Tuesday, September 01, 2009

Legal issues around appropriate literature reviews

I wanted to share this post from colleague from a hospital librarians' listserv. She provides some interesting points to explore how important appropriate and complete literature and evidence identification to the safety of the care process and instances where there was some legal leverage applied to underscore that importance.

Does this help support a defined role for librarians in a process that has been "googlized" to the point of removing it from "expert" hands and impacting its reliability?

Please, lets discuss!

I reproduce it here with her permission.

posted August 28, 2009


With regard to [my colleague's] comment about the existence of legal cases and how much awards are made when physicians fail to provide appropriate care because of lack of information, the following case comes to mind. There was a case in 1983 in the state of Washington where three physicians were found negligent in a wrongful birth case when they failed to search the medical literature or to consult other sources of information concerning the relationship between birth defects and the drug dilantin. Physicians have a legal responsibility to research the literature. The case is described in – Harbeson v. Parke-Davis – “Medicine and Law”, 4(2):189-194. l985 (PMID 3999949). The Harbesons asked three different physicians about any adverse effects of taking Dilantin while Mrs. Harbeson was pregnant and taking Dilantin for epilepsy. The Harbesons then had two children who suffered from “fetal hydantoin syndrome” as a result of Mrs. Harbeson taking Dilantin during her pregnancies.

In an article by M. Skolnick in “Medicine and Law” 4(3):283-98, l985, (PMID 4010498), Skolnick writes “An important element in the courts decision was the physician’s failure to conduct a literature search or seek alternative opinions.” He also writes “Failure to search the appropriate scientific literature is an obvious breach of the broader duty to perform at the level of knowledge and practice in the physician’s clinical specialty. The duties defined by the doctrine of informed consent may be discharged only if the physician remains abreast of current information, and can communicate it to his patients.” He further writes that “Far greater emphasis in both teaching and testing is placed on memorizing facts than in processing information to solve problems.” Lastly, Skolnick writes about the Harbesons’ physicians that “They relied on what they remembered and the kind of information shared in their practice setting, and produced a human tragedy. Had these physicians been educated through a process which induced them to access and process current information, their approach to the Harbeson’s question might have been profoundly different.”

Although it is much easier in 2009 to do a literature search than it was in l983, physicians need to conduct literature searches to help answer clinical questions. It is also important for physicians to receive initial training in literature searching in medical school and then continuing education in literature searching the medical literature throughout their career. As a hospital librarian in a teaching hospital, I have often helped physicians conduct literature searches that impact patient care. I’ve also helped physicians search the literature for information that impacts a court decision on a medical case.

The case of Harbeson v. Parke Davis indicates that there is some legal precedence for physicians to perform literature searches to support their clinical decisions. Personal experience also has shown me that physicians today still need help and instruction in performing literature searches. The problem then is to document the impact on patient care and then communicate this to the hospital administrator in charge of the library. A number of studies have been published that demonstrate the value of the hospital library in supporting physicians in their clinical decision-making. The Vital Pathways initiative of MLA will also help to foster the value of the hospital librarian. Since l997, physicians and others have had free, online access to Medline through PubMed. Currently, many hospitals have access to full-text articles online. Despite this access to the medical literature, physicians still need and benefit from the expertise of medical librarians to help them search this vast literature.

To me therefore, the legal precedence for physicians to search the literature is already established and physician’s need for help in searching the medical literature is still present. I hope that as an organization we can continue to work on ways to alert hospital administrators of the need not only for a medical library but also of the need for medical librarians to assist physicians in their clinical decision-making. Free access to Medline through PubMed and access to many journals online is not an adequate substitute for the expertise and training that medical librarians can bring to all of the hospital staff that they serve.


Carol Jeuell, MSLS, AHIP
Children's Memorial Hospital, Chicago, IL


Amanda said...

Many years ago, the head of my library was called to testify in a malpractice case. In her instance, the doctor sought her testimony to prove that knowledge of a particular side effect was not reported in the literature until after he had prescribed the medication.

It does raise interesting issues, because often I comply with search requests that are against my better judgment. Perhaps the client specifically requests that I only send results published after a certain date, or in English. At what point do I intervene and suggest that a broader look at the literature is required?

Lorri Zipperer said...

I wondered what would happen if you discussed this issue with your patient safety officer? Or a champion of yours that understands your interest in doing the best thing possible for both the clinicans you work with and their patients. If there an organizational culture hierarchy issue that is at play here -- what other latent failures does it allow in regards to gaps in appropriate and complete evidence and information delivery and application?

I would imagine that parallels could exist with nurses, care givers and other staff who may not want to "speak up" for fear of irritating or accidently insulting a colleague. If we don't speak up, who else will even think of this as a safety problem?