Medical librarians and physicians possess a unique partnership. The librarian in the hos-pital or medical center serves many health professionals. In this paper the relationship with the physician shall be examined. This illustrates current medical library practice.

Both medical librarians as well as physicians have experienced many changes throughout the past decade. These changes, both positive and negative, have influenced both professions and the unique partnership. Major economic and technological developments have acted as the catalysts for change.

The major focus of this paper is to illustrate the changes in the medical librarian's rela-tionship with the physician. Information retrieval practices of this user group continue to evolve and change. The implications for reference librarians are great. We have much to be optimistic about. This partnership between medical librarian and physician will continue to evolve, with greater sophistication. The partnership is positive because it works.

Physicians now possess many choices involving information retrieval. End-user search-ing is a reality for many physicians as well as other health professionals. The need for accurate information is very great. However various considerations regarding this phenomenon have appeared. Many physicians are confused by the astonishing array of information retrieval products, vendor promises, and changes in traditional medical library practices.

Within this environment both partners require continuing education. The medical librarian must not only master new technologies, but remain aware of physicians' needs and concerns. The librarian must not take this lightly because serious implications for the profes-sion, and the partnership with physicians is at stake. Complacency will result in the eventual erosion of medical librarianship into oblivion.

2. SOME FACTORS THAT INFLUENCE INFORMATION RETRIEVAL

It is a known fact that all libraries have experienced negative economic conditions over the past few years. Library budgets and institutional support has shrunk. The concept of "downsizing" has become a reality. In addition to this reduction in support, serials prices have risen dramatically, while database vendor charges have also increased. These are very impor-tant facts when discussing the information retrieval process.

While the demand for accurate, complete, and timely information is great, the demands on librarians have increased. Medical librarians typically work in two principal settings in the United States: hospital or academic medical center. Thus the work environment is institutional. As of 1990 there were approximately 5,000 members of the Medical Library Association. Founded in 1898 the goals of the Association are "to design and develop information systems, creation and provision of information services, and educational programs for health informa-tion users and research in health information science" (MLA, 1990).

In 1989, there were 600,789 physicians, in all practices, in the United States (AMA, 1990). As of 1990-91 there were 126 accredited medical schools in the United States. There is a current total of 64,986 medical students and a faculty of 74,807 (Jonas, 1991). These numbers are both impressive and large. This is a sophisticated group of students and faculty who have acute information need.

As these numbers suggest, medical librarians have great responsibilities. The large number of physicians, faculty, and students and the relatively low number of librarians has created much demand for the librarians time. Since the demand for competent and accurate information is very great, medical librarians must remain active in their profession as well as up-to-date on contemporary developments.

Admittedly there are some gaps in information delivery. The U.S. Government recently charged the National Library of Medicine with providing more information access to "under-served" physicians in all areas of the United States. Database vendors and others have also tried to "meet the needs" of physicians. Many impressive information retrieval services have been developed to target this user population. End-user searching has been "sold" to many as a solution to information needs. Ultimately the medical librarian is the final source for these users. Physicians consult librarians on many of these services. It is still more cost effective and efficient for librarians to store, disseminate, and conduct comprehensive database searches than any other group. The National Library of Medicine, disseminator of biomedical information, is proof of this point.

3. HEALTH CARE ECONOMICS IN THE UNITED STATES

The 1980's were not a good decade for the American economy. Economic developments have adversely effected the quality of libraries and the delivery of health care. Greater burdens have been placed on both physicians and librarians. It is true that many impressive technolo-gical advances have occurred in both medicine and librarianship. However the negative aspects of the economic situation have had a serious impact. This is undeniable.

Within the medical profession the trend to "corporatize" has been very great. Increasingly medicine has become subject to greater administrative and bureaucratic controls (Feinglass, 1990). A major cause of this trend has been the economic situation. Hospital expenditures have also risen. Between 1979 and 1982 these expenditures rose 16% per year (AHA, 1990). In the year 1970, $248.1 billion, or 9.1% of the GNP was spent on health care. By 1987 this figure rose to $500.3 billion, or 11.1% of the GNP (U.S. Bureau of the Census, 1990). As costs have obviously risen, a larger share of the GNP has been spent on health care. Yet, the number of hospitals that serve the American people has declined. In 1970 there was a total of 7,123 hospitals, but by 1980 there were 6,965. In 1987 the total fell to 6,821 (U.S. Bureau of the Census, 1990).

Many Americans are aware and concerned over these developments. The health care situation, combined with the war on drugs, educational concerns, and the national debt will remain major social issues throughout the 1990's. Another health care issue is health insurance coverage. Most Americans, regardless of their political views, believe that this is a serious issue. In 1988, 211.6 million persons (87.1% of the total population) possessed health insurance. However an additional 31.5 million persons were without coverage (Health Insurance Association of America, 1990).

