Brief communications
the self-contained medical university. One of these rooms, the newspaper reading area on the first level, is adjacent to the student reading room. The newspaper area offers students access to the top newspapers in China. Another reading room on the second level houses a collection of fiction materials.
VISITORS' IMPRESSIONS Sally Chu of the Health Sciences Library, Mills-Peninsula Hospital, Burlingame, California, and Frances Flynn of the New England College of Optometry, Winthrop, Massachusetts, visited the Beijing Medical Library in September 1991. Both were impressed with the effective use of natural light in the building, its modern western look, and the general sense of open space conveyed by its floor plan. They appreciated the user accessibility of the tidy stack areas, as most libraries in China do not have open stack areas. Chu also liked the shape of the building and the central wall on each level, used to mount various displays. She did express concern over the small area used to house the one terminal for CD-ROM MEDLINE and the library's ability to keep the computer room cool and free of dust-a problem brought about by having just one air-conditioned room. Both librarians believed the space is flexible enough to allow for change. Stack areas are large enough for ease in shifting materials and for additions to the collections.
ACKNOWLEDGMENTS The authors acknowledge the help and support of Stephanie Poole and E. Diane Johnson, head, Information Services, J. Otto Lottes Health Sciences Library, University of Missouri-Columbia, Columbia, Missouri.
REFERENCES 1. EDWARDS AJ, MEADOWS SE. A visiting scholar from the People's Republic of China. Med Ref Serv Q 1991 Win-
ter;10(4):39-47. 2. Beijing Medical University brochure. Haidian, Beijing, People's Republic of China. 3. ZHU, CHENG-GONG. User needs-the principal basis for designing college or university's library buildings. In: Adaptation of buildings to library use: proceedings of the seminar; held in Budapest June 3-7, 1985. New York: Saur, 1987: 206-15. 4. Beijing College of Traditional Chinese Medicine brochure. Beijing, People's Republic of China.
Received November 1991; accepted February 1992 374
APPENDIX Library planning and construction data Architect: Contractor:
Yin Liping Beijing Third Building Company Consultants: Li Xue Yu Hong Weixian Furniture designer: Beijing Shuan Qiao Furniture Factory Contact person: Department of Buildings, Beijing Medical University Total floor space: 10,200 square meters = 110,000 square feet Project cost: 21,000,000rmb = $3,900,000 Public seating: 1,700 total 170 specialized 1,530 general
Physician retraining, lifelong learning, and the library By Mary Moore, M.A. Senior Associate Director for Public Services Library of the Health Sciences, and Curriculum Developer, Texas Tech MEDNET JoAnn Van Schaik, M.L.S. Senior Associate Director for Technical Services Library of the Health Sciences C. L. Montgomery, M.D. Associate Dean, Continuing Education School of Medicine Texas Tech University Health Sciences Center Lubbock, Texas 79430 In a compelling article, Judith Messerle recently called on health sciences librarians to "enhance their positions as key players" in continuing education (CE). Librarians are in an ideal position, she wrote, to address individual learning needs [1]. The library at Texas Tech University Health Sciences Center (TTUHSC) has been instrumental in the development and administration of an innovative and individualized CE program. It has been called "the first in the country to address remedial education for doctors who have fallen behind the times in medical knowledge" [2]. The impetus for this program came from the Texas Medical Foundation (TMF), which provides physician peer review through its Quality Assurance Committee. This review "sometimes identifies a practitioner whose basic fund of knowledge in various fields Bull Med Libr Assoc 80(4) October 1992
Brief communications
of clinical medicine is deficient and would preclude delivery of acceptable quality care" [3]. Physicians so identified are "sanctioned" and may be excluded from the Medicare program for a period of time. To avoid exclusion, a physician may obtain continuing medical education. One of TMF's goals is to support the development of remediation programs for physicians who are sanctioned or identified as at risk for sanctioning. THE MINIFELLOWSHIP PROGRAM In December 1987, representatives from the Department of Family Medicine, the Department of Continuing Medical Education, and the library at TTUHSC met to develop a program to provide continuing medical education to identified physicians. The resulting program, dubbed the "Minifellowship," received funding from TMF in 1990. The program focuses on areas of educational or training deficiencies identified by TMF, tailoring educational offerings individually to help retrain physicians. To date, eight physicians have been referred for retraining. Most of the referrals come from the Texas State Board of Medical Examiners. Hospitals have also begun to refer physicians who have been identified as needing updated training. The strength of the program is that it provides active, problem-based, personalized continuing