Dealing with emotions: challenge

Today I want to gather my thoughts on what happens sometimes when I am faced with trying to help a patient who is suffering emotionally and so the consult ends up being about more than just finding information. When this happens, not too often thankfully, I am sometimes left with the feeling that I could and even should have done something differently, but at a loss as to how.

Health care professionals are formally taught how to communicate and establish trusting, humanistic relationships with their patients (though of course not all will excel at this).^{1 2 3 4} For obvious reasons, librarians/info professionals do not get such training. We are taught how to conduct a reference interview, sure, but not exactly what to do if a patient is referred to you and then angrily questions what you can do for them. They look from you to the computer and flat out state (with maximum scorn) that they could do what you are about to do for themselves and with the same results. They are not a "problem patron." You know they are suffering from anxiety, or depression, or have just been diagnosed with colon cancer and that their emotions are understandably running high, but you have no script, no checklist to smooth the interaction. Do you sympathize? Do you try to lighten the situation? Do you engage or remain impassive and try to conduct business as usual?

In situations like these my instinct is to throw the idea of finding information out the window in favour of just listening. I know a little bit about active listening (from life as well as from library school) so I try to paraphrase what is being said to me, while repeating as many times as possible that I understand their frustration, that I *might* be able to find something they have missed in the course of their own searches on Google (or at least validate that their search was well done), and that I will be available when they are ready if today is not good.

But this just an instinct. And once in a while I get flustered. Then I forget the above and I try to forge ahead, to prove myself by finding something useful, sometimes unsuccessfully (because of aforementioned flustered-ness). This of course undermines the trust that I am hoping so much to establish, and leaves me feeling inadequate and inadequately prepared.

Either way I have no real formal training to deal with such situations, and no way to establish whether my instincts are correct except based on how the situation resolves itself (i.e. are they still angry when they leave? Did they come away with something useful?). My thinking is that some of the literature developed for health professionals might be of service (just the reading from today was helpful). I wonder if any other information professionals working in my area of speciality have faced this kind of problem and how they have sought to resolve it. Your thoughts are welcome.


1 Branch WT, Kern D, Haidet PWeissmann P et al. The Patient-Physician Relationship. JAMA 2001;286(9):1067-1074. Accessed April 16 from: http://jama.ama-assn.org/cgi/content/abstract/286/9/1067
2 Gask L, Usherwood T. ABC of psychological medicine: The consultation [clinical review]. BMJ 2002;324:1567-1569. Accessed April 16 from: www.bmj.com/cgi/content/full/324/7353/1567
3 Bedell SE, Graboys TB, Bedell E, Lown B.. Words That Harm, Words That Heal [commentary]. Arch Intern Med. 2004;164(13):1365-1368. . Accessed April 16 from: http://archinte.ama-assn.org/cgi/content/full/164/13/1365
4 Hastings A. The Good Consultation Guide for Nurses. s.l.*:Radcliffe Publishing;2006.

*As a total aside- how come both Google Books and Amazon do not include location in their records? Very frustrating. I do not have the patience to check more than 3 sources today (also checked McGill's catalogue to see if they had a copy but no luck). Hopefully my readers will forgive my laziness:-b

Fundraising: challenge

My agreement with Herzl was that they would pay for a 2-year pilot project after which, if all went well, we would seek external support. Those two years are up in April of 2009, so finally the time has arrived for me to do some serious fundraising.

The good news is that the service is thriving. I have a steady stream of referrals, as well as direct requests from patients and from health professionals. The web site is being well used with somewhere in the ball park of 400 visits per month.* I am now in charge of managing the clinic's pamphlet collection which is steadily growing (I'm starting to run out of room), and which I supplement with handouts I have been developing on various topics.**

And there has been an exciting new development. Last week one of the GP's suggested that we test out a way for me to further integrate my service. This suggestion was made after reading a preprint of a forthcoming PLoS paper, which the authors kindly agreed to share with me, and which I will provide a link to once it is published. The research shows that a "just-in-time" librarian information service had a positive impact on "time, decision-making, cost savings and satisfaction" in primary care.*** While this just-in-time service works quite differently from mine (clinical questions are sent to librarians using hand-held devices) it still provides compelling evidence of the positive impact a point-of-care information service can have on clinical practise.

