CLINICAL LlBRARIANSHIP

Haliza YahayaLibrarian

Medical LibraryUniversity of Malaya

Abstrak: Artikel ini membincangkan tentang peranan pustakawan klinikal dan bagaimana konsepini dipraktikkan di beberapa buah perpustakaan di Amerika Syarikat dan Kanada. la menyentuhtentang teknik-teknik yang digunakan dalam penyebaran maklumat seperti LATCH, CurrentReferences, Latest Topics and Patient Care Related Readings. Kebaikan dari perkhidmatan initurut dibincangkan dan beberapa panduan diberikan bagi mempastikan kejayaan program ini.

Abstract: The role of the clinical librarians and how it is being practised at several libraries in theUnited States and Canada are discussed in this paper. This includes the techniques of informationand dissemination: LATCH, Current References, Latest Topics and Patient Care RelatedReading. The benefits of the service are discussed and guidelines on how to implement theproject successfully are given.

[Judul dalam bahasa Me/ayu: Kepustakawanan Klinika~

Introduction

Clinicians require access to current diagnosticand therapeutic information that is bothrelevant and patient specific. Efficient methodsof obtaining reliable information from theliterature are particularly important in acutecare settings where critical decisions must bemade quickly. The new and highly complexinformation technology requires that theclinicians learn new information retrieval skillsor receive assistance from an individualhaving these skills. The concept of the clinicalmedical librarian (CML) originated out of aperceived need to increase the healthsciences library's ability to respond to theseclinical information needs and bridge the gapbetween the medical literature and thepractitioner.

The CML is defined as a health scienceslibrarian who participates in clinical rounds.'The concept of a CML was developed over 20years ago. In the 1970's, CMLs were firstdefined as medical literature specialists whoaccompanied physicians and medical studentson rounds, then returned to the library tosearch for pertinent care-related articles anddeliver them within a very short time (rangingfrom minutes to hours). The programme

Kekal Abadi 15 (3) September 1996

enhances patient care by providing currentliterature quickly. It also enhances theeducational process for all team members bykeeping them aware of new techniques andtherapies. CMLs spend some time instructingteam members in the use of library tools andfacilities.

There are alternatives to rounds for the CMLprogramme. Staudt, Halbrook, and Brodman/report that in their programme, the clinicallibrarians did not go on rounds with thephysician and his team, but instead sat in onresidents' reports from which the librariansgleaned the problems for which a search ofthe literature might be appropriate. Also,Schnall and Wilson 3 note that as long as theCML is present at departmental discussions,held for reviewing management of currentcases, it is possible to have an effectiveservice without the librarian going on rounds.

First reported by Alqerrnissen," CML servicesdiffer from traditional library-based referencework in two significant ways. First, the CML"takes the library" to health professionals andstudents by attendance at the activities of aclinical department (for example, morningreport, attending rounds, and conferences).

5

Second, the presence of the CML at clinicalactivities allows the librarian to anticipatequestions and often results in the provision ofthe information even before it has beenrequested." In common with other libraryoutreach programmes, clinical librarianshipfosters exchange between the library and itsusers. Primarily the librarian disseminatesinformation. At the same time, however, he orshe learns more about user information needsand trends in various health specialties or inspecific units of the organization. This hasmany spin-offs, such as providing a betterbase for planning library services, increasingthe involvement of library staff in the activitiesof the hospital, and demonstrating therelevance of. the library's resources and staffto direct patient care. More recently, there hasbeen an emphasis on the instructional andconsultative aspects Of the CML's role. This isdue to the increase in searching by the healthprofessional, as the end-user, to gain accessto the literature."

Background

After collecting basic clinical and laboratoryinformation for their patients, physicians facethe complex task of medical management -sorting the data, planning further diagnosticwork, formulating problems and diagnoses,predicting course and outcome, and planningand monitoring the response to therapy.Physicians rarely seek out specific, .case-related information from the medical literature,even though such information might beexpected to improve the quality of care, asmuch as information derived from laboratorytestinq.'

One impediment to such case-related use ofthe literature is limited access since propersearches take time and skills usually notavailable to physicians. Clinical faculty tend tobe less knowledgeable about the literatureoutside their specific fields and tend tooverlook that literature in searching forinformation related to a patient problem. Forexample, Farmer and Guillaumin 8 report thata head and neck surgeon expressed a degreeof surprise when a CML brought somerelevant literature from ophthalmology inresponse to a request.

