Context, Uncertainty, and Information Needs Within Clinical Practice

Florence M. Paisey

The real problem is not whether machines think, but whether men do. B. F. Skinner

Mendels concept of the laws of genetics was lost to the world for a generation because his publication did not reach the few who were capable of grasping and extending it; this sort of catastrophe is undoubtedly being repeated all around us, as truly significant attainments become lost in the mass of the inconsequential. Vannevar Bush

Information seeking behavior was related to context in the early eighties when Wilson (1981) asserted that contextual factors precipitated and prompted information seeking behavior and use. Wilson identified these contextual factors as environmental aspects such as the social and cultural environment, the politico-economic environment, and the physical environment. Since the early eighties, however, little research has been conducted on the effects of context in information seeking behavior. Other modes of behavior e.g., social, business, electronic (netiquette, chat), travel, or educational, have commonly been contextualized and their appropriateness and productiveness understood on the basis of prescribed expectations or values assigned to behavior in each role. We often assign measures of normal or deviant, functional or dysfunctional, excellent or mediocre based on contextual factors, values, and expectations. We understand how varying contexts and diverse cultures affect behavior ones values, habits, health, happiness, motivation, attitudes and cultivation. One can start with Franz Boaz, Ruth Benedict and Margaret Mead; environment and context have long been understood as key determinants in human development and behavior, as abundant anthropological, sociological and psychological studies have demonstrated. Yet, information scientists have spawned a plethora of information behavior models that attempt to describe information behavior without placing it in an environment or context until recently. Times are changing. Investigations of different aspects of context have been central concerns in studies of information behavior, information seeking

processes, and information retrieval over the last decade. Currently, it is recognized that information behavior occurs within multiple, overlapping contexts that inform, direct, or shape the character of the informational interaction (Cool & Spink, 2002). Information seeking, use, and evaluation take place within multidimensional contexts(ibid). Recent theoretical models of information behavior (Belkin, 1996) view context as a core variable or level of analysis in information behavior and information retrieval. This may be news to the information world, but psychologists have been talking about context since Pavlov behavior is behavior is behavior. Ones environment, replete with contingencies, dimensions, and uncertainties, cannot be divorced from ones life or those events that impact ones life, both overtly and covertly. Although the value of context has been recognized, it has defied any single, precise definition or identification of those elements bearing actual or potential influence on the relationship of context to information seeking and information retrieval (Cool & Spink, 2002). Several theorists (Vakkari, 1997; Cool, 1991, Rieh, 2004 ; Allen, 1997; Sonnenwald, 1999) have pointed out the ambiguous, interchangeable use between the terms context and situation. Dervin (1997) describes context as an unruly beast due to the difficulty in gaining methodological control over it. She asserts that her Sense-Making methodology can provide a framework for studying human behavior contextually, incorporating time, space, movement, power, gap, constraint, and force, yet

finds it a slippery concept to define. In 1997, Dervin commented that there is no term that is more often used, less often defined, and when defined, defined so variously as context. Vakkari (1997) contends that situation and context are used interchangeably without any effort taken to distinguish between the two conceptually. Cool (2001) simply refers to the distinction between the two concepts as murky, while Sonnenwald (1999) attempts disambiguation by characterizing contexts as embedded in situations. Talja (1999) defines context as: frames of reference that allow us to choose the relevant elements for study and concludes[d] that one way of explaining and understanding information seeking phenomena is to define them as patterns of behavior [while] another way is to understand them as phenomena mediated by social and cultural meanings and values (p. 762). Fundamentally, Talja is looking at those factors or variables observed to affect individuals information seeking behavior: socio-economic conditions, work roles, tasks, problem situations, communities, and organizations with their structures and cultures etcetera(Kuhlthau and Vakkari, 1999). Though Talja approaches the problem of context from two angles, they intersect at points of observation, behavior, and elements. These points

characterize her notion of context as something that can be objectified, though interpreted within the perspectives of cultural and social meaning. Cool and Spink (2002) broadly define the parameters of context in an editorial introduction to a group of papers focusing on user needs and addressing context in information retrieval. This definition views context as information environments in which information behaviors occur. While Cool and Spink (ibid) refer to information environments and information behavior, there is no mention of information need. In a previous paper by Wilson (1999a) information needs are said to arise out of complex, interrelated contexts and roles prompted by a person's physiological, cognitive and affective needs any one of which may be the person himself, or the role demands of the person's work or life, or environments. With regard to clinical information behavior, particular attention might be placed on the context of the person himself the clinicians own sense of competency and capacity to resolve issues of professionally-related uncertainty. Cool and Spink (2002) facilitate an understanding of the dimensions of context by succinctly identifying four levels of context:

Information environment level where channels of communication would be examined. Information seeking level where a persons goals or problem resolution and the means by which one satisfies them would be examined given a problem definition one looks at context in terms of the information seeking behavior performed.

