How to add 100 specialists to your practice -- your hospital library

The author shares a view of some of the many medical books in her personal collection. Photo courtesy Dr. Sarah Hoggan If you have ever watched the cooking show, Chopped, you already understand what a strong library can do for your practice. The contestants are given only a few ingredients, but their access to a lavishly stocked pantry allows them to make a gourmet meal. A lavishly stocked library is exactly the same! It builds upon, and compliments, what you already have to optimize the outcome. The elements that define a strong in-practice library are three-fold: the medical library, the supporting library, and the medical journals. Medical libraries are a specialized category, “…designed to assist physicians, health professionals, students, patients, consumers, medical researchers, and information specialists in finding health and scientific information to improve, update, assess, or evaluate healthcare. Medical libraries are typically found in hospitals, medical schools, private industry, and in medical or health associations. A typical health or medical library has access to MEDLINE, a range of electronic resources, print and digital journal collections, and print reference books. The influence of open access (OA) and free searching via Google and PubMed has a major impact on the way medical libraries operate.”1 That definition relates to the human medical field; but the purpose is clear: a medical library elevates the level of care you can offer. It is like having continuous access to multiple specialists because each chapter, each book, is written by a specialist, or recognized authority in that particular subject. You have the gold standard of care at your fingertips for easy access, that you can go to as often as you like. Not only that, but if there are multiple ways to manage a condition, such as diabetic ketoacidosis, you can site your care reference into the medical record, “Intermittent IM injections of regular insulin administered with glucose monitoring. Technique from p. 211 Internal Medicine Text by Dr. X.” So, if your shift is ending, and the next doctor isn’t as familiar with the protocol, they can pick up exactly where you left off. Obviously, something that is routinely done at your hospital, such managing kennel cough, may not require frequent reference of its treatment protocol from the textbook. However, what about the hyperglycemic hyperosmolar syndrome patient, or a perineal hernia with bladder entrapment? If you are hours from a specialty hospital with a critical patient, a good textbook can make a lifesaving difference in the level of care you provide. For DVMs at all levels A medical library is not just a tool for a seasoned doctor to refresh their knowledge on rare conditions, or to grow medically when it’s utilized to save an incredibly complex case. An in house medical library can help a new doctor get more confidence and increase their level of learning as they cross reference what they are seeing clinically, with what is documented in the textbooks. Consider a marijuana toxicity patient. The dog is brought in with a history, “Acting weird. Shaking, urinated inappropriately, and seems scared.” The toxicology text describes some of the clinical signs of marijuana toxicity as, “tremors, mydriatic pupils, apprehension, and urinary incontinence.” Connecting what is seen with what is read will cement that knowledge and lay a solid foundation for recognition the next time a marijuana toxicity presents. As far as which medical texts you should have in your library; that will certainly have a level of personal preference associated with it, as well as variability depending upon your patient load. A practice that caters to local apiaries, or treats wildlife, will need those references versus a practice that treats predominantly dogs and cats. Also, having more than one reference on large subjects, such as surgery or internal medicine, can be beneficial because even specialists may have slightly different approaches to diagnostics and case management. Having multiple sources of information will augment and enrich your knowledge base as well. The support library is much less structured than the medical library. It is designed to augment and enhance what is essential to the practice of the medicine, as well as the culture your practice. Being an excellent doctor is more than knowing anatomy, physiology, and differential diagnosis. This library is designed to help the areas of practice that are more “outside the lines.” For example, if a new associate is struggling to do good quality physical exams, you can help them in two ways. One, get a medical textbook that describes how to do a proper physical exam and review that with them. That is simple and tangible. The next way you can help is to have them read some of The Adventures of Sherlock Holmes by Sir Arthur Conan Doyle.2 The character of Sherlock Holmes was based upon a Scottish physician named Joseph Bell. He was a brilliant diagnostician in that he was able to take what he found upon physical examination, and deduce key characteristics about a person from that