The clinical librarian specialty was developed in the 1970s as a way to offer research expertise to the medical team in light of the explosion in clinical knowledge. The potential benefits of integrating librarians into patient care include better treatment outcomes, reduced costs, and increased efficiency for physicians.
Elizabeth Laera is the senior medical librarian for Brookwood Baptist Health in Birmingham, Alabama. She shares duties with one other full-time librarian and their library serves six hospitals and more than 100 clinics. The library also supports approximately 100 residents across five programs and 40 medical students during their clerkship year.
In 2012, in collaboration with a newly created hospitalist teaching service, she established a clinical librarianship program. Specialists like her integrate into health care settings by participating in morning reports, bedside teaching rounds, and journal clubs; provide clinicians with relevant research as they care for individual patients; and support continuing medical and patient education.
NEJM LibraryHub spoke to Laera about what clinical librarianship looks like at her institution.
Q: What are your duties as a clinical librarian? Let’s talk pre-pandemic first, because I know things have changed in the past several years.
A: Pre-pandemic, one of my main responsibilities was rounding with our general inpatient medicine team. It’s a teaching team, composed of one attending faculty physician, one upper-level internal medicine resident, and four interns. There’s often a pharmacist and maybe a pharmacy resident, and then assorted medical and pharmacy students.
They begin the morning in a conference room and “run the list,” which involves going over what happened overnight with each patient, and what’s going on this morning, and then we talk about the plan for the day. We call this table rounds and it usually takes between 30 minutes [to] an hour. Inevitably, clinical questions come up. It might be something specific like how to titrate diuretic therapy for somebody who has a buildup of fluid in their abdomen from cirrhosis. Or it could be related to a more general teaching discussion about COPD or a particular type of cancer or the drugs used to treat diabetes inpatient vs. outpatient — although drug questions are often best answered by the pharmacist. But even they are sometimes stumped. The teaching is Socratic. If it becomes clear that people are having trouble answering questions about certain topics, I make a note, then later I’ll send everyone a review article or the latest treatment guidelines.
Occasionally, after we’ve run the list, I may accompany the team on the floor and see patients in the ICU and maybe the new admissions too. Sometimes an additional question may come up. My role is to find an answer by googling it or researching it on PubMed®, UpToDate®, or ClinicalKey®, so nobody else has to take the time do this. Most of the time they’re quick questions. Team members have a lot of decisions to make, a lot weighing on them, so I do anything I can to make things easier. I like attending rounds a lot because I learn how medicine works, and it makes me a better librarian.
Q: I understand that the pandemic has changed the way you work with the rounding team. How?
A: COVID put a temporary halt on rounding with large groups. Although this has resumed, I haven’t returned to the floor. The entire rounding process can take up to three hours, and then I have to do the research when I return to the office. So I have to be strategic about the best use of my time, which is during table rounds, which I still attend twice a week.
Another part of my clinical work is attending our internal medicine program’s didactic lectures three times a week at noon. One resident presents a case step by step — as an exercise in clinical decision-making. Usually, there aren’t a lot of questions that come up, but I am available if there are. Afterward, I will send everyone a clinical trial, a review article, [and] some guidelines — something related to what was covered in the lecture.
During the height of the pandemic, the lectures were on Zoom, which I really liked because I could drop links to my research into the chat. I would then send them out later for those who may have missed them. Admittedly, it’s sometimes hard to know if people are actually reading what you send, but at least you’re making them aware that there is something other than an UpToDate entry they should read. Now the sessions are back in-person. Because I have so many other responsibilities, I don’t make it to these every week.
Q: Other clinical duties?
A: I spend the largest portion of my clinical time answering questions specific to a certain patient for doctors. Someone will come up to me and say, “My patient is on this medication with this disease and I need to know more about it” or “I’m doing this surgery tomorrow and have this question about it.”
Q: How do you appraise the quality of the research you’re collecting?
A: I’ve taken classes in evidence appraisal and listened to lectures about it. But often, because of time pressures, your evaluation has to be quick and dirty. My method of evaluation goes like this: Do I trust the journal? If it’s an NEJM study, I’m going to trust it. Then I look at where the study was completed. For example, if it’s a blood pressure study done in China, it might be a great article, but it probably is not going to be applicable to our majority Black population in Birmingham, Alabama.
I’m more likely to trust a study that’s coming out of a well-resourced country that probably has good quality control methods. Then I’m going to look at whether the conclusion matches the objective. If it doesn’t, that’s a good indication of a bad methodology.
If I come across several studies on the same thing, I’ll use the more recent one or the one that’s in the better journal. If I’m finding a lot of studies, I’ll go looking for a meta-analysis or a systematic review. And if I’m unsure about the methodology, I look to see if they used the librarian in their systematic review. If they did, I have more confidence in the analysis.
Q: How do you send the result of your searches to clinicians?
A: Typically, I just send them the article, and I may even pull the answer out of the article and quote it in my email. For a more complicated question, I’ll send a list of abstracts, and then we will talk through them together. But what I’ve learned over the years is that most of the time, they just want the answer. They don’t want to read a bunch of articles.
Q: Are you able to index all the research you do in case the same question comes up again?
A: At one point, I created a database of the research I did for every question so I wouldn’t have to duplicate the searches, but I found that I was creating more work for myself trying to log all of that. And then, you run into the issue of medicine constantly changing, so there might be new studies that wouldn’t have been captured in the previous search — especially on topics like cancer or COVID. Sometimes I’ll remember I did a similar search and then just leaf back through my notes.
Q: At its core, clinical librarianship is about helping clinicians take better care of patients. Can you give me an example of a time your work had a direct impact on patient care?
A: It was a late Friday afternoon and I got a call from a doctor from one of our rural hospitals. He had a patient with a C. diff infection who was dying. He had located an article he believed could be helpful with treatment, but he couldn’t access the full text. I went into our inter-library loan system and found a couple of libraries in California that had access to the article. Because of the time difference, I knew they would still be open. I started calling until I found someone who could send us the article. Later, I got an email from the doctor saying he had saved the patient’s life.
This work is very satisfying. It connects me to the health care system and to patient care in ways that often feel very tangible.