ANATOMIC
PATHOLOGY
Original
T h e
i n
S u c c e s s
a n
o f
a
A c a d e m i c
Article
C l i n i c a l
A u t o p s y
L i b r a r i a n
P r o g r a m
P a t h o l o g y
S e r v i c e
MARIAN ROYAL, MLS,* WILLIAM E. GRIZZLE, MD, PHD,f
VIRGINIA ALGERMISSEN, MLS,* ROBERT W. MOWRY, MDf
Residents in pathology must acquire a broad base of knowledge in all
areas of medicine and the basic medical sciences. We report our experience with the first Clinical Medical Librarian (CL) program used to aid
resident training in anatomic pathology. This program was developed
by the Lister Hill Library of Health Sciences (LHL) of the University
of Alabama at Birmingham (UAB) to test the value of a CL program in
filling the clinical needs of medical students and residents by providing
key recent references to the wide variety of diseases seen in a busy
autopsy service. Use of a CL was accepted completely by both faculty
and residents as a method of increasing their efficiency in evaluating the
recent literature on diseases seen in the autopsy service. Our use of this
program broadened the scope and extent of specific case-oriented medical literature read by both residents and faculty. Am J Clin Pathol
1993;99:576-581
A Clinical Medical Librarian (CL) program was first established in 1971 at the University of Missouri-Kansas City
School of Medicine. The program was supported by a grant
from the National Library of Medicine, and was designed to
serve the biomedical needs of medical care providers and students in a representative general hospital.' Subsequent goals
included improved patient care through continuing education
to health professionals by facilitating their interaction with
medical literature.2
The Lister Hill Library of the Health Sciences (LHL) at the
University of Alabama at Birmingham (UAB) wished to introduce the CL concept at UAB to emphasize the importance of
medical literature in filling clinical information requirements
and to convey that importance to medical students, residents,
and faculty members.
Because anatomic pathology requires extensive knowledge
in most aspects of disease, pathology residents need a broad
base of knowledge in all areas of medicine and the basic medical sciences. The pathology department presented a major opportunity for a CL program. In December 1990, LHL and the
Department of Pathology at UAB began a pilot program in
which a CL from LHL participated with pathologists, residents, and medical students in all autopsy conferences and assisted them in identifying and obtaining relevant references to
the disease processes they encounter.
The CL program at UAB in Autopsy Pathology has improved the quality of literature searches by increasing the volume and broadening the scope of the more recent medical liter-
ature used by residents and faculty. The resources available to
faculty and residents increased because the clinical librarian
had more experience in searching the medical literature and
could efficiently locate relevant journal articles on the topics of
interest.
The CL program in autopsy pathology has resulted in five
additional benefits.
1. Pathology residents are better able to understand and evaluate the disease entities of the patients studied, improving
their discussions of the cases during autopsy and clinical
conferences as well as the final autopsy report.
2. A more comprehensive discussion of the disease in the final
autopsy report improves the education of pathology residents and facilitates the continuing education of the primary-care physicians (both faculty and residents) who took
care of the patient and who receive copies of the autopsy
report.
3. Residents learn the usefulness of a computerized data base
and also how to use it.
4. A computerized file of recent medical literature concerning
the diagnosis and treatment of patients with various disease
entities has been developed and is available in the autopsy
service.
5. The availability of the service aids in the recruitment of
pathology residents.
BACKGROUND AND METHOD
Historically the CL program provided a librarian trained in
medical sciences who joined the physician or health-care team
From the * Lister Hill Library ofthe Health Sciences and the ^Departon rounds. The librarian would search for publications that
ment of Pathology, University of Alabama at Birmingham, and pertained
the
to specific cases, retrieve the abstracts and/or perti%combined Autopsy Services of the University of Alabama at nent
Bir- parts of the whole articles, and then rapidly provide the
mingham and the Veterans Administration Medical Center, Birmaterial to the physician or team.3
mingham, Alabama.
In the 20-year history of the CL program, at least 30 libraries
associated with universities or hospitals have published deAddress reprint requests to Mrs. Royal: Lister Hill Library of the
scriptions of their programs. Programs exist in cancer chemoHealth Sciences, 1700 University Boulevard, UAB Station, Birmingham, Alabama 35294.
therapy, family health, gynecology, fetal/maternal medicine,
576
ROYAL ET AL.