The information retrieval context that examines the interaction between the user and the system within search sessions. The information query level where the linguistic context or the interaction between a query and the system is examined. (Does the system interpret the query correctly in terms of the context assigned?)

The notion of context is one which could easily occupy this paper, becoming a bid of a red-herring, if you will. However, human behavior does not occur in a vacuum, nor are human beings unresponsive to contingencies event, uncertainty, and information issues being one repertoire. I will satisfice(Simon, 1957) myself with the definition offered in Penguins Dictionary of Psychology: Generally those events and processes (physical and mental) that characterize a particular situation and have an impact on an individuals behavior (overt and covert). The specific circumstances within which an act or event takes place (Reber, 1995, p.159). Reber describes context as all those complex events processes, stimuli, and patterns that circumscribe a situation, distinguishing context as a descriptor of situation. In other words, a situation occurs within a particular context. This definition seems to reflect Sonnenwalds (1999) view. Ive explored an aspect of the concept of information seeking in context (ISIC). Physicians practice in particularly complex and distinct environments that

impose rigid contingencies, critical outcomes, and a multidimensional context on their work. No physician or clinician can practice effectively and safely outside of his or her medical context tools required to carry out their work are embedded in the context. There are, of course, extenuating circumstances that may necessitate clinical treatment outside of a standard medical context. However, these are exceptions and do not characterize the professional context. In some circumstances, remote diagnosis and treatment could be managed through telemedical devices and would be contextualized and defined on its unique elements and conditions. The context of information behavior for physicians is fraught with complications, obstacles, barriers or, as termed, within Wilsons general framework of information behavior (1999a), intervening variables. These barriers or intervening variables exist at the start of the patient encounter and throughout patient treatment to the end, in any medical situation. It is well to employ the concept of intervening variables as there are many contingencies, some of which may interact cohesively or randomly, decreasing uncertainty or escalating it. These contingencies bear on a clinician, where uncertainty presides and drives the need for information and subsequent information behavior. In the context of clinical care, uncertainty and a need for information are implicit with every patient appointment. Studies relating to how the context of a physicians work affects information behavior, a physicians pursuit or avoidance of

information, and informationist strategies to support clinical care occupy the remainder of this paper. Balsa (2003) maintains that uncertainty is a powerful force in medicine and supports Wennberg (1985) in viewing uncertainty as the single most important influence on a physicians [information] behavior (ibid) implying that the method by which a physician manages uncertainty will determine the level of expertise a patient will receive as well as the outcomes of that treatment. Numerous general models of information behavior view uncertainty as the prompt triggering an information need and ensuing information seeking behaviors (Wilson, 1981, 1996, 1999a; Belkin, 2005; Dervin, 1983; Krikelas, 1983; Kuhlthau, 1993, 1996). Wilson and Kuhlthau both employ the term uncertainty, while Belkin uses anomaly, and Dervin gaps. Wennberg (1985) identifies several types of clinical uncertainty: uncertainty about the patients ailment, uncertainty about whether treatment will be effective, and uncertainty about a patients personality their ethics and standards. Balsa (2003) identifies several additional roles of uncertainty, particularly with groups that differ ethnically from the clinician. Some of these uncertainties are not traditionally viewed as clinical information needs, however much they may affect the outcome of treatment. The relationship between doctor and patient has altered notably since the eighties, though traces of this alteration have been apparent since the seventies.

10

Previous to the eighties, physicians played a role in the therapeutic relationship characterized as authoritarian or paternal. Few patients questioned a physicians diagnosis; fewer arrived at the medical consultation with professional information regarding their ailment or known illness. Physicians carried a mystique(Plutchak, 2000) and were often felt to be unapproachable and inscrutable. This loftiness has faded as health care policies have changed, removing some of the privileges as well as preferred treatment and pharmaceutical courses that physicians once held in full control. Healthcare costs have soared and health benefits have decreased as a result of health insurance policies and the limitations placed on physician reimbursement and treatment. Rather than open ended consultations with ones physician, medical time is now, virtually, regarded monetarily, resulting in brief appointments that are routinely scheduled, offering little time to discuss the way one is feeling, the clinical questions a physician has time to ask, and the health-related questions a patient may need to ask. Though the physician may still be the source of diagnosis and treatment, the informed, healthliterate patient arrives at the clinic or the physicians office prepared with a series of questions, often written as a time-saving list. These questions are clinical questions to which a patient either receives an answer or doesnt. Gorman (1995) identifies four categories of clinical needs, yet relates none of these needs to the notion of uncertainty, anomaly or gaps. If there were no stimulus/uncertainty (anomaly, gap) no problem, no clinical question, or clinical information would exist or be necessary. It seems the issue of uncertainty

