Triage, Treat, Release:
Finding Medical Information Using MedlinePlus and PubMed
by Sarah L. Elichko
Hospital emergency rooms around the U.S. have instituted a protocol called Triage, Treat, Release to efficiently care for patients presenting with minor injuries. It’s also an apt metaphor for librarians helping patrons to find information, whether the reference desk is physical or virtual.
Medical questions can be challenging due to terminology, unfamiliarity with relevant resources, and concern about inadvertently providing medical advice rather than simple information. This article offers tips for connecting people with relevant information at an appropriate level for their needs. The basic process involves assessing the level of detail your user needs (Triage), selecting and searching appropriate resources (Treat), and encouraging your patron to discuss the information with their healthcare provider (Release).
A diagnosis or prognosis of a health issue or medical condition often sparks a search for medical information. The person requesting information could be a patient, family member, or friend. As a result, library users with medical questions are likely to be experiencing a range of negative emotions when they ask you for help. For example, I’ve met patients’ family members who come down to the hospital library in part to get away from the intensity of being bedside with their loved ones. They don’t need more stress. It is worth keeping this dynamic in mind before overwhelming them with search term suggestions or reams of printouts.
Fewer people are turning to librarians for help with medical questions, given the abundance of medical information available on the internet. Yet when these requests arise, it offers a valuable opportunity for helping a patron to find accurate and reliable information.
TRIAGE: PATIENT OR PROFESSIONAL LEVEL
Your main triage decision is whether your patron needs patient-level or professional-level information, or both. Although I’ve approached the topic in terms of patient-level and professional-level information, I’m largely focusing on helping patrons who are not health professionals. Doctors, nurses, medical school professors, pharmaceutical industry researchers, and other healthcare professionals may be expert searchers of the subscription databases found through Ovid, EBSCOhost, ProQuest, or Thomson Reuters. However, since access to these databases varies and some high-quality health information is available for free, I’m restricting this discussion to those free sources of information.
Patients and family members with general questions about diseases, tests, or treatments will probably appreciate patient-level resources. Students and researchers will probably prefer more detailed professional-level information.
Other cases are less clear-cut. Some patients and family members with chronic conditions are well-versed in the basics and require more detailed resources. They might arrive at the reference desk having extensively yet unsuccessfully searched for a specific answer. In some cases, patients and family members may prefer patient-level information but need some professional- level resources to answer a specific question. On the other hand, even healthcare professionals may need patientlevel materials on occasion. For example, a nurse came into my library looking for information on a particular treatment for lymphoma. Although she could understand and “translate” professional-level information, she wanted resources her family could read without her assistance.
As an information professional, part of the triage process is helping your user find high-quality and reliable information, rather than the mix of trustworthy and questionable resources one often finds from a simple Google search. Although Google search results for health-related topics have improved somewhat over the years, the quality of sources varies widely by question. A search for non-Hodgkin’s Lymphoma brings up PubMed Health, while a search for an alternative treatment, such as kava, returns a mixture of commercial and government sites. Medicine-focused tools such as MedlinePlus and PubMed offer resources that are more consistent in quality than a Google search.
The final step in triage is planning the treatment. For patient-level information, MedlinePlus is an excellent place to start searching. Wolters Kluwer Health’s UpToDate has
patient-level information resources that are also useful and
freely available. For professional-level patient information,
PubMed is the best freely available resource.
TREAT: FIND RELEVANT ARTICLES
Now that you have clarified your patron’s question and
level of detail needed, you can start using relevant resources
to actually find information. I’ll review patient-level
resources followed by professional-level information.
MedlinePlus (www.nlm.nih.gov/medlineplus) is a gateway
to high-quality patient information. The website is run by the
U.S. National Library of Medicine (NLM), part of the National
Institutes of Health (NIH), and uses Vivisimo for its search
engine. A simple search on MedlinePlus will yield links to a
range of resources from reputable organizations such as the
Mayo Clinic and NIH divisions, for instance the National
Heart, Lung, and Blood Institute. Yet there are numerous other
resources on MedlinePlus that are worth knowing about.
