J Med Libr Assoc. 2006 Jul; 94(3): 263–270.
PMCID: PMC1525305
Medicus Deus: a review of factors affecting hospital library services to patients between 1790–1950
This article has been cited by other articles in PMC.
Abstract
Question:
What are some of the historical societal, medical, and public health
trends leading to today's provision of hospital library services to
patients?
Data Sources: Literature from the archives of the Bulletin of the Medical Library Association
and other library sources, medical journals, primary historical
documents, and texts from the history of medicine form the core of this
review.
Study Selection: The period of
review extends from about 1790 through 1950 and focuses solely on trends
in the United States. Of primary concern are explicitly documented
examples that appear to illustrate the patient-physician relationship
and those between librarians and their patient-patrons during the
earliest years of the profession's development.
Data Extraction:
An historical timeline was created to allow the identification of major
trends that may have affected library services. Multiple literature
searches were conducted using library, medical, and health anthropology
resources. When possible, primary sources were preferred over reviews.
Main Results:
Juxtapositioning historical events allows the reader to obtain an
overview of the roots of consumer health services in medical libraries
and to consider their potential legacy in today's health care libraries.
Conclusion:
This review article highlights early developments in hospital library
service to patients. Further research is needed to verify a preliminary
conclusion that in some medical library settings, services to the
general public are shaped by the broader health care environment as it
has evolved.
Watch also the faults of the patients, many of whom often lie about the taking of things prescribed for by not taking disagreeable drinks, purgative or other, they sometimes die. Give necessary orders cheerfully and with serenity, turn his attention away from what is being done to him; sometimes you have to reprimand him sharply and severely, and sometimes you must comfort him with attention and solicitude … Perform (these duties) calmly and adroitly, concealing most things from the patient. [1]
Miss Kennedy: I had a case where a man asked me if we had any information about Peoria. I told him that this was a medical library. He said: “I know, but I thought you might have something about dentistry, too.” He wanted something on Pyorrhoea.Miss Walker: I always make them bring a letter from the doctor. [2]
INTRODUCTION
If
the author used the phrase “doctor as god” in conversation, readers
would likely recognize the concept it exemplifies: the old and slowly
dying physician-patient relationship, wherein one did not ask or argue
but was cared for by a beneficent father-doctor, whose decisions went
unquestioned. In their profession, librarians are nearly equally
familiar with the “‘missionary” roots of librarianship, wherein public
librarians led patrons along a path of higher thought toward
improvement. If knowing this history is instructive, then considering
the provision of consumer health information services in medical
libraries in the context of developments in medicine and public health
might also be valuable in looking toward the future.
This
review begins just before 1800, when the first medical schools began to
operate in the United States, and ends before 1957, when a landmark
court case ushered in the age of informed consent. The intent is to
trace modern evolutions in health care in their societal context, then
to place the growth of hospital library services in that context. The
importance of bibliotherapy in the creation of a unique niche for
medical libraries in the health care environment is emphasized. To
construct a timeline, a thorough scan of all early issues of the Bulletin of the Medical Library Association
(1911–1960) was performed, then the range of scrutiny was expanded to
include resources from each era from other library, medicine, and public
health publications. Because medical library development in other
countries took place in contexts unique to those environments, this
review is limited to the United States and its literature.
1790–1850: “MIASMIC CLOUDS” AND EARLY PUBLIC HEALTH
During
the last decade of the eighteenth century, poor or nonexistent waste
treatment facilities, lack of knowledge, and crowded living conditions
encouraged the rapid spread of disease. Yellow fever, typhus, influenza,
and cholera caused widespread mortality among an increasingly dense
urban population [3, 4].
Control of epidemic disease was limited to the use of quarantines,
which had begun to be enforced (albeit only during times of imminent
threat). States' rights were considered inviolable, so whatever was done
was local [5].
