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.

 

In 2022, Shannon Jones will become president of the Medical Library Association, the second African American to head up the organization in 123 years. Jones is director of libraries at the Medical University of South Carolina in Charleston. The school is a standalone academic medical center that confers degrees in medicine, pharmacy, nursing, dentistry, public health, and an array of other health professions such as physical therapy and health administration. The Medical University of South Carolina Libraries serves all six colleges. Jones also serves as director of the Regional Medical Library for Region 2 of the Network of the National Library of Medicine serving members in Alabama, Florida, Georgia, Mississippi, South Carolina, Tennessee, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands.

The majority of librarians, including health sciences librarians, are white women. Jones has made it a priority to hire and retain employees who are diverse across many dimensions and to mentor librarians of color across the country.

Q: How successful have the efforts been to increase diversity in the profession?

 A: In recent years, there has been significant investment in this. All of our professional associations have had diversity, equity, and inclusion (DEI) as goals for a very long time. I think the reasons you don’t see more diversity are complex. My understanding of the reasons is largely based on anecdote — specifically my conversations with African American librarians. I think people go to library school, but then they have difficulty getting hired. And if they get hired, it becomes a retention issue. If they’re not treated well or the library was not prepared for a diverse voice or to include someone who is different from the majority, then they end up leaving the profession. It’s troubling that we haven’t moved the needle much on this.

Q: How are you trying to address DEI at your library?

 A: We try to take a whole-systems approach to diversity — not just when it comes to race and ethnicity, but also skillset and background. I have a librarian who used to be a basic science researcher and two who have master’s degrees in public health. We also employ other professionals with advanced degrees in areas such as social work and IT. I didn’t realize how many Muslim students were on our campus until we hired a librarian who is Muslim and our Muslim students gravitate towards her. You don’t know some of the skills that people bring to the table until you allow that diversity to flourish.

Q: Can you talk about your recruitment approach?

A: First, we make sure that the search committee is trained in issues of diversity. For example, they receive training on implicit bias because all of us have biases that impact our decisions. I also make sure the committee has demographic data on our current staff as well as an awareness of the racial and ethnic demographic. I look at where we have gaps. For instance, in 2017, all of our male librarians retired or left, so that was an opportunity to try to recruit a male librarian. For an IT position, I’m conscious about finding good female candidates. But the bottom line is that we are going to hire the best of the best. I also like to cast a wide net for candidates.

Q: How do you do that?

A: I post the openings in all the usual places — ALA, MLA, SLA. But I also contact people I have met at conferences who are doing exciting work. I search LinkedIn profiles and then reach out to people — cold calling, so to speak. And I’ll look through papers or posters from conferences I’ve attended. I keep a running list of people doing interesting work with the idea that if someday I have [an open] position, I can connect with them.

Q: What’s your approach to retaining people?

 A: Retention starts the moment that we offer somebody a job. It could be something as simple as paying their relocation expenses. We also need to offer them a fair and competitive salary. I don’t ever want to be in the situation where an employee realizes that the person sitting next to them doing the same job is making $20,000 more than they are.

And then we invest in them. I encourage my librarians to do career development plans so that they are thinking about where they want to see their career going and then I try to help get them there. We invest financially in making sure that their skillset and knowledge are always top-notch and that they’re able to present at conferences and to publish. I want them to feel like they’re getting value out of their career and adding value to the campus.

I try to be flexible with people in terms of letting them set the tone for their work and how they accomplish it. I ask them what they need to be successful. We haven’t had a whole lot of turnover in our librarian ranks.

Q: Have you been successful in recruiting and retaining a diverse staff?

A: Yes. We’re diverse in terms of race and ethnicity, gender, discipline, and [the] type of work our employees do. Take a look at our staff profiles.

Q: What work do you do outside your library to support health sciences librarians of color?

A: I do a lot of mentoring work. One example is a Chat and Chew weekly meeting, which I started early in the pandemic. A group of us — usually about 20 people — meet virtually every Friday just to check-in, decompress, and support each other. Some of my Black counterparts are working in environments where they’re the only one and it can be hard. So sometimes you need to be among people who share that experience. In our group, there’s a lot of emphasis on wellness. For example, several of our members introduced a few of us to plant therapy.

I’m also proud of the virtual book club [MLA Reads], open to anyone across the country, that I created in 2018 and co-lead. Since 2018, 33 discussion group leaders have facilitated nearly 350 participants in discussing three books. We meet in groups of between nine and 11 people, and we all read the same book — once a year. The group evolved out of an implicit bias training that we held at the 2018 Medical Library Association meeting. After the training, people wanted to process the implications of biases on their work, in their libraries, and in their personal lives.

The first book we discussed was Blindspot: Hidden Biases of Good People by Mahzarin Banaji and Anthony Greenwald. We also read The Person You Mean to Be: How Good People Fight Bias by Dolly Chugh. We just read Damon Tweedy’s Black Man in a White Coat: A Doctor’s Reflections on Race and Medicine and in the fall we’re reading Caste: The Origins of our Discontents by Isabel Wilkerson.

We discuss each book over four sessions, including some supplemental programming. For example, we had a supplemental session on how to engage in critical conversations and one on implicit bias, microaggressions, and stereotypes. And it’s not just about race. Regardless of whether you are red, black, blue, or green, you’ve probably had an instance where you felt like you were not supposed to be at the table or in a certain space. Maybe you are a female in a male-dominated profession. The books I mentioned earlier have pushed people to really think about what privilege means to them. What does oppression mean to them and what does it look like every day in the workplace?

The book groups have also been a good networking opportunity for people because members are not just health sciences librarians. We have community college librarians, academic librarians, and public librarians, for example. Participants get MLA continuing education credits. Some of our members have been inspired by our group and started similar book groups in their own institutions.

Q: Tell us about your work with the African American Medical Librarians Alliance (AAMLA), which I understand is a caucus within the MLA.

A: There was a period when African Americans did not have seats at the MLA’s decision-making tables and weren’t serving on committees nor receiving the highest awards. AAMLA began as a social group in the 1980s, when members gathered for dinner at MLA’s annual meeting. In 2000, it became an official special interest group of MLA to strategically address this. Things have changed a lot thanks to the AAMLA. In 2016, we had our first black president. The librarian who is delivering the prestigious annual Janet Doe Lecture this year is African American. And we have the first African American woman getting the association’s highest honor, the Marcia C. Noyes award. One of my colleagues at Morehouse School of Medicine was elected to the board and we had three African Americans elected to our nominating committee.

The AAMLA is also working on documenting the history of African Americans within the MLA. Additionally, we try to connect with new African American members early so that they know that the AAMLA exists to support them in becoming the best librarians possible.

Q: Do you have any other advice for other librarians who would like to increase diversity at their libraries?

A: One piece of advice is from one of my mentors who told me that you should always be lifting as you climb. The other is that we need to normalize self-care. I’m trying to get better at this myself.  Diversity, equity, and inclusion work is tiring because you’re constantly getting pushed back, you’re constantly hitting walls. You might have some successes but you’re going to have some challenges and so you have to take care of yourself.

 

If you’d like to learn more about Chat and Chew or the MLA virtual book group, contact Shannon Jones at JoneShan@musc.edu.