The Success of a Clinical Librarian Program in an Academic Autopsy Pathology Service
577
TABLE 1. LOCATIONS OF CL PROGRAMS AND THE SERVICES THEY ASSIST"*
Location
Service/Purpose
University of California, San Francisco General
Hospital Medical Center
Veterans Administration Medical Center
San Francisco, CA
Family Practice Inpatient Service
Hampton, VA
Medical College of Pennsylvania
Baylor College of Medicine
Philadelphia, PA
Houston, TX
Medical and Library Services, for staff
morning meetings
Florence A. Moore Library of Medicine
Department of Family Medicine, for a family
medicine residency
Health Sciences Library, in information
services to help gastroenterology program
patients learn about their care
Division of General Medicine and John
Dempsey Hospital for Medical and
Pediatric services
Obstetrics/gynecology residency program
Cancer chemotherapy
Pediatrics and surgery teams
Rotating medical service
Institution
McMaster University
University of Connecticut School of Medicine
UCLA Los Angeles County Habor Medical Center
UCLA Biomedical Library
Hartford Hospital
West Suburban Hospital
Rush University, Rush Presbyterian—St. Luke's
Medical Center
Beth Israel Hospital
Wake Forest University
Bowman Gray School of Medicine
Hamilton, Ontario, Canada
Farmington, CT
Torrence, CA
Farmington, CT
Chicago, IL
Chicago, IL
New York, NY
Winston-Salem, NC
St. Luke's Hospital
University of Tennessee Health Sciences Library with
Stollerman Library
Roswell Park Memorial Institute
Southern Illinois University
Tufts University
Cleveland, OH
Memphis, TN
Yale University with New Haven Hospital
Thomas Jefferson University
Framingham University Hospital
Washington Hospital Center
Cedars of Lebanon
University of Washington
Cook County Hospital
Houston Academy of Medicine-Texas Medical Center
Washington University
Riverside Methodist Hospital
University of Cincinnati
New Haven, CT
Philadelphia, PA
Framingham, MA
Washington, DC
Los Angeles, CA
Seattle, WA
Chicago, IL
Houston, TX
St. Louis, MO
Columbus, OH
Cincinnati, OH
Buffalo, NY
Springfield, IL
Boston, MA
Department of Orthopedic Surgery
Information service for radiologists and
radiotherapists
For medicine and psychiatry
9 oncology nursing units
7 clinical departments
To place articles on charts for Patient Care
Related Reading Program
Pediatrics, psychiatry, medicine and surgery
Maternity and Newborn Unit
Surgery, pediatrics and obstetrics
Neonatal Intensive Care and orthopedics
Diversified pulmonary health-care team
With residents
Department of Medicine
* MESH Library services files:
pediatrics, psychiatry, pulmonary medicine, obstetrics, and
general inpatient information.4 A summary of the CL programs previously described are listed in Table 1. No published
material on a CL program applied to pathology was found.
At UAB the CL concept was introduced in 1990, after the
chief medical librarian from University of Missouri-Kansas
City School of Medicine, who had helped implement and evaluate the program there, became director of LHL and described
the concept to library patrons. A professor emeritus of Pathology suggested that the CL program might enrich the quality of
autopsy studies at UAB.
Because of the extent of the literature involved in a busy
autopsy service that examines approximately 400 patients per
year, it was postulated that the CL program might significantly
improve physician and resident access to the most recent information concerning the disease entities and problems of treatment affecting these patients.
The CL assigned to the program was already experienced in
working in a hospital setting. She was accustomed to clinical
and medical literature and understood clearly the need for confidentiality concerning all patient information discussed at the
autopsy conferences. In addition, she was introduced to the
viewing of organs presented at gross pathology conferences,
and felt comfortable observing these organs and participating
in such conferences. At this conference the patient's medical
problems during life are reviewed in the light of the preliminary
autopsy diagnoses.
It is critically important that the person chosen to participate
as a CL in a pathology program feel comfortable with death
and the observation of human organs. The CL also must
clearly understand the absolute confidentiality of information
presented at the autopsy conferences. Such information might
include human immunodeficiency viral status, sexual behavioral patterns, or alcoholic and illicit drug history. The data
might concern individuals from the community who may be
known to the CL.