In the case of our service, the idea is that I spend some time in the teaching room so that I can participate in cases as they occur and provide support and instruction to residents in "real time" so to speak. I spent a few hours in the teaching room last week and it was a great success all around. I learned a lot about what really goes on in consultations and was able to see ways in which I could be of service, the residents were able to benefit from my immediate support and in some cases were visibly relieved to have me there. And I have to admit, it was very cool to be able to really be a member of the team. If we can replicate this with some of the other teaching doctors, I would like to make it a regular component of the service.

All this to say that it would be lovely to be able to continue developing what is a unique and cutting edge service, one that has the potential to positively impact the quality of care being provided at the clinic.

I am new to the fundraising process, which I am hoping will not be a liability. So far, aside from continuing to develop the service and the website, I have been in touch with the hospital's foundation, and with public affairs who will be helping me to increase visibility of the service. I have also begun compiling a list of foundations and potential donors but I fear that I won't have the time to follow up on that.

If any of my readers has suggestions or knows anyone who might be interested in being a donor please don't hesitate to contact me.




* I am not a statistician so I don't have the exact figures. The content management software we use allows us to keep track of unique visits to each page, which if I add them up amount to over 400 visits, however I am sure that each visitor is going to more than one page. This is why I say visits and not visitors, though I'm sure that statistically I am not quite correct.

** These handouts consist of recommended online resources on various topics, such as Teen health, Pregnancy, Menopause etc. which one of the GP's at the clinic has requested. They are available on our website as well.

*** McGowan J, Hogg W, Campbell C, Rowan M. Just-in-time information improved decision-making in primary care: a randomized controlled trial. PLoS. Forthcoming 2009. [I will have to verify the correct publication date]

Barriers to use and referral: challenge

As time has passed I have been able to identify some of the potential barriers to use and to referral. I thought I would share these as they may benefit those of you who are interested in implementing a similar health information service at point of care (I know of at least one other centre that is considering doing so). That said I feel I should emphasize that this is based on my own personal observations and on the casually reported observations of others, rather than on any systematic study of the issue. We do intend to do a formal evaluation of the service, at which point we will be able to see whether these hypothesis are correct.

Not in order of importance:

1. Distractions in the waiting room. We have two big, beautiful, flat screen TVs in the waiting room that are impossible to ignore if you're sitting there, no matter which way you're facing. I just went out there to see what's playing. On one you have a talk show and on the other a soap opera. Even on mute they seem to be serious competition for my service. Gone are the interminable boring waits during which patients had time to think about where they were (the doctor's office), why they were there (sickness, checkup etc.), and maybe formulate a few questions they'd like answered. You may want to think about what could potentially distract your users from dropping in with questions. It could be TVs. It could be something else.
   
   The good a) patient satisfaction no doubt increases (time flies when you're having fun), b) as far as the TVs are concerned, there is an opportunity for promotion, to develop programming that could include information about the clinic and the service. The bad people may be distracted from asking questions while they wait.
   
   
2. The InfoRx. On the part of the HP, there may be uncertainty about how to insert the referral into a transaction with the patient. It may be hard for HPs to know when would be a good time to mention it, or who might benefit. Time is certainly a factor and it is probably all too easy to forget to write up an InfoRx. Telling HPs that they should consider referring a patient whenever they make a new diagnosis, prescribe a new medication, or the patient is faced with a treatment decision may not be enough. The idea that a librarian is now acting as a member of the team at point of care and can have patients referred to them same as any other specialist may be new and it may take a long time before knowledge becomes practice, even when everyone buys in to the idea. My feeling is that this is a change management issue. It has to do with the gap between theory and practice, between intention and action.
   
   Hoping to find something along the lines of the PLISSIT model* that could be used to assist health professionals at that crucial moment during their visit with the patient and family, I've been doing some reading about barriers to improving practice, and barriers to implementing practice guidelines and shared-decision-making. I think the latter is particularly relevant, because helping a patient or family member become well informed is a crucial component of the shared-decision-making process.**
   
   The bad this is a very complex issue that may be difficult, if not impossible, to solve, The good this could be an opportunity to further develop a new model of health care, and there may be evidence to help us in the process.
   
