Information-seeking behavior of medical residents in clinical practice in Bahia , Brazil *

In the last twenty years, several researchers around the world have explored issues related to information and clinical practice [1–6] and the role of the librarian in this context [7–11]. Several studies have focused specifically on residents’ information needs and behavior [12–16]. This body of research indicates that preceptors serve as preferred information sources for many residents [12, 15], rather than textbooks or other resources [1, 17–19]. Additional studies have illustrated that residents may encounter a number of questions in clinical practice [15, 16], most frequently relating to topics such as therapy or diagnosis [13, 15, 20]. However, clinical questions are not often pursued by residents [12, 15]. Among pursued questions, the answers to these questions have been shown to change the management of the patient in up to 70% of the cases [15]. Common obstacles in the information-seeking process identified by residents include lack of time, doubt about the existence of relevant information, retrieval of too much information, and difficulties with navigation and searching [6, 14–16]. Few studies have focused specifically on health professionals’ information needs in Brazil [19, 21– 23], and none of these included residents.


INTRODUCTION
In the last twenty years, several researchers around the world have explored issues related to information and clinical practice [1][2][3][4][5][6] and the role of the librarian in this context [7][8][9][10][11].Several studies have focused specifically on residents' information needs and behavior [12][13][14][15][16].This body of research indicates that preceptors serve as preferred information sources for many residents [12,15], rather than textbooks or other resources [1,[17][18][19].Additional studies have illustrated that residents may encounter a number of questions in clinical practice [15,16], most frequently relating to topics such as therapy or diagnosis [13,15,20].However, clinical questions are not often pursued by residents [12,15].Among pursued questions, the answers to these questions have been shown to change the management of the patient in up to 70% of the cases [15].Common obstacles in the information-seeking process identified by residents include lack of time, doubt about the existence of relevant information, retrieval of too much information, and difficulties with navigation and searching [6,[14][15][16].Few studies have focused specifically on health professionals' information needs in Brazil [19,[21][22][23], and none of these included residents.

Residency training in Brazil
Medical residency in Brazil is a graduate-level course of study, a specialization characterized by training in the clinical environment under medical professionals' supervision [24,25] and limited by law to sixty hours per week.An individual residency may last two or three years; some specialties (e.g., cardiology, plastic surgery, angiology) require a second residency in either general medicine or general surgery [26], thus requiring a total of five to six years to complete.
Residents at the Professor Edgar Santos University Hospital (HUPES) of the Federal University of Bahia Medical College (UFBA-FAMEB) in Salvador, the capital city of the Brazilian state of Bahia, have direct access to several important resources including the HUPES Library, the UFBA-FAMEB Library, freely accessible regional and international electronic databases, and the Capes Portal ,www.periodicos.capes.gov.br., a powerful information tool providing access to several databases and more than ten thousand full-text scientific journals.
To explore the information needs and behavior of housestaff at this institution, the researchers surveyed a group of residents from October 2004 through December 2004.The team hypothesized that (a) consultation of scientific information constituted a crucial element of patient care; (b) residents were familiar with available information resources; and (c) they were able to handle these resources efficiently.This survey also aimed to identify the role of health sciences libraries and resources available in Brazil in meeting physicians' information needs for clinical practice.

Sample
In 2004, 120 residents were enrolled at HUPES in 23 different specialties.For the survey, all residents in the third year of residency were selected due to the small size of the group (n517) relative to those in other years of residency.For each third-year resident, 2 residents in the first year and 2 in the second year were randomly selected from a list of residents, resulting in a final pool of 85 residents.

Survey techniques
The authors employed a survey [27] with a critical incident component [28] to explore residents' reported information needs and behavior.

Questionnaire design
Investigators developed a six-part questionnaire with thirty-five questions (Appendix online) exploring: (1) demographic data, (2) respondents' behavior when faced with a clinical information need, (3) habits and preferences for information resources management, (4) information-related skills, (5) most frequent information needs, and (6) examination of a particular situation in which the resident needed information to support clinical care.

Pilot testing and survey distribution
A pilot version of the questionnaire was administered to ten senior medical students.Eight copies with answers were returned.Results of this pilot-testing revealed the need to reformulate some of the questions to clarify their intention.The instrument was refined to reflect these observations.Printed copies of the final questionnaire were distributed to residents in person by the researchers with a deadline for completing the questionnaire.Two reminders were sent to residents who had not yet completed the survey.Whenever possible, the resident completed the questionnaire at the time of initial delivery.

Analysis
SPSS version 12 was used for all analyses.Differences between groups were analyzed using Fisher's exact test.For ordinal variables and continuous quantitative variables, respectively, the Mann-Whitney U test and Student t test were used.