medical education. The curriculum varies according to the specific needs of the individual, but it primarily emphasizes critical care medicine. During the week-long program, the physician participant is introduced to the teaching hospital, the intensive care units, and the library. On the first day, the participant is assigned a standardized "patient," one of a number of trained volunteers. The history of the patient is taken, and a simulated physical examination is conducted. The physician participant is asked to recommend laboratory and radiologic tests and to make a diagnosis and recommendation for therapy. The participant then receives an evaluation and oral feedback. These results are used to identify specific focus areas for the rest of the retraining week. With the exception of the first patient, most of the clinical retraining is accomplished in the medical intensive care unit and the coronary care unit with actual patients. The physician participant performs on these patients the procedures previously conducted with the simulated patient. At the end of each day, the participant and the teaching specialist review each patient chart, discuss its organization and content, and consider problem-solving approaches. Together they identify areas for specific study. A new patient is added each day, while previous patients are followed. At the end of the week, the physician is following at least four patients. Bull Med Libr Assoc 80(4) October 1992
THE LIBRARY'S ROLE
The library plays a key role in the Minifellowship. Each participant spends 5 to 10 hours of the 40-hour Minifellowship in the library. On the first day, the librarian provides the participant with a tour of the library and instruction in the use of GRATEFUL MED software. On the second day, the librarian teaches the participant to develop a contract for individualized lifelong learning, as described by adult educator Malcolm Knowles [4]. (This process is similar to the one used by Nelson Gilman at the University of Southern California, Los Angeles, California. [5]) The librarian helps the participant identify specific learning objectives, resources available to reach those objectives, deadlines for each step in the process, and evidence of accomplishment. For example, a learning objective might be to update knowledge about the treatment of cardiac arrest. To identify resources, the physician would run a search using GRATEFUL MED. While some articles would be available in the library, others could be requested through LOANSOME DOC. The librarian also would help the participant use the automated catalog to identify other materials, including monographs, videotapes, slides, and computer-assisted instructional packages. Together, the librarian and physician would review the list for relevance. Relevant items would be included in the learning contract as resources. The physician would spend the remaining library time studying these resources. The librarian verifies that, during the next three days, the physician spends time in the library using these resources to accomplish the objectives set forth in the learning contract. The librarian's goal is to teach each physician to access information for lifelong learning.
EVALUATION AND SUMMARY The librarian and the participant together determine whether the contract objectives have been met. If the participant has not satisfied the objectives, then the librarian provides information on additional resources that can be obtained locally or through interlibrary loan. Participants provide feedback on the effectiveness of the program to the dean of continuing medical education. Participants have reacted favorably to the library component of the Minifellowship, although they have recommended improvements in other facets of the program. Participants also are evaluated by pre- and posttraining testing. They are sent a test to complete before they arrive and another test to complete after they leave. To date, there has been a 10% differential between pre- and posttest scores. Whether this im375
Brief communications
provement is satisfactory remains to be demonstrated. In any case, the real proof is not in the test results, but in how physician performance improves over six months to a year as evaluated by TMF. This evaluation is ongoing. According to Messerle, "Tying the work of the library to CE and lifelong learning could strengthen the library's relationship to the institutional mission of the parent organization" [6]. The Minifellowship program offers support for that assertion, as it has established the TTUHSC library as an active partner in CE.
REFERENCES 1. MESSERLE J. The changing continuing education role of health sciences libraries. Bull Med Libr Assoc 1990 Apr; 78(2):180-7. 2. SMITH JM. Statement to the Texas Medical Association House of Delegates, November 1987. 3. CAIN CR. Letter to Dr. Deluca, National Board of Medical Examiners, 8 June 1987. 4. KNOWLES MS. Using learning contracts. San Francisco: Jossey Bass, 1986. 5. MANNING PR, CLINTWORTH WA, SINOPOLI LM, TAYLOR JP ET AL. A method of self-directed learning in continuing medical education with implications for recertification. Ann Intern Med 1987 Dec;107(6):909-13. 6. MESSERLE, op. cit., 186.
