Clinicians frequently raise clinical queries which need to be answered promptly.1 Medical research continues to expand providing libraries of medical knowledge at a seemingly exponential rate. At the same time, we strive to practise evidence-based medicine and to relate with well-informed healthcare consumers. The task is getting bigger, although the tools, it would seem, are improving too.

Doctors are increasingly relying on internet-based resources to aid with the acquisition of medical information.2 3 D’Alessandro et al reported that computer-based resources for answering medical queries are as effective as paper-based resources and more time-efficient.4 Furthermore, an integral part of the doctor–patient relationship is explanatory communication with “information prescriptions” becoming a key component.5

Our aims were to explore the information-seeking behaviours of paediatricians (paediatric registrars and consultants) in answering clinical queries. We wished to focus, in particular, on the role that information technology plays. We also wished to examine how paediatricians facilitated patients and their families to access appropriate internet-based healthcare information.

METHODS

In June 2005, a questionnaire was distributed to the 236 hospital-based paediatric registrars and consultants working in the Republic of Ireland. Each of the 17 paediatric units in the country was contacted to establish an accurate list of currently practising paediatricians. A second copy of the questionnaire was sent 3 months later requesting those who had not already responded to do so. All questionnaires were accompanied by a self-addressed and stamped reply envelope. The questionnaire was reviewed by two medical statisticians and piloted to 10 paediatricians prior to general distribution.

RESULTS

We received 156 completed questionnaires with a final total response rate of 66.1%. The demographics are displayed in table 1. The availability of information technology resources, its point of access and what web-based resources paediatricians utilise are displayed in table 2.

Web-based medical resources were seen as a “useful resource” by all respondents. The majority (84%) believe that web-based resources have improved medical practice, with 88% reporting that web-based resources are essential for medical practice today.

Most (93.5%) paediatricians agreed that “attempting to answer clinical questions as they arise is an important component in practising evidence-based medicine.” However, 75.5% of paediatricians report finding it difficult to keep up to date with all the new information relevant to their practice. Most (88%) paediatricians believe that doctors-in-training need to be taught skills to competently utilise information technology resources.

DISCUSSION

This study examines the impact of information technology on the way that paediatricians seek to answer clinical queries. Despite its apparent pervasiveness, there is little written on the subject, especially from outside the USA.

We surveyed the opinions of consultants and the more experienced junior doctors in hospital practice. The responder’s sex distribution is similar to the division of all hospital paediatricians. Interestingly, there were a similar number of respondents under and over 40, with no obvious differences in responses between these age groups.

In this study, the majority (75%) of paediatricians are using the internet as a first “port of call” to seek healthcare information. Those paediatricians who access the internet for a medical query do so on a regular basis. The majority (71.9%) access the internet at work, emphasising the importance of adequate access to and provision of work station terminals with broadband internet access. Unrestricted or unlimited access to medical information online is currently a point of debate, and specific journal access at present is largely dependent on institutional, organisational or personal subscriptions.6 7

Of all paediatricians using the internet to help research a medical query, the majority (57%) reported using Pubmed as their primary resource. Interestingly, a significant number of paediatricians (34.5%) utilised a general search engine such as Yahoo or Google. “Googling” for a differential diagnosis has recently been the subject of discussion. Internet traffic to websites hosting scholarly publications are receiving multiple times more referrals from the Google search engine than even that of PubMed.8 9

In a survey of US physicians, by De Leo et al, the vast majority (92%) of respondents reported accessing medical portals to gather information rather than a general search engine web browser, such as Google.3 A major concern expressed by respondents was the accuracy of the information returned by a general web browser. Conversely, a survey by Kitchin and Applegate in a younger demographic found 83% of radiology residents using the internet as their “first port of call” resource, with 77% using Google as their first source.2 Johnson et al specifically investigated the utility of Google, compared with other web-based resources (medical and non-medical) for identifying answers to targeted medical queries.10 The authors concluded that Google was both more efficient than and as reliable as all other tested web-based resources. PubMed was the main web portal used to access medical information in our responders. Falagas et al, in their comparison of the content coverage and practical utility of PubMed and Google Scholar, noted that PubMed updated more frequently, cited online early publications as well as published articles and based retrieved results on relevance and chronology rather than Google’s frequency of “hits” paradigm.11 Andrews has summed up the challenge of “Googling” as not simply knowing where to find information, but knowing what to do with the information once we have it.12 In our survey, we did not ask responders how they discriminated between various online sources, but it was clear from their responses that most use a small selection of trusted sources.