RESULTS
Analysis of the 73 returned questionnaires (86% response rate) showed that respondents' ages ranged from 23 to 43 years (mean 27.6+/23.2SD); 39 were male (53%); and 39 were in their first year of a given residency (53%), while 24 (33%) were in their second year and 10 (14%) in their third year.Almost half of the sample (n533, 45%) consisted of doctors pursuing their first residency, and the same number were in their second residency.Seven residents (10%) did not respond to this question.
Residents reported that they cared for an average of 13.5+/26.3SD patients a day in an average of 7.5 (SD 2.8) daily work hours.Four residents were not carrying out patient care activities, and 2 did not answer the question.

Information needs
All respondents noted information needs in the previous 30 days.The most frequent categories of these needs included drug therapy (n532, 44%) and diagnosis (n521, 29%).The most frequently used information sources during this period are shown in Table 1 (online).Concerning the motivations prompting residents to search for information in the past 30 days, doubts (n553, 71%) and rare medical cases (n552, 71%) were the most frequently noted (Table 2 online).Barriers encountered during searches for information are described in Table 2 (online).
Preferred information sources are summarized in Table 3 (online).Individuals in their second residency preferred to consult their preceptors (11/33, 33%), while those in their first residency gave priority to consulting their private collections (17/33, 52%) (Mann-Whitney U P50.03).The contents of residents' private collections are illustrated in Table 4 (online).
Residents reported that having either books (n562, 85%) or a computer with Internet access (n558, 79%) available near the clinical floor was necessary to support good clinical practice.Many also indicated that an up-to-date collection in the hospital library was essential (n549, 67%).
Most HUPES residents had not received training in using databases: 48 (73%) of the 66 individuals who performed their own searches reported that they were self-taught and only 1 had been trained by a librarian.Regarding the searching process in databases, many respondents explained that they usually entered keywords in the first dialog box (25/66, 38%).Some reported using the ''advanced search'' option (15/66, 23%); few noted combining several keywords with Boolean operators (16/66, 24%) or using ''limits,'' ''fields,'' or ''index'' resources (5/66, 8%).Many reported that they were dissatisfied with their search results (45/66, 68%), and 23 of 66 (35%) indicated a need for learning more about search techniques (Table 5

online).
Several problems were identified in the information searching process.Many residents noted difficulties in choosing among the large number of documents retrieved in searches (35/66, 53%), and lack of time was also noted as a problem (25/66, 38%).When asked about criteria for selecting references, the most important factors were free full-text availability (49/66, 74%) and currency or novelty of the information (41/66, 62%).Regarding access to the full text, few residents said they visited a library to check document availability (12/66, 18%), ordered articles through a library (6/66, 9%), or used other online ordering systems (6/66, 9%).Approximately half of respondents preferred electronic tools for literature searching (35/66, 48%), yet most indicated they preferred to print the documents (61/66, 92%) rather than read them online (5/66, 8%).

Critical incident results
Seventy-one residents (97%) answered the critical incident portion of the questionnaire, and 67 (92%) were able to recall a specific occasion in the previous month during which they needed scientific information for patient care.Among them, 2 declared not having pursued a search related to that information need.Those who verified an information need during their clinical practice reported that the associated clinical subject was diagnosis or diagnostic tests (26/ 67, 39%); drug therapy (19/67, 28%); other kinds of therapy (9/67, 13%); etiology or harm (5/67, 8%); and prognosis (3/67, 5%).Additional results obtained in the critical incident section of the questionnaire are shown in Figure 1.

DISCUSSION
In accordance with earlier studies [13,15,20], information needs reported by residents of HUPES often related to therapy, particularly drug therapy, or diagnosis.Previous research illustrated that physicians frequently consulted another doctor, generally a specialist or other colleague [12,15].In the present study, residents relied on preceptors to solve doubts, although books were also mentioned for filling information gaps.A preference for books as a source of information was almost unanimous in research with similar populations [2,[17][18][19], and, similar to the current results, these books were often part of a private collection.Research has also concluded that information sources (e.g., the library, electronic databases) were of fundamental importance in a clinical environment given their direct contribution to decision making in health issues, often making the difference in patient survival [20,[29][30][31].Libraries, however, were not heavily used in the current study, visited by only 40% of residents and ranking sixth in preferred information sources, a trend echoed in other studies [19,[30][31][32][33][34].
Residents of HUPES affirmed a need to learn more about research techniques.This reported lack of skill in handling databases and other electronic resources has also been noted by others [6,14,15,34,35].
Due to its focus on a group of residents in Brazil, the present research may have limited generalizability to other settings; however, similarities between the current results (full data available in dissertation [36]) and resident information needs in other studies [12][13][14][15][16] point to commonality of challenges and preferences among residents, perhaps independent of geographic location.These observations reaffirm that important opportunities remain for librarians and libraries in both providing access to information resources and educating clinicians in how to efficiently and effectively utilize such tools.The numbers may be higher than totals, as respondents were allowed to choose more than one option for the question.

Figure 1
Figure 1 Critical incident results