Received February 1991; accepted February 1992
Dial-in access to CD-ROM databases: beyond the local area network By Patricia W. Onsi, M.S.L.S. Technical Services and Systems James A. Capodagli, M.L.S. Reference and Computer Search Services Diane K. Hawkins, M.L.S. Reference and Computer Search Services
Health Science Center Library at Syracuse State University of New York 766 Irving Avenue Syracuse, New York 13210
work (LAN) was implemented in 1989, beginning with three MEDLINE workstations and later expanding to the current seven. During this same time, an online catalog became available and a campus network was developing. Users, naturally, expected that remote access to MEDLINE would follow. Until recently, large in-house databases were stored on magnetic tapes loaded on a mainframe computer, a system that entailed high costs, huge space requirements, and complex interfaces. A better system was needed to combine the storage and searching advantages of CD-ROM with the access capabilities of a mainframe computer. Most CD-ROMs use the MSDOS operating system and are not readily compatible with the VAX network environment on the HSC campus. Remote CD-ROM searching has been described in the literature; however, some of those systems require specialized communications software, and others provide very limited access [2-5]. THE VAX MS-DOS LINK
The HSC Library has implemented a dial-in access system, using generally available communications software, capable of supporting a large user population. The system is called the Compact Disk Library Information Network (CDLink). The key component is an MS-DOS server from Logicraft that handles the communications link between the campus VAX terminals and the compact disks. The system capacity is sixteen concurrent sessions using terminals, or microcomputers emulating terminals, running MS-DOS applications in tape, disk, or CD-ROM formats. With the present configuration, nine of the sixteen can proceed simultaneously without noticeable degradation. A planned menu requiring less memory should allow full implementation. The CDLink configuration includes two CD-ROM units with four drives each, linked to the MS-DOS server located in the computer services department. In the library, the reference area is equipped with eight workstations for accessing the VAX. Six are hardwired terminals, and two are microcomputers to accommodate downloading and file transfer to and from the VAX. Terminal servers are being placed in every campus building to provide network access to more users. A fiber-optic ethernet backbone supports all telecommunications activities, 9,600-baud on campus and 1,200/2,400-baud off campus. The network configuration is shown in Figure 1.
INTRODUCTION IMPLEMENTATION AND TESTING CD-ROM databases have revolutionized access to biomedical literature. The Health Science Center (HSC) Library at the State University of New York at Syracuse first offered MEDLINE on CD-ROM on a single workstation in November 1986 [1]. A local area net376
Several issues had to be resolved before the system could be offered to the entire user community. Keyboard mapping was a primary concern because MSDOS applications rely heavily on the use of function Bull Med Libr Assoc 80(4) October 1992
the self-contained medical university. One of these rooms, the newspaper reading area on the first level, is adjacent to the student reading room. The newspaper area offers students access to the top newspapers in China. Another reading room on the second level houses a collection of fiction materials.
VISITORS' IMPRESSIONS Sally Chu of the Health Sciences Library, Mills-Peninsula Hospital, Burlingame, California, and Frances Flynn of the New England College of Optometry, Winthrop, Massachusetts, visited the Beijing Medical Library in September 1991. Both were impressed with the effective use of natural light in the building, its modern western look, and the general sense of open space conveyed by its floor plan. They appreciated the user accessibility of the tidy stack areas, as most libraries in China do not have open stack areas. Chu also liked the shape of the building and the central wall on each level, used to mount various displays. She did express concern over the small area used to house the one terminal for CD-ROM MEDLINE and the library's ability to keep the computer room cool and free of dust-a problem brought about by having just one air-conditioned room. Both librarians believed the space is flexible enough to allow for change. Stack areas are large enough for ease in shifting materials and for additions to the collections.
ACKNOWLEDGMENTS The authors acknowledge the help and support of Stephanie Poole and E. Diane Johnson, head, Information Services, J. Otto Lottes Health Sciences Library, University of Missouri-Columbia, Columbia, Missouri.
REFERENCES 1. EDWARDS AJ, MEADOWS SE. A visiting scholar from the People's Republic of China. Med Ref Serv Q 1991 Win-
ter;10(4):39-47. 2. Beijing Medical University brochure. Haidian, Beijing, People's Republic of China. 3. ZHU, CHENG-GONG. User needs-the principal basis for designing college or university's library buildings. In: Adaptation of buildings to library use: proceedings of the seminar; held in Budapest June 3-7, 1985. New York: Saur, 1987: 206-15. 4. Beijing College of Traditional Chinese Medicine brochure. Beijing, People's Republic of China.
