UMHealth System

Ralph H. and Ruth F. Gross Lecture Series

Medical Libraries: Past, Present and Future

Thank you for that most gracious introduction. It is truly my pleasure to be here as the 7th Ralph and Ruth Gross lecturer. It is a great honor, first, as I follow a truly great and distinguished list of lecturers and second, because I honor a truly wonderful lady and friend, Ruth Gross.

History and Context

It is now almost 40 years since I entered the world of medicine, its libraries, education, research and practice; the last 35 I have spent as, first, director of the University of Rochester’s School of Medicine Library for 10 years, and, second, as director of the University of Miami School of Medicine Library for the last 25 years. I was privileged to participate in the celebration of each school’s 50th anniversary, The University of Rochester School of Medicine in 1975, and Miami’s in 2002. Altogether then I was intimately involved with celebrations of two institutions that together spanned the last 75 years of the most incredible century in the history of humankind. History, and certainly the history of our profession, must be understood in the context of the times in which it occurred. It is this context that gives meaning to those events. Nothing occurs in a vacuum and to understand our history, or our sub-set of it, it is necessary to be cognizant and aware of the culture, not only of the sciences we serve, but of the institution, our profession and the cultural environment of the worlds in which we function, now, or in times past.

The importance of this relationship between context and meaning can best be illustrated by a personal experience. My mid-life crisis caused me to return to school, law school in fact. I was in my first month of my first semester when I turned fifty. My staff chose to celebrate the occasion with a surprise party. The staff room was decorated in black crape and amongst other surprises I received many “joke” gifts, one of which was, a huge button, at least six inches in diameter that read, “Over the Hill”. The day was October 19th 1991. I had to go directly from the party to School as I had class that evening. When I arrived all my friends in class wanted to know where I got the Clarence Thomas button. At first I didn’t get what they were talking about but then realized that this was the day when Clarence Thomas was confirmed by the US senate for a seat on the Supreme Court. He was definitely over the hill, Anita Hill that is!

To have been so closely involved in anniversaries that covered the last three quarters of the last century was, as I have said, a rare privilege. At the end of the 20th century, common people were better educated than they had been at the beginning of the century. People with an unusual amount of money were less showy and, unlike the beginning of the century, whites were less inclined to find status in their race. Despite all the wars, social upheaval, famine, environmental pollution and other threats to well being, humanity thrived – largely because of advances in modern medicine, science and technology. During the 20th century, epidemics of typhus, measles, dysentery, small pox, polio and tuberculosis were diminished or eliminated. The greatest triumph of all was that humanity, with its new ability to destroy itself, had not done so.

It is my intent today to give a historical overview of medical libraries, where we were, where we are and where we are going and it is quite daunting to know exactly where to begin. So taking the advice of the King of Hearts given to the White Rabbit: “It is best to start at the beginning, keep going until you get to the end and then just stop”. That history is important is almost too obvious to note. The great eighteenth century Italian Philosopher Giambattista Vico is generally regarded as the founder of the modern philosophy of history. Vico developed a theory of the origins of human consciousness based upon the three Egyptian periods for nations. Each age had its own kind of arts, skills, laws and government. All human endeavors were based in the use of language and this use indicated the age at which the society was in: The hieroglyphic; the symbolic; the epistolary or vulgar. Another twist on this fundamental scheme of Vico’s theory was that these ages were cyclical. It is in Vico’s ideas that Schlesinger’s theories of history and Santayana’s axiom on the fate of he who neglects its study resonate. Whenever I discourse on history I try to avoid pomposity and arrogance by quoting from a short essay that a little boy wrote on Socrates. “Socrates was the father of and the greatest of philosophers, Socrates taught Plato, and Plato taught Aristotle, Socrates told all the people all their faults. They poisoned him”. (1)