exam. Doyle worked with Dr. Bell at the Edinburgh Royal Infirmary; he saw his techniques first hand. That allowed him to capture the deductive reasoning process Holmes utilizes as he explains his conclusions to Watson; just as Dr. Bell would explain his deductive process to the students he was teaching at Edinburgh. For someone who maybe struggling to make that leap in practice, piecing together the clues gained from a physical exam, it can serve as road map to developing that critical thinking. Books for ‘soft skills’ The library also has applications beyond medicine. Thoughtful practice management is essential to a well-run veterinary facility. While some people may have an intrinsic sense for management, for most people it is a skill that is learned and improved over time. If you have a practice management team, you can have books in your library that help explain the culture of your practice so new managers can learn in a way they can actually go back and reference, versus just passively observing. An example of teaching the management culture is Legacy,3 which tells the management techniques utilized by the All Blacks rugby team of New Zealand. For those not familiar with the All Blacks, the team was founded in 1903 and has “a 77 percent winning record in test-match rugby, and is the only international men’s side to have secured more wins than losses against every opponent.”4 Putting all fandom aside, that record shows a management style that is time-tested and still proves effective. A sports team and a medical team are not that different. Every individual has a role to play, every person brings a different level of experience and expertise to the team, and everyone is united by a common goal. It is common for individuals who grew up playing team sports to utilize the “team” skills they learned in management roles: how to communicate effectively without bruising egos, how to handle stressful situations, and how to make decisions when under pressure. If someone never played team sports, or could just use some guidance with these skills, they can reference books like Legacy to see how mastering these skills make a difference. Another facet of management that can be challenging is how to work with different personality types on the treatment team. Extroverts tend be outgoing, speak up in groups, and have a degree of comfort when they are in the spotlight. They tend to function well in group interactions such as team meetings. Introverts, however, are just as valuable to the team, but they function best in different circumstances. Quiet5 explains how introverts work best and what can be done to help accommodate their strengths, so their contributions are not lost when group communication is used for efficient exchange of ideas or making plans. Perhaps one of the most critical portions of the support library actually caters to exactly that subject: support. All types of medicine are challenging to practice because the reality is pain and death cannot be separated from day-to-day operations. This takes on an even heavier burden for veterinary medicine because euthanasia is a part of our practice and families quite literally make life and death decisions based upon our recommendations, and most tragically, our fees. This is a heavy load to bear, even the most stoic professional still has feelings. Dealing with grief While one practice member may be struggling with the processing of grief, another may be batting a personal demon of perfectionism that is quietly chiseling away at their sense of self-worth. Having books on hand that can be referenced, or even silently observed and then privately ordered, can help someone who is struggling. The Gifts of Imperfection: Let Go of Who You Think You’re Supposed to Be and Embrace Who You Are6 addresses the challenges faced by being a perfectionist and offers guidance to temper that drive and redirect it into a more productive and accepting cadence. Meetings at the Edge Dialogues with the Grieving, and the Dying, the Healing, and the Healed7 gives firsthand accounts by hospice personnel, terminally ill patients, and family members of terminally ill people. This book is designed to help individuals understand how to process, accept, and talk about death. While the process of saying goodbye to a pet is different than the process of losing a human family member, the frank, but thoughtful discussions, are an excellent tool, and a place to start, to develop a level of comfort with having end of life discussions. The Grief Recovery Handbook8 is a literally a road map for processing grief in a healthy way that allows for understanding, accepting, and then forward progress, after suffering a loss. This book can be helpful to staff that may be struggling with experiencing euthanasia, or for giving owner’s guidance after they have lost a pet. Post-It tabs come in a variety of colors and sizes, and make finding frequently referenced pages instantaneous. Color coding allows for further organization: the author’s system is red for procedures, blue for tables, green for drug protocols, and yellow for intern rounds topics. Photo courtesy Dr. Sarah Hoggan Monthly specialists The last