Such searches if done by physicians would

6

also be disruptive to care duties and incurunacceptable costs in terms of physicianmanpower. Moreover, for input from themedical literature to serve a useful purpose inongoing case management, thecharacteristics of access must be modifiedfrom those of traditional retrospectivesearches. The questions asked and searchesmade must be highly refined. Searches mustbe sharply focused and conducted with extrapromptness, speed, and efficiency for theinformation to reach the clinician.

The CML, as an extension of referenceservices, has been in existence primarily inthe United States. The CML programme'soriginal concept grew from a need observedby Dr. Getrude Lamb when attending roundsat the University of Missouri-Kansas City(UMKC) School of Medicine to observeteaching patterns. Due to the questoins thatarose during these rounds and in view of thelibrarian's speciality in accessing the currentliterature, it was decided to add a librarian tothe health care team.

The first CML project began in 1971 at UMKCunder Lamb's direction. This was partiallysupported by a Public Health Service grantfrom the National Library of Medicine whichcovered ~he time period of May 1, 1972 - April30,1975. In 1973, Lamb moved to HartfordHospital (Connecticut) where she alsodeveloped a CML programme, in cooperationwith the director of the University ofConnecticut Health Center and the help of atwo year medical library resource project grantfrom the U.S Public Health Service. These twoprojects are the seminal work in clinicallibrarianship.

Other CML programmes appeared in varioushealth care settings after Lamb spoke aboutthe innovative UMKC programme at the 1972annual Medical Library Association (MLA)meeting in San Diego. In the 20-year history ofthe CML programme, at least 30 librariesassociated with universities or hospitals havepublished descriptions of their programmes.Programmes exist in cancer chemotherapy,family health, gynecology, fetal/maternalmedicine, pediatrics, psychiatry, pulmonarymedicine, obstetrics, and general inpatientinformation.

Although the activities and target population ofmany CML programmes differ, the major goalis basically the same: to place an informationintermediary within the primary patient caresetting where information is needed. Morespecific goals achieved by various CMLprogrammes are: (1) to save the time of healthcare professionals by providing skilledpersonnel to perform literature searches, (2)to make health care professionals moreefficient and independent future users of thelibrary by providing on-the-spot awareness oflibrary resources, (3) to assist in building areading file to be used as a permanentresource, and (4) to provide the CML with amore thorough understanding of patient careproblems which will enhance retrieval of themost relevant literature and influence futurelibrary acquisition and services."

Format of CML Programme

There are several CML programmes inoperation today. It is safe to say that allprogrammes have made some modificationsof the original concept. The exact format of aCML programme varies with the institution.Different institutions have developed CMLprogrammes with different goals in mind.

In Canada, the CML programme at theMcMaster University Medical Center differsfrom other programmes in the United States intwo major ways. Firstly, the programme istime-limited and education oriented. Ratherthan having clinical librarians permanentlyassigned on a full-time basis to one patientcare setting as is frequently the caseelsewhere, the programme allows for a half-time librarian to rotate through differentsettings, each for a limited time period.Emphasis is placed on teaching healthprofessionals information-seeking skills forongoing use. Secondly, the service isavailable to patients, families and to healthprofessionals. This recognition of the patient'sneed for information is in response to thegeneral movement towards greater consumerparticipation in health care and acknowledgesthe right of individuals to make informeddecisions about their own care and treatment.The clinical librarian plays a special role inidentifying patients' questions, locating

materials, and making health professionalsmore aware of patient and family informationneeds."

An awareness of the options that are availablewill allow the librarian to select the programmewhich is best suited for the institution.Increased information literacy should be amajor goal of any CML programme so that theuser can function independently in the future.

CMLs do face problems. Mosby andNaisawald" recommend two ways toovercome these problems. The first is to visitall the members of the health care teambefore initiating the service, and thoroughlyexplain the aims of the service and encourageuse of the service. The second is to have awell planned, enthusiastically acceptedprogramme.

Areas that may present difficulties inimplementing the CML programme are asfollows:

a) Question negotiation

It may be difficult at times to get a chanceto clarify requests because a CML isproviding reference service "on the run". ACML new to the service is going to needtime and help to become familiar with theterminology. Since the CML is probablygoing to choose articles, she will needmore information that might bevolunteered at the usual referenceinterview.

b) Document delivery

The question of cost arises here. Theremay be a problem in deciding who paysfor the photocopies, the user or the library,or perhaps the department.

c) Acceptance of the programme (and theCML)

There is constant tension between theneed to prove the efficiency of the service,and the personal need of the CML to feela sense of rapport with the team on theone hand, and the need to avoidbecoming a "gofer" or fostering unhealthy

7

dependence on the other. Any CML has tohave a correct blend of assertiveness,flexibility, self-esteem and goodcommunication skills.

d) Action and reaction

There may be a tendency to provide toomuch material especially in the beginning,to avoid missing anything. 1314

The constant exposure to illness anddeath may be difficult for the CML to copewith.1s

Some members of the health care teammay object to the CML's presence in thepatient's room.