Certainly the statistics presented here have influenced the quality of life and the delivery of health care. These developments have naturally effected librarianship. Much remains to be done throughout the 1990's to solve these problems.

4. IMPLICATIONS FOR MEDICAL LIBRARIANS

The statistics and trends presented in section three of this paper are disturbing. Despite these negative socio-economic indicators, medical librarians continue to provide professional levels of service. The demand for health sciences information is very great. New technologies have enabled us to provide higher levels of service, instruction, and document retrieval to physicians. End-user searching, despite some problems, has been a librarian led success story. With impressive technologies such as full-text searching, local area networks, hyper-media, and CD-ROM, user expectations have risen. The user is now fully cognizant that he is a part of "the global information village," and is not content simply to utilize his institutions library only. Thus, end-user searching has provided more work for Interlibrary loan librarians and support staff.

Like other librarians, the medical librarian faces the dilemma of shrinking budgets, reduced staff, the need to keep up with new technologies and increased responsibilities. Some of these new technologies are cost prohibitive. Because of the decline in monetary support, other library services are carefully assessed and monitored. Serials, books, audiovisuals and index subscriptions have all increased in cost. In 1988 scholarly journal prices increased by more than 2.5 times the rate of inflation in the United States as measured by the CPI (Con-sumer Price Index) (Marks, 1991).

We know that an exciting and powerful array of technological products exist for informa-tion retrieval. However the costs involved in these services present librarians with obstacles. Difficult decisions must be made. Because it was believed that various institutions, areas of the United States, and groups of health professionals were left out of new developments, the United States Congress authorized the National Library of Medicine to disseminate its services to the underserved. NLM products such as Grateful Med is marketed to health care profes-sionals through the Regional Medical Library program. One possible solution to the serials dilemma is the electronic journal. Several scientific associations in the United States are about to offer this delivery service. However this is still in an experimental stage, it is not yet on a convenient mode of operation (Wilson, 1991).

The position of hospital libraries is precarious. In 1990, the American Hospital Associa-tion (AHA) conducted a survey of hospitals in the United States. This survey was sent to 6,853 hospitals. Of this total 2,167 (31.6%) possessed libraries that met the following four criteria:

1. An organized collection of printed or other library materials,

2. A trained staff to provide and interpret materials,

3. An established schedule in which services are available to clientele, and

4. Physical facilities necessary to support such collections.

A total of 1,671 hospitals did not meet any of the four criteria. One or more criteria was met by 863 institutions, while 696 possessed no services or facilities (AHA, 1991).

Is this really an acceptable situation? Medical librarians are a skilled group that deserves more support from institutions. The support that now exists is not optimal and requires impro-vement. Librarians must demonstrate their skills and continue to remain up-to-date with new developments. We cannot remain complacent or complain like children. Naturally we work in our institutions to serve faculty, health professionals, students, interns, and residents. How-ever "we are here for the patient." (DeBakey, 1991). Ignorance of this basic truth will have further adverse effects on the physician-librarian partnership.

5. INFORMATION NEEDS OF PHYSICIANS

This user group is very dependent on the written or spoken word. The format now includes audiovisual, teleconference, database or the traditional book or journal article. Like librarians, continuing education is necessary for professional performance.

The medical profession is not static. .It is based on research, clinical studies, case reports, drug trials, animal experimentation, and other activities. Current information is the lifeblood of this user group. It cannot be emphasized enough that this user group requires efficient, accurate, and accessible information resources. Thus, access to information services provided by a professional medical librarian is essential.

The medical librarian remains a major factor in the dissemination and delivery of biome-dical information. Librarians retrieve, interpret, store, disseminate, and index information more efficiently and accurately than any other information provider. Others may provide the service (and charge much for it), yet it is not as cost effective as the librarian. Therefore the librarian remains a focal point in the information process. Yes, many physicians perform their own database searches on end-user systems. However these users do depend on librarians to meet their information needs.

In a study of clinical teaching, up to 23% of questions asked required the use of library resources. Half of the questions required the consultation of patient medical records. Many questions required the synthesis of both medical knowledge and patient information (Osheroff, 1991). From one's own experience many physicians will consult library materials to confirm their findings.

6. THE MEDICAL LIBRARIAN AND THE PHYSICIAN AS END-USER

As mentioned previously, the medical librarian plays an important role in the information process. Access to professional librarians' services is even more necessary because of the introduction of new technologies. Many users not only require assistance in conducting data-base searches, but also require advice in the selection of relevant software and other services. While end-user searching has been well reported and praised in literature, yet it has been found that advice and instruction from librarians to the user population remain significant. Further-more some studies have found that end-users searching of MEDLINE sometimes field medio-cre or unsatisfactory searches (McKibbon, 1990).

