International Journal of Medical Informatics (2003) 71, 9
/15

www.elsevier.com/locate/ijmedinf

REVIEW

Knowledge management in clinical practice: a

systematic review of information seeking behavior
in physicians
Martin Dawesa,*, Uchechukwu Sampsonb

a
Department of Family Medicine, McGill University, 515 Pine Avenue, Montreal, Canada H2W 1S4
b
Cardiovascular Disease Division, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115,
USA

KEYWORDS Summary Objectives: To determine information seeking behavior of physicians. Data

Knowledge management;
Clinical practice;
Physicians
sources: Systematic review of 19 studies that described information seeking behavior
in a number of different settings using differing methodologies. Analysis was limited
to quantitative studies describing sources of information sought by physicians.
Results: Investigators have used questionnaires, interviews and observation to
identify the information seeking behavior of clinicians. The results were mainly
obtained from trials in the United States and showed a wide variation in primary
information sources used by physicians. The most frequent source for information
used are text sources, second is asking colleagues and only one study found electronic
databases to be the primary resource. Physician’s desk reference is the commonest
cited printed resource. Convenience of access, habit, reliability, high quality, speed
of use, and applicability makes information seeking likely to be successful and to
occur. The lack of time to search, the huge amount of material, forgetfulness, the
belief that there is likely to be no answer, and the lack of urgency all hinder the
process of answering questions. Conclusions: The wide variation in information
seeking behavior implies a need for further categorization of information need and
information sources. Careful planning of information delivery to physicians is required
to enable them to keep up to date and to improve knowledge transfer.
– 2003 Elsevier Science Ireland Ltd. All rights reserved.

1. Introduction information flow through which knowledge transfer

The advent of clinical governance demands the
incorporation of research-based evidence into
clinical practice [1]. Implicit in this demand is the
need for access to both medical information and
knowledge. Knowledge-need and information-re-
trieval are distinct entities of the spectrum of
*Corresponding author.
E-mail address: martin.dawes@mcgill.ca (M. Dawes).
occurs [2].
A dilemma has arisen from the explosion in
volume of published medical research. Physicians
have to effectively deal with the resultant snow-
storm of information in order to make informed
evidence-based decisions [3]. The encouragement
of physicians to adopt the principles and practice
of evidence-based medicine should not take place
in isolation from the problems associated with
knowledge transfer and information retrieval.

1386-5056/03/$ - see front matter – 2003 Elsevier Science Ireland Ltd. All rights reserved.
doi:10.1016/S1386-5056(03)00023-6
 10
Table 1 Summary of characteristics of trials investigating knowledge or information seeking behavior of physicians

Study Date Method Subjects Setting Description of sam- Validated process of Response
pling process data collection rate (%)

1 Strasser 1978 Questionnaire 258 practicing doctors Upstate New York Systematic sample Yes 45.6
2 Northup et al. 1983 Semi-structured interview and 256 doctors University of New Random sample Yes 60
critical incident technique Mexico
3 Covell et al. 1985 Questionnaires and two post- 47 primary care doctors Office Los Angeles Random sample Not stated 24
clinical session interviews
4 Timpka et al. 1989 Questionnaire, including criti- 84 general practitioners Sweden Urban Center Purposive sample Yes 87
cal incident question
5 Williamson et al. 1989 Questionnaire (phone inter- 492 primary care doc- United States office- Random sample Yes 78.6, 89.8a
view) tors, 90 opinion leaders based
6 Woolf and Ben- 1989 Administered questionnaire 67 primary care physi- Maryland Academic Random sample Not stated 84
son cians Center
7 Connelly et al. 1990 Questionnaire survey 126 family physicians Minnesota Convenience sam- Yes 52
ple
8 Ely et al. 1992 Observation 34 family physicians Columbia, MO Convenience sam- Sole participant 88
ple
9 Dee and Blazek 1993 Case review and interview 12 doctors 83% in pri- Central Florida Convenience sam- Sole participant 100
mary care ple
10 Bowden et al. 1994 Questionnaire 442 doctors Texas (five counties) Random sample Yes 52.2
11 Gorman and 1995 Interview 49 doctors Oregon office-based Stratified sample Yes 98
Helfand rural and non-rural
12 Chambliss et al. 1996 Interview and dictation after Nine family physicians Columbia, MO group Convenience sam- Not stated 74.4
clinical session practice ple
13 Shelstad and 1996 Questionnaire 99 general surgeons New Mexico Purposive sample Not stated 74.4
Clevenger
14 Barrie and Ward 1997 Semi-structured interview 27 general practitioners Australia urban gen- Random sample Yes 82
after clinical session eral practice
15 D’Alessandro et 1999 Interview and critical incident 28 radiology residents University of Iowa Purposive sample Yes 100
al. technique hospitals and clinics

