International Journal of Medical Informatics 139 (2020) 104144

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International Journal of Medical Informatics

journal homepage: www.elsevier.com/locate/ijmedinf

Clinical information seeking behavior of physicians: A systematic review T

a b b, c
Azra Daei , Mohammad Reza Soleymani , Hasan Ashrafi-rizi *, Ali Zargham-Boroujeni ,
Roya Kelishadid
a
Department of Medical Library and Information Sciences, School of Management and Medical Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
b
Health Information Technology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
c
Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
d
Department of Pediatrics, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Diseases, Isfahan University
of Medical Sciences, Isfahan, Iran

A R T I C LE I N FO A B S T R A C T

Keywords: Introduction: Physicians encounter a large number of questions during patient care. Therefore, finding high-
Barriers quality evidence provides a good opportunity to improve patient care and continue learning.
Clinical information-seeking behavior Objectives: The present study aims to obtain a comprehensive understanding of the physicians’ clinical in-
Facilitators formation-seeking behavior.
Information need
Methods: A systematic review was conducted according to the PRISMA guidelines. The Web of Science, PubMed,
Patient care
Scopus, ProQuest, Emerald, Wiley Online Library, Science Direct, Cochrane Library, and Embase databases were
Point-of-care
systematically searched based on the defined criteria. The inclusion criteria were the original articles in the
context of patient care and full-text articles published in English from 2002 to 2017. The articles were reviewed,
selected, and analyzed in group discussions.
Results: Seventy-three articles met the study criteria. Therapy, diagnosis, and epidemiology ranked the highest
ones among physicians’ information needs. The mean frequency of questions raised during patient care was
varied from 0.18 to 1.5 per patient, and the percentage of questions answered ranged between 22.8 and 93 %.
The time taken to find the answers to the questions was between 2 to 32 min. Consultation with colleagues,
alongside reviewing journal articles, Internet websites, textbooks, and MEDLINE/PubMed were the most fre-
quently used sources reported in the retrieved articles. Further, common search strategies used by physicians
included keywords, Boolean operators, similar medical terms, and advanced search. In addition, lack of time,
and information searching skills and the unawareness of accessible sources were the most frequent barriers while
easily searching and finding information and summaries and synthesized evidence-based materials mainly fa-
cilitated information seeking.
Conclusions: Physicians increasingly encounter clinical point-of-care questions. However, the facilitation of ac-
cessing online information sources has not enabled the physicians to find answers to many of their questions.
Considering the fact that they often refer to colleagues, Internet websites, and databases to find answers, the
quality of information should be improved by evaluating the physicians' information-seeking behavior in the first
stage, and developing information technology in a point-of-care environment, integrating EHR systems to
communicate with colleagues, and accessing databases in the second stage.

1. Introduction
Medicine is an information-based science. A major part of clinical
actions includes gathering information about patients, processing the
information, and eventually taking action based on it, so that physicians
can act properly for the right patient at the right time [1]. Therefore,
physicians' right to access appropriate clinical information for making
key decisions is indisputable [2]. Today's problems such as high costs,
poor quality of services, physician burnout, and patient dissatisfaction
have revealed inefficient information management practices [3]. Un-
doubtedly, access to accurate, immediate [4], reliable [5], and up-to-
date clinical information [6] leads in fewer referrals, better diagnostics
and more effective treatments [3], reduced medical errors [4,7,8], ac-
cess to the best evidence [9], and higher patient satisfaction and

⁎
Corresponding author at: Hezarjerib Street, Postal code: 8174673461, Isfahan, Iran.
E-mail addresses: adaei@mng.mui.ac.ir (A. Daei), soleymani@mng.mui.ac.ir (M.R. Soleymani), hassanashrafi@mng.mui.ac.ir (H. Ashrafi-rizi),
azargham@gmail.com (A. Zargham-Boroujeni), kelishadi@med.mui.ac.ir (R. Kelishadi).

https://doi.org/10.1016/j.ijmedinf.2020.104144
Received 15 February 2019; Received in revised form 25 February 2020; Accepted 7 April 2020
1386-5056/ © 2020 Elsevier B.V. All rights reserved.
A. Daei, et al.
recovery [4,10,11]. Accordingly, high quality medical services can be
provided and various health problems will be resolved [4].
Considering the challenge of information overload in the healthcare
sector, where information is doubled every 20 years [4,9,12,13], and
due to the complexities of care, physicians increasingly encounter
clinical point-of-care (POC) questions [3,14]. Physicians can answer
only a limited number of questions and in most cases, they use their
memory although some have outdated or incorrect information [6].
Surprisingly, physicians are not able to find answers to a significant
percentage of questions despite the easy access to information sources
[15]. Accordingly, some clinical questions remain unanswered [15,16]
and this affects the quality and outcome of the decisions [14].
Recent advances in online clinical knowledge bases have offered
opportunities to solve this problem. These opportunities have provided
online evidence for POC, which is a strategy to make evidence-based
decisions [14] and may be a daunting process for physicians who lack
time, confidence, and expertise to synthesize the retrieved studies [17].
Previous studies have indicated that these resources are capable of
providing correct and appropriate answers to clinical questions and
improving physicians’ performance [9,14,15,17,18], which require ac-
cessing electronic resources and promoting appropriate information-
seeking skills [4]. However, despite the increased access to online re-
sources, physicians still prefer using print resources, continuing medical
education, and consulting with their colleagues in order to find the
answer to clinical questions [9,14,19]. There seem to be major barriers
to use a wide range of databases and digital archives, such as evidence-
based medical resources, for supporting clinical decisions [15,20].
Some of these barriers refer to lack of easy access to reliable and up-to-
date information, problem in formulating search strategies [14,21],
processing a considerable amount of information at a very short time
inpatient care setting [15], lack of basic information technology (IT)
skills, and the institutionalization of the idea that the information found
has no effect on improving their medical practice [22]. In addition,
despite the development of medical information technology in the de-
signing field, most medical information systems have failed to meet the
expectations mainly due to lack of knowledge regarding the informa-
tion needs and information-seeking behavior of physicians, along with
not understanding the nature of clinical procedures such as POC [3,6].
Hence, it is essential to identify the needs and find ways to meet them,
as well as understanding the physicians' information-seeking behavior
[2].
A complete understanding of the information-seeking behavior
starts with the information needs [10]. After individuals determine
their information needs, they attempt to seek and the information-
seeking process begins. Information-seeking behavior is considered as
the complex pattern of humans' interactive behavior when seeking any
kind of information [23]. Wilson considers the information-seeking
behavior as a process, which is developed in permanent interactions
between individuals, social networks, situations, and contexts. He be-
lieves that social contexts and situations create information needs and
limit the individuals to use certain accessible resources [24]. In this
regard, the category of occupational tasks, which is known as a fun-
damental environmental issue, affects the information-seeking pro-
cesses. The logic related to formulating a framework for seeking in-
formation is rooted in the belief that information-seeking processes
should be investigated in a wide occupational context, rather than out
of context [25]. According to Davies [10], identifying the information
need is regarded as the first stage in the physician's information-seeking
process. Then, the physician should formulate a question in order to
achieve an answer. In the next stage, a method for accessing the in-
formation should be considered. Physicians' clinical information-
seeking behavior varies due to their sensitive job and occupational
tasks; and is, also, largely depended on their workplaces, such as an
office or a hospital, where it is of great significance to receive high-
quality information in the shortest possible time.
In addition to the systematic reviews by Dawes and Sampson [26]
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International Journal of Medical Informatics 139 (2020) 104144
and Del Fiol et al. [27], several informal literature reviews have been
conducted regarding information-seeking behavior [27]. Dawes and
Sampson’s review covered the articles from 1966 to 2001 that de-
termined the nature of physicians’ information resource preferences in
clinical practice. Del Fiol et al. reviewed the articles up to 2011 and
dealt with the clinical questions posed by the clinicians, including
nurses, nurse practitioners, physician assistants, medical residents,
physicians, dentists, and managers. Therefore, a systematic review
specifically about physicians is needed since variety in a population can
create ambiguity in the results of the study due to different occupa-
tional contexts and different settings. Accordingly, the present review is
updated and expanded of the Dawes and Sampson’s review and the
studies include related to the physicians’ clinical information-seeking
behavior during patient care. As another main characteristic in the
present review, the term "clinical" is used to distinguish it from the
information-seeking behavior associated with teaching, research, and
administration. Therefore, the present study was targeted to obtain a
full understanding of the physicians' clinical information-seeking be-
havior. To this end, this systematic review has provided an updated and
expanded of Dawes and Sampson’s review [26] based on the following
objectives:
- To determine the physicians' clinical information needs and re-
sources used to meet;
- To determine various aspects of physicians' clinical information-
seeking behavior;
- To determine the barriers and facilitators affecting the physicians'
clinical information-seeking behavior;
- To determine the theories and models of information-seeking be-
havior used in the articles.
2. Methods
The present study is an update of the prior systematic review by
Dawes and Sampson's [26] which includes articles about information
needs and information-seeking behavior of physicians. The review is
conducted according to the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) guidelines.
2.1. Data sources and search strategies
Databases in the present study included the Web of Science,
PubMed, Scopus, ProQuest, Emerald, Wiley Online Library, Cochrane
Library, Science Direct, and Embase. The keywords selected to be
searched in the databases in the title, abstract, and keywords of the
articles included information-seeking behavior, information need,
knowledge exchange, information searching, knowledge need, mana-
ging information, information behavior, physician, doctor, medical
personnel, healthcare personnel, health practitioner, clinician, and
healthcare professional. Complete overview over the applied search
strategies are described in the Table 1 supplement. Duplicated citations
were removed using EndNote software and a manual revision was
conducted for verification.
2.2. Inclusion and exclusion criteria
The articles which investigated different aspects of the physicians’
information need, information sources, and the behaviors, barriers,
facilitators, and theories related to information seeking were selected in
the first stage. The inclusion criteria of the selected articles included
being full-text and original, written in English, and published from
2002 to December 2017. In this regard, based on the initial studies, the
research team decided to consider the starting point of this review from
end of the search of Dawes and Sampson's systematic review [26] that
covered the articles from 1966 to 2001. In addition to our findings, Del
Fiol et al. [27] identified Dawes and Sampson's systematic review as the
A. Daei, et al. International Journal of Medical Informatics 139 (2020) 104144