A rotating house staff and student usergroup may make it difficult for the CML toestablish rapport.

There may be objection to offering thisservice to one department and not toothers.

The maintenance of a file system ofsubjects searched, strategies used, and/oruseful articles may be burdensome. 16

Some of these may be transitory problemareas that disappear as the CML· gainsexperience. For example, daily contactwith illness and death needs anadjustment to these realities; thelibrarian's close involvement with thehealth care team usually increasessensitivities in these areas and the healthprofessionals' activities.

e. Ethical and legal considerations

A Patient's Bill of Rights, approved by theHouse of Delegates of the AmericanHospital Association on February 6, 1973has three sections which impinge directlyon clinical librarianship.17 Section #2 and#3 of the bill would promote a climate'favourable to CML programmes. Section#4 however might be interpreted aseliminating the possibility of having alibrarian attend bedside rounds. It alldepends on whether the librarian is

8

perceived as a member of the health careteam, and "directly involved in the patientcare". Legal problems may also arise ifinformation provided by the CML isattached to or included in the patient'srecord. If a physician does not incorporatethe information into the therapeuticregime, for whatever reason, it mayultimately be interpreted as malpractice.

Mechanisms of Information Disseminationin CML Programme

There are four mechanisms used in thedissemination of information in the CMLprogramme. The first mechanism is theLiterature ATtached to the CHart or popularlyknown as LATCH. It is a problem-orientedsystem. It depends on the presence of theCML at house staff rounds each morning. TheCML searches for and analyzes documentsfor inclusion in a folder giving medicalinformation pertinent to the patient. It consistsof a collection of a few good current articles onsome aspect of the patient's illness. Thiscollection is attached to the chart of the patientat the request of any of the health carepersonnel attending him. Bibliographies citingreferences to additional information areincluded for members of the team who maywish to study the disease or technique ingreater depth.

An online LATCH programme was initiated bythe Health Sciences Library at Lehigh ValleyHospital Center in September 1982. LATCHwas placed on the hospital's computerizedinformation system. The unit clerk will key inpatient information on the terminal after a staffmember places a LATCH request on thepatient's chart, and the request is transmittedto the library with all the necessaryinformation. The request is picked up by thelibrary staff who forward the literature directlyto the unit to be attached to the patient'srecord. Computerized LATCH has expandedthe service concept of the library byestablishing a formal process by whichlibrarians can communicate online with otherdepartments. It demonstrates a shift in theidentification of the library from an isolated unitto an interactive resource centre.18

The second mechanism is a weekly selectionof abstracts entitled Current Referencesdesigned for medical students and faculty atUMKC. It is one of the most popular of theinformation disseminating techniquesdeveloped by the CMLs. The service nowincludes key articles and editorials selected byeach of the CMLs on the basis of theirpertinence to actual patient care problems. Asarticles are selected and abstracted by theCMLs, index terms and codes from theNational Library of Medicine's Medical SubjectHeadings vocabulary are assigned for quickand consistent subject retrieval. Each citationand abstract are then printed on a three-by-five inch card. Eight to ten of these cardsmake up one issue of Current References.This format has the advantage of allowingeach user to retain selectively and file forfuture reference those abstracted articlesfound most useful.19

Latest Topics, the third mechanism, consistsof a master file essentially generated fromdemand search-document delivery. The fileincludes documents retrieved which do notnecessarily represent a current patientproblem. It anticipates users' needs and caneffectively produce information for a current orrepeated request.20

The last mechanism is the Patient CareRelated Reading. It is a hospital-basedprogramme of continuing medical education inwhich the librarian actively participates in thepreselection, packaging, and routine deliveryof literature for use by physicians caring forpatients with certain clinical disorders.Librarians compile bibliographies, reviewarticles, and prepare preliminary packets.Physicians review these packets and makesuggestions for each article. Librarians thenprepare final packets following reviewers'recommendations and distribute them as aroutine procedure to all physicians caring forpatients with a diagnosis corresponding to theprepared topics. Packets are used byphysicians to add to their knowledge, and forreview and teaching purposes:"

In most cases, MEDLINE searches answeredpatient-care questions quickly and efficiently.Other searching resources included ExcerptaMedica, Science Citation Index, and

textbooks. Interlibrary loans were reported asanother resource used to fulfill CMLinformation needs.