11

is vital in gaining a full or holistic account of the doctor/patient encounter. The four categories that Gorman (ibid) identifies include:

Unrecognized needs: inferred by measurement of physician knowledge or observation of clinical practice. Recognized needs: those articulated by the physician. Pursued needs: information seeking behavior is either observed or recalled at a later time. Satisfied needs: those needs for which information has been needed and for which information as been found and satisfied.

Gormans identification of unrecognized needs serves as a crude gauge of many uncertainties and problems that critically affect patient care, yet go unreported as they may not be viewed as clinical in nature. Since the IOM reports, To Err is Human(1999) and Speaking of Health(2002) policy centers and the Centers for Disease Control have identified dimensions of the doctor/patient relationship as of clinical concern, and identified these concerns as issues of health care. Uncertainty, as it relates to information needs and seeking, may insidiously cause corrosion in doctor/patient relationships. These unrecognized needs, activated by uncertainty are discussed briefly. One obvious, fundamental way in which uncertainty can affect clinical care is in the physicians own confidence in their skills. This variable or source of uncertainty results in varying behaviors. Such uncertainty may inhibit the initiation of information behavior, resulting in a barrier or placebo-like treatment. It may trigger vital information seeking behaviors that may include consulting

12

other physicians, or it may result in a referral to another physician or specialist. The relationship a physician has with himself/herself will decisively influence their efficacy as a clinician and incentive to resolve clinical uncertainty through purposive goal-oriented information behavior. Uncertainty also arises from the variables inherent in complex subjective, or discretionary tasks demanded in diagnostic and therapeutic evaluations. This uncertainty arises from the diagnostic ambiguity of clinical symptoms, laboratory tests, and unresolved differences of opinion or perspectives regarding the reliability of diagnostic and laboratory interventions. Numerous other sources of uncertainty affect a clinicians treatment. The Institute of Medicine (IOM, 2002) has identified language and cultural barriers as significant sources of mistrust, misunderstanding, and misdiagnosis. Various forms of communication barriers significantly affect doctor/patient relationships and account for considerable noise or uncertainty, and mistrust. A few communication barriers have been identified and may be briefly discerned as:

Possible (and frequent) miscommunication between clinician and patient. Inability of the patient to understand the physicians direction, diagnosis, and/or prescribed treatment. Doubt about quality and reliability of the clinicians assessment, particularly when cultural barriers exist. Communication noise between physician and patient may interfere with a patients confidence in the physicians judgment resulting in non-compliance with prescribed treatment.

13

It is clear that a physician faces a multilayered, multidimensional set of uncertainties during a doctor/patient encounter, particularly with a new patient. Those behaviors outlined above are sources of uncertainty that arise in a routine context with ostensibly few complicating clinical variables. Yet, many of these sources of uncertainty underlie the performance of critical health-related behavior (IOM, 2002; 1999). Wilson (1999) maintains that information behavior is relevant to levels of uncertainty and the solution of a problem or resolution of uncertainty. He argues that an individual progresses from uncertainty to increasing certainty through identifiable stages in a problem resolution process. The need to reduce uncertainty underlies purposive, goal-seeking behavior, identified as information seeking behavior. Basically, he views information behavior as a problem-solving process based on the notion of uncertainty reduction. Wilson et al. (2002) conducted a qualitative study of uncertainty and information seeking as it relates to Wilsons problem solving model (1999a) and factors originating in Ellis behavioral model, and Kuhlthaus process model. Wilson et al. (ibid) found that the uncertainty concept served as a useful variable in understanding information behavior. This finding supports the long-standing notion that uncertainty brings about information seeking due to a lack of understanding, a gap in meaning, or a limited construct (Kuhlthau, 1993a).