only systematic review on clinicians’ information-seeking behavior. In

order to obtain authoritative information, our study included only peer-

Evaluation criteria: 1. How was the quality of the tools and methods? 2. Why is it
reviewed journal articles and the articles published in a format other
than the original paper, such as reviews and editorial letters, and the
proceedings were removed. We used a narrow definition for clinicians
encompassing general practitioners, family physicians, residents, fel-
lows, specialists, and sub-specialists who faced some questions during
their clinical practice and needed clinical information to answer them.
We excluded dentists, rehabilitation physicians, psychiatrists, ortho-
pedic doctors, physician assistants, complementary and alternative
medicine practitioners, medical students, nurse practitioners, nurses,
medical librarians, care managers, and any patient care providers due
to the different nature of their fields from clinical physicians such as
different educational backgrounds, work in different settings and their
different approaches of helping patients. Accordingly, the articles in

associated with Review questions?

which a combination of clinical physicians and other care providers
were used as the population, were removed in order to achieve more
specific, uniform, and integrated results. Further, we excluded the ar-
ticles about physicians' information-seeking behavior outside the con-
text of patient care, such as research and training.

2.3. Abstract screening

In this stage, all titles and abstracts of articles were screened based
on the objectives to select relevant studies. The titles and abstracts of all
retrieved references were reviewed by two members of the team (A.D. &
M.S.), individually; and the articles were labeled as “not relevant” or
“potentially relevant”. H.A., individually, reviewed 10 random samples
Related research

of the references.
questions

2.4. Article selection

The full texts of the articles labeled as “potentially relevant” were

Findings

retrieved and considered for eligibility and methodological quality by

two members of the team (A.D & H.A.), individually. Any disagree-
ments between the two reviewers were reconciled through consensus
Model details presented in the

with a third reviewer (M.S.). In addition, references of the included

articles were checked for other articles eligible for this review.

2.5. Data extraction

Reviewers, individually, analyzed the selected articles to extract the

data into a fixed spreadsheet tool for data abstraction (Table 1), which
study

was designed and used in systematic reviews by Rahimi et al. in 2013,

2014, & 2018 [28–30]. This tool kept the extracted information con-
Research tools

sistent: title/author/year, study type, objectives, population, research

tools, model details presented, findings and evaluation criteria. The
evaluation criteria included: validity, reliability, generalizability and
relevance of the research methods, tools and measurements, and in-
terpretations.
Population

Then, the analyses were discussed in group meetings. The results of

the discussions on each study were presented in a specific format in
order to reach common viewpoints and were summarized in the
Objectives

Table 2. In this regard, three sessions were held by the authors to fi-

nalize the analyses and solve any potential conflicts.

3. Results
Study type

The initial search strategy in the electronic database retrieved 9785

articles without any limitations. Then, 7776 articles were retrieved with
Title/ author/ year

time, language, and research type limitations, among which 5381 ar-
ticles were eliminated due to duplicate items. After screening the titles
Research tool.

and abstracts, 2162 articles were excluded and 243 articles were se-
lected for full-text screening, among which 73 articles met the study
Table 1

criteria. Fig. 1 illustrates the strategy for searching and selecting the
articles based on the PRISMA guidelines [31].

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A. Daei, et al. International Journal of Medical Informatics 139 (2020) 104144

Table 2 3.1. Physicians’ information needs

Group meetings analysis form.
Title/ author/ First Researcher Second researcher Agreements Types of physicians’ information need in patient care are presented
year analysis analysis in Table 3. In this section, physicians’ clinical information needs have
been reported and non-clinical necessary information such as education
and research were excluded. The initial analysis showed that among the
24 studies which evaluated physicians' clinical information needs,
treatment and diagnosis were of top priorities. In this regard, 15 articles
The details of the included articles and their specific features such as
referred to the treatment as the first rank and 7 articles considered it as
the authors, published year, research purpose, subjects, setting, and
the second rank among clinical information needs. Meanwhile, the di-
study design have been evaluated as illustrated in the Table 2 supple-
agnosis was ranked first in 7 articles and second in 11 articles. In ad-
ment. The results have indicated that most of the articles were con-
dition, epidemiology was another most frequently found item in the
ducted between 2011 and 2017. The largest number, i.e. eight, and the
articles, generally ranked as the third. Prognosis, prevention, and
smallest number, i.e. one, of the articles were performed in 2016 and
etiology were sequentially the least frequent items referred to as the
2010, respectively. The questionnaires, interviews, observations, and
physicians’ clinical information needs.
think-alouds were sequentially the most frequently used tools in the
Further, most articles included drug therapy in the treatment cate-
articles. The studies were mainly conducted in the United States,
gory. Rahmner et al. [32] classified physicians’ pharmaceutical in-
Canada, and England. The results showed that most studies were con-
formation needs, by using a qualitative method, into seven categories,
ducted in the hospitals and others in practicing offices. The specialists,
out of which the first four have been referred to in other articles. The
general physicians, residents, and subspecialists were sequentially the
seven categories encompass the drug interactions, adverse effects of
largest study populations in the retrieved articles.

Fig. 1. Flow Diagram Showing a Selection of Articles Reviewed in Accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) Guidelines.

