The Internet and MEDLINE

In 1997, the National Library of Medicine (NLM) helped initiate a new era in American medicine when it made MEDLINE, its comprehensive online bibliography of published medical information, accessible to the public through the World Wide Web. That event may prove to be a symbolic watershed of 20th century American medicine. It will impact every aspect of medicine, from the manner in which physicians are educated to the way they run their daily practices. In order to understand why this is so, we need to examine how and to whom medical information was previously disseminated in this country.

The Roots of MEDLINE

The collection and distribution of medical information in America has always been intimately tied to the NLM. The NLM began with a few dozen books and journals in the library of Joseph Lovell, the first Surgeon General of the United States Army (Wyndham, 1985). Thirty years after his death, at the end of the Civil War, the library had only grown to 2,000 volumes. That changed in 1867 when John Shaw Billings was appointed librarian and began to aggressively purchase books and journals from all over the world. As the library grew, however, it became more and more difficult to find specific information, especially in the bound journals. To solve this problem, Billings personally began the enormous task of creating a subject index for the library's journal collection. Index Medicus, the monthly bibliography of the world's medical literature, was an outgrowth of his early card catalog. It was first published in 1879 and soon became the library's best known service.

By the 1960s, the process of collecting, cross-referencing and printing thousands of new Index Medicus citations each month had become such a chore that a computer database system, MEDLARS (Medical Literature Analysis and Retrieval System), was developed to speed the process. MEDLARS was initially used to conduct literature searches within the NLM and to prepare the printed version of Index Medicus. In 1972 the NLM expanded access to the system through MEDLINE (MEDlars onLINE), an online computer service that gave medical libraries around the country the ability to search the Index Medicus database. Unfortunately, the early MEDLINE searches were so complicated that they could only be conducted by trained librarians.

As the number of requests for MEDLINE searches increased, the cost of providing the service became prohibitive. This problem was solved in the 1980s by the development of simpler computer programs like Grateful Med that gave people without extensive computer training the means to perform their own MEDLINE searches. Most medical libraries offered free MEDLINE access to their health care professionals using this software. Physicians who did not live near a medical library had to conduct their searches through private information companies that charged an hourly fee for the service.

In the early 1990s the pharmaceutical industry remedied this problem by offering free MEDLINE service to every physician who had access to a personal computer. The NLM's recent decision to provide free access to MEDLINE on the World Wide Web is a significant step beyond that. It represents a policy decision by the government that medical information should be freely available, not only to physicians, but to every citizen.

How to Find MEDLINE

You can gain access to MEDLINE through the National Library of Medicine's Web site at <http://www.nlm.nih.gov>. Once you arrive at the NLM home page, click on the button that says "Free MEDLINE." The next page that appears will provide entry to the NLM's two search systems, Internet Grateful Med and PubMed. Both systems allow you to search MEDLINE and several other medical-biology databases. Internet Grateful Med is an adaptation of the online search software that was used for many years before the development of the Internet. It's easy to use and adequate for most literature searches.PubMed is based on an entirely new concept. It is the central component in what will eventually become a comprehensive Internet biomedical information network. PubMed was developed by the National Center for Biotechnology Information, at the NLM, in conjunction with several publishers who provide the complete text of their journals, including tables and illustrations, on the Web.

PubMed links MEDLINE citations directly to the articles in these full-text journals. This means that when you find a specific citation in the MEDLINE database you can go directly to the article at the publisher's Web site. Furthermore, the references at the end of these articles are also linked to MEDLINE and to other full-text journals. If a reference cites a journal that is on the Web, a click on the reference will take you directly to the cited paper.

Other Journals on the Web

Currently, almost 100 clinical and research journals offer full-text versions on the Web. Most charge a subscription fee. Some offer free trial periods. You can find a list of all these journals at <http://www.ncbi.nlm.nih.gov/PubMed/fulltext.html>.

Most of the journals allow you to print copies of articles. The easiest way to do this is to print the article directly from your browser. This will give you all the text, tables and illustrations, but the printed copy will not look the same as the bound journal version. For that, you must download a copy of the article in PDF file format. PDF files are written in a special publishing language that allows you to reproduce the article exactly as it looks on the printed journal page. In order to view or print a PDF file you must have a copy of Adobe Acrobat Reader software installed on your computer. This program can be downloaded free from the Adobe web site at <http://www.adobe.com>.

MEDLINE and Consumers

Until now I've spoken about the advantages of MEDLINE on the web for physicians, but not about it's impact on the general public.

Today, although the average person believes in the validity of modern medical information, he often questions the decisions that his physician makes using this information, and even the extent of his physician's knowledge.

There are many reasons for this. Unlike earlier Americans, today's citizen has an increasing faith in his ability to understand medical science. This change has occurred gradually over the last 40 years as more and more scientific and, specifically, medical information has proliferated in the popular press.