14

In a case study where one subject was a medical resident, Kuhlthau (1996) looked at the relationship between uncertainty and the complexity of a task. The medical resident reported that the complexity of the task affected her approach to information seeking. Complex tasks were identified by the participant as those needing substantial searching to acquire adequate information to meet her information goals. Kuhlthaus (ibid) findings support the notion of redefining roles and tasks associated with providing information service in the workplace. The medical resident in this study identified four levels of informational assistance she had encountered during her medical training. Three informational encounters with librarians were ineffectual; the first was described as just a room of journals; the second was described as just a person who sits behind the desk and has the job of filing things; the third was described as a real library where the librarian does searches for you; the fourth was described as quite apart from the others. When asked about the fourth librarian the resident described her as collaborative and interactive. The resident explained that when she gave the fourth librarian some keywords she would respond with what about this, and what about that, and let me see what I come up with. She regarded her as helpful to have her there and be able to interact. This fourth librarian was engaged with the researcher and associated information needs. The characteristics of the effective librarian advised on resources and process in addition to interpreting and connecting disparate pieces of information. This interactive librarian differs

15

from the traditional librarian whose role or relation to the patron has been more passive, providing access to references and sources on a particular topic. While the medical resident in Kuhlthaus (1996) study understood that the complexity of the task influenced her information behavior, she provided only a general statement about how she dealt with the complexity of a task complex tasks required substantial searching to acquire adequate information to meet her information goals. In this case an intermediary, the librarian, performed her substantial searching. For whatever reason, she did not manage the task herself. Kuhlthau (ibid) supported her notion of redefining roles and tasks in the workplace by illustrating the difficulty a medical resident experienced in seeking information that would address a complex task or problem. The context of this study involved research that a medical resident was conducting, either to resolve a clinical problem that arose in a clinical context or a research problem that an instructor or professor had assigned. In either context, the task for which the resident required intervention was perceived as a complex task, a task that the resident could not perform herself and required information to meet her goal. In this scenario the librarian (either in a hospital or university) intervened by locating sources and assisting with the interpretation and integration of information, reducing the residents uncertainty, or anomalous state of knowledge. The more complex the task the greater the potential uncertainty and need for information. The complexity of a task is a central feature in determining

16

consequent information needs (Vakkari, 1999). The concept of predeterminability and structuredness are both features of task complexity, or perhaps task architecture. If one has prior knowledge of a task, one can determine its structure and consequently the information required for its accomplishment, reducing uncertainty. The more one knows about the dimensions or structure of a task, the less complex it becomes. Complex tasks are new and genuine decision tasks where the information required for accomplishment can not be determined in advance (Vakkari, 1999). Such tasks, particularly of a critical nature, in a time constrained context, require intervention. Clinical medicine is a fertile source of scenarios that illustrate the complexity of tasks where the information need may be unexpressed or imperfectly understood. The strategy one employs in approaching complex tasks in the context of clinical medicine may also differ as one extracts, synthesizes, and applies knowledge to a clinical problem complicated by all those elements that individual personalities bring as patients. It is well to understand information behavior as a form of human activity in an attempt to understand human lifehow individuals and groups behave in varying cultures, what is of significance and meaning, what we can do to improve conditions, ensuring quality life. Over the last two decades, scientific and technological developments have led to the means of producing and distributing information in exponentially greater quantities. Electronic communication has impacted and transformed the tools we employ to communicate and interact in

17

society and culture. It has added yet another tool that socio-economic affluence will offer to those who have it, yet deny the tool to those who havent. New expressions to communicate this impact have emerged: the digital divide, the global South, the World Information Society Day (sponsored by the U.N.). As information has become more and more profuse, the process of finding needed information has also changed. Quality sources are buried among tiers of sources, some relevant, some disreputable, all requiring the skill of discernment. This process of identifying required sources amid abundance is a sophisticated skill, but of enormous importance. Within the an incomprehensible quantity of information, is a slim slice of knowledge or piece of information that can save a life, forecast disaster, manufacture fuel. The problem information professionals face is developing interactive indexing and retrieval systems that provide efficient, accurate access when we need it, where we need it, and how we need it with efficiency and ease. These systems can be designed and built, but first, it is necessary to understand the information behavior characteristics of specific user populations, and build systems that complement and meet their needs. No profession is in greater need of possessing such technology and skill than medicine. The proliferation of information in medicine is endemicmore information is produced, more research is conducted, more papers are published. How does one keep up, and if not keep up, simply gain accurate, efficient access? Right now, most clinicians dont; a scant few who research and practice in