Over half of paediatricians (55.3%) in our study have recommended specific websites to an enquiring patient or parent with a similar number (63.4%) of paediatricians providing printed information sourced from the internet for families on healthcare-specific issues.

The provision of accurate, unbiased, evidence-based patient educational material is an increasingly common request to paediatricians, although there is little evidence that this influences outcomes.13 Both patients and parents are performing their own medical literature searches online. Recent surveys report that 56–80% of families search the internet for health-related information.14^–16 These patients are representative of a better-informed healthcare consumer, thus evolving the nature of the doctor–patient relationship.17

Attempting to answer clinical queries as they arise was almost universally seen as an important component in practising evidence-based medicine among our responders. Graber et al in 2006–7, noted that emergency medicine physicians attempted to answer clinical queries as they arose 81% of the time, with success reported 87% of the time.1 The major barriers to answering a clinical question at the point of care was lack of time or competing distraction, with the mean time given to answering a question being 2 min 30 s. This is in contrast to an older study by Ely et al which was carried out 10 years earlier in 1996–7.18 In this study of family doctors, only 36% of questions were immediately pursued with the comment raised in the discussion that computers at the time were perceived to be “too slow and too bulky” to be feasible in a clinical setting.

Similar findings were noted with internal medicine residents from the late 1990s, where only 29% of questions that arose in a medical consult were pursued with lack of time being reported as a barrier in 60% of cases.19 Although these studies are looking at different groups over time, there does seem to be a change in doctor behaviour perhaps based an increased willingness as much as improved technology.

A major concern of many clinicians in this study (75.5%) is the ability to keep up to date with the volume of literature published annually relevant to their practice. The internet represents a continually updateable information resource to provide point-of-care assistance in decision-making at the bedside. A recent study by Jones et al explored the preferred information sources of paediatricians to inform their clinical practice and reported that the top three sources were professional meetings and conferences, peer-reviewed journals and medical colleagues.20 Electronic databases were considered next in importance as an information source. They postulated that as electronic databases increased in availability, especially for paediatricians in the community, they would become an increasingly important source of information.

The imperative of training junior doctors with the skills to competently utilise information technology resources is a strongly held belief among responders (88%). Provision of access to online resources may not result in the application of evidence-based medicine (EBM) to patient care. In a survey of UK paediatricians contacted while on call, the majority of doctors had access to evidence-based medicine resources, but despite this few of them used it to help make on-call clinical decisions.21 The authors concluded that perhaps resources would be better utilised in training doctors to be “practitioners” of EBM, to know where to find preprocessed evidence and how to apply it rather than to be able to perform complex critical appraisals through training in clinical epidemiology. Krupski et al, in their review of online evidence-based resources, commented that the use of electronic databases of preappraised evidence can greatly expedite the search for high-quality evidence.22 This can then be integrated with the patient’s individual circumstances to provide a clinically relevant answer to a point-of-care question.

Conclusion

Web-based paediatric resources are of increasing significance in the day-to-day clinical practice of evidence-based medicine, be that in performing literature searches, downloading medical images or providing information prescriptions for patients and their families. There is much debate as to the quality and the most efficient mode of accessing online relevant medical content. Many paediatricians now believe that not only is it essential to have training in the skills necessary for utilising online resources but the quality of patient care depends on it. Information technology resources and training in how to access relevant, high-quality answers will play a key role in helping paediatricians to deliver timely solutions to clinical queries at the point of care.