   
3. The Internet. You will likely wish to have a web component to your service, as I have done. Our website is advertised in our H-PHIS brochures which are disappearing from the displays at a steady rate. Statistics show that the website is being visited regularly. From this I feel I can say that I am successfully helping people help themselves. I wonder if this makes them less likely to ask for help.
   
   The good people will probably use a website if you have one, The bad people may go to your website instead of using your service.
   
   
4. Availability. It is unlikely that you will be on site and available every day all day. I am only on site 7 hrs per week, and the librarian at the Monkfield Medical Practice was also there only part time. This means that you may not always be available when needed, and not always be around to remind people to use the service and to guide people through the process. The point of having a service on site is to avoid the whole "out of site out of mind" thing.
   
   The good the demand may be greater than the supply, which may justify an increase in staffed hours The bad not having enough hours to make the service work.
   

I would love to know your thoughts on these issues, so any comments or suggestions from my readers are very welcome. Since I began writing this post I have found a couple of models that may be useful in facilitating shared-decision-making. Stay tuned. I will discuss them in my next posts...


*
I came across this model recently while researching the question of how to help HPs bring up sexuality issues with gynecologic cancer patients.

**
Haines A, Kuruvilla S, Borchert M. Bridging the implementation gap between knowledge and action for health. Bulletin of the World Health Organization 2004;82:724-32.

Cabana MD, Rand CS, Powe N, et al. Why don't physicians follow clinical practice guidelines?: A framework for improvement. JAMA 1999;282(15):1458-1465 (doi:10.1001/jama.282.15.1458)

Freeman AC, Sweeney K. Why general practitioners do not implement evidence: A qualitative study. BMJ 2001;323:1100-2.

Gravel K, Legare F, Graham ID. Barriers and facilitators to implementing shared-decision-making in clinical practice: A systematic review of health professionals' perceptions. Implementation Science 2006;1:16. (doi:10.1186/1748-5908-1-16)

These are just a few of the articles I've found. I will try to include a more detailed list in a future post.

Privacy and professional autonomy: challenges

Dean Giustini recently brought me to the attention of his readers on the Google Scholar blog which prompted some very interesting questions in the comments. I promised to respond to those questions here.

Q: The first question raised by Anon had to do with patient privacy, a question that was not raised at the CHLA conference and has in fact not come up at all until now. The poster expressed legitimate concerns over whether placing my consults in the patient charts* is "a violation of the librarian's code of ethics to keep questions confidential."

A: I completely agree that when I am in the library and a person approaches me with a question it should be kept confidential, and this is our practise, except when I am seeing a Herzl patient at the library, in which case I make a copy of the consult and place in the their chart at the clinic, this being considered an extension of my service there. In the case of the Herzl service, it is being delivered at point of care, and the expectations of privacy and confidentiality are different. I am recognized as being a member of the team who participates in the provision of care. Most people come to me having been referred by their physician or nurse in the first place which means that the question is already known to them.

I make a point of explaining to anyone who comes to me without a referral or meets with me in the library exactly how the system works i.e. that the consult will end up in their chart and why this is so. I also let them know that if this bothers them I will keep it confidential. So far no one has expressed concern over this or refused to have their consult put into the chart. Perhaps I should try to make the process more transparent by explaining it every time. I haven’t always done this for the same reason I know it is difficult for health professionals to remember to send their patients to the library or to my service: time can be an issue, and also it doesn’t always occur to me when I am focused on conducting a thorough reference interview and answering the question. You have given me something to think about.

Q: The second question/comment had to do with professional autonomy. Anon wondered whether it would be difficult for a librarian to maintain professional autonomy given the hierarchical nature of the clinical setting.

A: If I understand correctly, Anon is expressing concern that a librarian in my situation could be pressured to provide information to patients in support of whatever treatment decision was being recommended by the referring health care professional. It is not always easy for librarians, even for those of us working in a clinical setting, to uphold another of our professional codes which is to provide access to balanced and unbiased information to all, regardless of what our own opinions are on the question or the asker. We are human after all. And often we are limited by what information is actually available to us. Regardless, I do my very best to uphold this code. I am also very careful to make it clear that I cannot interpret the information I am providing access to, nor can I offer any kind of opinion regarding treatment.