CML Programme Evaluation

A CML program should be evaluated. Firstly, itis important to determine the quality of theservice provided. Is the information retrievedby the clinical librarian relevant and of goodquality? Secondly, the clinical librarian needsto know if the procedures of providinginformation are satisfactory. Are therequesters receiving the needed information ina timely manner? Is the information readilyaccessible to everyone who needs it? Thirdly,it is necessary to keep track of the costs andtime involved in order to ensure adequatestaffing. How much time does the clinicallibrarian spend in retrieving the neededinformation? What are the computerizedliterature search costs, photocopy andmaterial costs? And finally, the clinicallibrarian needs to have feedback from thephysicians, residents and students who usethe service. How do they rate the quality of theservice and the librarian's ability to locaterelevant lnforrnation."

The reports that discuss the merits of CMLprogrammes have stressed the timeeffectiveness of having a CML provide accessto case-related literature, thus freeing the busyclinician to devote more attention to patientcare. Furthermore, these articles haveemphasized the cost-effectiveness of such aprogramme when compared with othereducational expenditures and with standardlaboratory or radiologic tests as a means offurtherin~ knowledge about an individualpatient."

The CML programme allows a thorough-evaluation of the medical literature and itsprovision in a time-efficient manner. Thisprogramme also improves contact betweenhouse officers and the library staff and leadsto increased use of literature search and otherlibrary resources.

Objections to CML programmes do appear inevaluations. A CML on rounds added to analready overcrowded situation. The patientmight feel the discomfort of having so many

9

people in his room. The librarian might also beuncomfortable during the physical examinationof a patient. Sometimes the CMLmisunderstands questions during rounds andprovides irrelevant or unsolicited information.The use of the CML as a primary source ofinformation is questioned, as well as theCML's knowledge of medical terminology.Information service for the departmentinvolved, undeniably becomes associated withone individual "specialist" (the clinicallibrarian). Therefore, some users identified theCML as an individual rather than part of thelibrary team.

There is also the impact of the CML's activityon the medical library itself. At the Southern-Illinois University School of Medicine Library, amodified CML programme was offered for fiveyears (1976-1980). Nineteen percent of alllibrarians' time was spent on the CML~programme. General reference service to theentire medical school was suffering becausereference desk coverage availability wasreduced up to 38 percent when the librarianswere out of the library.

Some claimed that the CML's service is toolabour intensive due to the fragile chain ofevents that must work in order to translate theoriginal request into working knowledge for thehealth care provider. Most often theinformation must be immediately obvious inthe article or book, it must deal with verysimilar circumstances/patients as therequester sees. Furthermore, realizing that ananswer is of no use sitting in an office or pick-up file, the clinical librarian may be deliveringarticles to the ward, intensive care unit orphysician's office.

Characteristics of a Good Clinical Librarian

A CML must have a good undergraduaterecord with a successful completion ofgraduate work in medical librarianship. TheCML needs to be well-versed in medicalterminology to thoroughly understand specificconservations on rounds or at conferencesplus the added talent of being able to shedhis/her timidity and corner a medical studentor resident and ask him/her to explain whathe/she is talking about. He/she should have

10

some reference experience including onlinetraining and familiarity with health scienceenvironments. The "right" personality traitsshould include: willingness to learn;enthusiasm; service orientation; self-confidence; the ability to make connections,be assertive, and to identify and takeadvantage of opportunities.

Clinical librarians spend much of their time ina non-library environment with people whomay be unaware of what librarians can do.Initially, a clinical librarian will need both to sellthe service and define ils scope whichrequires public relations sense, diplomacy,and solid reference ability and credibility.Physical stamina (CMLs spend a good deal oftime standing and often put in long hours), anda healthy attitude about being in patient careenvironments are all fundamental to the job.

Clinical librarians must learn quickly, feelsecure in a nontraditional role for a librarian;and above all, have a commitment to supportothers as they take care of patients.

Conclusion

As CMLs continue to function as part of thehealth care team, the skills and techniques.needed in order to respond successfully toinformation needs are becoming increasinglysophisticated. Rapid changes in technologyand budget constraints are forces whichrequire more and better administrative skills.The CML must deal with people, both librarystaff and other institutional members. Theyneed good interpersonal skills. Today's CMLmust be adaptable, ready and willing to acceptinnovations and to implement them. With thegreat expansion of personnel and educationalfacilities in the health care field, CMLs canenjoy being vital, contributing members of thehealth care team, as well as cooperating andsharing resources with other health careteams through the biomedical communicationnetwork."