Libraries and Society

While it is the context of the times in which we function that informs us and from which we take meaning, it is also true that we as a profession have made significant and single contributions to the societies in which we exist: personal, institutional, professional and social. Ours is a noble profession, one that was honored and esteemed from the earliest times. To illustrate this inter-relationship between our profession and the society in which it functions, as well as the high place we occupy, I look to the Library at Alexandria, founded around 300 BC. It was the first of its kind. The Library of Alexandria was comprehensive, embracing books of all sorts from everywhere, and it was public. The Library and Museum was literally a place to acquire and cultivate the arts. The member librarian/scholars consisted of noted writers, poets, and scientists, and were appointed for life. They were very handsomely compensated and their salaries were tax exempt. In addition, they were provided with free food and lodging as well, not bad! Further the library was well endowed when it was founded. For quarters Ptolemy, the first, turned over an area of the Palace. Librarians were spared the lowly details of daily life in order to spend their time on elevated intellectual pursuits. This in turn made possible the growth of scholarship. The prime motive was not just the progress of learning, but rather to further the achievement of a modern rationality.

Kallimachos of Cyrene wrote the first catalogues which inventoried all the works in the library as well as the lives of their authors. Others wrote critical works of these publications and the degree of inter-referencing was remarkable; it was really a case of writing books about books. Crucial also, was the increased separation between the performance and the book. Thus, a literature that is not only internally cross-referential, results in the unpacking of canonical works. The Library of Alexandria changed the relationship between oral and written culture. The different phases of Alexandrian scholarship and the Librarians’ influence produced traditions that are still impacting us to this day. The critical commentary, exploited by generations of subsequent commentators, is the ancestor of today’s annotated editions. Other indispensable tools of scholarship that were produced include the authorative text edition, the glossary, the grammar and the science of lexicography. Talk about impacting society and culture! We librarians are indeed part of a noble enterprise.

Libraries and Medical Education in the 1960s and 1970s

With the hazard of the boy’s essay on Socrates in mind, let me share with you certain of my reflections about the world of medical education and medical libraries, as it was when I found my way to it. I began my career in Medical Libraries at the New York Academy of Medicine, where I was privileged to get to work with and know some of the giants of our profession; Gertrude Annan, Janet Doe, Jacqueline Felter and Lee Ash to name but a few. The year was 1963 and it was a time when the Federal Government was funding the establishment of new medical schools. One of the new schools was Mount Sinai School of Medicine and I was hired to work in the new Library.

It was in this setting that I had my closest contact with the undergraduate medical student. In the late sixties and early seventies there was social unrest among college students, including medical students. The dissension was to a considerable degree generated by antagonism toward our involvement in the Vietnam War. Like their younger colleagues (students in colleges), the medical students displayed a strong social conscience. Unlike their juniors they were more restrained and sober in their critiques of medical education and of medical practice, and so far as I know, did not resort to physical destruction of offices, laboratories and classrooms. The medical students were antagonistic toward organized medicine. They were concerned about the need to improve health care for the disadvantaged. They strongly supported the recruitment of minorities to medical schools.

They criticized the lack of relevance of much of preclinical instruction as it related to patient care. At the same time, they were critical of the intellectual level of preclinical teaching, particularly in biochemistry, because many had had advanced work in that field in their college preparation. They insisted on direct work with patients during the preclinical period and were critical of the insensitive manner in which several of their clinical teachers presented patients for their teaching purposes. They demanded more permissive curricula with multiple options and pass/fail grading. They wished to take part in grading and asked for representation on several faculty committees. In the five-year period from 1974 to 1979, there was an increase in students choosing primary care specialties; internal medicine, pediatrics, and family medicine, an increase which was not sustained but which we again see today, for very different reasons – economic rather than idealistic. Students were given formal participation on faculty committees, especially those dealing with the curriculum. Student groups developed programs to work in the inner city and rural areas and students were invited to participate actively on several faculty committees, including Library Committees.

When the students got to the patient floors the scene was also very much reflective of the times. The following is a description by Dr. Romano of what both the medical students and residents encountered on the inpatient psychiatry floors at the time of my arrival as Director of the Edward G. Miner Library at the University of Rochester School of Medicine:
When the students come to these floors, unlike the other clinical services, they find that most of the staff is not in uniform. They find them in open shirts, loose gypsy blouses, hip-hugging jeans, wooden shoes, Indian beads, and an abundance of hair. There are nurses, nursing assistants, nurse clinicians, assistant clinicians, psychiatric technicians, social workers, social work assistants, mental health aides, program coordinators, psychology students, primary therapists, secondary therapists, family and group therapists, mental health information service clerks, junior psychiatric faculty, senior psychiatric faculty (not many of these), full-time (less of these), part-time (often in a hurry), some time, one time, and characteristically, most of them never on time. From day to day, from out of the medical mist emerges a silent, white-coated person with a stethoscope, who conducts a physical examination of the patient, records such illegibly in the ever-burgeoning chart, and leaves almost as quietly as he came. We brought them, all of them, to our floors, in our evangelical egalitarianism. Most patients now are called clients and soon may be called penitents. Small wonder the medical student asks, “Who is the psychiatrist, and what does he do?”

