which the doctors approached the interviews. I was privileged to hold a position of trust among GPs at the three Surgeries with a Librarian. Indeed, I was so well integrated into these practice teams that there is a sense in which the study benefited from informal participant-observation. GPs at other Training Practices knew me by reputation and appeared predisposed to contribute to the study. It appears that these factors had a positive impact on the quality of the data gathered.

Nevertheless, it proved difficult to engage the cooperation of that majority of GPs with whom I had no direct connection. One requested a fee and although he relented once the academic nature of the research was explained, he was unable to schedule a meeting. One Practice Manager explained that some GPs routinely expect payment of £100, or more, for giving interviews to market researchers.³² Un-returned telephone calls were a common problem. Some receptionists were unwilling to take messages; others appeared not to have delivered them.

These barriers were overcome by means of the two Group Discussions and by persistence. Nevertheless, the experience suggests that external researchers, new to General Practice and unknown to the participants, may find it difficult to progress research in this field.

It is vital for those eager to influence the adoption of clinical evidence in primary care to recognize the strength of feeling amongst family practitioners about ‘information overload.’ Nevertheless, we may take heart from the evidence of this study that General Practitioners place emphasis on their wish to keep up to date and will wish to take note of their preference for electronic sources of information over personal contacts. This last is a significant finding, which does not accord with the reports of earlier research.³³

The data emphasize the significance of Vocational Training as a prompt for information seeking, perhaps opening up the possibility of targeting Trainers as Educationally Influential Opinion Leaders?

Finally, the case study shows that the role of the Practice Librarian in the Aylesbury area has influenced the use of information by GPs. It is recommended that librarians develop community-based information services that meet the needs and preferences of family doctors.

In conclusion, the study demonstrates that General Practitioners are prompted to seek out information by a range of needs that they can define, and to which they attach differing levels of importance. Also, the input of a Practice Librarian influences both perceptions and behaviours.

This study successfully captured the perceptions of a sample of GPs. An interviewer using a pre-structured research instrument, rather than an ethnographic approach, might well have classified information needs differently from these informants. For instance, previous researchers have perceived pharmacological information as an integral component of patient care. By giving voice to these informants, the study has demonstrated that, from their perspective, pharmacological information is a separate theme from their dominant need for information on aspects of patient care, and ranks lower than either the need to keep up-to-date or to provide information to patients.

These data suggest that family doctors rank gaps in their knowledge and curiosity fourth and fifth, respectively, as reasons to pursue information. Issues around uncertainty and evidence rank sixth (and last) amongst their perceived information needs.

I’d like to give the final word to a General Practitioner from Aylesbury Vale, whose remarks epitomize the attitudes of her peers towards evidence-based practice :

There’s a lot less evidence available than I would like, and I would like to be able to answer more questions than I can. The limiting factors are my time, everybody’s time, the accessibility of the evidence, and skills in asking the right questions and also in implementing the answers. And the motivation for getting round to those things.³⁴

 

Sue Lacey Bryant

1. Lacey Bryant, S.M.J. The information needs and information-seeking behaviour of General Practitioners :  a case-study of family doctors in Aylesbury Vale. A dissertation submitted to the School of Information Studies, University of Central England in Birmingham, in partial fulfilment of the requirement for the Degree of Master of Science. University of Central England in Birmingham, July 1999.

2. Lacey Bryant, S. The information needs and information seeking behaviour of family doctors : a selective literature review. Health Libraries Review June 2000, Not yet published.

3. Haug, James D. Physicians’ preferences for information sources : a meta-analytic study. Bulletin of the Medical Library Association July 1997, 85(3), 223-232.

4. Hughes, Charles C. "Ethnography" : What’s in a Word - Process? Product? Promise? Qualitative Health Research November 1992, 2 (4), 439-450.

5. NHS Executive. Patients not paper : Report of the Efficiency Scrutiny into Beaurocracy in General Practice. Leeds : NHS Executive, June 1995.

6. Prestige bias is discussed by Oppenheim, A.N. Questionnaire design, interviewing and attitude measurement. New ed. London : Pinter Publishers Ltd., See p139.

7. See General Medical Practitioners : Analysis by type and sex. Table 1. Department of Health : General Medical Services Statistics : England and Wales. 29 March 1996. Leeds : Department of Health, 1996.

8. Paton, M.Q. How to use qualitative methods in evaluation. Newbury Park, California : Sage, 1987.Quoted by Payne, Philip. Sampling techniques and recruiting respondents. In Slater, Margaret.(ed) Research methods in library and information studies. London : Library Association, 1990. 23-43.

9. Detailed descriptions of the purpose and nature of different types of ethnographic questions, including descriptive and structural questions, are provided by Spradley, James P. The ethnographic interview. Fort Worth : Harcourt Brace Jovanovich College Publishers, 1979. See p60-91.

10. Finch, Helen. Analysing qualitative material. In Slater, Margaret. (ed) Research methods in library and information studies. London : Library Association, 1990. 128-147.

11. Owen, Clare. Notes from GP Half Study Day Thursday 11 March 1999. Not published. Discussion 11/03/99. Group Discussions file. GP Half Study Day. Notes, p1.

Interview 8/04/1999. Practices without a Librarian file. Transcript 19, p4.

Interview 12/03/99. Practices with a Librarian file. Transcript 16, p3.

Interview 9/02/99. Practices without a Librarian file. Transcript 6, p2.

Interview 5/03/99. Practices with a Librarian file. Transcript 12, p2

Interview 5/03/99. Practices with a Librarian file. Transcript 12, p3.

Interview 18/03/99. Practices without a Librarian file. Transcript 17, p4.

Interview 18/01/99. Practices with a Librarian file. Transcript 1, p1.

Interview 3/02/1999. Practices without a Librarian file. Transcript 4, p4.

Interview 8/02/99. Practices without a Librarian file. Transcript 5, p3.

Interview 20/02/99. Practices with a Librarian file. Transcript 2, p2.

Interview 27/01/99. Practices with a Librarian file. Transcript 3, p3.

Interview 9/02/99. Practices without a Librarian file. Transcript 6, p4.

Discussion 26/02/99. Group Discussions file. Trainers’ Group Notes, p2.

Interview 9/02/99. Practices without a Librarian file. Transcript 6, p2.

Interview 8/02/99. Practices without a Librarian file. Transcript 5, p3.

Interview 11/02/99. Practices with a Librarian file. Transcript 7, p2.

Interview 24/02/99. Practices without a Librarian file. Transcript 10, p4

Interview 12/02/99. Practices without a Librarian file. Transcript 8, p4.

Interview 3/03/1999. Practices without a Librarian file. Transcript 11, p3.

Interview 12/02/99. Practices without a Librarian file. Transcript 8, p3.

Jill Blackburn. Practice Manager, Meadowcroft Surgery, Aylesbury. Personal communication March 1999.

See Verhoeven, Anita A., Boerma, Edzard, J. and Meyboom-de Jong, Betty. Use of information sources by family physicians : a literature survey. Bulletin of the Medical Library Association January 1995, 83(1), 85-90.

Also Tomlin, Zelda., Humphrey, Charlotte and Rogers, Stephen. General Practitioners’ perceptions of effective health care. British Medical Journal 5 June 1999, 318 (7197), 1532-1535.

Interview 24/02/99. Practices without a Librarian file. Transcript 10, p4.

This document was added to the Education-line database on 12 May 2000