There are several factors that can ensure thesuccess of the CML programme.

1. The existence of health professionals whohave information needs, who wish to have

these needs met, and who are willing toaccept the service of the clinical librarian.

2. An effective and cooperative health careteam, whose members work comfortablytogether.

3. A positive attitude on the part of themembers of the health care team towardsthe provision of information to thosereceiving the services of the clinicallibrarian.

4. Acceptance of the. clinical librarian as amember of the health care team.

5. Effective communication between theclinical librarian and the health care team.

6. Strong support by at least one seniorindividual in the clinical setting whounderstands the role of the librarian andwho initially legitimated this role in theeyes of the other health professionals.

7. Emphasis on the positive and non-threatening nature of the librarian'sparticipation in the clinical setting, that is,that the librarian is not trying to take overthe role of other health professionals inpatient education (in cases where patientsalso receive the services of the clinicallibrarian), nor to point out theirweaknesses with regards to providinginformation.

8. Willingness on the part of the librarian toundertake a new role in a new setting andto work cooperatively as a team member.

9. Support of the library staff.

10. Adequate support and funding. 25

The programme effects a speedier transfer ofinformation to the patient care team, increasesthe CML's awareness of the team'sinformation and time frame needs anddemonstrates the library's role in patient careactivities. Other benefits include creating anew awareness of library services, teachingresidents how to utilize the information toolsand alerting faculty to areas requiring furtherresearch. All of the above, reinforces the

changing image of librarianship and thegrowing appreciation of the role of the librarianwithin a patient care setting.

Despite the advantages, severalconsiderations should be viewed in the light ofthe evolvement of the librarian's role and newtechnology. Although clinical librarianshipemphasizes the team approach, care shouldbe taken to preserve the librarian's essentialfunctions. Unless the bounds of service arecarefully defined ahead of time between thelibrary's planning team and the clinicaldepartment's representative, the clinicallibrarian programme runs the risk of beingreduced to a fetch-and-carry service and thelibrarian becomes a variation of thephysician's handmaiden."

This labour-intensive and consequentlyexpensive service needs careful evaluation.The few reports of discontinued programmesindicate that the lack of budgetary support forthe clinical librarian is the major reason for aprogramme's demise. Since libraries areproviding the service, it is their responsibility tostate the salient points of the CML to thevarious clinical department heads who mightbenefit from these services. An opencommunication between these two groups andthe consideration of a shared fundingagreement could equalize budgeting to makethe CML programme a viable commodity inthe health care setting. Clinical departmentsthat desire CML services need to have costfactors explained.

Librarians must market the library and itsvisible accomplishments. Libraries need toaggressively negotiate funding with hospitaladministrators for library services and attenddecision-making meetings. An effective CMLon rounds, at conferences, on hospital floorsand in the library can truly be referred to asthe information specialist - trained to addressthe information needs of other health careprofessionals. If libraries can deliver what theypromise, the library's worth to medical centreswill be realized, and budget approval forprogramme may consistently be a positiveconsideration. 27

The increase in end-user searching currentlyseen in libraries has significant implications for

11

CML programmes. There is controversyregarding what the effect will be. On the onehand, there is the opinion that as their onlinesearch skills develop, the clinician will nolonger need the CML and the concept willbecome unnecessary. The opposing view isthat there exists an opportunity for the CML toemphasize education and consultation withrespect to searching skills in addition to moretraditional information provision services.Rather than threatening the existence of CMLprogrammes, teaching computerizedsearching and bibliographic skills can make itpossible for librarians to expand existingprogrammes and enhance the role of the CMLby adding a'variety of educational experiencesto CML services and creating a moreworthwhile relationship with clinical staff. 28

Surveys done on CMLs regarding their workshow that interaction with people and freedomare the job characteristics of CML that theyliked best. There are comments which includethat CML is one of the most interesting fieldsin medical librarianship today and a mustexperience for all medical librarians.Respondents felt that they learned muchabout the practice of medicine and havebecome better able to discuss health care asa peer among profesisonals. 29

Mosby and Naisawald,JOin their paper statethat an important thing to remember is thatCML programmes should not be perceived asa 'frill' to perk up a library's image, but as avital service which should be incorporated fullyinto an institution's provision of health careand which should have a positive impact onthe quality of that health care.