18

bleeding-edge research and teaching hospitals do, but how many patients reach those few? Practicing medicine well, and applying current research findings, requires expert management as well as innovative information systems, finely organized with ground-breaking retrieval features. Information overload requires professionals trained in information management as well as expert knowledge managers who can search these systems once theyre built. Ultimately, one would want an information system so intuitive, so efficient, that any literate search, within context, could satisfy a question put to it. Evidence-based, point-of-care medicine will drive this effort, but, these systems have yet to be built, and information behavior has yet to be adequately understood to design such systems. Many systems have already been built, but few have come systems are still too inefficient, too imprecise, too crude to be effective for general practitioners. To illustrate the proliferation of medical literature and the urgent need for advanced retrieval systems, one might consider that about two million biomedical articles are publishedeach year. A physician would have to read six thousand articles a day to keep up with all possible relevant biomedical literature (Verhoeven, 1999). And if that isnt sufficiently staggering, consider that biomedical literature has grown 267% in ten years (ibid) and the rate of publication is still climbing. In view of this quantity of biomedical literature, when practicing clinicians are uncertain and perceive an information need, they need to engage in effective information searching behavior.

19

Leckie et al. (1996) performed a meta-review of information seeking characteristics of physicians and healthcare workers (among other professionals). They found that the range of information behavior among physicians in the role of clinician varied significantly and organized their reported findings as variablerelated differences relating to context, demographics, and complexity. Variables in reported specialties included: the focus of patient care, and those who looked at psychological aspects of illness. Variables in information behavior were widely scattered and identified as:

The specialty or discipline Experience, Age Type of practice Location or work site The number of questions posed. The number of questions answered. The size of the primary hospital.

In terms of patient care surgeons focused on routine monitoring, While pediatricians looked at what psychological effects may be influencing the illness. Recent graduates were contrasted with the variable of age use of library resources, and books increased with recency of training, and consultation with colleagues decreased as physicians grew older. This demographic of age as a descriptor of information behavior may be questionable. Does age predict information behavior or some other variable? A more recent study by Ely (1992)

20

refuted age as a descriptor, finding no significant difference between those demographics. It seems that looking at age as a demographic variable has some inherent bias. Recent clinicians may have been researchers during early years, changing to practice later. Those who choose to practice when young or as recent graduates, may re-tread as researchers and lecturers. Often, particularly in higher end practices, clinicians do both, practice a few days while teaching and researching others. As stereotypical notions regarding any population, in this caseage, fade, a more accurate notion of what drives professionals to scholarly literature may surface. Type of practice or specialty were found to influence information behavior or methods of research. General practitioners used unsolicited medical literature and consulted colleagues. Ob/Gyns preferred consultations with colleagues, rather than research professional literature or other sources. Internists were found to prefer journals and textbooks, while family practitioners consulted colleagues. Those clinicians working in an urban setting were found to use colleagues more than in other locations and clinicians in institutional practice informally consulted colleagues. A significant area of concern that Leckie et al. did not deliberate regards questions and time. Those physicians practicing in urban areas asked more questions given time, but pressured by a heavy case load, tended to ask the fewest. The statistics reported on answering questions were particularly disconcerting. Covell (1985) as cited by Leckie et al. (1996) reported that only 30% of perceived

21

and recognized physician information needs were met; this finding was corroborated by Murrays (1992) finding that only 1 out of 4 questions arising from a patient visit was met. Given that statistic, 75% of physician information needs are unsatisfied. Leckies research on the information seeking of professionals was published in 1996, a decade ago. Her findings were based on literature researched and published prior to that, some back to the eighties. It would be interesting if she conducted the same study now, comparing data. Much more information on types or categories of clinical questions are available Ely et al. (2000) have developed a taxonomy of clinical questions in order to better understand the information needs of clinicians. Verhoeven (1999) conducted an extensive study on the information needs of general practitioners, offering a rich source of information on their clinical uncertainties, information needs, and information seeking behaviors. Leckie et al. (1995) produced a general model of information seeking for professionals, based on their literature review. The model identifies work roles and tasks as fundamental to understanding a professionals (in this case, clinicians) practical information needs. Context was not included in their model, although it is implicit that contextual elements and structure will impact work performed in varied sites. According to their model of information seeking, the user is identified as seeking information with the objective of outcomes. No behavioral strategies, such as Ellis model or Kuhlthaus are included in this model. It seems that such