I describe these scenes so that you might have an appreciation of the events that shaped my beliefs. I have some caution about how one presents a retrospective of his field, its contributions and history. The dangers were wonderfully illustrated by a review I read some time ago. This was a review by Ed Zern of “Lady Chatterly’s Lover,” published in Field and Stream. It read, “This fictional account of the day by day life of an English gamekeeper is still of considerable interest to the outdoor-minded reader, as it contains many passages on pheasant raising, the apprehending of poachers, ways to control vermin, and other chores related to the profession of gamekeeping. Unfortunately, one is obliged to wade through many pages of extraneous material in order to discover and savor these sidelights on the management of a midland shooting estate, and (underlined) this book cannot take the place of J. R. Miller’s, Practical Gamekeeping.”

From my time at Rochester, through my years at the University of Miami medical library, library operations and service programs have changed so dramatically that their world can be likened to a celestial body moving through space, with new concepts on the cutting edge appearing, and either becoming a permanent part of the system or burning off in a short space of time. I, for one, can remember libraries without computers – remember vividly the introduction of the TWX, printing interlibrary loan requests at 10 characters per second! What a marvel of technology – how ingenious to apply it to library operations and how, in one fell swoop, it made library networks and cooperative projects a reality. Today we are all refocusing the medical library’s faculty, staff, resources and services in a response to the rapid and widespread growth of the Internet and World Wide Web as the international network for desk top access to information. At my library, beginning in 1995, access to the Web was incorporated into our day-to-day activities. We hope, in this way, to continue as a leader in the development of virtual access to knowledge-based information, and at the same time preserve the integrity of the library’s more traditional resources and services. With this explosion of information and access to it we find ourselves having to deal with a new group of client, one that is growing at exponential rates, namely, the satisfied inept. I am sure we all have had experience with people who because they can find something think they have found everything.

When we look back, we always seem to see the past with a rose-colored glow. We become nostalgic and long for those days when life seemed a lot less complicated. This is true of our professional as well as personal lives. That it is not the reality we believe it to be is also true. This rate of change only brings to mind words spoken by Paul Valery, the French poet, who shortly before his death in 1945 said, “The trouble with the world today is that the future is not what it used to be.” Valery probably referred to the claim that more basic and far-reaching changes occurred in the middle third of the 20th century, than during the three hundred years preceding it. American medicine and medical education were dramatically affected by this extraordinary rate of change and were a part of the universe of new conditions that caused Valery such distress.

Henry Sigerist, the greatest medical historian of the century, pointed out that the medical ideal has changed greatly throughout the centuries and is evolving constantly. The physician was a priest in Babylonia, a craftsman in ancient Greece, a cleric in the early middle Ages, and a scholar in the later middle Ages. With the increased study of the natural sciences in the 19th century, the physician began to apply scientific principles to the art of medicine, and today the physician has become more of a businessperson than ever before. (3)

The European Tradition of Medical Education

In our country Medicine, its education and practice, was rooted in European traditions. It is not surprising to learn that when the European colonists came to this country they naturally brought with them the traditions and customs of their native lands. It was a natural consequence that the first medical schools in the United States were hospital based. The first general hospital engaged in medical teaching was Pennsylvania Hospital, founded in Philadelphia in 1751 with the help of Benjamin Franklin. Students attended William Osler’s ward rounds at Johns Hopkins in the 1890s and perhaps earlier at the University of Pennsylvania. In addition to Pennsylvania Hospital there was the New York Hospital, the Massachusetts General and many others. Indeed by 1845, nine American cities had thirteen general hospitals, in which attending physicians made rounds with their students. (4)