Received November 1991; accepted February 1992 374
APPENDIX Library planning and construction data Architect: Contractor:
Yin Liping Beijing Third Building Company Consultants: Li Xue Yu Hong Weixian Furniture designer: Beijing Shuan Qiao Furniture Factory Contact person: Department of Buildings, Beijing Medical University Total floor space: 10,200 square meters = 110,000 square feet Project cost: 21,000,000rmb = $3,900,000 Public seating: 1,700 total 170 specialized 1,530 general
Physician retraining, lifelong learning, and the library By Mary Moore, M.A. Senior Associate Director for Public Services Library of the Health Sciences, and Curriculum Developer, Texas Tech MEDNET JoAnn Van Schaik, M.L.S. Senior Associate Director for Technical Services Library of the Health Sciences C. L. Montgomery, M.D. Associate Dean, Continuing Education School of Medicine Texas Tech University Health Sciences Center Lubbock, Texas 79430 In a compelling article, Judith Messerle recently called on health sciences librarians to "enhance their positions as key players" in continuing education (CE). Librarians are in an ideal position, she wrote, to address individual learning needs [1]. The library at Texas Tech University Health Sciences Center (TTUHSC) has been instrumental in the development and administration of an innovative and individualized CE program. It has been called "the first in the country to address remedial education for doctors who have fallen behind the times in medical knowledge" [2]. The impetus for this program came from the Texas Medical Foundation (TMF), which provides physician peer review through its Quality Assurance Committee. This review "sometimes identifies a practitioner whose basic fund of knowledge in various fields Bull Med Libr Assoc 80(4) October 1992
Brief communications
of clinical medicine is deficient and would preclude delivery of acceptable quality care" [3]. Physicians so identified are "sanctioned" and may be excluded from the Medicare program for a period of time. To avoid exclusion, a physician may obtain continuing medical education. One of TMF's goals is to support the development of remediation programs for physicians who are sanctioned or identified as at risk for sanctioning. THE MINIFELLOWSHIP PROGRAM In December 1987, representatives from the Department of Family Medicine, the Department of Continuing Medical Education, and the library at TTUHSC met to develop a program to provide continuing medical education to identified physicians. The resulting program, dubbed the "Minifellowship," received funding from TMF in 1990. The program focuses on areas of educational or training deficiencies identified by TMF, tailoring educational offerings individually to help retrain physicians. To date, eight physicians have been referred for retraining. Most of the referrals come from the Texas State Board of Medical Examiners. Hospitals have also begun to refer physicians who have been identified as needing updated training. The strength of the program is that it provides active, problem-based, personalized continuing medical education. The curriculum varies according to the specific needs of the individual, but it primarily emphasizes critical care medicine. During the week-long program, the physician participant is introduced to the teaching hospital, the intensive care units, and the library. On the first day, the participant is assigned a standardized "patient," one of a number of trained volunteers. The history of the patient is taken, and a simulated physical examination is conducted. The physician participant is asked to recommend laboratory and radiologic tests and to make a diagnosis and recommendation for therapy. The participant then receives an evaluation and oral feedback. These results are used to identify specific focus areas for the rest of the retraining week. With the exception of the first patient, most of the clinical retraining is accomplished in the medical intensive care unit and the coronary care unit with actual patients. The physician participant performs on these patients the procedures previously conducted with the simulated patient. At the end of each day, the participant and the teaching specialist review each patient chart, discuss its organization and content, and consider problem-solving approaches. Together they identify areas for specific study. A new patient is added each day, while previous patients are followed. At the end of the week, the physician is following at least four patients. Bull Med Libr Assoc 80(4) October 1992
THE LIBRARY'S ROLE
The library plays a key role in the Minifellowship. Each participant spends 5 to 10 hours of the 40-hour Minifellowship in the library. On the first day, the librarian provides the participant with a tour of the library and instruction in the use of GRATEFUL MED software. On the second day, the librarian teaches the participant to develop a contract for individualized lifelong learning, as described by adult educator Malcolm Knowles [4]. (This process is similar to the one used by Nelson Gilman at the University of Southern California, Los Angeles, California. [5]) The librarian helps the participant identify specific learning objectives, resources available to reach those objectives, deadlines for each step in the process, and evidence of accomplishment. For example, a learning objective might be to update knowledge about the treatment of cardiac arrest. To identify resources, the physician would run a search using GRATEFUL MED. While some articles would be available in the library, others could be requested through LOANSOME DOC. The librarian also would help the participant use the automated catalog to identify other materials, including monographs, videotapes, slides, and computer-assisted instructional packages. Together, the librarian and physician would review the list for relevance. Relevant items would be included in the learning contract as resources. The physician would spend the remaining library time studying these resources. The librarian verifies that, during the next three days, the physician spends time in the library using these resources to accomplish the objectives set forth in the learning contract. The librarian's goal is to teach each physician to access information for lifelong learning.