The CL assigned to the pilot program fulfilled all these criteria. She attended the two main autopsy conferences each week.
Vol. 99 • No. 5
578
ANATOMIC PATHOLOGY
Original Article
Roqi ipster
Subject of Request
Hate Rw]i ipstfl^
Pat° Rpop iup d
Please help us evaluate this program by indicating your answers below. Fold, staple and return this pre-addressed form to Lister
Hill Library.
1. Information arrived:
4
1
?
3
5
Earlier than
On time for
Too late
expected
my purposes
2. The information provided by the Clinical Librarian was useful as follows:
1
Greatly updated my
knowledge of the
disease process
1
Changed my
interpretation of the
pathology of some cases
1
The information aided
my literature review greatly
0
%
4
Provided some
new information
?
3
Gave some
new insight
4
?
3
Provided a few
new references
4
5
Provided no new
information to me on
the disease process
5
Had no effect
on any case
interpretations
5
Provided no
references
of which I was
unaware
3. The volume of information was appropriate.
1
O
3
Agree completely
4
Agree
somewhat
8
Disagree completely
4. How useful is the Clinical Librarian program to you personally?
1
9
a
Very useful
4
Somewhat
useful
5. How useful is the Clinical Librarian program to the Autopsy Conference attendees as a group?
4
1
?
3
Very useful
Somewhat
useful
6. Do you feel this program should be continued?
1
?
Strongly agree
to continue
3
O.K. to continue
5
Not very useful
4
5
Not very useful
5
Program should be
discontinued
7. The program would be more useful if the following changes were implemented:
FIG. 1. Autopsy Service CL Evaluation Sheet.
The first of these, the gross conference, was a review of the
clinical history and presentation of the gross pathology for each
case autopsied during the previous week. This involves the
viewing of gross specimens taken from the autopsied patients
including the livers and brains with tumor metastases, hearts
with areas of infarction, and tissues with infections that might
be transmissible (eg, tuberculosis and a variety of other pathologic conditions). Some individuals without medical training
may feel distinctly uncomfortable under those circumstances.
The second conference, the review conference, at which final
diagnoses and interrelations are presented, follows approximately 3 weeks later. At this conference the case is discussed
thoroughly. Lantern slides of selected gross and microscopic
appearances and the list offinalanatomic diagnoses are shown
and discussed. Because the faculty consultant and resident sign
each final autopsy report, the review conference also is called
the sign-out conference.
When each case is presented at the gross conference, the CL
queries the involved faculty and residents concerning their
need for literature on any aspect of the diagnosis and care of the
deceased. Subsequently, the CL performs a computerized
search of the topics requested and provides the results along
with three to five selected references to the resident and/or
faculty member. Sometimes computerized searches are supplemented by manual searches of other sources, such as specialized texts and monographs.
At the sign-out conference, additional issues concerning the
autopsyfindingsand clinical course may be raised by the atten-
A.J.C.P.-May 1993
ROYAL ET AL.
The Success of a Clinical Librarian Program in an Academic Autopsy Pathology Service
TABLE 2. EVALUATION RESPONSES FROM PARTICIPANTS
Answers on Scale of 1-5
Where 1 is Top Score
Questions or Statements on
Evaluation Form
How useful is CL to the
residency program or autopsy
conference attendees? (two
respondents skipped this
question)
How useful is CL to you
personally?
Information provided greatly
updated my knowledge of the
disease process.
Information provided changed
my interpretation of the
pathology in some cases.
Information aided my literature
review greatly.
CL program should be
continued.
579
case of four. Each search provides a print-of citations and abstracts for 5 to 25 articles and full texts of 3 to 5 of the most
relevant articles.
The autopsy cases included patients of all ages, from infants
to adults. Primary clinical diagnoses included respiratory failure, systemic lupus erythematosus, hemorrhage, heart failure,
cancer, and congenital abnormalities. Because the UAB Hospital has a large patient population representing cardiology, neonatal medicine, transplant surgery, and cancer treatment, the
28
30
19
TABLE 3. ALPHABETICAL LIST OF THE 25 JOURNALS
CITED MOST OFTEN WITH THE NUMBER OF TIMES
EACH WAS USED IN EACH AUTOPSY CASE
4
—
AJR
IS
14
Am J Cardiol
13
25
Am J Clin Pathol
Am J Med
15
31
Questions 1-6 appeared on evaluations after 6 months and after individual searches: 60%
Am J Med Genet
of the evaluation forms covering thefirst6 months were returned. Individual search evaluation forms were distributed on a random basis and almost all of them were returned. In
addition, evaluations returned after 11 months noted that the CL program greatly enhanced
Am J Obstet Gynecol
the residency program and the respondents personally.