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A. Daei, et al. International Journal of Medical Informatics 139 (2020) 104144

Table 3
Ranking of information needs utilized by physicians.
Authors Treatment Diagnosis Prognosis Etiology Epidemiology Prevention

Schwartz et al. 2003 [36] 1st – 2nd – 3rd –

D'Alessandro et al. 2004 [37] 1st 2nd – – 3rd –
Magrabi et al. 2005 [14] 2nd 1st – – – –
Schilling et al. 2005 [17] 1st 2nd – – – 3rd
Boissin et al. 2005 [19] 2nd 1st
Schaafsma et al. 2006 [38] – 2nd 1st – – –
Gonzalez-Gonzalez et al. 2007 [6] 2nd 1st – – – –
Norlin et al. 2007 [39] 2nd 1st – – – –
Ely et al. 2007 [18] – 1st – 2nd – –
Lauscher et al. 2008 [40] 2nd – – – 3rd 1st
Devi et al. 2008 [35] 1st 2nd – – – –
Gagliardi et al. 2008 [41] 1st 2nd – – – –
Chase et al. 2009 [42] 1st 2nd – – 3rd –
Yoon et al. 2010 [43] 1st – – – – –
Flynn et al. 2011 [8] 1st 2nd – – – –
Perzeski 2012 [44] 1st 2nd 4th 3rd – –
Shaw et al. 2014 [45] 1st 2nd 3rd – – –
Goldbach et al. 2014 [46] 1st 2nd – – – –
Papi et al. 2015 [47] 1st – – – – –
Ciarlo et al. 2016 [48] 1st 2nd – – – –
Kostagiolas et al. 2016 [49] 1st – – – 2nd –
Schuers et al. 2016 [50] 2nd 1st – – – 3rd
Mikalef et al. 2017 [22] 1st 3rd – – 2nd –
Heale et al. 2017 [11] 2nd 1st – – – –

drugs, data on risks for allergy or hypersensitivity with the prescribed
drugs, drug dosage related to age, indication, duration and treatment
plans, recommended drugs and guidelines, and registries containing
pictures of the drugs. The drug dosage was expressed as an information
need in the articles by Casebeer et al. [33], Bennett et al. [34], and Devi
et al. [35]. The drug interactions and adverse effects of drugs were
mentioned by Devi et al. [35], and the data on risks with the prescribed
drugs were suggested by Heale et al. [11].
3.2. Frequency of the information needs
The number of questions raised by the physicians, the number of
questions answered, time spent to find the questions, place where the
search was conducted, and the number of navigations for each item are
listed in Table 4. Among the 17 retrieved articles, three reported the
frequency of the questions per patient ranged from 0.18 to 1.5
[6,16,39]. In the study conducted by Magrabi et al., the physicians
carried out an average of 8.7 searches per month in order to meet their
information needs [14]. Schaafsma et al. stated that 10.5 questions
were raised by physicians every half-day. However, the number of
visited patients per day was not mentioned in the article [38]. Devi
et al. reported that the physicians needed information and searched the
resources for 60 % of the patients who had visited them for care [35].
In nine articles, where the physicians were looking for answers to
their questions, the percentage of the questions ranged between 22.8 %
and 93 %. The results indicated that the physicians found the answers
to the clinical questions in most cases after they decided to seek the
answers. Accordingly, the results related to five articles pointed out that
the physicians managed to answer over 70 % of the questions.
Except for two articles among the retrieved ones, other articles have
not addressed search navigations. In a study by Tawfik et al. [51], the
physicians obtained the answers after an average of 11 clicks when
conducting semantic searches and 35 clicks when conducting browsing
searches. Heale et al. [11] conducted their study using observations and
computer logs and concluded that the physicians performed 8.5 navi-
gations and movements in each case.
The time taken to find the answers to questions varies between 2
and 32 min. In most studies, the physicians spent less than 10 min to
find the answers. In a study by Gonzalez-Gonzalez et al., the time
physicians took to find answers during consultation, i.e. 2 min, was
much less than that of after consultation, i.e. 32 min. The amount of
time spent vary based on the type of search. For instance, semantic
searches take less time [6]. Tawfik et al. reported that the physicians
spent 140 s on semantic searches and 239 s on browsing searches [51].
All the retrieved articles, except for Bennett et al.’s article, reported
that the most frequent place where the physicians conducted their
search was their workspace, such as hospital wards, offices, and visiting
rooms while a small percentage of the physicians conducted their
search at home [34]. The type of systems was added to the table to
determine what system the physicians used to answer their questions.
In this regard, the information is provided in the resource section. The
differences observed between the above-mentioned categories in dif-
ferent articles may be due to the physicians' different specialties or
different search methods in the articles, resulting in complicating the
direct comparison of the results.
3.3. Information sources used by the physicians
Based on the retrieved articles, the information sources used by the
physicians for their clinical information needs are presented in Table 5.
Information sources are divided into 5 main categories and 31 sub-
categories. The main categories include text, pharmaceutical, elec-
tronic, and interpersonal sources, along with other sources. The fre-
quency of the sources was reported and the ranking of sources was
overlooked due to the large number of the retrieved sources and various
methods used in each study.
The most frequent subcategories in the retrieved text sources to
which the physicians referred in order to meet their information needs
are journal articles, textbooks, and guidelines with 20, 17, and 5 re-
ferences, respectively. In pharmaceutical sources, the most frequent
source belongs to the drug representatives with 6 references. The most
repeated electronic sources used by the physicians belong to the
Internet websites and MEDLINE/PubMed with 20 and 16 references,
respectively. Online databases (in general) with nine and the Cochrane
Library with five references are fallen in the next rankings. In inter-
personal sources, consulting with colleagues was ranked as the highest
with 22 references. In the category of other sources, continuous medical
education, and conferences and seminars are the most frequently used
sources with eight and seven references, respectively. By comparing all
the subcategories in Table 5, it can be concluded that consultation with

5
 A. Daei, et al.

Table 4
Typology of clinical questions raised and answered in physicians' practice.
Authors Questions Answered Navigations per case Time Where to search Systems to search

Ramos et al. 2003 [16] 274 questions; Residents 1.5 87% of the – Most were less than 2 min – Not clearly declared
questions per patient & faculty questions
0.8.
Schwartz et al. 2003 [36] 92 questions 54 % of the – 5–10 min – InfoRetriever; DynaMed; TRIP
questions Database;Clinical Evidence
D'Alessandro et al. 2004 607 questions – – Control/Intervention 8.3 – Internet; Medline; GeneralPediatrics;
[52] min vs 19.6 min Micromedex; MDConsult
Schilling et al. 2005 [17] 158 questions 89 % of the – – – Medline; database or Web site (UpToDate, MD
questions Consult, Cochrane Library and …)
Magrabi et al. 2005 [14] 63 questions 73 % of the – – Consulting rooms Quick Clinical
8.7 searches/month questions
Bellman et al. 2005 [53] – – – – 89 % at work; 30 % at home online Journals; Medical books; Medline;
health care databases
McKibbon et al. 2006 2 questions 2 – 13 min – MEDLINE; Google and other
[54] Internet sites; PubMed; Cochrane Library; MD
Consult
Schaafsma et al. 2006 10.5 questions per half day – – – – Not clearly declared