22

strategies are assumed in the seeking process. Outcomes, in a clinical sense could be interpreted as laboratory results, or any diagnostic technology employed to provide clinical information, aiding in a diagnosis. It seems that if outcomes suggest some ambiguity or uncertainty, the model depicts the user seeking information from sources. Sources, in the model, remain unidentified. The strength of Leckies model lies in her contextualization of information needs and the connection of context to a professionals role and consequent tasks. There are a few weaknesses: the lack of identifiable behaviors in seeking information in sources and the lack of reference to who will do the information seeking. In view of the vast sources of clinical research findings and publications, it seems unrealistic to expect physicians to conduct information seeking as a matter of routine. Clearly there are some issues that are best handled through ready reference or possibly a simple search. However, if 75% of clinical questions go unsatisfied, it is clear that not only do systems require greater efficiency, but a professional skilled in dealing with clinical questions and biomedical literature would be of great service. This paper has only skirted over the issues that the medical professional is facing with regard to clinical context, uncertainty, information needs, and searching. It is clear that research findings are not being used optimally, and cannot be use optimally, given the amount of biomedical literature available and the time it takes to search, filter the search and identify studies of direct relevance to the immediate clinical information need. Davidoff and Florance (2000)

23

proposed that a clinical librarian, an informationist, as they have termed the specialization, take on a clinical role as an integral member of a clinical group with a specialized expertise that can contribute vitally to clinical situations. The clinical librarian would read the full text of pertinent articles, extract relevant findings, write up a synopsis and present the research findings on rounds. With evidence-based medicine at the door, information overload, patient overload, and research findings that are lying in waste, unread, and unknown to the general practitioner in all specializations, the concept of a clinical librarian, an informationist, standing tall on a medical team and ready to pick up on any clinical uncertainties expressed or unperceived is a rescue conscientious clinicians would welcome with open arms. How will such a librarian be trained? Who will pay? These are the issues on the table. But, as Scott Plutchak, President of the Medical Library Association has said, If you think the information profession has changed over the last few years, you aint seen nothing yet. (Plutchak, 2000)

References

24

Agosto, D. E., & Hughes-Hassell, S. (2005). People, places, and questions: An investigation of the everyday life information-seeking behaviors of urban young adults. Library & Information Science Research, 27(2), 141-163. Belkin, N. J. (2005). Anomalous state of knowledge. In K. Fisher (Ed.), Theories of Information Behavior. New Jersey: ASIS&T. Booth, A. (2005). The body in questions. Health Information and Libraries Journal, 22(2), 150-155. Bystrm, K. (2002). Information and information sources in tasks of varying complexity. Journal of the American Society for Information Science and Technology, 53(7), 581-591. Cool, C. (2001). The concept of situation in information science. In M. E. Williams (Ed.), Annual review of information science and technology (Vol. 5). Medford, NJ: Learned Information. Cool, C., & Spink, A. (2002). Issues of context in information retrieval (IR): an introduction to the special issue Journal or Information Processing Management, 38(5), 605-611. Coumou, H. C. H., & Meijman, F. J. (2006). How do primary care physicians seek answers to clinical questions? A literature review. Journal of the Medical Library Association, 94(1), 55-60. Covell, D., Uman, G., & Manning, P. (1985). Information needs in office practice: are they being met? Annals of Internal Medicine, 103, 596-599. Davidoff, F., & Florance, V. (2000). The informationist: a new health profession? Annals of Internal Medicine, 132(12):996-8.(12), 996-998. Dervin, B. (1997). Given a context by any other name: methodological tools for taming an unruly beast. In P. Vakkari, R. Savolainen & B. Dervin (Eds.), Information seeking in context: proceedings from an international conference in information needs, seeking, and use in different contexts (pp. 13-38). London: Taylor. Dervin, B. (2005). What methodology does to theory: Sense-making methodology as exemplar. In K. Fisher (Ed.), Theories of Information Behavior (pp. 25-29). New Jersey: ASIS&T. Edwards, E. (1964). Information Transmission. London: Chapman & Hall.