Battlefield hygiene and medical practice was even worse, with infection
acting as a major contributor to death counts during the War of
Independence, the War of 1812, and the Mexican-American War [3].
However, the devastation of disease in epidemic proportions, especially
among soldiers, focused attention on the need for change, and, by the
early 1800s, the most affected cities had appointed boards of health,
imposed quarantine measures, and otherwise had begun to take action [3].
Because
cause was unknown, noncontagionists and contagionists argued for
primacy (the former, who argued for the existence of “miasmic clouds”
created by rotting organic materials that spread disease, versus the
latter, who felt quarantine was crucial because disease was spread by
contact in some way), and the prevailing voices of power, including
those concerned with the economic well-being of the cities, usually
dictated the approach to public health [5].
Typical of the era, disease was considered to be the result of moral
failure, with the well person presumed to be an upstanding and
God-fearing citizen [5].
During
the earliest years of the nineteenth century, bibliotherapy was
regarded as the function of the physician, rather than the medical
librarian. In 1802, Benjamin Rush recommended the establishment of a
small library in each hospital whose function would be to provide for
the “amusement and instruction of patients” [6].
The purpose of the educational materials was the advancement of the
patients' educations—particularly in the areas of philosophy, morals,
and religion—and no mention is made of providing medical information.
Rush recommended that bibliotherapy be used for treatment and called for
trained professionals to work with asylum patients. Because novels, at
that time, were thought to contribute to insanity, his suggestions were
primarily for the use of nonfiction books [6, 7].
Such
was the atmosphere in 1844, when the first hospital library intended
for patients was begun at Massachusetts General Hospital. In an
historical overview, Panella notes that the term “hospital library” was
actually used to designate what we might now term patient or consumer
health libraries—though at that time, the functions, collections, and
purposes were entirely different [8]. This first library began by providing religious and moral reading materials to patients as they left the hospital [7].
Reports from the hospital's Library Committee record sustained
collection growth and popularity. Interestingly, the library also used
interlibrary loan from local public libraries to provide materials
including technical, business, Braille, and foreign languages books [8].
1850–1900: THE IMMORAL ILL
Epidemics
continued to rage through the country between 1850 to 1900, killing
thousands: yellow fever, influenza, cholera, smallpox, typhoid, scarlet
fever, typhus, and diphtheria were all widespread. In 1867, more than
3,000 people died from yellow fever in New Orleans; the following year,
the same disease caused more than 13,000 deaths in the lower Mississippi
Valley. It was the latter that led to the establishment, by Act of
Congress, of a National Board of Health to enact quarantine and other
measures. Though the board encountered tremendous political opposition
due to states' rights and personality conflicts, it did effect some
changes, most notably, a marked lessening of epidemic-related mortality [5, 6].
Even
after Robert Koch had discovered the cause of tuberculosis in 1882,
finding effective treatment proved a far more difficult task. The
disease affected the poor disproportionately, and health practitioners
remained convinced that its causes were immorality, “bad heredity,” and
poor sanitation. Patients were often moved to a cleaner, more
disciplined setting, which gave health care staff the opportunity to
teach patients about good hygiene and dietary habits [9]. Although the New York Sanitary Commission was established in 1861, the efforts were underfunded and sporadic [10]. One 1865 report cited garbage and filth piled to a depth of two or three feet along New York streets [11].
When
Herman Biggs, of the New York City Department of Health, became a
leading figure in the efforts to prevent the spread of cholera, for the
first time the need to involve patients in their care through education
was recognized. With a strong background in bacteriology [11],
Biggs was ideally suited to bring about the needed changes. He
instituted mandatory notification, free examinations, nursing follow-up
of reported cases, isolation of identified active cases, and, finally,
the promotion of awareness throughout New York [9, 12].
Directly related to these efforts, the New York City Henry Street
Nursing Service began in 1893 to provide nurses who taught hygiene,
infant care, and the care of tuberculosis patients by their families [6].