References:

1. DEMAS, J.M.; Ludwig, L.T. Clinicalmedical librarian: the last unicorn? BullMed Libr Assoc 1991 Jan.; 79(1): p. 17.

2. STAUDT, C.; Halbrook, B.; Brodman, E. Aclinical librarian's program: an attemptat evaluation. Bull Med Libr Assoc 1976Apr.; 64 (2): p. 236-8.

3. SCHNALL, J.G.; Wilson, J.W. Evaluationof a clinical medical librarianshipprogram at a university health sciences

12

library. Bull Med Libr Assoc 1976 Jul;64(3):p.278-83.

4. ALGERMISSEN, V. Biomedicallibrarians In a patient care setting atthe University of Missouri-Kansas CitySchool of Medicine. Bull Med Libr Assoc1974 Oct; 62(4): p.354-8

5. CLAMAN, G.G. Clinical medicallibrarians: what they do and why? BullMed Libr Assoc 1978 Oct; 66(4): p.454

6. MAKOWSKI, G. Cltnlcal medicallibrarianship: a role for the future.Bibliotheca Medica Canadiana 1994;16(1): p. 7

7. SCURA, G.; Davidoff, F. Case-relateduse of the medical literature: clinicallibrarian services for improving patientcare. JAMA 1981 Jan 2; 245(1):p. 50

8. FARMER, J.; Guillaumin, B. Informationneeds of clinicians: observations froma CML program. Bull Med Libr Assoc1979 Jan; 67(1): p. 54

9. MOSBY, M.A.; Naisawald, G. Clinicallibrarianship. (Continuing Educationcourse text 668-81) Chicago: MLA, 1981May, p.3

10. YATES-IMAH, C.; Goldschmidt, R.H.;Johnson, M.A. The clinical librarian:new team member for a family pracltceinpatient service. Fam Med 1985 Nov-Dec; 17(6): p. 62

11. MARSHALL, J.G.; Neufeld, V.R. Arandomized trial of librarianeducational participation in clinicalsettings. J Med Educ 1981 May; 56: p.410

12. MOSBY, M.A.; Naisawald, G., p. 32-8

13. COLAIANNI, L.A Clinical medicallibrarians In a private teaching hospitalsetting. Bull Mad Libr Assoc 1975 Oct;63(4): p. 410

14. ROACH, AA; Addington, W.W. Theeffects of an Information specialist on

patient care and medical education. JMed Edu 1975Feb; 50: p. 178

15. COLAIANNI,L.A., p.410

16. MARSHALL, J.G.; Hamilton, J.D. Theclinical librarian and the patient reportof a project at McMaster UniversityMedical Centre. Bull Med Libr Assoc1978Oct; 66(4): p. 425

17. MOSBY,M.A.; Naisawald,G., p. 36-8

18. NIPPERT,C,C. Online LATCH. Med RefServ Q 1985Spring;4(1): p. 23

19. CHRISTENSEN,J.B et al, A role for theclinical medical librarian in continuingeducation. J Med Educ 1978;53: p. 515

20. ALGERMISSEN,V., p.355

21. HUTCHINSON, S. et al. Preselectingliterature for routine delivery tophysicians in a community hospitalbased Patient Care related Readingprogram. Bull Med Libr Assoc 1981 Apr;69(2): p.236

22. HARMONY, S.E. Evaluating a clinicalmedical librarian program: a necessary

evil or valuable tool. Clinical LibrarianQuarterly 1983Jun; 1(4): p. 1

23. BARBOUR,G.L.; Young, M. N. Morningreport: role of the clinical' librarian.JAMA 1986;255(14): p. 1922

24. ROACH, A.A. The health sciencelibrarian: a member of the health careteam responsive to emerging trends.Lib Trends 1979; p. 260

25. MARSHALL,J.G.; HamiltonJ.D., p.425

26. HORAK,E.B. Clinicallibrarianship in anera of end users. Med Ref Serv Q 1987;6(2): p. 66

27. DEMAS,J.M.; Ludwig L.T., p. 26

28. HALSTED, D.O.; Ward, D.H.; Neeley,D.M. The evolving role of the clinicalmedical librarians. Bull Med Libr Assoc1989Jul; 77(3): p. 299

29. SULLIVAN, M.G.G.; Sarkis, J.M. Theclinical medical librarian program asperceived by the CML. Bull Med LibrAssoc 1987Apr; 75(2): p. 170

30. MOSBY, M.A.; Naisawald, G., p. iii

13