6
[38]
Bennett et al. 2006 [34] – 51 % of the – – 38.2 % at home after work; 35.7 % during Online journals; Professional association
questions breaks in the day; 9% during a patient Web sites; Medical point-of-care databases
encounter
Gonzalez-Gonzalez et al. 635 questions; 0.18 questions 22.8 % of the – During consultation: 2 min; 9.6 % of the questions during the consultation; Books; Journals; Databases
2007 [6] per half day questions afterward: 32 min 13.2 % after the consultation.
Norlin et al. 2007 [39] 170 (19.1 %) questions; 0.22 27.5 % of the – – – Not clearly declared
questions per patient questions
Devi et al. 2008 [35] 80 queries in 6 months: 0.8 93 % of the – 30 min during patient encounters Online Journals; Abstracts through Pub Med;
questions per patient questions Textbooks
Prendiville et al. 2009 – – – – Office: 72 %, Ward: 15 %, Library: 13 % Pubmed; General search engine (Google or
[55] Yahoo)
Flynn et al. 2011 [8] 1–5 clinical questions each – – – 40 % at home after work; 40 % during breaks Textbooks; Journals; Internet; databases
week in the day; 15 % periodically; 5% during
patient encounters
Tawfik et al. 2014 [51] – – 11 clicks/semantic search, 35 140 s/semantic search, 239 – Cerner System
clicks/browsing method s/browsing method
Del Fiol et al. 2016 [15] 17 questions 88 % of the – 4.5 min – Clinical Knowledge Summary (CKS)
questions
Heale et al. 2017 [11] – – 8.5 navigations per case 7 min – UpToDate; PharmGKB (Pharmacogenomics
Knowledge Base)
International Journal of Medical Informatics 139 (2020) 104144
A. Daei, et al. International Journal of Medical Informatics 139 (2020) 104144

Table 5
Typology of information sources utilized by physicians.
Category Subcategory (num. of ref.) References

Text sources Textbooks [16] Zack et al. 2006 [56], Gonzalez-Gonzalez et al. 2007 [6], Yousefi-Nooraie et al. 2007 [57], Callen
et al., 2008 [5], Davies 2011 [10], Shabi et al. 2011 [20], Oussalah et al. 2015 [58], Ciarlo et al.
2016 [48], Sarbaz et al. 2016 [59], Sahapong et al. 2009 [60], Ramos et al. 2003 [16], Prendiville
et al. 2009 [55], Bernard et al 2012 [9], Alghanim 2011 [61], Kosteniuk et al. 2013 [62], Norbert
et al. 2013 [4]
Journal articles [20] Schilling et al. 2005 [17], Zack et al. 2006 [56], Gonzalez-Gonzalez et al. 2007 [6], Yoon et al.
2010 [43], Ciarlo et al. 2016 [48], Bennett et al. 2004 [63], Boissin et al. 2005 [19], Sahapong
et al. 2009 [60], Yousefi-Nooraie et al. 2007 [57], Sarbaz et al. 2016 [59], Chiu et al. 2009 [64],
Kostagiolas et al. 2016 [49], Perzeski 2012 [44], Oussalah et al. 2015 [58], Shabi et al. 2011 [20],
Salinas 2014 [65], Bernard et al 2012 [9], Norbert et al. 2013 [4], Shaw et al. 2014 [45], Mikalef
et al. 2017 [22]
Paper-based records (e.g. ambulance sheet, ED Ayatollahi et al. 2013 [66], Kannampallil et al. 2013 [67], Zack et al. 2006 [56]
records, patients’ tests, …) [3]
Guidelines [5] Bennett et al. 2005 [68], Prendiville et al. 2009 [55], Kosteniuk et al. 2013 [62], Salinas 2014
[65], Le et al. 2016 [69]
Systematic reviews [1] Sahapong et al. 2009 [60]
Printed pamphlets [1] Shaw et al. 2014 [45]
Drug sources Drug compendium [2] Gonzalez-Gonzalez et al. 2007 [6], Yoon et al. 2010 [43]
Pharmaceutical/drug representatives or companies Boissin et al. 2005 [19], Yoon et al. 2010 [43], Shabi et al. 2011 [20], Formoso et al. 2016 [70],
[6] Kosteniuk et al. 2013 [62], Le et al. 2016 [69]
Pharmaceutical agencies’ web pages [2] Mikalef et al. 2017 [22], Le et al. 2016 [69]
Electronic sources MEDLINE/PubMed [15] Devitt et al. 2004 [71], Schilling et al. 2005 [17], McKibbon et al. 2006 [54], Chiu et al. 2009 [64],
Flynn et al. 2011 [8], Norbert et al. 2013 [4], Sarbaz et al. 2017 [2], Papi et al. 2015 [47], Ajuwon
2006 [72], Shabi et al. 2011 [20], Sahapong et al. 2009 [60], Perzeski 2012 [44], Goldbach et al.
2014 [46], Mikalef et al. 2017 [22], Prendiville et al. 2009 [55]
Cochrane [5] Devitt et al. 2004 [71], McKibbon et al. 2006 [54], Chiu et al. 2009 [64], Flynn et al. 2011 [8],
Sahapong et al. 2009 [60]
Uptodate [2] Schilling et al. 2005 [17], McKibbon et al. 2006 [54]
Hinari [2] Shabi et al. 2011 [20], Norbert et al. 2013 [4]
EBSCO and Embase [1] Sarbaz et al. 2017 [2]
MD Consult and Ovid EBMR [1] McKibbon et al. 2006 [54]
Online databases [9] Kostagiolas et al. 2016 [49], Alghanim 2011 [61], Yoon et al. 2010 [43], Shaw et al. 2014 [45],
Norbert et al. 2013 [4], Davies 2011 [10], Shabi et al. 2011 [20], Chiu et al. 2009 [64], Ayatollahi
et al. 2013 [66]
Internet websites [20] McKibbon et al. 2006 [54], Zack et al. 2006 [56], Gagliardi et al. 2008 [41], Shaw et al. 2014 [45],
Ciarlo et al. 2016 [48], Sarbaz et al. 2016 [59], Shabi et al. 2011 [20], Sarbaz et al. 2017 [2], Flynn
et al. 2011 [8], Bennett et al. 2004 [63], Bennett et al. 2005 [68], Boissin et al. 2005 [19],
Lauscher et al. 2008 [40], Prendiville et al. 2009 [55], Alghanim 2011 [61], Kosteniuk et al. 2013
[62], Le et al. 2016 [69], Mikalef et al. 2017 [22], Norbert et al. 2013 [4], Perzeski 2012 [44]
Medscape [1] Perzeski 2012 [44]
Government agencies/hospital or Doctor’s personal Mikalef et al. 2017 [22], Prendiville et al. 2009 [55]
web pages [2]
Social media (Wikipedia, Facebook groups, Mikalef et al. 2017 [22]
YouTube) [1]
Interpersonal sources Colleagues/consultants [22] Ramos et al. 2003 [16], Brown et al 2004 [7], Bennett et al. 2005 [68], Zack et al. 2006 [56],
Gonzalez-Gonzalez et al. 2007 [6], Callen et al., 2008 [5], Shabi et al. 2011 [20], Naeem et al.
2015 [73], Sarbaz et al. 2016 [59], Boissin et al. 2005 [19], Sahapong et al. 2009 [60], Bynum
et al. 2011 [74], Perzeski 2012 [44], Kosteniuk et al. 2013 [62], Le et al. 2016 [69], Yousefi-
Nooraie et al. 2007 [57], Gagliardi et al. 2008 [41], Ayatollahi et al. 2013 [66], Norbert et al. 2013
[4], Alghanim 2011 [61], Davies 2011 [10], Salinas 2014 [65], Soeyonggo et al. [75]
Other local colleagues (pharmacists, paramedical Gagliardi et al. 2008 [41], Kannampallil et al. 2013 [67], Alghanim 2011 [61], Zack et al. 2006
staff and so on) [5] [56], Davies 2011 [10]
Other sources Conferences/congresses and seminars [7] Bernard et al 2012 [9], Ciarlo et al. 2016 [48], Formoso et al. 2016 [70], Shabi et al. 2011 [20],
Shaw et al. 2014 [45], Bynum et al. 2011 [74], Zack et al. 2006 [56]
Continuing medical education (CME) [8] Bernard et al 2012 [9], Shaw et al. 2014 [45], Formoso et al. 2016 [70], Bennett et al. 2004 [63],
Alghanim 2011 [61], Kosteniuk et al. 2013 [62], Salinas 2014 [65], Soeyonggo et al. [75], Le et al.
2016 [69]
Medical association [3] Norbert et al. 2013 [4], Yoon et al. 2010 [43], Mikalef et al. 2017 [22]
Library/Hospital library [5] Norbert et al. 2013 [4], Boissin et al. 2005 [19], Naeem et al. 2015 [73], Sahapong et al. 2009
[60], Shabi et al. 2011 [20]
Medical apps [1] Goldbach et al. 2014 [46]
Grand rounds [1] Shaw et al. 2014 [45]
Personal files/collection [4] Naeem et al. 2015 [73], Bryant et al. 2004 [76], Boissin et al. 2005 [19], Alghanim 2011 [61]