The homepage lets you search a medical dictionary and
see what people are currently interested in searching. It
gives links to current news items and provides general information on health issues. You can also click on Health
Topics, Drugs & Supplements, or Videos & Cool Tools for
other information. These three options appear throughout
Entering the term diabetes in the main search box at
the homepage, for example, yields an overview of the disease,
followed by a list of carefully selected external links.
Use the facets on the left-hand side to narrow your search
results by type or by keyword. The types remain constant,
although if there is no information for a particular type, it is
grayed out. Keywords change depending upon search terms
entered. Under the Keyword facets, note the word “remix”
to the right of “All Results.” Click this to reorder the list.
Click on Health Topics at the MedlinePlus homepage and
you can choose to select information alphabetically or
based on body location/systems, disorders and conditions, diagnosis and therapy, demographic groups, or health and
wellness issues. Click on any of these and the resulting webpage
combines short topical overviews with external links
organized by category. The links are updated daily and
include the latest news as well as general resources from
Link categories include “Start Here” (introductory material),
symptoms and diagnosis, treatment, nutrition, alternative
therapies, clinical trials, and suggestions for further
research. The categorization makes it easy to quickly find a
resource to answer a particular question. From a relevant
Health Topics page, your patron can find a short video
overview of his topic, a handout on a diagnostic test his
physician is considering, and information on a drug typically
prescribed for the condition. Many patient handouts
are available in Spanish and English.
In addition to Health Topics pages, MedlinePlus offers
reliable drug information under the Drugs & Supplements
tab. It’s organized according to frequently asked questions
such as, “What should I do if I forget a dose?” and “What
side effects can this medication cause?” Herbs and supplements
are also included in the drug information profiles.
UPTODATE PATIENT EDUCATION
Wolters Kluwer Health’s UpToDate tool (www.uptodate.com) is familiar to health professionals and serves as a useful resource for free patient-level information. Patient
handouts are divided in two categories: Basics and Beyond
the Basics. The latter are helpful for patrons who need
detailed information yet cannot understand the terminology
in professional-level information. The Beyond the
Basics handout for Hodgkin lymphoma clearly explains the
criteria for staging the disease (i.e., identifying stage 1 versus
stage 2), specific chemotherapy regimens, and side
effects for specific treatments.
To find free patient information, click the button
marked “Patients” at the top of the screen. Then you can
search just patient-level information. It’s worth noting
that many of the links within the patient-level articles
point to professional-level information that subscribers
PubMed (www.ncbi.nlm.nih.gov/pubmed) is a freely
accessible database maintained by the NLM. As of May
2012, it contains more than 21 million citations to biomedical
journal articles. PubMed is built on a controlled vocabulary
called Medical Subject Headings (MeSH), which
enhances search precision. It is particularly helpful for
translating plain speech into medical terminology. In May
2012, the NLM made significant changes to the PubMed
interface. PubMed now features faceted searching that
allows users to narrow down their search results by publication
date, patient age, and other criteria.
Unlike the patient resources, most articles in PubMed can
only be accessed by subscription to the relevant medical
journal. Abstracts (summaries) are available for most articles.
Your users can at least print abstracts to show their
healthcare providers. It’s also possible to limit your PubMed
search just to freely available articles.
Let’s say your user wants to find articles discussing surgical
treatments for an overactive thyroid condition in children.
To start a search using MeSH, click on the link for
MeSH Database in the right column. Enter your first keyword,
such as “overactive thyroid”, and click Search.
In this case, you’ll see a record for the MeSH term hyperthyroidism.
You’ll see a list of subheadings such as diagnosis,
genetics, and psychology. Since your patron wants
information on surgical treatments, check the box for
“Surgery.” Then click the button “Add to Search Builder” to
start a search. Click the search button to pull up a list of articles
that discuss surgery for hyperthyroidism.