facet of a strong in-practice library are the professional journals. They are knowledge that is “refreshed” much more frequently than textbooks. Journals are essential to continued professional growth and awareness. That means journals should absolutely be a portion of a hospital’s library, but not to the extent they resemble the dusty stack of National Geographic magazines you remember from your grandparent’s basement. Journals are meant to be “harvested,” which is why they are in a paperback format. Take for example JAVMA, the Journal of the AVMA. Each issue has a variety of topics covered – some articles pertain to small animal medicine and some are equine, exotics, or other species centered. If you operate an exclusive small animal practice, you do not need the equine, bovine, or mixed animal portions of the journal. You can cut out the portion you want to keep and recycle the rest. If you just want to save each pertinent abstract for quick reference, and use that as a stepping stone to find the full article in a digital format, you can reduce a six-foot stack of older issues to a single binder in a matter of hours. If you don’t want to have any print journals around and have strictly digital access, that is just as valid. Simply make sure the list of accessible journals, and the log-in information for each, is readily available so the resource is utilized. Building the practice library can be done bit by bit, in spurts, or in a larger block investment style. All purchasing plans will work, you are only limited by your resources of finance and storage. If you want to have multiple books immediately, but don’t have a budget to cover everything you want, there are options. If you are lucky enough to live near a veterinary school or textbook repository, you may be able to buy used copies of the books you want. Amazon also offers used copies of some veterinary textbooks and the inventory is always changing so if a book isn’t available immediately, patience may pay off. Also, ordering older editions can be less expensive and may contain enough of the information you want to meet your needs. Thriftbooks.com is a website that sells thousands of used books and will allow you to make a “wish list” with notifications when your desired books become available. If you want new or latest editions of books, conferences are an excellent place to find books and vendors often will give discounts if multiple books are purchased. Finally, once you have built your practice library, it needs to be understood that it is a delicate instrument and one that is shared by the team. Unfortunately, not everyone treats books equally. To protect your library from accidents or ignorance, some basic rules should be displayed so everyone understands. No books may be taken home without permission. No books are allowed on the wet tables. They may be nearby on a mayo stand if being utilized for guidance on a procedure. Absolutely no one is to write, or highlight, in the books. Post-it tabs are acceptable to mark pages or passages. Do not pull heavy books off the shelf by the binding. That is like picking up a patient by their skin; it causes damage. (That last bit is a bit melodramatic, but like all things, compliance improves when the reason for the instruction is understood.) All books should be put away when readers are done using them. A rich in-practice library is an investment that will pay dividends of saved time, increased knowledge, improved skills, and superior case management. There is a reason books are burned when the ideas they contain are deemed too volatile; what is not written and saved, is lost. Even if you knew how to do something once, does not mean you will remember it years later. Textbooks, journals, and support books are patient and non-judgmental teachers, counselors, and coaches, whose sole objective is your success. Why wouldn’t you want that in your practice? Sarah Hoggan, DVM, is residency trained and has worked exclusively as an emergency doctor since 2003. She is the medical director at VCA California Veterinary Specialists in Murrieta, CA. She grew up in Idaho and attended veterinary school at WSU. Resources Wikipedia The Free Encyclopedia: Medical Library Doyle, Sir Arthur Conan. The Complete Sherlock Holmes Collection. 2017; Wordsworth Editions Ltd. Hertfordshire, England. Kerr, James. Legacy. 2013; Constable and Robinson, London, England. Wikipedia The Free Encyclopedia: New Zealand national union rugby team Cain, Susan. Quiet. 2013; Crown Publishing, New York. Brown, Brene’. The Gifts of Imperfection: Let Go of Who You Think You’re Supposed to Be and Embrace Who You Are. 2010; Hazelden Publishing. Levine, Stephen. Meetings at the Edge Dialogs with the Grieving and the Dying, the Healing and the Healed. 1984;Anchor Books Doubleday Publishing, New York. James, John W. and Russell Friedman. The Grief Recovery Handbook. 2009; Harper Collins Publishers, New York.

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How to add 100 specialists to your practice -- your hospital library

These resources are musts for both seasoned veterinarians and new grads

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