colleagues, journal articles, Internet websites, textbooks, and MED-
LINE/PubMed are ranked higher than the other sources used by the
physicians.
3.4. Information-searching behavior of the physicians
As illustrated in Table 6, all the items about physicians' information-
seeking behavior classified in four general categories, including the
search strategy, factors affecting the search, factors affecting resource
selection, and consequences. Although each of these categories can be
divided into separate subcategories within themselves, we avoided this
subcategorization due to the small number of sources found in this field
and the increased number of tables.
Retrieved articles indicated that the physicians use keywords
[44,60], Boolean operators [60], similar medical terms [60], and ad-
vanced searches [44] as their search strategies. Using search filters

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A. Daei, et al. International Journal of Medical Informatics 139 (2020) 104144

Table 6
Typology of information seeking by physicians.
Category Subcategory References

Search strategy
Factors affecting searches
Outcomes
Factors affecting resource
selection
Using keywords (95 %), Boolean operators (AND, OR, NOT) (76.4 %), similar medical terms (75.8 %), Sahapong et al. 2009 [60]
medical subject headings (MeSH) (72.6 %), the clinical queries in PubMed (60.7 %)
Only 20 % used the basic keyword search strategies, only 19 % used the advanced search options or limits Perzeski 2012 [44]
tab, and very few respondents used the Clinical Queries tool, the Related Citations link, or the Medical
Subject Headings tool
Use of filters makes improvement in efficiency, use of the narrow form of the clinical queries filter alone Shariff et al. 2012 [77]
maximally improved the overall search performance
Most of their queries were built with natural language without using controlled terms. Schuers et al. 2016 [50]
Combination of professional responsibilities and personal characteristics Bryant et al. 2004 [76]
Specific patient problems, being aware of latest research in a specific topic Bennett et al. 2006 [34]
User-friendly features (smart features & interactive functionalities) Rahmner et al. 2012 [32]
Support and feedback from colleagues when consulted Addison et al. 2013 [80]
Context and content of physicians (presence of trainees, patient factors, criticality of the situation) Maggio et al. 2014 [78]
Easy access to information and access to a large amount of information from various sources Sarbaz et al. 2017 [2]
Improved patient care Magrabi et al. 2005 [14]
Improved patient care, improved communication, improved confidence in care, improved knowledge, Schilling et al. 2005 [17]
improved care for future patients, affected clinical decision making and altered management plan
Improved patient care, fulfilled professional obligations, encouraged formal referrals Perley 2006 [79]
Reduced delay in commencing treatment, avoided unnecessary diagnostic test(s), reduced delay in Addison et al. 2013 [80]
diagnosis, change in treatment, reduced time to discharge
Doctors’ increased job satisfaction Kostagiolas et al. 2016 [49]
Improved patient care, improved personal knowledge, reduced possibility of a medical error, avoided Mikalef et al. 2017 [22]
unnecessary medical exams, improved communication with colleagues, improved professional status,
improvement professional reputation
Credibility, relevance, unlimited access, speed, and ease of use Bennett et al. 2004 [63]
Relevance, reliability, resources already selected Bernard et al 2012 [9]
Credibility of sources Casebeer et al. 2002 [33], Cook
et al. 2013 [3]
Credibility, quality, completeness, usability Formoso et al. 2016 [70]
Reliability, easy access, being up-to-date Sarbaz et al. 2016 [59]
Resources frequently selected, familiar resources Schuers et al. 2016 [50]

improves search efficiency [77]. However, only a small percentage of
the participants used clinical queries and MeSH tools in their searches
[44,60]. In this regard, Shariff et al. showed that using filters such as
clinical queries alone could lead to maximum improvement in
searching [77]. In another study, Schuers et al. concluded that a large
number of general practitioners and residents were not aware of the
role of keywords and Boolean operators in conducting searches. Many
of them made their queries in search strategies based on natural lan-
guage and without using controlled terms [50].
Based on the previous studies regarding the factors which can affect
physicians' searches, we can refer to personal and interpersonal factors,
context of physicians caring for patients, and features of information
systems. Several personal factors, including personality traits [76] and
interest in knowing about recent researches in specific areas [34], as
well as interpersonal factors, including the provision of support and
feedback from the colleagues, have been studied. Considering the
context of physicians’ caring for their patients, we can refer to the
presence of trainees, criticality of the situation [78], patient's specific
problems [34,78], and physician's professional responsibilities [76]. In
addition, user-friendliness plays an important role among the factors
which affect the design of the information systems, indicating that
smart features and interactive functionalities can contribute to higher
user-friendliness of a system [32]. Easy access to a large amounts of
information from various sources are considered as the next most im-
portant factor in this regard [2].
Relevance [9,63], credibility [3,33,63,70], reliability [9,59], ac-
cessibility [59,63], and usability [59,63,70] can have significant effects
on the selection of the sources by physicians. In addition, physicians
more commonly use the familiar sources which they have frequently
used [9,50].
When clinical information need arises, the physician seeks in-
formation in various ways in order to meet the requirements. This
clinical information-seeking process can have different outcomes, the
most common of which is the improved patient care [14,17,22,79].
According to Schilling et al. [17], Addison et al. [80], and Mikalef et al.
[22], the most prevalent outcomes regarding patient treatment, re-
sulted from a correct clinical information-seeking behavior, include
reduced delay in commencing treatment, changes in treatment,
avoiding unnecessary diagnostic tests, reduced delay in diagnosis, ef-
fects on clinical decision-making, and reduced medical errors. In ad-
dition, a correct clinical information-seeking behavior increases
knowledge [17,22], improves communication with colleagues as well
as professional status and credibility [22], boosts confidence in treat-
ment [17], and helps physicians to fulfill their professional obligations
[79].
3.5. Barriers to information seeking by physicians
The results of the retrieved articles indicated that the physicians
referred to multiple barriers to meeting their information needs and
accessing sources, as presented in Table 7. Among personal factors, lack
of time was considered the most frequent barrier in 14 articles. Lack of
information-searching skills and unawareness of accessible sources
were among the next barriers, sequentially. The most frequently re-
ported barriers among technical factors were information overload and
too much information to scan referred to in seven articles, as well as
low relation between the sources found and the needed information. In
the category of organizational factors, poor and expensive commu-
nication infrastructure was regarded as the most common barrier.
3.6. Facilitators to information seeking by physicians
The facilitators to physicians' information-seeking behavior are il-
lustrated in Table 8. According to the physicians, the top facilitator was
easily searching and finding information reported in four articles.
Among other frequent facilitators, we can refer to the access to sum-
maries and synthesized evidence-based materials and electronic
sources, enhanced information searching skills, awareness of preferred