25

Elfreda, A. C. (1991). Life in a small world: Applicability of gratification theory to information-seeking behavior. Journal of the American Society for Information Science, 42(6), 438-449. Ellis, D. (2005). Ellis' model of information seeking behavior. In K. Fisher (Ed.), Theories of Information Behavior. New Jersey: ASIS&T. Ely, J. W., Osheroff, J. A., Ebell, M. H., Bergus, G. R., Levy, B. T., Chambliss, M. L., et al. (1999). Analysis of questions asked by family doctors regarding patient care. BMJ, 319(7206), 358-361. Ely, J. W., Osheroff, J. A., Gorman, P. N., Ebell, M. H., Chambliss, M. L., Pifer, E. A., et al. (2000). A taxonomy of generic clinical questions: classification study. BMJ, 321(7258), 429-432. Fisher, K., Erdelez, S., & McKechie, L. (Eds.). (2005). Theories of information behavior. Medford: ASIS&T. Florance, V., Guise, N., & Ketchell, D. (2002). Information in context: integrating information specialists into practice settings. Journal of the American Medical Library Association, 90(1), 49-59. Ford, N. (1999). IR and creativity: towards support for the original thinker. Journal of Documentation, 55(5), 528-542. Foxlee, R. (2003). The information specialist in the clinical team: building expertise in evidence-based healthcare. Paper presented at the 10th Asia Pacific Special Health and Law Librarians Conference, Adelaide, Australia. Fuller, S., Ketchell, D., Tarczy-Hornoch, P., & Masuda, D. (1999). Integrating knowledge resources at the point of care: opportunities for librarians. Bull Med Libr Assoc. , 87(4), 393-403. Gaslikova, I. (1999). Information seeking in context and the development of information systems. Information Research: an international electronic journal, 5(1). Glimcher, P. W. (2005). Indeterminacy in brain and behavior. Annual Review of Psychology, 56(1), 25-56. Gorman, P. (1995). Information needs of physicians. Journal of the American Society for Information Science, 46(10), 729-736.

26

Inglis, I. (2000). Review: the central role of uncertainty reduction in determining behavior. Behavior, 137(12), 1567-1599. IOM. (1999). To err is human: building a safer health system. Washington, D.C.: The National Academies Press. IOM. (2002). Speaking of health: assessing health communication strategies on diverse populations. Washington, D.C.: The National Academies Press. IOM. (2004). Health literacy: a prescription to end confusion. Washington, D.C.: The National Academies Press. Jarvelin, K., & Wilson, T. (2003). On conceptual models for information seeking and retrieval. IRinformationresearch, 9(1). Keeling, C., & Lambert, S. (2000). Knowledge Management in the NHS: positioning the healthcare librarian at the knowledge intersection. Health Libraries Review, 17(3), 136-143. Ketchell, D. S., St. Anna, L., Kauff, D., Gaster, B., & Timberlake, D. (2005). PrimeAnswers: A Practical Interface for Answering Primary Care Questions. J Am Med Inform Assoc, 12(5), 537-545. Klein, M., & Ross, F. (1997). End-user searching: impetus for an expanding information management and technology role for the hospital librarian. Bulletin of the Medical Library Association, 85(3), 260-268. Kuhlthau, C. (1996). The concept of a zone of intervention for identifying the role of intermediaries in the information search process. Paper presented at the ASIS 1996 Annual Conference Proceedings, Baltimore, Maryland. Kuhlthau, C. (2006). The information process: a search for meaning rather than answers. 2006, from http://www.scils.rutgers.edu/~kuhlthau/Search%20Process.htm Kuhlthau, C., & Vakkari, P. (1999). Information seeking in context (ISIC). Information Processing and Management, 35, 723-725. Leckie, G., & Pettigrew, K. (1997). A general model of the informationseeking of professionals: role theory through the back door? . Paper presented at the Information Seeking in Context: Proceedings of an International Conference

27

on Research in Information Needs, Seeking, and Use in Different Contexts, Tampere, Finland. Leckie, G., Pettigrew, K., & Sylvain, C. (1996). Modeling the information seeking of professionals: a general model derived from research on engineers, health care professionals, and lawyers. Library Quarterly, 66(2), 161(133). Marchionini, G. (1998). Information seeking in electronic environments. Cambridge: Cambridge University Press. Maviglia, S. M., Yoon, C. S., Bates, D. W., & Kuperman, G. (2006). KnowledgeLink: Impact of Context-Sensitive Information Retrieval on Clinicians' Information Needs. J Am Med Inform Assoc, 13(1), 67-73. Miller, G. (1968). Psychology and Information. American Documentation. Plutchak, S. (2000). Informationists and librarians. Bulletin of the Medical Library Association, 88(4), 1-3. Richardson, J. V. (1999). Understanding the reference transaction: A systems analysis perspective. College & Research Libraries, 60(3), 211-222. Sackett, D., William Rosenberg, J. A. Muir Gray, Haynes, R. B., & Richardson, S. (1996). Evidence based medicine: what it is and what it isn't British Medical Journal, 312, 71-72. Schulz, A., & Luckmann, T. (1974). The structures of the life-world. London: Heinemann. Schwartz, K., Northrup, J., Israel, N., Crowell, K., Lauder, N., & Neale, A. V. (2003). Use of on-line evidence-based resources at the point of care. Family Medicine, 35(4), 251-256. Shershneva, M. B., Slotnick, H. B., & Mejicano, G. C. (2005). Learning to use learning resources during medical school and residency. Journal of the Medical Library Association, 93(2), 263-270. Shipman, J., Cunningham, D., Holst, R., & Watson, L. (2002). The Informationist Conference: report [special report]. Journal of the American Medical Library Association, 90(4), 458-464. Simon, H. (1957). Models of man -- social and rational. New York: Wiley & Sons.