There have been a a few cases where the information I have provided has suggested a different course to the patient than the one originally proposed by their referring physician. There have also been cases where the patient only agreed to the proposed treatment after receiving information from me. I see both as examples of shared decision-making and am pleased to have played a part in that process. My impression is that the health care providers I work with are aware that it could go either way when they send someone to me, and this is a risk they take because they believe in the process.

*Important note: the charts I am referring to are kept at the Herzl and are not available hospital-wide or electronically.

Testing boundaries: how much is too much? Challenge

Sometimes you're sitting with a patient or family member, conducting your reference interview so you can determine what their information needs are, perhaps trying to find a balance between what their health care provider suggested they be given (say, information about hormone replacement therapy), and what they themselves are truly or additionally interested in learning about (say, returning to a normal sex life after surgery), and it becomes clear that what's really important here is not the information but the time spent talking to someone, being heard.

There are times when I find myself talking with someone for far longer than it took to meet their information needs. One person will want to tell me about his children, how they're doing at school, how he met his wife, another might go into more detail than necessary about a previous surgery, about a seemingly unrelated health issue, or about her love of gardening. On the surface it all seems unrelated, but if you put yourself in their shoes for a moment, then it's clear that everything is intimately related because it's their life we're talking about, not just their illness, and the one cannot be separated from the other.

So I listen, and I listen for clues to what might be hidden information needs. Sometimes what seems on the surface like chit chat is secretly or unconsciously a question. My job is not only to help people find information but to show them what kind of information is available, and even to help them figure out what it is they really want to know, because this is not always clearly formulated from the get go.

On rare occasions it feels like I'm having hundreds of questions fired at me all at once, and I can't be sure which to take seriously. When this happens I try to bring things back to the matter at hand and keep things focused. I have to wonder though, where exactly to draw the line. Is an hour too long if all of it is spent researching the question? Is it too long if 30% of it is spent researching the question? How many questions can reasonably fit into one session? And how much do I want to know? What is it appropriate for me to know? Is okay for this to be dependent on my own personal and professional sensibilities balanced with the desires of the person I'm helping?

Other times I get asked difficult questions, like "what would you do?", or "what should I do?" In these cases I must be extremely careful to not give any answer other than, "I am not a health professional. I cannot give you advice about what to do or how to interpret this information. Your doctor or nurse will be happy to go over this with you." Sometimes I have to say this over and over.

It's tough. I want to help people and feel that they're satisfied with my help, but in these cases everyone involved is left with a feeling of dissatisfaction. I know that their doctor or nurse will not always be able to go over it with them in the kind of depth they want or need, not because they don't wish to but because there isn't the time. I also know that consultations with doctors and nurses are often stressful and all the hundreds of questions can fly straight out of a person's head when it comes time to ask, even if they've been organized and proactive and have brought a list with them. But I still cannot give any other answer. It helps that I genuinely don't know it.

Ethics resolved: challenge

It's been a couple of weeks, during which time I had a much needed vacation, and was able to resolve the ethics dilemma I mentioned in my last post. I am relieved to report that I will be able to continue posting cases. It's really quite simple: the cases need to be unrecognizable to the people involved and not just to everyone else. So what is required is a bit of fictionalization. The idea is to keep the important details that make each case interesting and potentially useful to my readers, and to fib on the ones that are unnecessary but unique enough to allow someone to recognize themselves. I have added a bit about this under Author's note:

Important: While based on real consultations, the cases posted in this blog have been mashed up, fictionalized, posted out of sequence, and otherwise tinkered with in order to maintain the privacy and comfort of the parties involved.

With this in mind, over the next few weeks I will be editing and reposting the cases from before, and adding new ones as I go. This makes me think about a recent interesting post of David Rothman's in which he discusses the problem of versioning in blog posts. It occurs to me that if I chose not to be transparent about this process, there would be no way (that I know of) for anyone to know for sure that anything had changed. I have chosen transparency for the same reason I decided to create this blog in the first place, which is to share the challenges I encounter in the course of implementing this new service with others, and, selfishly, to allow myself a space in which explore my experiences and thoughts. But I also feel that in these cases it's a good thing that the new version overwrites the old.