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A. Daei, et al.
Table 7
Studied articles related to information seeking barriers.
Category Subcategory
Personal factors Not recognizing a gap in knowledge and not feeling a
need to seek
Difficulty in interpreting information and
formulating or answering a question
Clinical question tracking
Lack of time
Insufficient importance of the question
Lack of personal initiative
Lack of knowledge
Lack of confidence in digital information
Language barriers
Lack of computer skills
Concerns about communication with patients
Unawareness of available resources
Doubt that the search would yield an answer
Difficulty in remembering questions for later studies
Gaps in specialists' knowledge of the complex nature
of treatment
Lack of information searching skills
Cost of access
Technical factors Slow Internet connection
Interruptions during searches
Insufficient access to information resources
Quality concerns
Low relevance
Overly complex access methods
Technical & equipment difficulties
Information overload & too much information to scan
Too little specific information to answer a defined
question
Software incompatibilities
Lack of specific information
Navigation/searching difficulties
Cost of information resources
Preferred resources are not available online
Organizational factors Team dynamics
Institutional culture
Lack of systems to support multidisciplinary care
Poor and expensive ICT infrastructure
Lack of computers and access to Internet
Not supported by supervisors and colleagues
Lack of uniform data standards within the PHC
center
Lack of inter-library loan services
Poor documentation system
No health science librarian
No on-site library
Online resources are too expensive
Lack of institutional support
Work overload
websites and textbooks, and teaching environments.
3.7. Studies conducted with or having reached a model
Based on the findings of this review, the most frequently used tools
to assess physicians' needs and information seeking behavior was re-
searcher-made questionnaires. Fewer models and theories related to
information-seeking behavior were used in these studies for designing
tools. The models, patterns, and/or theories used in the retrieved arti-
cles are represented in Table 9. In addition, the studies which have
reached a conceptual model based on physicians' information needs
International Journal of Medical Informatics 139 (2020) 104144
References
Ely et al. 2002 [21], Schaafsma et al. 2006 [38]
Schwartz et al. 2003 [36], Ely et al. 2002 [21]
Green et al. 2005 [81], Ely et al. 2002 [21]
Green et al. 2005 [81], Schaafsma et al. 2006 [38], Norlin et al. 2007 [39], Flynn et al. 2011
[8], Bernard et al 2012 [9], Cook et al. 2013 [3], Norbert et al. 2013 [4], Bellman et al. 2005
[53], Sarbaz et al. 2017 [2], Papi et al. 2015 [47], Alghanim 2011 [61], Davies 2011 [10],
Perzeski 2012 [44], Ciarlo et al. 2016 [48]
Green et al. 2005 [81], Norlin et al. 2007 [39]
Green et al. 2005 [81]
Zack et al. 2006 [56], Bernard et al 2012 [9], Davies 2011 [10], Ciarlo et al. 2016 [48],
Albarqouni et al. 2017 [82]
Norlin et al. 2007 [39], Kostagiolas et al. 2016 [49]
Callen et al., 2008 [5], Bernard et al 2012 [9], Cook et al. 2013 [3], Kostagiolas et al. 2016 [49]
Callen et al., 2008 [5], Bernard et al 2012 [9], Naeem et al. 2016 [83], Kostagiolas et al. 2016
[49]
Bernard et al 2012 [9], Cook et al. 2013 [3]
Cook et al. 2013 [3], Bellman et al. 2005 [53], Schaafsma et al. 2006 [38], Papi et al. 2015
[47], Naeem et al. 2016 [83]
Cook et al. 2013 [3]
Cook et al. 2013 [3]
Shaw et al. 2014 [45]
Kostagiolas et al. 2016 [49], Papi et al. 2015 [47], Ajuwon 2006 [72], Green et al. 2005 [81],
Bennett et al. 2004 [63], Ely et al. 2002 [21]
Ajuwon 2006 [72], Bernard et al 2012 [9]
Schwartz et al. 2003 [36], Sarbaz et al. 2017 [2], Ajuwon 2006 [72], Bennett et al. 2005 [68]
Schwartz et al. 2003 [36]
Green et al. 2005 [81], Flynn et al. 2011 [8], Norlin et al. 2007 [39]
Bernard et al 2012 [9], Naeem et al. 2016 [83]
Bernard et al 2012 [9], Norbert et al. 2013 [4], Sarbaz et al. 2017 [2], Davies 2011 [10],
Albarqouni et al. 2017 [82]
Bellman et al. 2005 [53]
Sarbaz et al. 2017 [2], Boissin et al. 2005 [19]
Casebeer et al. 2002 [33], Bennett et al. 2004 [63], Bennett et al. 2006 [34], Bennett et al. 2005
[68], Bernard et al 2012 [9], Cook et al. 2013 [3], Ajuwon 2006 [72]
Casebeer et al. 2002 [33]
Bennett et al. 2005 [68]
Bennett et al. 2006 [34], Bennett et al. 2005 [68], Bennett et al. 2004 [63], Schwartz et al.
2003 [36], Norlin et al. 2007 [39]
Bennett et al. 2005 [68], Sarbaz et al. 2017 [2], Davies 2011 [10]
Perzeski 2012 [44]
Naeem et al. 2016 [83]
Green et al. 2005 [81]
Green et al. 2005 [81]
Gagliardi et al. 2008 [41]
Norbert et al. 2013 [4], Naeem et al. 2016 [83], Alghanim 2011 [61]
Norbert et al. 2013 [4], Naeem et al. 2016 [83]
Albarqouni et al. 2017 [82], Kahouei et al. 2015 [84]
Alghanim 2011 [61]
Alghanim 2011 [61]
Alghanim 2011 [61]
Naeem et al. 2016 [83], Alghanim 2011 [61]
Naeem et al. 2016 [83]
Naeem et al. 2016 [83]
Albarqouni et al. 2017 [82]
Albarqouni et al. 2017 [82]
and/or information-seeking behavior have been listed in the table.
Choo's model [63] provides a framework to assess three dynamic ele-
ments in information-seeking behavior, including determining what
information is needed, searching for the information, and using it. This
model attempts to address the gap between what a physician already
knows and what s/he needs to know in order to understand the pro-
blem. Each search for information is conducted in an environment
which indicates cognitive needs, affective responses, and situational
demands [63]. The Wilson model (1996) shows that information users
are getting involved with in information-seeking behavior to satisfy the
perceived need. The users search for information in formal or informal
9
A. Daei, et al. International Journal of Medical Informatics 139 (2020) 104144

Table 8
Studied articles related to information seeking facilitators.
Category Subcategory References

Technical factors
Personal factors
Organizational factors
Simple interface with customized content Ketchell et al. 2005 [85]
Ease of searching and finding needed information Shabi et al. 2011 [20], Casebeer et al. 2002 [33], Bellman et al. 2005 [53], Bernard
et al 2012 [9]
Availability of summaries and synthesized evidence-based Shabi et al. 2011 [20], Bernard et al 2012 [9]
materials
Closeness to Internet facility Shabi et al. 2011 [20]
Websites with selected documents or useful links Bernard et al 2012 [9]
More relevant information for clinical practice Bernard et al 2012 [9], Bellman et al. 2005 [53]
Readily access to electronic resources Cook et al. 2013 [3], Casebeer et al. 2002 [33]
Access in the clinical setting Bennett et al. 2006 [34]
Internet and information searching utilization skill Shabi et al. 2011 [20], Norbert et al. 2013 [4]
More available time Bernard et al 2012 [9], Shabi et al. 2011 [20]
Personal interest Norbert et al. 2013 [4], Kahouei et al. 2015 [84]
Knowing preferred sites or textbooks Norbert et al. 2013 [4], Bennett et al. 2006 [34]
Colleagues’ encouragement & support Kahouei et al. 2015 [84]
Up-to-date knowledge about disease and new health Norbert et al. 2013 [4]
technologies
A climate for evidence-based practice implementation Kahouei et al. 2015 [84]
Financial cost Shabi et al. 2011 [20]
Organizational support Kahouei et al. 2015 [84]
Strong organizational culture Kahouei et al. 2015 [84]
Teaching environment Kahouei et al. 2015 [84], Bellman et al. 2005 [53]
Increased awareness of resources Bellman et al. 2005 [53]
Encouragement to improve the quality of decisions Schaafsma et al. 2006 [38]