Throughout
the last years of the 1800s, and with the shift from what had been a
largely rural population to more of an urban one, labor disputes and
civil unrest signaled growing dissatisfaction with a widening gap
between the new social classes. Riots and strikes by an increasingly
angry populace brought change, including the eight-hour workday, child
labor laws, and worker's compensation. Awareness of a growing disparity
between technological, economic growth, and lagging public health
services sparked new social reform movements. Middle- and upper-class
women began to join social change movements, including those concerned
with salary reform, suffrage, temperance, and public health education,
and worked with the newly established school nurses and well baby
clinics to educate mothers about breast feeding and infant care [5].
Beginning
in the mid-1800s, medical inventions began to appear on a more frequent
basis, though for the most part, they were initiated in Europe because
American medical schools were less than productive. With 40,000 doctors
in the United States by 1850 [13],
it would seem that the country's citizens were well cared for, but
medical education itself was far from ideal. Encouraged by the early
shortages of doctors, some practitioners found it lucrative to
supplement their income by starting their own “medical schools” (which
could consist of a one-room office and one practicing physician) where
students could attend subscription lectures and then graduate to
practice having had little hands-on experience. Even the larger and more
reputable venues for medical education were inadequate: Harvard Medical
School's 1870 medical exam consisted of nine professors questioning the
degree candidate for five minutes each [3].
In a widely read medical etiquette manual, The Physician Himself,
published in 1881, C. W. Cathell recommended practices that included
concealing facts from patients, using misleading terms for medications
(for example, “kalium” instead of potassium), and calling diseases
something other than what they were. The rationale for such practice was
the widespread belief that the relationship of trust between physician
and patient—and hence, the therapeutic efficacy—depended on the
patient's ability to put his or her health entirely in the doctor's
capable hands [14].
The presence of hope was viewed as central to the effectiveness of a
cure: active avoidance of the disclosure of the patient's condition was
most desirable. As Bartlett noted [14],
it was not entirely unknown (though rare) that patients would question
or even challenge their caregivers—much more so, he states, than was
common in Europe, where the authority of the practitioner went without
question. This might have been due to the lack of respect for physicians
in American culture [15, 16]
and to the lack of medical certainty, as well as the widely publicized
negative accounts of bad practices. In general, distrust of medicine by
the lay public was very common and not misplaced: “It was not until
about 1910 that a patient consulting a doctor had a better than a 50–50
chance of benefitting from the encounter” [16].
The
prevailing model of the physician-patient relationship may have led to
the rationale, in bibliotherapy, that distraction from illness was most
desirable and that the provision of salutary materials tailored to the
patient's mental and physical status functioned therapeutically in
healing the patient. By 1880, the Massachusetts General Hospital, where
the first hospital library was begun, had started to permit the
circulation of religious and moral reading materials while patients were
still in the hospital, rather than sending them home with the patients
upon discharge, as had been the practice. The 4,000-volume collection
also included works of “fiction, travel, biography, poetry, and history,
works in sixteen foreign languages and twenty popular magazines” [17].
The hospital library's connection to bibliotherapy began in the mid-1800s, when John Minson Galt published On Reading, Recreation, and Amusements for the Insane [16],
thought to be the earliest writing on the topic. In it, Galt
recommended titles useful to patients with particular problems and
provided guidelines for bibliotherapeutic work. It is with bibliotherapy
that librarians first began to provide direct assistance to patients on
a more than casual basis. During his tenure as the superintendent of
the Eastern Lunatic Asylum of Virginia, Galt saw no problem with
permitting patients access to books not only for the purpose of “moral
therapy,” but for entertainment. He became well known for his advocacy
of patient libraries in asylums and was often a featured speaker on the
topic of bibliotherapy. Supervision of the library was performed by an
assistant physician, so that records could be kept of the patients'
reading, with all records made available to the asylum's director. Brief
mention is made of a librarian, but no specific recommendation is made
for a trained staff member.