That medical education was hospital based in Europe resulted from the waves of barbarian invasions of the Mediterranean basin that caused the disruption of medical care and medical education. As the barbarian hordes swamped the Roman Empire the Goddess Hygeia suffered the fate of other deities, the dark ages set in and conditions on the European continent became steadily more odious. It was not until the 12th century and the influence of the 1st European Medical School at Salerno that the formal training of groups of physicians again made use of the methods of observation and study which was devised by Hippocrates of Cos, Paul of Aegina and Alexander of Tralles. The School at Salerno was first spoken of in the early 9th century and reached its greatest influence in the 12th century. Early on Salerno enjoyed a widespread reputation. This probably derived from the time in which a hospital founded by the Benedictines, toward the end of the 7th century, attracted patients from distant parts of the Byzantine Empire. That Salerno was still a part of the Byzantine Empire, is probably what accounted for the availability of many of the Greek texts and continuation of the Hippocratic tradition. Greek texts, the existence of which, is most likely owed to the librarians of Alexandria.

Salerno was but the first in a whole stream of medical schools in Europe, which were based on the patient as the unit of training. Side by side with the sterile university based medical schools, such as those found in Paris and Oxford, where students studied books instead of people -- until the rise of humanism changed all of this -- the hospital based medical school gave a sounder and much more objective education to its students. These hospitals were not of course the same as those in ancient Greece or Salerno but originated in the Catholic Church’s chain of inns and resting places meant primarily for travelers or for use as charity houses.

As you know the modern words, hospital, hotel, hostile, all stem from the same root and commemorate this Catholic tradition. I am sure that many of you in your travels, here in the United States, have seen this same pattern in the missions of California. Since, inevitably, some travelers become sick, a section of the establishment was fashioned into a sick bay where the poor patient could be fed, nursed back to health, or persuaded to die in a churchly manner. It was as the two streams of history, the Salarnan and Greek hospital on the one hand and the church hospital on the other came together that the use of such institutions for teaching became standard. The great hospital schools, L’Hotel Dieu and the Charite in Paris, St Bartholomew, and St. Georges, in London, became preeminent as teaching establishments. In our own country one need only read of the politicking carried on by David Hosack, who was on the first faculty of Columbia P&S and a founder of Bellevue Hospital in New York City, and Daniel Drake of Ohio, for the exclusive rights to bring their medical schools into the hospital, to realize how long into the nineteenth century that the hospital was the sine qua non of medical education. In fact Drake founded the Commercial Hospital in Cincinnati in 1827 primarily for teaching.

What brought change to this situation was the tendency to provide the appearance without the actuality, of the hospital experience, resulting in the disgraceful diploma mills that existed in the United States at the turn of the twentieth century. This in turn brought reaction from conscientious physicians and educators and led directly to the famous Flexner report of 1910, which described conditions in American Medical Schools and compared them unfavorably with the Flexner ideal and model – the very successful German, so called scientific school, which was attached to a university and based as much on the laboratory and the dead house as on the hospital. However, it was in the first fifty years of this century that medical education, as we know it came to be. Dr. John Morgan, the first professor of medicine in the United States at the University of Pennsylvania in Philadelphia, was the one who described the paradigm for medical education and this he did in the 1760s. It was a paradigm, which was only finally realized with the innovations of President Gilmore at the Johns Hopkins University almost a century later. While President Elliot at Harvard was the first to begin the affiliation of the medical school with the university, it was Hopkins that truly developed the model of medical education that remains substantially unchanged to the present day.