Am Rev Respir Dis
Ann Thorac Surg
16
dees, who are viewing selected photomicrographs. This sometimes generates a modified or different final diagnosis. The
sign-out conference provides another opportunity to search the
literature on additional questions or a more focused aspect of
the patient's illness. The literature provided usually aids in the
final diagnoses of the autopsy, particularly the case interpretation.
After the CL program had existed 6 months, evaluation
forms were sent to residents and faculty who participated. In
addition, evaluation forms for individual literature searches
were distributed to participants on a random basis. Finally, an
overall evaluation was distributed after the program had been
in effect 11 months. A sample of the evaluation form is shown
in Figure 1.
18
16
12
6
Arch Pathol Lab
Med
Arch Intern-Med
13
Br Med J
13
Cancer
25
Chest
19
Hum Pathol
J Pediatr
16
10
J Thorac Cardiovasc 12
Surg
Lancet
22
N Engl J Med
27
Neurosurgery
Obstet Gynecol
14
12
Pediatrics
10
Radiology
16
South Med J
18
Transplant Proc
10
Transplantation
10
RESULTS
The evaluations of the CL program are summarized in Table
2. They indicate that respondents believed that (1) the CL program benefitted them personally and the autopsy service as a
whole, (2) the medical literature changed their interpretation of
the pathology in some cases and provided new insights concerning the disease process, and (3) the information updated
their knowledge of specific diseases and facilitated their literature review.
As of March 1992, the CL program involved 159 literature
searches (for 159 autopsy cases), producing 2,462 citations. Although the autopsy service covers approximately 400 cases per
year, many do not require literature searches. Usually the
searches were requested to answer specific question(s) concerning a disease entity (eg, rate of a complication of a disease
process or therapy). The CL was asked for information in one
Vol. 99 • No. 5
One case used the journal three
times and two used it twice.
One case used the journal four
times and three used it twice.
Five cases used the journal twice.
One case used the journal four
times, one used it three times,
and three used it twice.
One case used the journal five
times, two used it three times,
andfiveused it twice.
One case used itfivetimes.
One case used it seven times.
One case used the journal nine
times, one used itfivetimes, and
two used it twice.
Five cases used the journal twice.
One case used the journal four
times.
One case used the journal six times
and one used it twice.
Two cases used the journal four
times, four used it three times,
and four used it twice.
One case used the journal three
times and three used it twice.
Two cases used the journal twice.
One case used the journal seven
times.
One case used the journal five
times, three used it three times,
and four used it twice.
One case used the journal six
times, two used it three times,
andfiveused it twice.
Three cases used the journal three
times and one used the journal
twice.
One case used it four times.
Two cases used the journal four
times and two used it twice.
Two cases used the journal three
times and one used it twice.
One case used the journal three
times and two used it twice.
One case used the journal three
times and one used it twice.
One case used the journal four
times, one used it three times,
and one used it twice.
Two cases used the journal three
times and three used it twice.
580
ANATOMIC PATHOLOGY
Original Article
TABLE 4. LIST OF 82 JOURNALS CITED FREQUENTLY, BUT NOT IN THE TOP 25, LISTED ACCORDING
TO NUMBER OF TIMES THEY WERE CITED
Journal Abbreviation
J Virol Methods
JAMA
J Clin Pathol
J Cardiovasc Surg (Torino)
Gastroenterology
Am J Gastroenterol
J Infect Dis
Br Heart J
J Neurosurg
Rev Infect Dis
J Am Coll Cardiol
Am Heart J
Am J Surg Pathol
J Urol
Ann Surg
Ann Intern Med
Int J Cardiol
Arch Neurol
Br J Surg
Br J Cancer
Prenal Diagn
Am J Pathol
Am J Surg
Arch Dermatol
J Surg Oncol
J Reprod Med
Neurology
J Hepatol
Surgery
J Immunol
Semin Liver Dis
Pediatr Infect Dis J
Ann Neurol
Mayo Clin Proc
Pediatr Pathol
Am Fam Physician
SAfrMedJ
Klin Wochenschr
Arch Dis Child
Acta Neuropathol
Br J Obstet Gynaecol
Intensive Care Med
Journal Abbreviation
No.