information sources or services. They may use the information if the
search is successful. Otherwise, they have to repeat the search process,
where they may encounter intervening variables including personal
characteristics, the characteristics of the resource, as well as emotional,
educational, demographic, social/interpersonal, environmental, and
economic variables [4,49]. The visual information-seeking mantra
proposed by Shneiderman has seven visualization tasks, including
overview, zoom, filter, details on demand, relation, history, and ex-
traction. The tasks have been summarized in three rules described as
the information overview from each source, followed by zoom and
filtering, and then on-demand access to details [15]. In Bates' berry
picking model of information-seeking behavior, the information seeker
is a non-expert. Based on this model, an individual searches different
points, called berry, to meet the information needs. Each related berry,
found by the individuals, improve their understanding of the problem,
resulting in enhancing more precise strategies. Every iteration of in-
formation seeking leads to a faster and more complex search [11]. In
another study, Green et al. reached a conceptual model of barriers. The
model suggests that prior to technical barriers, cultural and attitudinal
barriers can considerably reduce a physician's willingness to answer a
question [81]. Cook et al., eventually reached a key-decision model in
physicians' point-of-care learning using the grounded theory (GT). The
key decisions in this model were made based on the following ques-
tions: “what to search”, “when to search”, “where to search”, “what
type of resources to use”, “what specific resource to use”, and “when to
stop” [3].
4. Discussion
In this systematic review, 73 articles were identified regarding
physicians’ clinical information-seeking behavior. The physicians'
clinical information needs, resources to be used, barriers, facilitators,
and related theories had been analyzed in the articles. Several types of
questions, including etiology, prevention, epidemiology, diagnosis,
therapy, and prognosis generally arise for physicians during patient
care. The answers to these questions vary depending on age, gender,
and ethnicity [13]. The results of the present review ranked therapy,
diagnosis, and epidemiology as the highest among the categories of
needed information by the physicians. Delfoil, et al.’s systematic review
[27], which encompassed several groups including physicians, in-
dicated that 34 % of the questions were concerned with drug treatment
and 24 % were related to the potential causes of a symptom, physical
findings, or diagnostic test outcomes. Davies showed that the top ca-
tegories of physicians’ information need were treatment or therapy,
diagnosis and drug therapy/information [86]. Given the physicians'
limited time, clinical librarians can also identify the information needs
and different types of information in order to demonstrate their great
ability in supporting the required data [44]. Furthermore, the time
spent on searching and finding information can be reduced by teaching
information literacy skills to the physicians, as well as introducing the
sources which have more thoroughly discussed these three items.
The frequency of physicians' questions extracted during patient care
varied between 0.18 and 1.5 per patient based on the articles. Davies’s
review showed that the frequency of doctors’ information needs varied,
ranging from 0.16 to 1.27 questions per patient [86] and Delfoil, et al.’s

Table 9
Studies having reached a conceptual model or having applied ISB models or theories.
References Model

Bennett et al. 2004 [63] Using Choo's model

Green et al. 2005 [81] Suggested a conceptual model about barriers
Norbert et al. 2013 [4] Based on the Wilson (1996) model
Cook et al. 2013 [3] Suggested a conceptual model: Key Decisions Model in Physicians’ Point-of-Care Learning
Del Fiol et al. 2016 [15] Based on Shneiderman’s visual Information seeking principles
Kostagiolas et al. 2016 [49] Based on the Wilson model
Heale et al. 2017 [11] Based on Bates' berrypicking model of information seeking