This university affiliation recognized that it is the university, which must insure the setting to attract the young so that they may participate in its central pervasive function and concern, which is the imaginative acquisition of knowledge. Alphred North Whitehead insisted that this was true. His thesis applied to all the scholarly divisions of the university, to literature and history, to science, and the professions. He said, “The University is imaginative or it is nothing, at least nothing useful.” (5) In 1983, Steven Muller, President of Johns Hopkins University, wrote an eloquent statement on the place and role of the medical school within the contemporary American Research University. His central point is that the medical school needs the university, that external forces may be pulling the medical school away, and that reconsideration of the teaching mission may be needed, both to re-inspire the university and to restore the medical school to it more fully. He, too, speaks of the downgrading of the teaching responsibility of the medical school, He said, “Teaching is, after all, the central mission that led to the creation of the university in the first place, long before research as we think of it today was even conceptualized. Teaching remains without question a vital mission of the medical school but, even so, it seems to trail both research and clinical care among the three priority missions of medical faculties. Obviously, there is no contradiction among excellence in clinical care, research, and excellence in teaching; on the contrary high quality is mutually reinforcing. But time – human time – is finite, and the rewards of teaching time are less than the rewards for time invested either in research or patient care. Patient care is directly compensated, if not to the individual physician – or not exclusively – then to the department, the medical school itself, and of course the teaching hospital that depends upon its availability. Research may also be directly compensated by grants and contracts and is also the road to professional advancement. Teaching is part of both – not a thing apart – but is usually not directly compensated, or only marginally. (6)

Early Medical Libraries

What of libraries? I took this occasion to reread Flexner’s comments. He said you can talk about museums and pointed out how neglected and barren they were. “Practically the same may be said on the subject of books. While Flexner did note that The College of Physicians and Surgeons of Chicago and the Medical College of Virginia have small working libraries, he lamented that no funds were set aside for the purchase of books. He goes on to note that, “The school grind is merrily independent of medical literature. The University of Maryland possesses, indeed, a large library under a separate roof, in a building that was unheated when visited in midwinter, and at best, is open only two hours a day. Denver and Gross, Denver, Colorado, and the Medico-Chirurgical College of Philadelphia have limited accumulations of textbooks and cheap periodicals, the former behind a counter in a business office, practically inaccessible, the latter at the college clubhouse. Long Island and Albany had no books at all. At the College of Physicians and surgeons in Los Angeles, the word, ‘Library’, is proudly painted on a door which on being opened reveals a classroom innocent of a single volume.” (7)

If not in medical schools, where were the libraries, collections and librarians trained in their maintenance and care? I am sure that some of you have read Dr. Brodman’s Development of Medical Bibliography, and realized that there were so many bookmen of importance and many were physicians. The father of bibliography was a physician, Conrad Gesner, of Zurich. The most important bookman was John Shaw Billings who’s enormous contributions, from the old Army Medical Library to the Index Catalogue of the Surgeon General’s Office, led directly to his appointment as Director of the New York Public Library. In fact as Director of the combined Astor, Lenox, and Tilden foundations he consolidated the collections and supervised the construction of the central library building on 5th Ave. and 42nd St. Of course, over the years, physicians had their own libraries in their homes. Not just the avid collectors like Osler, but the ordinary physician. Our libraries have all benefited from gifts of their collections.

Institutional medical libraries in this country, the early ones at the end of the eighteenth century, were in hospitals, notably, Pennsylvania Hospital and the New York Hospital. Interestingly the by-laws of the New York Hospital spelled out the duties of the Librarian, which along with instructing that on every title page it must be written, the property of the New York Hospital, had other significant departures from the guidelines for the Librarian laid out by the Duke of Urbino in the 15th century. Federigo da Montefeltro, the 2nd Duke of Urbino, flourished in the middle 15th century, and was the subject of an episode of Arthur Clark's wonderful series, Civilization. Federigo was the very model of a renaissance prince and his greatest passion his greatest cultural legacy was books. He set down the rules for the library at Urbino, which were: “The librarian should be learned, of good presence, temper and manners. He must preserve the books from damp and vermin, as well as from the hands of trifling, ignorant, dirty and tasteless persons. To those of authority he ought, himself, to exhibit them with all facility and courtesy, explaining their beauty and the remarkable characters in the handwriting and miniatures." A librarian's charge remains the same. In today’s language, acquire, organize, preserve, disseminate and store, although those of the New York Hospital did require a few things more. Namely, that the Librarian, who shall be the house physician, before he enters on the execution of his office shall give sufficient security in a sum not less that 250 dollars (a lot of money in those days) so that he could indemnify the corporation for any loss or damage which may be sustained by his negligence or misconduct. In addition they go on to spell out the rules for cataloging.