7
15
15
14
14
13
13
13
13
13
12
12
12
12
12
12
11
11
11
10
10
10
10
10
10
10
10
9
9
9
9
9
8
8
8
8
8
8
8
8
8
patient profile in the autopsy service may reflect more cases in
these fields than would be the situation in hospitals that have
less emphasis in these specialties. Hospital admissions data
from October 1990 through July 1991 show the highest number of admissions to the following services: obstetrics, cardiology/open heart surgery, general medicine, orthopedics, normal
newborns, general surgery, neonatology, oncology, and pulmonary medicine.
The searches involved 719 journals. Of those, 25 were used
most often—referenced from 16 to 46 times. The journals cited
most often in order of usage, were Cancer (46 times); Lancet
(42); the New England Journal ofMedicine (35); Chest (29); the
Journal of Thoracic and Cardiovascular Surgery (27); Obstetrics and Gynecology (27); the American Journal of Medicine
(26); the Archives of Pathology and Laboratory Medicine (24);
the Southern Medical Journal (23); AJR (23); the American
Journal ofMedical Genetics (22); the American Journal of Obstetrics and Gynecology (21); the American Journal of Clinical
Am J Dis Child
NZMedJ
Thorac Cardiovasc Surg
Med Clin North Am
Blood
Br J Haematol
Circulation
Acta Pathol Jpn
Surg Neurol
J Med Genet
J Clin Invest
J Inherited Metab Dis
J Perinatol
Eur Heart J
Ann NY Acad Sci
Antimicrob Agents Chemother
Clin Obstet Gynecol
Dig Dis Sci
Eur J Cardiovasc Surg
Hosp Prac [Off]
J Cardiovasc Pharmacol
J Clin Invest
J Clin Microbiol
L Heart Transplant
Medicine (Baltimore)
Semin Oncol
Clin Neuropathol
Virchows Arch A Pathol Anal Histopalhol
Virchows Arch B Cell Pathol
Gut
J Neurol Neurosurg Psychiatry
J Pediatr Surg
Hepatology
Pediatr Radiol
Hum Genet
Acta Obstet Gynecol Scand
Pathol Res Pract
J Biol Chem
Int J Radiat Oncol Biol Phys
J Clin Endocrinol Metab
Arch Surg
No.
15
7
7
7
7
7
7
7
7
7
7
7
7
7
6
6
6
6
6
6
6
6
6
6
6
6
6
6
2
6
6
6
6
6
6
6
6
6
6
6
6
Pathology (21); Annals of Thoracic Surgery (20); Radiology
(20); the American Journal ofCardiology (19); the British Medical Journal (19); the American Review of Respiratory Disease
(19); Human Pathology (18); Neurosurgery (18); Transplantation (18); Transplantation Proceedings (17); the Archives ofInternal Medicine (16); Pediatrics (16); and the Journal of Pediatrics (16).
The number of times a particular journal was cited in each
search for each autopsy case varied. In some instances, a journal was cited several times in one search for one autopsy case.
Although several citations of one journal in a single case does
not diminish its rank among the top 25, the concentration of
citations identifies the fact that the number of times the journal
was cited reflects extensive information in a specific case than
one or two citations in many cases. Table 3 shows the number
of times each of the top 25 journals were referenced for each
case.
Journals that were cited repeatedly, but not often enough to
A.J.C.P. -May 1993
ROYAL ET AL.
581
The Success of a Clinical Librarian Program
in an Academic Autopsy Pathology Service
make it to the top 25 are listed in Table 4. They were cited from
6 to 15 times.
DISCUSSION
The CL program can be an important aid in resident training
in pathology. Although residents have access to computerized
medical information data base via the LINK* system, they considered it a great benefit to have the CL provide them with
tailored computer-generated bibliographies plus three or four
full-text articles judged by the CL to be most relevant to the
specific case. These key references permitted the residents to
expand their literature evaluation and rapidly review secondary articles. Throughout the program, the CL provided references to residents and at the same time helped them learn how
to effectively search for material on their own.