EVALUATION AND SUMMARY The librarian and the participant together determine whether the contract objectives have been met. If the participant has not satisfied the objectives, then the librarian provides information on additional resources that can be obtained locally or through interlibrary loan. Participants provide feedback on the effectiveness of the program to the dean of continuing medical education. Participants have reacted favorably to the library component of the Minifellowship, although they have recommended improvements in other facets of the program. Participants also are evaluated by pre- and posttraining testing. They are sent a test to complete before they arrive and another test to complete after they leave. To date, there has been a 10% differential between pre- and posttest scores. Whether this im375
Brief communications
provement is satisfactory remains to be demonstrated. In any case, the real proof is not in the test results, but in how physician performance improves over six months to a year as evaluated by TMF. This evaluation is ongoing. According to Messerle, "Tying the work of the library to CE and lifelong learning could strengthen the library's relationship to the institutional mission of the parent organization" [6]. The Minifellowship program offers support for that assertion, as it has established the TTUHSC library as an active partner in CE.
REFERENCES 1. MESSERLE J. The changing continuing education role of health sciences libraries. Bull Med Libr Assoc 1990 Apr; 78(2):180-7. 2. SMITH JM. Statement to the Texas Medical Association House of Delegates, November 1987. 3. CAIN CR. Letter to Dr. Deluca, National Board of Medical Examiners, 8 June 1987. 4. KNOWLES MS. Using learning contracts. San Francisco: Jossey Bass, 1986. 5. MANNING PR, CLINTWORTH WA, SINOPOLI LM, TAYLOR JP ET AL. A method of self-directed learning in continuing medical education with implications for recertification. Ann Intern Med 1987 Dec;107(6):909-13. 6. MESSERLE, op. cit., 186.
Received February 1991; accepted February 1992
Dial-in access to CD-ROM databases: beyond the local area network By Patricia W. Onsi, M.S.L.S. Technical Services and Systems James A. Capodagli, M.L.S. Reference and Computer Search Services Diane K. Hawkins, M.L.S. Reference and Computer Search Services
Health Science Center Library at Syracuse State University of New York 766 Irving Avenue Syracuse, New York 13210
work (LAN) was implemented in 1989, beginning with three MEDLINE workstations and later expanding to the current seven. During this same time, an online catalog became available and a campus network was developing. Users, naturally, expected that remote access to MEDLINE would follow. Until recently, large in-house databases were stored on magnetic tapes loaded on a mainframe computer, a system that entailed high costs, huge space requirements, and complex interfaces. A better system was needed to combine the storage and searching advantages of CD-ROM with the access capabilities of a mainframe computer. Most CD-ROMs use the MSDOS operating system and are not readily compatible with the VAX network environment on the HSC campus. Remote CD-ROM searching has been described in the literature; however, some of those systems require specialized communications software, and others provide very limited access [2-5]. THE VAX MS-DOS LINK
The HSC Library has implemented a dial-in access system, using generally available communications software, capable of supporting a large user population. The system is called the Compact Disk Library Information Network (CDLink). The key component is an MS-DOS server from Logicraft that handles the communications link between the campus VAX terminals and the compact disks. The system capacity is sixteen concurrent sessions using terminals, or microcomputers emulating terminals, running MS-DOS applications in tape, disk, or CD-ROM formats. With the present configuration, nine of the sixteen can proceed simultaneously without noticeable degradation. A planned menu requiring less memory should allow full implementation. The CDLink configuration includes two CD-ROM units with four drives each, linked to the MS-DOS server located in the computer services department. In the library, the reference area is equipped with eight workstations for accessing the VAX. Six are hardwired terminals, and two are microcomputers to accommodate downloading and file transfer to and from the VAX. Terminal servers are being placed in every campus building to provide network access to more users. A fiber-optic ethernet backbone supports all telecommunications activities, 9,600-baud on campus and 1,200/2,400-baud off campus. The network configuration is shown in Figure 1.
INTRODUCTION IMPLEMENTATION AND TESTING CD-ROM databases have revolutionized access to biomedical literature. The Health Science Center (HSC) Library at the State University of New York at Syracuse first offered MEDLINE on CD-ROM on a single workstation in November 1986 [1]. A local area net376
Several issues had to be resolved before the system could be offered to the entire user community. Keyboard mapping was a primary concern because MSDOS applications rely heavily on the use of function Bull Med Libr Assoc 80(4) October 1992