In the past, it was difficult, for the average person to gain access to detailed medical information. That obstacle disappeared when MEDLINE was placed on the Web. This democratic leveling of the playing field, so to speak, between doctors and their patients is exactly what the government intended.

Vice President Albert Gore stated that one of the main reasons for offering MEDLINE on the Internet was to give American consumers access to timely and accurate information about medicine that might lead to quicker and better treatment for their illnesses. The NLM reinforced that point of view by giving examples of how average citizens had successfully used MEDLINE and Index Medicus to discover effective treatments for themselves and their relatives (NLM, 1997).

Despite these optimistic endorsements, however, some professionals will argue that the average person doesn't understand enough about the technical aspects of medicine to use this new information safely and effectively. That is certainly a realistic concern. It is reasonable to ask what impact increasing access to medical information will have on the treatment of patients and especially on the doctor-patient relationship. Consider, for example, the following scenario:

Sally E. is a professional woman in her late 20s who has been suffering from periods of intense anxiety for several months. Her internist recently prescribed diazepam (Valium) for the anxiety, but it was only moderately effective. After a few days, Sally-concerned that she might become addicted to the medication-discontinued it and decided to learn everything she could about her mental problem on her own.

She began research at a local bookstore where she read DSM-IV and several popular books on anxiety. Based on her reading, she concluded that she was suffering from a panic disorder and that there were several treatments available, including behavioral therapy, cognitive therapy and medication. Sally continued her research on the Web, using search programs like Alta Vista and Yahoo to find general information on panic disorders. She also did a MEDLINE search on the pharmacologic treatment of panic disorder. One of her friends, a nurse, helped her understand the drug study reports.

After finishing her research, Sally made an appointment with a psychiatrist. She informed the doctor that her symptoms met the criteria for a panic disorder and requested treatment with a specific selective serotonin-reuptake inhibitor (SSRI). To support her request, she gave the doctor copies of abstracts from several relevant articles about the drug that she had discovered during her MEDLINE search.

Is this a realistic scenario? I believe it is not only realistic but that it will become a common occurrence in the future. It is part of an evolving trend that is demystifying the practice of medicine and radically changing the nature of the doctor-patient relationship. Most physicians realize that there are several modes of treatment for every illness. Many believe that the ultimate decision about which treatment should be used belongs to the patient.

Self-help Available

In the past, however, the patient has relied on the physician to provide information about the various appropriate treatments. Now, new self-help books, home medical software, the Internet and MEDLINE mean that more and more patients can find detailed information about their illnesses independently. As a result, many patients have an idea how they wish to be treated before they even see their doctor. They may even know more about the latest medical studies than their physician! One result of this change is that the patient may feel more of a partner in the process of treatment because he or she has had an active role in its choice.

Does this mean that every teenage computer hacker will know more about current medical practice than an overworked physician who finished training 10 years ago and doesn't have time to read all his journals? Of course not; experience counts for a great deal in medicine. Physicians have a responsibility to use their experience to guide patients. Just because a patient has increasing access to medical information and makes a decision about his diagnosis and treatment doesn't mean he is correct. A physician has no obligation to give a patient exactly what he or she wants if it isn't appropriate. At the same time, a physician should be tolerant of a well-informed, outspoken patient who has an appropriate request for treatment. Rather than interpreting the patient's demands as a challenge to his knowledge and competence, a physician should view it as an impetus to learn more about the new medical information resources so he can integrate them into his practice of medicine. MEDLINE on the Web is a good place to begin this process. If Sally's psychiatrist is not familiar with the drug she wants him to prescribe, he should freely admit it, do his own MEDLINE search, and then help her sort out the results.

In 1889, William Osler, M.D., advised graduating medical students at The University of Pennsylvania that they must cultivate a sense of "aequanimitas" or equanimity, especially when confronting the uncertainty of medicine and the credulity of the "ordinary citizen" (Osler, 1947). He might have had some difficulty maintaining his equanimity if patients came into his consulting rooms with detailed medical information and demands for a specific treatment. Nevertheless, despite its superior and patronizing quality, his advice has some value today. We need to realize that the professional role of the physician is shifting to that of an educator, interpreter and guide, as much as a healer. Social changes of this magnitude produce anxiety on all sides. Everyone subject to such change can benefit from a little equanimity.

References:

References

1.

NLM (1997), Vice President Launches Free Access to World's Largest Source of Published Medical Information on World Wide Web. National Library of Medicine. June 26. (

http://www.nlm.nih.gov/news/press_releases/free_medline.html

).

2.

Osler W (1947), Aequanimitas, 3rd ed. Philadelphia: The Blakiston Company.

3.

Starr P (1982), The Social Transformation of American Medicine. New York: Basic Books.

4.

Wyndham MD (1985), A History of The National Library of Medicine. National Institutes of Health NIH Publication No. 85-1904.