1900–1950: TWENTIETH CENTURY DEVELOPMENTS TO 1950
By
1902, the program of awareness begun to control tuberculosis had grown
to become the country's first mass education campaign whose focus was on
a particular disease. The association created during this effort, known
as the Society for the Prevention of Tuberculosis (now the American
Lung Association), was first of many such efforts [9].
Following this example, others began to promote maternal-child health
and prevention of heart disease, cancer, and many other diseases and
conditions, spawning today's proliferation of associations focused on
prevention and public education [14].
Still,
there was much room for improvement. Political support for public
health was further boosted by the realization, at the onset of World War
I, that many conscripts were physically or mentally unfit for service.
Coupled with the devastating influenza epidemic of 1916 to 1918, the
need for public health education was increasingly viewed as a key to
change. During this era, patient and public health information was
published and distributed not only in English, but also in German,
Hebrew, and Italian. Even with the changes in public health, however,
conscription examinations for World War II in 1939 revealed that many
young men were still unfit for service [5].
An
important contributor to the expansion of public health involvement was
the Committee of One Hundred on National Health, whose purpose was
foreseen as nothing less than the control of preventable illness. Led by
J. Pease Norton and Irving Fisher, the committee gathered its “One
Hundred” from among the leading figures in public health, medicine,
social policy making, business, politics, labor, and agriculture to
assess current problems and recommend changes. Recommendations made to
the National Conservation Commission included school health programs,
research in preventive health, provisions for the collection of vital
statistics, and mother-baby care—an ambitious agenda that became the
foundation for public health in the early 1900s [9].
Additionally, the committee recommended that the government should
“provide for the dissemination of information” to the general public
just as it provided information to farmers about conservation and animal
husbandry, making the comment that one of the purposes of the committee
should be to “lay to rest claims that animals were better cared for
than humans” [18].
If
the primacy of Western medicine had become entrenched by improved
medical education and a movement toward licensure and standards for
health care, federal involvement between 1900 and 1950 further supported
that predominant voice. Public health itself—particularly the efforts
lent to preventive medicine—began to lose political support, with the
result that far more money was expended on curative than on preventive
medicine, a trend that would continue [11].
The 1921 adoption of the Maternity and Infancy Act, known as the
Sheppard-Towner Act, by the United States Congress matched state funds
for creating public health initiatives to prevent child mortality by
providing prenatal care and teaching mothers about child hygiene and
care [14],
though opposition to this program by increasingly powerful medical
voices brought about its defeat by 1928. School health programs
supported by public health were also regarded with distrust by many
health care professionals, who saw such practices as interfering with
their own [5].
By 1946, the leading causes of death were heart disease, cancer, and accidents, bringing increased focus on chronic disease [5].
In 1946, the passage of the Hill-Burton Act provided funds for new
hospital construction, so that health care services were more accessible
for all citizens [5].
This improvement also brought about change in the social functioning of
rural areas and small towns, which were transformed from communities
whose churches, extended families, and neighbors shared home care for
the sick, socialization of the young, and support for those in crisis to
communities that increasingly relied on this new presence in their
midst [11].
Both
public health and medicine, as in the late 1800s, continued to
emphasize the individual's responsibility for healthy living, with the
failure to be healthy seen as a result of their refusal to comply with
standards. Instead of working to improve sweatshop conditions, medical
professionals counseled the public to desist from spitting on public
sidewalks, and, rather than working to clean up and enforce housing
standards in tenements, they taught mothers infant hygiene [5].
Hospitals were viewed by practitioners as places where the invalid
could not only have their health restored, but where they could learn to
be healthy [19].
The 1910 publication of Abraham Flexner's Medical Education in the United States and Canada [20] is recognized as having changed the course of medical education altogether [11].
Charged to investigate “conditions which, instead of being fruitful and
inspiring, are in many instances commonplace, in other places bad, and
in still others, scandalous,” Flexner reported on 155 medical schools [20].