M. Dawes, U. Sampson
16 Ely et al. 1999 Observation 103 family physicians Eastern Iowa Random sample Yes 80
17 Cogdill et al. 2000 Interview after clinical session 15 primary care physi- North Carolina Purposive sample Not stated 100
cians
18 Green et al. 2000 Semi-structured interview 64 residents in internal Yale University, CT Purposive sample Yes 100
after clinical session medicine
19 Gorman 2001 Questionnaire 486 primary care physi- Portland, OR Random sample Yes 48.6
cians
a
Practitioners and opinion leaders, respectively.
Knowledge management in clinical practice
Advances in information technology have
brought into existence electronic information re-
sources such as MEDLINE, EMBASE, and the Co-
chrane Library of databases. It was expected that
these electronic resources would help tackle the
problems of information overflow in clinical prac-
tice [4]. However, concerns still exist regarding the
gaps in knowledge base of the physician, with lack
of timely access to information [5].
Regardless of the etiology, such gaps in knowl-
edge impede the proper practice of evidence-
based medicine. The doctrine of evidence-based
medicine raises fundamental questions regarding
how often physicians generate questions in clinical
practice, what the categories of frequently asked
questions are [6], what resources are available to
them and what resources they frequently patronize
in seeking answers to clinical questions.
In the past two decades, a number of studies
have addressed directly or indirectly, the informa-
tion needs of physicians. One review in particular
in 1996 described the state of clinical information
need [7]. This systematic review updates that
review and evaluates the information-seeking ha-
bits of physicians determining the nature of their
information resource preferences.
2. Methods
2.1. Selection criteria
We selected trials or reviews that identified
information seeking behavior, frequently asked
questions, information needs, clinical questions,
information sources, or knowledge resources. Trials
had physicians as their primary or sole subjects.
Studies had to explicitly or implicitly define in-
formation need as medical information need rather
than the need for non-medical information or
patient data. We excluded studies that did not
report quantitative observational or survey data in
the form of frequencies, ranks or proportions on
the category of questions and/or information
sources utilized. We excluded non-systematic re-
views or articles that focused on methodological
quality of published studies, however, these were
utilized for cross-referencing.
2.2. Search strategy
The Cochrane Library, MEDLINE and EMBASE from
1966 to December 2001 were searched for physi-
cian, medical-personnel, health-care-personnel,
doctor*, health-practitioner, or health profes-
sional, and question*, frequently asked questions,
11
frequent questions, common* asked question*, or
frequent* question* asked. One author (SU) as-
sessed retrieved titles and abstracts for relevance.
A second more specific search using common
phrases found in retrieved articles ‘‘information
needs’’, ‘‘information need’’, ‘‘knowledge ex-
change’’, ‘‘information seeking’’, ‘‘information
searching’’, ‘‘managing information’’, ‘‘knowledge
need’’, ‘‘knowledge needs’’ or ‘‘clinical questions’’
was subsequently performed. An author search was
carried out as well as hand search of relevant
references. Authors involved in this field were
contacted personally to identify further published
and unpublished studies. Both authors indepen-
dently assessed all articles from titles and ab-
stracts for relevance. In cases of uncertainty of
relevance full text of the article was used to assess
relevance.
2.3. Data extraction and study appraisal
We extracted the following data from each
study: method(s) of data collection, sampling
process, subjects and setting, data collection
process and response rate, and sources of informa-
tion. A study was deemed to have a validated
method of data collection if the instrument used in
data collection was piloted before use, and/or a
second researcher oversaw the data collection
process reviewed, and/or the collected data was
reviewed for independent interpretation amongst
researchers.
Two reviewers independently extracted the data
from each study, and any disagreements were
resolved by consensus discussion. There was sub-
stantial heterogeneity in the methodology and
results of the trials found making meta-analysis
inappropriate.
3. Results
The initial search returned over 7000 papers. The
second search returned 1947 papers. Nineteen
studies met the eligibility criteria (Table 1). The
methods used to collect information seeking beha-
vior were questionnaire in nine (47%) studies and
interview in eight (42%). Some studies employed a
combination of both methods of data collection.
The remainder were record reviews or observa-
tional in nature. The majority of studies involved
primary care physicians; one study involved sur-
geons and one radiologist.
The most frequent method of sampling was
random sampling (8, 42%) although no study de-
scribed the randomization process. Five studies
 12
Table 2 Primary and other information sources used by physicians