One of the authors of this article, who is the Director of the
Autopsy Service (W.E.G.), noticed a significant improvement
in the quality of autopsy discussions in conferences and in the
final autopsy report after the CL program was initiated. Even
the most experienced senior faculty rapidly accepted the program and requested literature reviews on various subjects.
The literature aided not only the residents in their conference presentations, but also the faculty, who found the references to be useful in their presentations at various clinical interdepartmental conferences, such as Surgical Death and
Clinical Pathologic Correlation Conferences. When medical
students rotated through the autopsy service, they also found
the CL service to be valuable.
The success of a CL program in the Autopsy Service at UAB
parallels the successes found in evaluations of the early CL
programs established for clinical programs 20 years ago. Evaluations cited in early literature show that (1) the CL identified
the information a user needed with 90% or better accuracy, (2)
the CL and the patron had a high degree of correlation in their
judgment as to the value of documents in meeting the user's
needs, and (3) a limited number of journals provide the information users needed.1 Evaluations from users in early programs showed that a significant number of participants found
that the information they received influenced their treatment
of specific cases and that the service rated with laboratory work
and x-rays in helping them determine case treatment.5,6
The CL for the UAB Autopsy Service benefitted the library
and the CL providing the service in a variety of ways. Conference attendance offered educational opportunities not realized
by most health science librarians. The CL's knowledge of hu-
* LINK is a remote dial-in service provided by LHL that allows
patrons to use a modem and computer at their offices and homes to
search a comprehensive data base containing more than 25 years of
medical literature. The service is described in the article, "Bringing the
Mountain to Mohammed Without Falling Off the Cliff of Unmanageable Technology," to be published in the June 1993 issue of Information Technology and Libraries.
man anatomy, disease processes, and the practice of medicine
in general was increased significantly and enhanced through
the observation of organs, participation in case discussions,
and scanning the literature for key articles. This enhanced
knowledge improved the CL's job skills, increasing her value in
the Autopsy Service and in routine library responsibilities. This
was a bonus for the library as well. A third benefit was in the
increased job satisfaction for the CL performing the service.
Working with the Autopsy Service is educational as well as
interesting and fulfilling. The educational opportunities, enhanced job skills, and tremendous variety of requests make the
work interesting and rewarding. Providing a CL service for autopsy pathology can be difficult and demanding, but it offers a
rare opportunity to participate in clinical medicine and thereby
become a better health information specialist.
The literature searches and articles provided to the Autopsy
Service will permit the development of a permanent collection
of medical articles for pathology residents and medical students. The computerized searches and selected references can
be indexed in various ways to facilitate access. These are available for new residents who want to learn more about disease
problems that have been discussed in conferences. It also provides more senior residents with quick references to aid them in
preparation for the Pathology Board Examination.
Because patients are referred for autopsy from all medical
specialties, autopsy pathologists must have broad knowledge of
all primary-care specialties and some knowledge of all medical
specialties, as well as an understanding of diagnostic support
services. For example, pathologists frequently must correlate
autopsy results with radiologic procedures, including routine
x-rays, radionuclide scans, computerized tomography, magnetic resonance imaging, ultrasonography, and echocardiograms. In addition, pathologists must be familiar with complex
therapeutic regimens that range from complicated drug interactions and their side effects to complex surgical reconstructions. Consequently, it is in the autopsy service that the widest
range of medical literature must be mastered and applied to
disease diagnosis and treatment. In a busy autopsy service, the
CL provides an important educational aid, not only to residents and medical students but also to faculty.
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the University of Missouri-Kansas City School of Medicine.
Bull Med Libr Assoc 1974; 62:354-358.
2. Lamb G. Clinical Librarianship. Clin Lib Q 1984; 3:10,12.
3. King D. The contribution of hospital library information services
to clinical care: A study in eight hospitals. Bull Med Libr Assoc
1987;75:291-301.
4. Cimpl K. Clinical medical librarianship: A review of the literature.
Bull Med Libr Assoc 1985;73:21-28.
5. Scura G, Davidoff F. Case-related use of the medical literature:
Clinical librarian services for improving patient care. JAMA
1981; 245:50-52.
6. Schnall J, Wilson J. Evaluation of a Clinical Medical Librarianship
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