While the early institutional libraries were in hospitals the mid and later 19th century saw the emergence of the great Society Libraries. As I have already mentioned I began my career at the New York Academy of Medicine Library. The Academy itself was founded in 1847 and one of its three expectations for the future was the establishment of a library. During the early years, until its first building was erected in 1875, the volumes were kept in the quarters of whatever physician-member was designated Librarian. It was not until several years after the building was ready for the Library that the Academy employed its first Librarian. He had been the assistant librarian of the Astor Library, now a part of the New York Public Library. Mr. Brown was appointed in 1880 and was still librarian when Dr. Archibold Malloch came as Director of the Academy in 1924. A long tenure during which Mr. Brown lived in the building and served as custodian as well as librarian.

1875 was also an important date in Boston because the Boston Medical Library was then established. There had been an earlier library with that title, but Harvard Medical School was so happy to know that there was going to be a permanent medical library that it immediately presented the new library with its total collection of 4000 volumes. There was a significant library, earlier than any of these. In 1830 the Medical and Cirurgical Faculty of the State of Maryland was established with a library. Elizabeth Sanford wrote a very good history of this Library, which was published in the Maryland State Medical Journal in June of 1975. In the article there is a picture of Marcia Noyes, who was the first true librarian to be appointed by the Faculty. She was hired in 1896 by William Osler, on the basis of her experience at the Enoch Pratt Free Library and because she could fulfill the requirement that she reside in the building and be on duty 24 hours a day! Happily she did not also have to serve as custodian. (8) It is notable that as recently as 1925 Margaret Brinton, Librarian of the Mayo Clinic Library, reported that of the 400 people in this whole country working as medical librarians, only forty were trained as librarians. (9) Of course the librarians over the centuries were the scholars, the bookmen, those who were dedicated to learning and among them were many physicians. Even when not serving as Librarian, these dedicated physician bookmen and scholars were deeply involved with their libraries and our libraries have benefited greatly from their care and concern.

These libraries were all Medical Society Libraries, and the Society Library predominated for many years, in fact right up until the end of the Second World War. These were very large resource libraries and in addition to those mentioned included the Kings County in Brooklyn, the College of Physicians in Philadelphia, the Crerar in Chicago and many state society libraries.

Medical Libraries After World War II

The whole picture changed at the end of the Second World War basically because of two different but related factors. The first was Research. The remarkable achievements made by research in science in the Second World War led, as you all know, the federal government to invest millions of dollars to further research. It is hard to think now that when we look at the enormous complex of the National Institutes of Health that this was started from scratch. Imagine Louise Darling started the library that now bears her name at UCLA and the Medical School there did not admit its first class until 1951. In fact, of the 158 medical schools in the United States and Canada, 68, or 43%, were founded on or after 1945. This includes Osteopathic schools but the figure is comparable to that for Allopathic schools as 40% of them were either founded or admitted their first class after World War II. (10) All of the new medical schools and many of the old have been brought up to date and with very effective and fine libraries, many of them to support research. Funds were available to hospitals, laboratories and medical schools that were involved in research. There were no funds available to the Society libraries serving the practicing physician. The second factor was the exponential explosion of publications after World War II. This meant that no one library, except perhaps the National Library of Medicine, was able to collect everything published in the field.

These developments led directly to the great co-operative networks and ventures, which culminated in the development of the Regional Medical Library Networks that now cover the country. The explosion in publication stimulated our colleagues, trained librarians all, to develop extraordinary programs to maintain bibliographic control of the literature. Obvious examples include the early innovations of Fred Kilgore’s Ohio College Library Center (OCLC) using the MARC record to set a national standard for the organization and classification of the monographic literature; Estelle Brodman’s PHILSOM network for periodical subscription and control; Eugene Garfield’s development of the Institute of Scientific Information based on citation indexing and Irwin Pizer’s SUNY Biomedical Communication Network which put the entire MEDLINE database online while the National Library of Medicine was still developing AIM-TWX, to the latest revolutions in our profession: Nina Matherson’s conceptualization and development of the IAIMS program, as well as, Naomi Broering’s LIS (Library Information System) at Georgetown. It was this revolutionary and pioneering work of trained librarians that enabled entrepreneurs such as Mark Nelson and Jerry Kline to develop successful commercial systems, OVID and III , respectively. One would think that on the record of these phenomenal achievements for control and access to information that the Library and the trained librarian would rest secure in their role in the medical enterprise. Yet today we find that institutional support for library budgets is increasing at lower rates and has, in some instances, leveled off, or in fact decreased.