10
A. Daei, et al.
study showed the frequency of questions ranged from 0.16 to 1.85 per
patient seen [27]. The variety in the results can be due to the specialty
of doctors and the research methods used in the studies since the studies
conducted in simulated settings can have different results from those
conducted in real clinical settings or by surveying and opinion polls.
Although all the studies have confirmed that information needs and
clinical questions generally arise during patient care, some clinical
questions have still remained unanswered despite the growing avail-
ability of online information sources [27,50]. Therefore, the present
need is to motivate and encourage physicians to search, provide op-
portunities to develop search skills, and create environments where
clinical librarians can assist physicians. Clinical librarians can play a
major role in clinical decision-making and use information sources to
create opportunities to fill different types of physicians' information
needs [76]. They can participate in performing specialized searches,
providing desirable search results, ranking the quality of the existing
evidence, organizing the evidence to boost the usefulness and ease of
use for different treatment teams, and offering effective strategies to the
physicians to seek evidence by themselves [87,88].
Large amount of information reveal how poor search or navigation
problems among physicians can prevent retrieving necessary evidence
[2,10,21,47,49,63,68,72,81]. According to the information specialists,
converting a clinical question into a searchable strategy in order to
conduct a search and retrieve the required information is one of the
vital search skills. A combination of the following instances may occur
among the inexperienced searchers. They may use inappropriate search
terms or make spelling errors, or they may have difficulty in inter-
preting, tracking, and formulating a clinical question or answer
[21,36,81]. Further, choosing a wrong or inappropriate database [86],
using inappropriate operators [50], or having linguistic problems
[3,5,9,49] can be counted as other examples of wrong approaches to
information searching. In most cases, this lack of skill is justified by the
lack of relevant evidence [2,4,9,10,82] whereas the problem lies in the
physician's search strategies.
The results obtained from the retrieved articles revealed that the
time spent to find the answers to questions vary from 2−32 min.
Delfoil, et al.’s systematic review showed clinicians spent a mean of less
than 2−3 min seeking an answer to a specific question [27]. Some
types of information are considered as time-sensitive in a particular
way, especially when they are regarding patient care. Alghanim cate-
gorized the speed of accessing information into urgent and less urgent.
The urgent access is used when dealing with a patient and the second
one is related to occasions such as morning report sessions, and con-
sultation and discussion with colleagues about a specific case [61].
Finding answers before, during, and/or after a consultation can be ef-
fective. Gonzalez-Gonzalez et al., showed that the time taken to find the
answer to each case was 2 min during a point-of-care consultation and
more than 30 min if the search was done after the consultation session
[6]. These results are only limited to one retrieved article and further
research is needed due to the importance of this issue. If physicians are
equipped with the required search skills, less time will be spent to find
the relevant information [4,20]. In addition, simple user interfaces
[85], simple search methods [9,20,33,53], smart searches [32,51], and
the presence of the summaries for EBM sources [9,20] can play im-
portant roles in reducing the time spent by physicians. In this regard,
Tawfik et al. compared the semantic search method with the browsing
approach. In browsing search, the average navigation rate was 35 clicks
per item, lasting about 239 s while in semantic search, the rate reached
11 clicks per item, lasting 140 s [51].
The electronic health record (EHR) is considered as one of the in-
novative tools which helps the physicians identify gaps in their
knowledge, cover the gaps, and ultimately improve their practice. EHRs
can make questions and answers accessible to the whole treatment team
and the team members can participate and cooperate in order to obtain
appropriate answers [27]. Further, smart features linking to EHRs and
interactive features which increase electronic communication with
11
International Journal of Medical Informatics 139 (2020) 104144
colleagues can be helpful [32]. The reason relates to the fact that based
on the technology acceptance model (TAM), the ease of using a tech-
nology and understanding its usefulness are regarded as the predictors
in the actual use of that technology [15]. In addition, clinical decision
support tools such as info-buttons which have custom links to back up
information sources [15] are very useful tools for responding to a wide
range of physicians' information needs.
Along with the issues related to technology, lifelong learning is
necessary for improving search skills, and continuous medical educa-
tion is a common method. Several studies have pointed out that many
physicians use this method for their information needs
[9,45,49,61,63,65,69,70]. In this regard, clinical librarians can use the
sessions with the physicians to teach search skills, introduce informa-
tion sources, direct clinical information needs, and improve informa-
tion-seeking skills although in all the retrieved articles only two studies
referred to the role of clinical librarians in the treatment environment
[61,83]. Practice and repetition by the physicians are also among other
important skills. Based on the results, repetition is the main reason for
improving the quality of the search, and search skills will be degraded if
not used regularly [86].
The retrieved articles revealed consultation with colleagues, journal
articles, Internet websites, textbooks, and MEDLINE/PubMed were se-
quentially regarded as the most frequently used sources among the
physicians for their information needs. These results are not in line with
those of Dawes & Sampson’s review [26], where the most frequent
sources for information were text sources and asking colleagues and
only one study found electronic databases as the source. The results
suggest that physicians’ preferences for the type of sources have
changed over the years. Nowadays, a wide range of information sources
can be used by the physicians and a physician generally uses a parti-
cular type of source to achieve potential efficacy in the clinical decision-
making process. The sources may vary depending on the place, where
the clinical question arises such as the office, hospital, educational
hospital, the patient's critical and urgent situation [34,78], as well as
the belief about whether the answer can be found in the sources or not
[3]. In general, the previously used or familiar sources are more com-
monly used by physicians [9,50]. In addition, a person who has in-
troduced a specific source or institution such as national health agen-
cies, hospitals, and universities, which has contributed to providing
information for that source, has an effect on choosing that source [50].
Consulting with colleagues is one of the most common sources which
can be used more due to its quick and easy accessibility [59,63]. As
another source, journal articles contain more up-to-date information
than textbooks do, because of their type of publication, and are reliable
with respect to the proper evaluation of the articles by journals. For
years, textbooks have been among the first ranks in terms of accessi-
bility. Although they have higher credibility [3,33,63,70], relevance
[9,63], and reliability [9,59] than other sources, their information is
not completely up-to-date. MEDLINE/PubMed [59,63,70] is referred to
repeatedly in the retrieved articles as a popular information source, due
to its usability. This popularity is associated with simple user interfaces,
supporting multiple search methods, and comprehensiveness. The Co-
chrane Library is a database, where evidence sources are filtered and
evaluated, and it is a usable and understandable source. MEDLINE
contains data which have not been evaluated and it takes physicians a
large amount of time to evaluate these raw data [86]. Nevertheless,
Ramos et al. and Ajuwon reported that the Cochrane Library is among
the sources rarely used [16,72] while MEDLINE is one of the most
frequently used sources among the physicians. Dawes and Sampson’s
systematic review already pointed out convenience of access, habit,
reliability (high quality), quick use, and applicability were the reasons
of physicians’ information resource utilization and preference [26].
The most common barriers mentioned in the articles included lack
of time and information search skills, unawareness of accessible
sources, information overload and too much information to scan, and
low relationship between the sources found with information needed.
A. Daei, et al.
The barriers in Dawes and Sampson’s study [26] were the lack of time
to search, huge amount of material, forgetfulness, belief that there is
likely no answer to be found, and lack of urgency which all hinder the
process of answering questions. The results indicated that most of the
barriers have remained unchanged over the years. As Del Fiol et al. [27]
pointed out lack of time and the doubt about the existence of a useful
answer were regarded as the main barriers.
An Information-seeking model shows a series of information-seeking
stages performed by individuals from the beginning of a search until
reaching a desirable result in information channels. The four informa-
tion-seeking behavior models developed by Choo, Wilson, Bates, and
Shneiderman were used in five studies. There are many more models
and theories in the field of information science, such as Ellis', Cogdill's,
and Kuhlthau's theories, which mostly focus on the behavior of re-
searchers, academics, and other specialists. In the domain of healthcare
providers, there is only one review conducted by Leckie et al. which
states the information-seeking rules and behavior of primary care
providers are determined based on their daily duties and needs [50]. In
this domain, physicians have more diverse information needs and in-
formation-seeking behaviors than the rest of healthcare providers since
they face a great wealth of information in order to make evidence-based
decisions and treat patients. Hence, conducting further research and
creating a theory or model of physicians' clinical information-seeking
behavior can greatly help assess physicians’ behavior with respect to
clinical information seeking.
5. Limitations
This systematic review has several limitations:
- The heterogeneity of the articles (simulated settings, real clinical
settings, surveying and opinion polls) confronted us with difficulties
in concluding many factors, and hindered the possibility of com-
parison. Therefore, the research team often contented themselves
with using a number of retrieved sources in each case.
- The present systematic review excluded non-English articles.
Therefore, there may be non-English studies which provide good
information about the objectives of our study.
- The present study, along with other studies, has attempted to ad-
dress the needs and questions identified by the physicians. However,
there may be some questions left not answered due to lack of
knowledge, haste, or lack of considerations. Therefore, more re-
search is needed to consider these questions in future.
- This review provides an overview of the physicians’ clinical in-
formation-seeking behavior, but clinician expertise (i.e., years of
practice, domain knowledge and skills in the searching techniques
and access to information resources) have not been investigated due
to a lack of available data. Further research is needed to investigate
these gaps.
6. Conclusion
The present systematic review aimed to evaluate the physicians'
clinical information seeking-behavior during patient care. The study
confirmed that the physicians need job-specific information sources in
order to meet their information needs, mostly in the field of treatment
and diagnosis. Questions raised during POC and, consequently, finding
high-quality evidence promote continuous learning, improve patient
care, and enhance patient care decision-making.
Sources such as journals, communication with colleagues, text-
books, and knowledge bases are widely used by the physicians in
clinical settings. However, these sources can also have disadvantages
such as incorrect online information, and the likelihood that a collea-
gue's suggestion is not from EBM resources, or obsolete and outdated
printed information. Developing new technologies in clinical settings
can be effective in meeting physicians' clinical needs by removing the
12
International Journal of Medical Informatics 139 (2020) 104144
barriers to these sources.
To the best of our knowledge, there is no study regarding the pro-
cess of the physicians' POC information seeking-behavior, and future
research in this field would be of great help. In addition, further studies
are needed to determine effective methods for encouraging physicians
to use EBM during practice [38], which can be done by the organiza-
tions through providing an appropriate environment for conducting
EBM [84], informing resources in medical practice settings [53], and
developing appropriate ICT infrastructure [4]. Further studies could
determine how to effectively integrate databases with EHR systems in
order to meet the information needs of the physicians and healthcare
providers in an integrated way so that the usability, accuracy, and
depth of knowledge bases, the quality of patient care, and the integr-
ability of EHR with other systems improve.
Authors’ contribution
Abstracts of all retrieved references were collected by A.D. and M.S.
independently and articles. Full-text of the articles that were labeled
potentially relevant were retrieved and considered for eligibility and
methodological quality by A.D and H.A. independently. A.D. drafted
the manuscript, and H.A., M.S., A.Z and R.K. revised the manuscript
critically. All authors approved the submitted manuscript.
Summary points
What was already known on the topic?
- Some types of questions arise for physicians during patient
care, including etiology, prevention, epidemiology, diag-
nosis, therapy, and prognosis.
- The most frequent source used for obtaining information is
text sources and the second one is asking colleagues.
What did this study contribute to our knowledge?
- Most of the literature regarding physicians' information-
seeking behavior during the last 16 years have been focused
on the information need and sources to meet the needs.
- Therapy, diagnosis, and epidemiology ranked the highest
within the scope of information needed by the physicians.
- Previous studies have not dealt with the process of physicians'
information-seeking behavior in point-of-care.
- Few studies have used the models and theories related to the
information-seeking behavior.
Declaration of Competing Interest
The authors report no conflict of interest.
Acknowledgements
This manuscript is the result of a part of a PhD dissertation in
medical library and information science of Isfahan University of
Medical Sciences, with the registered number of 396524.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the
online version, at doi:https://doi.org/10.1016/j.ijmedinf.2020.
104144.
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