At some point the end-user will make the decision to consult the experienced searcher, abandon end-user searching, or request a mediated search from the librarian. Providing advice and instruction is challenging to librarians and remain an intellectual extension of the reference interview. It is a rewarding exercise that provides insight into the physicians' information query. Thus, end-user searching has extended the scope of reference activities without dimini-shing the role of the librarian.

It is important for medical librarians to realize this change in reference service. It would be optimal to provide more support to end-users such as the offering of database updates, refresher courses, and other related activities.

7. WHITHER THE MEDICAL LIBRARIAN-PHYSICIAN PARTNERSHIP?

Some of the various negative factors that have influenced the medical librarian-physician partnership have been described in this short paper. A brief overview has been provided on this unique area of librarianship. The partnership will survive because both parties are interested in its success. The professional character will be maintained for several reasons:

• Librarians are efficient and cost-effective information professionals. They provide their users with indexing, document delivery, interpretation, information storage and retrieval, and access. While end-user systems continue to attract new physicians, librarians remain the expert in this field. Both information consumers and providers consult with librarians.

• Librarians have been adversely effected by the negative aspects of the world economy, but fundamentally their services are needed.

• Complacency within the professions remains a problem that cannot be ignored. We should all contemplate the larger purpose for which we work. This is true not only for librarians, but physicians as well. As professionals we hold responsibilities to our institutions, those we serve, and our professions. Continuing education activity is essential for all aspects of our work. Through this activity we build upon our knowledge and experience while we remain contemporary within our fields. Failure to do this will result in a drift into oblivion.

• Reference librarianship has a bright future. The reference interview has obviously been expanded through the proliferation of end-user systems, and the plethora of questions that ema-nate from this activity. This has served to strengthen the medical librarian-physician partner-ship. A greater intellectual component has been added to this relationship. It will continue to expand because new users are constantly added.

The prioritization of activities within this partnership is essential. As partners we work together toward identical goals -- better patient care and medical education and research through improved information access. Medical librarians must advance their own interests, as physi-cians already do, in order to strengthen this relationship. We must realize our professional capabilities and limitations. Many developments have taken place, and many more shall occur. Medicine, librarianship, and society as a whole is in a state of flux!

REFERENCES

American Hospital Association. Hospital Statistics 1990-1991. Chicago, IL: American Hos-pital Association, 1990. p.xxxi.

American Hospital Association. Survey of Health Sciences Libraries in Hospitals--1989. Executive Summary. Chicago, IL: American Hospital Association, 1991. p.2.

American Medical Association. Physician Characteristics in the U.S. Chicago, IL: American Medical Association, 1990. p.8.

DeBakey, M.E., "The National Library of Medicine: Evolution of a premier information cen-ter," JAMA 266 (9): 1252 (September 4, 1991).

Feinglass, J., and Salmon, J.W., "Corporitization of medicine: The use of medical manage-ment information systems to increase the clinical productivity of physicians," International Journal of Health Services, 20 (2): 233-253 (1990).

Health Insurance Association of America. Source Book of Health Insurance Data 1990. Washington, D.C.: Health Insurance Association of America, 1990. p.22.

Jonas, H.S., Etzel, S.I., and Baransky, B., "Educational programs in US medical schools," JAMA 266 (7): 913-920 (August 21, 1991).

McKibbon, K.A., Haynes, R.B., Dilks, C.J., Ramsden, M.F., Ryan, N.C., Baker, L. Flemming, T., & Fitzgerald, D., "How good are clinical MEDLINE searches? A comparative study of clinical end-user and librarian searches," Computers & Biomedical Research 23 (6): 583-593 (December 1990).

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Medical Library Association. MLA Directory, 1990/91. Chicago, IL: Medical Library Asso-ciation,1990. p.1.

Osheroff, J.A., Forsythe, D.E., Buchanan, B.G., Bankowitz, R.A., Blumenfeld, B.H., & Miller, R.A., "Physicians' information needs: Analysis of questions posed during clinical teaching," Annals of Internal Medicine 114 (7): 576-581 (April 1, 1991).

U.S. Bureau of the Census. Statistical Abstract of the United States 1990 (110th edition.) Washington, D.C.: U.S. Government Printing Office, 1990. p. 105, 134.

Wilson, D. L., "Testing time for electronic journals," Chronicle of Higher Education 38 (3): A22-A24 (September 11, 1991).