This is happening while at the same time the trained librarian is having to cope with PhDs without grants and physicians without patients, styling themselves as medical informaticans and wanting to hang their hats on the librarian’s hook. This concern is not new. Sir William Osler in an address given at the university of Wales said: “The old notion of the right person to have charge of books is going, but by no means gone; the sooner it goes the better for everybody. Many think still that a great reader or writer of books will make an excellent librarian. This is pure fallacy.” (11)

Research, Education and the Practice of Medicine are dependent upon access to information. The measure of success for the researcher, teacher, student and physician is directly proportionate to this access. Today’s challenge is the need to synthesize information pouring in from many disciplines that bear on matters of health and disease, yet whose languages are as disparate as talking in tongues. There is specialization with ever narrowing interests of investigations in the face of an increasing need for broad understanding of man and his world. We have an embarrassment of riches of specialists, becoming more denotative as each day passes, but a sorry lack of generalists, of persons capable of recognizing the common denominator and to suggest unifying principles. Automation and artificial intelligence are here to stay, but unlike Paul Dukas’ Sorcerer’s Apprentice, I hope we may be able to maintain control. That hope rests squarely on the abilities of the Librarian.

Today we are in the midst of a revolution that will impact man and the way he lives, works and functions, every bit as much as the industrial revolution. This technological revolution, a continuation of the Industrial Revolution, has had, and is having, an extraordinary impact on the librarian and his world. Today one can walk into one of our medical libraries and observe a whole universe of new and exciting programs and innovations. Most amazing is that these library services no longer require a trip to the library but merely access to a computer wherever you happen to be in the world at your moment of need.

Medical Libraries in the Future

In what directions will we lead our libraries in the future? One model might be that described by Bill Gates. At Microsoft, the Library, now staffed by more than 40 people, is an integral part of the corporation, responsible for all aspects of information management, including maintenance of an Intranet.

It is not unreasonable to expect to see the Library providing the publication expertise for the revitalization of the University Press. Scientists could now return to a pre-Guttenberg model for the dissemination of research results. Specifically publish on the Web. This is analogous to the pre-print scientist conducting his experiment, recording his observations, drawing his conclusions and putting such in a letter to his colleagues asking, “what do you think?” Libraries can now provide preprint servers for the researcher where, once an author has produced a suitable text version of a paper; it could then be listed on line for international peer review. If it proves worthy it could be archived in print or remain on line for eternity. This is only one of a number of publishing alternatives being actively considered in reaction to the constant, increasing costs of commercial publishing.

Librarians will continue to provide leadership on issues of copyright, now so much more complex with the reality of electronic publishing. Issues of copyright and its collateral issue of licensing agreements for dissemination of electronic resources will continue to dominate in the immediate future but fade as the full publishing and communication potentials of the new digital world are realized. It is a world in which the Library and librarian will play a significant role. As we move ahead into this brave new world we must keep our feet grounded in a firm dedication to our purpose coupled with an acute awareness of our past.

To talk on the history of libraries in medicine one must talk on the history of medicine. Indeed a moment’s reflection should remind us that we all are giving of our talents to help those engaged in the treatment of illness, distress and despair. We aim to assist them in the restoration of health. Most simply, this enterprise is the primary goal, the principal objective of all medicine. Tarlov predicted that the central objective of the coming era in medicine will be the maintenance and improvement of health, that is, the maintenance and improvement of optimal functioning in the everyday life of the person at home, at work, at school or in leisure. (12) It reminds one, in a sense, of the prescient remarks of Henry Sigerist, who in his Messenger Lectures at Cornell in 1940 said the following, “The goal of medicine is not merely to cure diseases. It is rather to keep men and women adjusted to their environment as useful members of society or to readjust them when illness takes hold of them. The task is not fulfilled simply by physical restoration, but must be continued until the individual has again found his place in society, his old place, if possible, or if necessary, a new one. This is why medicine is basically a social science.” (13)