Study Date Denominator Print source Professional col- Association CME Electronic Pharma Primary source Patients
leagues meetings source reps

1 Strassera 1978 258 n/a n/a n/a n/a n/a n/a Papers n/a
2 Northup et al.a 1983 404 252 (62%) 136 (34%) n/a n/a n/a n/a Books n/a
3 Covell et al., 1985 182 111 (61%) 56 (31%) n/a n/a n/a n/a Booksc 3 (1.6) and
Reporteda lab data
Covell et al., 80 21 (26%) 43 (53%) n/a n/a n/a n/a Colleagues 11 (13%)
Observeda and lab
data
4 Timpka et al.a 1989 166 96 (58%) 63 (38%) n/a n/a n/a n/a Colleagues
5 Williamson et 1989 n/a n/a n/a n/a n/a n/a n/a Colleagues
al.
6 Woolf and Ben- 1989 n/a n/a n/a n/a n/a n/a n/a Books
son b
7 Connelly et al. 1990 n/a Used daily Approached B/monthly Physicans desk
every week reference
a
8 Ely et al. 1992 41 21 (51%) 12 (29%) Physicians’
desk reference
9 Dee and Blazek 1993 n/a n/a n/a n/a n/a n/a n/a Colleagues
10 Bowden et al. b 1994 442 373 (84%) 330 (75%) n/a n/a n/a n/a Books and
journals
11 Gorman and 1995 105 50 (48%) 32 (30%) 2 (0.2%) Books
Helfand a
12 Chambliss et 1996 45 9 (20%) 32 (71%) Electronic
al.a
13 Shelstad and 1996 99 95 (96%) 92 (93%) 96 Meetings
Clevengerb (97%)
14 Barrie and War- 1997 70 44 (63%) 19 (27%) 1 (1%) Physicians’
da desk reference
15 D’Alessandro et 1999 Textbook 37% Colleagues 58% Colleagues
al.a

M. Dawes, U. Sampson
16 Ely et al.b 1999 399 273 (68%) 161 (36%) 10 (2%) Books
17 Cogdill et al.a 2000 162 43 (69%) 17 (27%) Books
18 Green et al.a 2000 80 42 (53%) 14 (17%) Books
19 Gorman b 2001 Drug text 98%, general Consultants 96%, Physicians’
text 80%, clinical manual Colleague 80% desk reference
68%, specialty text 68%
a
Percentages represent proportion of total number of information resources.
b
Percentages represent proportion of the total number of participants.
c
Although the participants believed that they used print sources more often than using their colleagues, in actual office practice the reverse was found.
Knowledge management in clinical practice 13

Fig. 1 Forest plot of proportion (95% CI) of health professionals using printed sources to answer information needs
taken from 13 studies ordered by size of study.

Fig. 2 Forest plot of proportion (95% CI) of health professionals using colleagues to answer information.