Abstracts (you may want to explain these as summaries to
your patrons) are provided for many articles in PubMed. To
read an abstract, click on the article title. You’ll see a new
page with citation information and the abstract, if one is
available. Return to your search results by clicking the Back
button in your browser.
Most PubMed searches return a lot of citations. Use the
faceted search feature (formerly accessible from the Limits
page) to narrow the search results to a manageable number
of relevant articles. You’ll often use multiple limits at once.
Here are some tips for effectively using limits in PubMed.
Ages: Since you’re looking for articles on surgical treatment
of hyperthyroidism in children, you can narrow your
search results to that age group. To turn on this limit, click
on the “Choose additional filters” link. Then check the box
for “Ages” and click “Apply.” Select the limit for “Child (0-18
years).” You’ll see a smaller number of search results. Most
will focus on pediatric topics.
Journal categories: Setting the journal categories limit to
“Core clinical journals” lets you focus your search on major,
well-regarded medical journals. It’s particularly helpful if
you’re unfamiliar with the medical literature and don’t know
which journals are well-respected. The journal categories
limit is usually hidden. Click on the “Choose Additional
Filters” link, check the box for “Journal categories,” and click
“Apply.” Then select “core clinical journals.”
Species: For some searches, you’ll see a lot of articles
about animal studies. If you’re more interested in reading
about human health than laboratory rats, click on the link
for “Humans” to limit your search results.
Languages: It’s easy to narrow your search results to articles
written in the language(s) your user speaks. Click on
“more …” for a list of available languages, then check the
boxes next to the ones you want to include. Then click “Apply.”
Article types: This limit requires more explanation than
the others we’ve looked at so far. PubMed search results contain
many different types of articles including letters to the
editor, reviews, and reports from clinical trials. The article
type you need depends on the kind of question you have.
Luckily, you don’t need to be an expert in research methodology
to select the appropriate article types. Review articles
are often a good place to start because they evaluate multiple
studies done on the same topic. For example, a review could
compare different studies on the effectiveness of cognitivebehavioral
therapy for insomnia. Review articles are particularly
useful when many studies have been done on a
particular topic. To limit your search results to review articles,
click on the “Review” limit under “Article types.”
You can also use limits to search for individual studies. The
most useful limit for this is “Randomized Controlled Trial.”
RCTs are considered the gold standard of medical evidence
because the treatment (or other intervention) being studied
is tested against a sham treatment (placebo). Participants in
the study are randomly selected. This practice helps to
ensure that any observed changes in the participants’ health
are due to the intervention and not some other factor.
Free full text available: Some published research articles
are available for free online. The NIH Public Access Policy
mandates that biomedical studies conducted with NIH grant
money must be made available to the public through PubMed
Central. Other articles are freely available because of the journal’s
policy or the author’s choice to publish open access.
You can easily focus your PubMed search results on free
articles using the “Free full text available” limit. However,
most medical journal articles are not free.
RELEASE: FIND FULL TEXT
AND ENCOURAGE DISCUSSION
If the article your user wants is not available for free or
through your institution’s journal subscriptions, you have a
few options. You can encourage your user to bring the
abstract to her physician, nurse, or other healthcare provider.
Even an abstract can be informative to a health professional.
Furthermore, the healthcare provider may have access to
that journal through his employer, a professional organization,
or a personal subscription.
Interlibrary loan is also a possibility. It may be worth calling
your local hospital library and asking about its policies
for nonaffiliated users. Some hospital libraries only serve
the hospital staff, while others welcome the public to use
their resources. Always call in advance before sending your
patron over to the hospital library to avoid inconveniencing
your user or the library staff.
Encourage your patron to share any articles or abstracts
of interest with her healthcare providers. While you can
assist users in finding information, only qualified health
professionals can interpret the information and help
patients assess its relevance to their healthcare.
Thinking about providing health information using the
Triage, Treat, Release metaphor will help you put the search
process in a framework that will guide you and your users to