The concept of a library as the hushed sanctuary of the scholar has long been shattered. Changing functions and techniques of today’s libraries lead to questioning the very substance of the library of the future. The librarian’s role should point toward a synthesis of the use of all available mechanisms into the most suitable application so that the total library will be a living force for the enrichment of mankind. The total library is not just a depository of the literature of a subject but rather a source of all forms of intellectual storage and all types of services. In short the librarian should be the protector and conservator and, more importantly, the interpreter of the humanistic heritage of man. The total library is both an intellectual resource and mechanism for the rapid transfer of current information. The willingness or ability of society to provide the means to reach our goals of gathering the information of the past and bringing it to bear on the problems of today, and the effectiveness of us as medical librarians in devising the best methods to reach these goals all relate to our mission as gathers, storers, preservationists and disseminators of information. The solutions must evolve from the problems addressed as posed in the context of institutional society and cultural norms and backgrounds. John Ziman reminds us that for the three uses of scientific knowledge – the creation of new knowledge, the social use of physical resources, and the solution of social problems, information is useless, unless it is communicated.

Life has not become simpler. Many feel alienated by these new technologies, they wish for individual needs and worth to be recognized, for this technological complexity to somehow be brought to human scale, for man, not the machine, to be the measure. Our society is bearing these two seemingly conflicting trends into its future, and our profession is being carried with them. As knowledge and information increase in complexity, so does the need increase for people trained to thread their way through this maze of information, to find what is pertinent, combine it with what is related, and merge it into what is needed.

As we move into the future we should guard against being content in these new roles. The time when we could rest easy in the knowledge that schools and government would support libraries and collections has yielded to an era of unprecedented change. We should push and explore, ever aware that the ways in which we perceive and conceptualize are influenced by our habits of mind and by our view of the world. Confident that as we move into the future, the sounds we hear are not the hoof beats of the four horsemen but rather the rumbling clouds of, the late Indian poet, Tagore’s new dawn. We can be sure that we will never arrive. Montaigne was right. It’s the journey that matters. If it is too hectic, too confusing and altogether overwhelming, the only advice I can offer is, to repeat Bismark’s counsel, that we should move to Luxembourg because there, after all, everything happens at least twenty years later.

  1. Severinghaus, A.E., Carman, H.J., Cadbury, Jr., W.E. “Preparation for Medical Education in the Liberal Arts College.” New York: McGraw Hill Book Company, Inc., 1953.
  2. Romano, J. On the Teaching of Psychiatry to Medical Students: Does It Have To Get Worse before It Gets Better? Psychosomatic Medicine, 42:103-111, Supplement 1980.
  3. Sigerist, H.E.: Civilization and Disease, Ithaca, N.Y.: Cornell University Press; 1945.
  4. Segal, Harry, L., Beyond the Walls, To Each His Farthest Star, The University of Rochester Medical Center, 1975., p. 337.
  5. Romano, J., “Comments on the 10th Anniversary of the Faculty Senate,” University of Rochester, May 7, 1973, Published in Proceedings of the Faculty Senate, pp. 3-4, October 1973.
  6. Muller, S., “The Medical School in the University.” JAMA. 252(11): 1455-7, 1984 Sep 21.
  7. Flexner, A.: Medical Education in the United States and Canada; The Carnegie Foundation for the Advancement of Teaching, 1910. P. 82, 315.
  8. Sanford, E.G.: The Medical and Chirurgical Faculty of Maryland Library, Maryland State Medical Journal, 24:35-40, June 1975.
  9. Brinton, M.: Medical Librarianship Some of Its Present Day Problems, Bulletin of the Medical Library Association, N.S. 14,28-38, 1924/1925.
  10. World Directory of Medical Schools, “6th ed. With supplementary information 1988-1996”, WHO
  11. Op.Cit. p. 28
  12. Tarlov, A.R., Shattuck Lecture: “The increasing supply of physicians, the changing structure of health-services system, and the future practice of medicine,” New England Journal of Medicine, 308:20,pp. 1235-1244, May 19, 1983.
  13. Sigerist, H.E., “Civilization and Disease.” Ithaca, NY; Cornell University Press, 1945.


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