(26%) used purposive sampling, four (21%) used had a sole data collector (sole participant). The
convenience samples, one systematic sample and response rate varied from 24 to 100% with median
one a stratified sample. Twelve studies (63%) had a response rate of 80%. Three studies had less than a
validated process of data collection. Two studies 50% response rate.
14
13 studies reported text sources as the primary
source of information (books, seven; papers, two;
desk reference, four), four studies reported col-
leagues as the primary source and one found
electronic sources to be the primary source (Table
2).
The heterogeneous pattern of use of human and
print resources did not show any marked variation
in the past two decades covered by the studies
constituting this review.
The proportion of physicians using printed mate-
rial as an information source is in the range of 50
/
80% but there is wide variation (Fig. 1). The
proportion of physicians using colleagues shows a
similar wide variation although possibly the trend is
to less use of colleagues than printed material (Fig.
2).
One paper found that health professionals in
urban counties reported a greater use of profes-
sional colleagues than those in the semi-urban or
rural counties; similarly, those engaged in practice
within institutions utilized professional colleagues
more than those in solo or group practice [8].
Convenience of access [5,9
/11], habit [9], re-
liability (high quality) [10,11], quick use [10,11],
applicability [5] makes information seeking likely
to be successful and to occur. The lack of time to
search [5,11
/13], the huge amount of material [5],
forgetfulness [13], all hinder the process of an-
swering questions.
This leads to physicians only pursuing 30% of the
questions that arise in office practice [14].
4. Discussion
The weakness of this systematic review lies
partly in the drawbacks of the individual studies
and partly in the inherent differences of the
studies.
Data collection methodology can be fraught with
weaknesses that distort study results; for example,
there is the concern of potential bias when mail
survey method is adopted. Covell et al. [14]
compared questionnaire responses with observa-
tions made during office-based interviews. The
results of this study demonstrated that the study
participants overestimated their information seek-
ing, underestimated their need for information,
and had a misperception of their information
resource utilization and preferences. The advan-
tages of a broader approach to information need is
reflected in the above example, and has been
advocated by others [15].
Failure to adopt a method of randomization for
selecting physicians for inclusion may have led to
M. Dawes, U. Sampson
significant bias in several of the included studies.
The validity of the results of such studies should be
considered in the light of the adopted method of
sample selection. Another potential weakness is
the differences in the questions being asked. Using
a taxonomy of questions as suggested by Ely might
lead to a better consensus of information sources
relating to different types of question. However, it
may be better to further break questions down into
foreground and background. It is likely that differ-
ent sources would be more effective [16].
Despite these weaknesses a credible pattern of
physicians’ information resource utilization ap-
pears to be evident. In general, physicians make
use of print sources and consultations with collea-
gues in an effort to answer questions that arise in
clinical practice. The print sources utilized are
usually in personal libraries. These findings suggest
that physicians make use of readily available and
applicable resources given that such resources
require minimal cost (time and money) to obtain.
If the usefulness of medical information is inversely
related to the work done to obtain the information
[17], then it stands to reason that information
resource preference may be inversely related to
the ‘‘work-to-access’’ such resource. With the use
of regression analysis, Connelly et al. [18] demon-
strated that availability and applicability signifi-
cantly predict knowledge resource use. In the same
study, the addition of independent variables */
colleagues and PDR (a readily available print
source)*/further improved the explanatory power
of the regression equation; this was attributed to
the resource group characteristic.
In the various studies included in this review, the
participants implicated the lack of time as the
major factor that impeded the search for informa-
tion; likewise the perception that information may
not be found if sought. A recent qualitative study,
Ely et al. [19] evaluated the obstacles encountered
by doctors in their attempts to answer questions
arising in clinical practice; the lack of time was
identified as a paramount issue. This underscores
the need for available, accessible and applicable
information resources at point-of-care settings.
The finding that physicians have frequently
consulted with colleagues may be reflective of
special needs that otherwise cannot be met: a
psychological need for reassurance as well as the
need for tacit knowledge, which usually embodies
the experiential knowledge of another individual.
The frequent use of colleagues also raises concerns
regarding physicians in solo practice; and perhaps
the generation of fewer clinical questions by
physicians in solo practice is a reflection the lack
of interaction with other colleagues. As shown by
Knowledge management in clinical practice
Covell et al., physicians may not be aware of the
degree to which they need to consult with their
colleagues as shown by the differences in reported
and actual use of colleagues as a knowledge
resource [14].
Only one study documented electronic systems
as a major resource utilized by their participants
[20]. However, the study by Chambliss [20] com-
pared the usefulness of two information resources
MEDLINE and textbooks with respect to answering
clinical questions; the fact that this study pre-
cluded the use other information resources may
have accounted for its finding.
A review 6 years ago [7] stated that the doctor’s
information tool of the future might be some sort
of combination between the patient record and the
Internet, with the doctor and the patient posi-
tioned together at the intersection but not having
to pay attention to the technology. Evidently, the
use of electronic information resources for physi-
cians like computerized bibliographic systems has
not paralleled the information technology explo-
sion and the expectation that the latter will help
reduce the burden of information overload in
medical practice. The conclusion in 1996 was that
probably whatever sophisticated tools may be
developed, a major source of information will
remain colleagues. We found no evidence to alter
this impression.
The results of this review also highlight the
remarkably low number of studies that have
explored information seeking behavior of clini-
cians. This review demonstrates the need for
further research into information and knowledge
provision. What is clear is that it needs to be
useful, relevant and fast.
Acknowledgements
Professor Paul Glasziou, Professor in Clinical
Epidemiology, Department of Social and Preventive
Medicine, Mayne Medical School, The University of
Queensland, Qld., Australia. Dr Scott Richardson,
Associate Professor of Medicine, Chief, Division of
General Internal Medicine, Wright State University
School of Medicine, Dayton, OH, USA.
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