Thank you for your patience!

Staff requests: 2 cases and Ethics: challenge

It has recently been brought to my attention that there may be ethical problems with posting cases the way I have been, even though I have been very careful to remove any personally identifying information. Hopefully I will be able to continue once I have spoken to the ethics consultant at the hospital in order to confirm that all is indeed okay.

In the meantime I have taken the cases offline (hopefully temporarily), and today I will write about a couple of requests I've gotten from staff.

Case#1

Scenario

One of the health professionals (HP) at the clinic asks me to find some information regarding which vaccines that do not contain thimerosal (a mercury-based preservative used in multi-dose vials to prevent contamination) are available in Canada, as one of his patients has expressed concerns over the additive. He gives me a list of possible vaccines.

Resolution

I run several searches in Google which verify the correct spelling and allow me to narrow my results to those pertinent to Canada. Unfortunately, as I write this, I do not remember my exact searches, except that I did not include the vaccines from the list in my searches. I do remember running several relatively convoluted ones before I was able to find the information I was looking for. I have tried to reproduce my search for the purposes of this post and for some reason I am only able to find an older 1 March 2003 version of the 2007 document I am ultimately able to find for the HP:

Canada Communicable Disease Report
Volume 33 • ACS-6
1 July 2007 An Advisory Committee Statement (ACS) National Advisory Committee on Immunization (NACI)
Thimerosal: Updated Statement

Discussion

I find the older version by typing in thimerosal canada which is a search I know I would have run the last time, so I am doubly confused at to why I did not find the older version last time but have now found it so easily. Having found it there would have been no reason to keep looking as there is no indication that there is a more recent version available. This is yet another example of why searching for information using Google can be hit and miss. I have tried to reproduce searches before and have had similar problems, something I demonstrate in the Google course I developed for the Health Sciences Library: Google-eyed? Don't despair! How often do we take screen captures of our search results? It is way too easy for us to doubt ourselves and not the tool we have become so dependent on.

Total time: 30 mins

Case#2

Scenario

One of the GPs at the clinic asks me where he can find decision aids to use with his patients and their families.

Resolution

I happen to have a very useful site already bookmarked in MyHq so I show it to him: Ottawa health research Institute A-Z Inventory of Patient decision aids.

I also show him a really neat one I have found recently during an encounter with a family member in the Gynecologic Oncology department: Ovarian Cancer Treatment Guidelines for Patients– Version III, April 2007. The reason I like this one so much is that is not just a list you can print out and tick off, but rather a fully interactive tool that works something like a choose you own adventure.

Total time: 5 mins

Librarian floating in a sea of MDs: report from a medical conference*

As mentioned in the "About me" section of this blog, last week I attended the STFM Conference for Practise Improvement: Patient Education and Health Information, where I presented a paper titled: Implementing an integrated information prescription model in family medicine. The PowerPoint presentation is available at the Family Medicine Digital Resources Library for anyone who is interested. You need to register to have access but registration is free.

The presentation went very well. I had a mere 20 mins to present but discussion continued for another 20. Two MD's have expressed an interest in implementing a similar model and we will hopefully be in touch.

I would like to share some thoughts about what it's like to be a librarian attending a non- librarian conference. The problem is that I have never been to a library conference so I don't have any basis for comparison. I can't say whether certain aspects of my experience are unique to me, to this particular conference, whether they are unique to medical conferences, or whether they apply to conferences in general. Perhaps I will hold off on trying to analyse my experience on any profound level until I have attended an actual library conference.

I will say that I met and spoke with many interesting people, particularly at the poster sessions where I was able to chat with the representative from UptoDate who told me that librarians are their toughest critics, and with several people from the Mayo Clinic who
work in the area of patient education and were surprisingly modest about their work, and the incredible resources they have at their disposal.

What was missing to some degree was the urge to connect again in future, which I suspect would have been there had we been professional colleagues. In general my impression is that librarians are respected for the work they do, it is recognized that much of what we do overlaps and even sometimes duplicates the work of health care workers in the area of consumer health education, and our resources are being used with enthusiasm. But we are nonetheless justifiably considered separate entities from the health care team. This model (perception? habit? philosophy?) is of course what I am working to change at my own clinic, for the most part successfully.