28

Sonnenwald, D. (1999). Evolving perspectives of human behavior: contexts, situation, social networks and information horizons. Information Processing and Management, 36(3), 461-479. Soo Young, R. (2004). On the web at home: information seeking and web searching in the home environment. J. Am. Soc. Inf. Sci. Technol., 55(8), 743-753. Spink, A., Wilson, T. D., Ford, N., Foster, A., & Ellis, D. (2002). Information-seeking and mediated searching: theoretical framework and research design. Journal of the American Society for Information Science and Technology, 53(9). Sundin, O. (2000). Brief Communication. Qualitative research in health information user studies— a methodological comment. Health Libraries Review, 17(4), 215-218. Swinglehurst, D. A. (2005). Information needs of United Kingdom primary care clinicians. Health Information and Libraries Journal, 22(3), 196-204. Talja, S., Keso, H., & Pietilainen, T. (1999). The production of "context" in information seeking research: a metatheoretical view. Information Processing and Management, 35, 751-763. Tarczy-Hornoch, P., Kwan-Gett, T., Fouche, L., Hoath, J., Fuller, S., Ibrahim, K., et al. (1997). Meeting clinician information needs by integrating access to the medical record and knowledge resources via the Web. Paper presented at the Proceedings of the AMIA Annual Symposium. Taylor, R. S. (1985). Citation Classic - Question-Negotiation and Information Seeking in Libraries. Current Contents/Social & Behavioral Sciences(47), 24-24. Vakkari, P. (1997). Information seeking in context: a challenging metatheory. In P. Vakkari, R. Savolainen & B. Dervin (Eds.), Information seeking in context: proceedings from an international conference in information needs, seeking, and use in different contexts (pp. 451-464). London: Taylor Graham. Vakkari, P. (1999). Task complexity, problem structure and information actions integrating studies on information seeking and retrieval. Information Processing and Management, 35, 819-837.

29

Verhoeven, A. (1999). Information seeking by general practioners. University of Groningen, Groningen. Vygotsky, L. (1978). Mind in society: the development of higher psychological processes. Cambridge, MA: Harvard University Press. Webb, R. E. (1995). Platform for change: the Medical Library Association's response to the professional development challenge. Health Libraries Review, 12(1), 23-27. Wilson, T. (1999). Exploring models of information behavior: the uncertainty project. Information Processing and Management, 35, 839-849. Wilson, T. (2000). Human Information Behavior. Information Science Research [special issue], 3(2), 48-55. Wilson, T. (2000). Models in information behavior research. Journal of Documentation, 55(3), 249-271. Wilson, T., Ellis, D., & Ford, N. (2000). Uncertainty in information seeking. InformationR.Net. Wilson, T., Ford, N., Ellis, D., Foster, A., & Spink, A. (2002). Information seeking and mediated searching. Part 2: uncertainty and its correlates Journal of the American Society of Information Science and Technology, 53(9), 704-715. Wilson, T. D. (1981). On user studies and information needs. Journal of Librarianship, 37(1), 3-15. Wilson, T. D. (1999). Models in information behaviour research. Journal of Documentation, 55(3), 249-270. Wilson, T. D. (2005). Evolution in information behavior modeling: Wilson's model. In K. Fisher (Ed.), Theories of Information Behavior. New Jersey: ASIS&T. Wilson, T. D., & Walsh, C. (1996). Information behaviour: an interdisciplinary perspective (a report on a review of the literature): British Library Research and Innovation Report. Yoon, S., Kaufman, D., Mendonca, E., Cimino, J., & Johnson, S. (2004). Scenario-based assessment of information needs. International Medical Informatics Association