If teams are to be truly multi and interdisciplinary, then it stands to reason (at least to my mind) that they should include members of any profession who brings added value to the care the team provides. In order for this to happen, more of my professional colleagues will need to enter the trenches (this is a challenge in every sense of the word).

The question is: why is this so important?

The first and most important reason in my mind is that of trust. This is something I got to thinking about when I was preparing my presentation. It was of course necessary for me to answer the question: why in house? There were several reasons (the library is far, the health professionals need support too, the librarian is better placed to understand the needs of the community) but the one that resonated most, for myself and for my audience, was trust. Trust can come into the equation in several important ways:

1. The health professional may be more likely to trust the librarian to provide health information to his or her patient if the consult is treated as a clinical encounter and documented in the chart.
   
   
2. The patient or family member may be more likely to trust the librarian to provide health information if their doctor or nurse has referred them to a service which is down the hall from the exam room.
   
   
3. Perhaps most importantly: the patient or family member may be more likely to trust that their doctor or nurse wants them to be informed and is willing to discuss the information they are accessing, if the information is being provided by a member of the health care team. The message then is this: we want you to be empowered, we support shared decision making.
   

*My apologies for not posting last week. I was hoping to be able to publish a post from the conference but at $4 per 15 mins of Internet time it didn't end up being reasonable.

Privacy: challenge

Challenge

I am in the H-PHIS room creating a handout on local fibromyalgia resources for patients and it is a busy day in the waiting room. People are starting to browse the pamphlets which we have displayed in two very nice wooden displays along the wall. Small children especially seem to like to run into my room and play with the pamphlets on the bottom row. I will have to think of something more interesting to put there for them to play with.

Today I see the beginnings of what will be a great challenge. My room opens directly onto the waiting room which is good because I am visible and people can feel free to drop in and ask a question or browse pamphlets even when I'm not there. What's not so good is that there is no privacy, either for me when I am working (it can be hard to concentrate when a four-year-old runs in and fake-sneezes on you), or for any person who wishes to ask me to help them find information on a topic that requires privacy. One of the dietitians has to go through my room to get to her office and, while she has put up shades, the glass door and wall do not give her patients much privacy either. How to balance the two? How to make sure that people are welcome to come in and use the service, and that if they need they can have a little privacy?

Picky eaters: case

Case/challenge

Scenario

A young man follows his child into the room and sees a pamphlet he's interested in but we only have the French version displayed. He asks if we have it in English and I pull it out from one of the many boxes I am keeping under the extra desk until we can find someplace to store them. Eventually the plan is to have an extra computer at that desk that patients and their families can use while they wait. The pamphlet is called Feeding your child ages 2-5. The man tells me his daughter is 2 years and 7 months old and a very finicky eater. I offer to see if I can find some other resources. He's nervous about staying in the room with me as he might not hear his name being called. The waiting room is quite animated this morning and a vacuum is being used nearby. I offer to find some information for him and tell him she can pick it up after his appointment.

Resolution

I find a few good resources that will supplement the pamphlet nicely:

From Eat Right Ontario: Picky eaters and serving sizes
From Kids Health: Nutrition & Fitness section
From the BC Ministry for Children and Families: Feeding your toddler with love and good food (pdf)

I print these out and place them handily on my desk for the man to pick up when he leaves. He never returns for them.

Discussion

I'm not sure what to do with the 10 pages or so that I have printed. We have not yet established a procedure for this eventuality but I am now inspired to create one. Some things to consider: a way for patients to be located when they are with me and their name is called; a way to get printed information to a patient in case they forget it (email, fax?); a place to put abandoned printed information that may be used at a later time.

Further resolution & discussion

The following week I decide to try and track down the man and see if he still wants the information. I go to the chief administrator at Herzl to ask if she can suggest how to find the man using only a first name. Medivisit, the clinic's appointment scheduling software, only allows a search using both first and last. She randomly calls one of the team coordinators, who as it happens knows the man we are looking for. I have contact information in my hands within 2 minutes. I call the man and he does still want the information. I leave it with the team coordinator for him to pick up at his next visit. I am very impressed with how well the teams seem to know their patients.

What not to feed gout & whose pager is it anyway?: case

Case/challenge

Scenario

I am at the library helping to conduct a workshop for a small group of residents. They are reviewing how to use selected EBM resources to answer clinical questions and a couple of the cases at the end of the session are specifically related to providing health information to patients and families. This is why I have agreed to assist during a time when I would normally be on site and available to patients. It is also an opportunity to promote the service to residents, who have so far been extremely enthusiastic about using the service. A short way into the workshop a beeper goes off. After a moment's pause I realize it's mine. I excuse myself to call in and am told that a patient is waiting for me at the clinic which is in an entirely separate building. I run over to the clinic and arrive slightly out of breath to find a young woman waiting for me. Her father's physician would like him to have some information about which foods to avoid when suffering from Gout.

Resolution

I do a quick search on MedlinePlus and find a link to the Arthritis Foundation that answers the question (literally since it is a Q&A from the Arthritis Foundation's consumer health magazine Arthritis Today, in the On call section). I ask if she thinks her father would like more information and shen answers that for now she thinks it will be enough and will contact me if she or her father have more questions. I run back to the library in time to cover the 2 cases that deal with the information needs of patients and families.

Discussion

In this case what is interesting is not so much the information need or how it was met, but rather the challenge that was presented by the fact that I was engaged in other aspects of my position which required that I be off-site during a time when I would normally be available to patients. In the end my having a pager helped to resolve the issue to everyone's satisfaction and the timing worked out just right. Had the person been unable or unwilling to wait the ten minutes it took for me to arrive on site, an opportunity to provide the service would have been lost. This has already happened once so far. The fact that a librarian was paged in a room full of physicians was an added bonus! I could not have found a better way to promote the service than that.

Pushing boundaries or juggling hats: challenge

Although my two positions at the hospital are intricately connected, I am paid for them separately, so I try to keep my work in each location as separate as possible in order to honour my obligations to both.

When I got the request for information at the library on pediatric MS from a Herzl resident, it had not yet been established what to do when a Herzl request comes to me when I am at the library. I had another request at the library from Herzl that same week so it seemed imperative that a decision be made regarding procedure.

It has since been decided that I will treat the request as a PFRC request, and also fill out a consult at the Herzl which can then be placed in the chart, which is what I had instinctively thought to do. This seems like a reasonable solution, although it does mean that I may be occasionally counting a single encounter twice.

The head librarian is also available to consult with patients and has said she is happy to help with Herzl requests coming to the library should I not be able to. This is where having the additional support of a library and especially of an existing patient resource centre makes having an in-house service slightly more feasible, especially when the librarian is only on site part-time.

Reinventing the wheel, changing habits & time management in the first months after implementation: challenge

Because the UK service we are basing our model on is no longer operational following the retirement of its librarian, we are in essence reinventing a structure we know exists but do not have the blueprints for. Much of the first months have been spent dealing with the practicalities of setting up the service, establishing policies and procedures, and promoting the service to health care, administrative and support staff as well as to patients.

One of the biggest challenges has been to get health care staff into the habit of referring patients to me. It is my hope that the cases presented here will help. For now I have given the following guidelines:

When to use the service:

• Anytime anything is new (i.e. treatment, diagnosis, medication etc.)
• When more information would help your patient make a decision
• When you’ve been asked for more info but don’t have time to provide it
• When info is needed in a language other than English and French
• When info is needed at an easier reading level

**** do not discount patients you suspect have low literacy****

I am only on site 7 hours per week and this is problematic because I am not always immediately present to fill prescriptions. This will necessitate that those needing my services be prepared to make appointments for a later date and/or to send me their request by phone or email. It has taken some time to establish me in the system so that patients can make appointments to see me with their team coordinators. It is only this week that this has become possible. in the meantime I had asked that referrals be left for me in my mailbox. I have received my first referrals (yellow InfoRx sheets torn from the pads I had printed) in the past two weeks. I have left messages for patients and made contact with one: my first appointment is on Oct. 1st, this coming Monday.

Since I do not yet have cases to present I will instead describe a few I have handled in the past several months at the Library's Patient and Family Resource Centre (PFRC)- see next post.