His recommendations included nothing less than a complete overhaul of
medical education, and his emphatic descriptions of colleges that were
churning out new doctors after brief and repetitive didactic training
led to the closing of 76 schools. In response, standards in education
became far more stringent, inevitably moving toward licensure,
professionalism, and an increasingly homogenous Western medical ethos [11].
Unlike
the previous era, the early 1900s saw tremendous advancement in the
role of libraries and librarians in the hospital setting. By 1904, the
Patients' Library at the Massachusetts General Hospital became the first
organized library [21]
to hire a full-time librarian. Edith Kathleen Jones published
extensively, and her views on the organization and management of library
services in hospitals were widely influential, including her four
principles:
- First, an organized central library
- a librarian with personality, knowledge of books and library technic (sic)
- third, an annual appropriation sufficient for the purchase of new books as they are published
- fourth, the exclusion of morbid, gruesome and unwholesome literature [22].
Jones's
recommendations exemplified an approach to early patient libraries that
matched the physicians' view of patients as children, evident in
medical publications of the era [17, 19, 23].
A 1927 article recommended that librarians' education should include
not only psychology, literature, and sociology, but also hygiene, both
“physical and mental, of physiology, and sanitation” [17]. Librarians were encouraged, in this prescriptive article, to “probe quite carefully and cautiously in to very closely [sic]
personal problems,” including the patient's “mental background,”
education, the interactions of physical state with mental well-being and
whether the patient would be “content with the sensationalism of much
of the present day output” or whether the patient might need, “mentally
speaking, milk for babes or food for thought” [17].
Librarians'
roles in the institution needed to be carefully considered to gain the
approval and support of those in power, and their limits were made
clear. One example of this was the pronouncement of Morris Fishbein,
editor of the Journal of the American Medical Association, in his 1934 address to the Hospital Libraries Round Table of the American Library Association:
Medicine has been the subject of intense overspecialization during the past quarter of a century. That same period has witnessed the coming of social work, dietitians, hospital librarians, radio technicians, and innumerable other accessories to medical care. Physicians have viewed this invasion of their responsibilities somewhat askance. Let it be emphasized that all of these services must be accessory to medical care itself. … The hospital librarian will, of course, realize that as yet her relationship to medical care is an exceedingly modest one, yet its potentialities are only beginning to be realized. [23]
Only
brief mention is made of the provision of medical information to
nonmedical visitors in the medical library literature of the day. In one
such article, the author described the type of requests she received,
including a narrative of health information–seeking behavior. Even
though this was not described as common, Beausejour's wording seemed to
suggest that while such needs were not often encountered, neither were
they turned away (although no effort was made to follow up—Mary Ann was
left on her own to find what she needed):
Mary Ann was in the hospital with a new baby. She took a love story. During a conversation with me she intimated that she was afraid of her inability to take care of the baby when she got home. I suggested a book or two on the care of the baby, and one day much later I discovered Mary Ann prowling in the vicinity of the Parent-Teacher bookshelf. [21]
Perhaps
due to the long-term nature of their institutionalization, private and
public hospitals for the insane were some of the earliest to establish
patient libraries. In 1906, the secretary of the Iowa Library
Commission, Alice S. Tyler, visited one such asylum, and her appalled
reaction to the state of patients at that time—“hopeless and
aimless”—led her to persuade the Iowa legislature to appoint an
institutional library supervisor whose task it would be to organize
libraries in state institutions, including hospitals. Using a “group
system,” librarians were assigned to several institutions and were
responsible for selection, cataloging, and services, including the
hiring and training of a person at each location, frequently an inmate
or patient, to perform the role of librarian. The first supervisor
funded by the Iowa legislative act was Miriam E. Carey, who set up the
system and then began the same work in Minnesota. Carey's description of
the patient librarian's activities mentioned visiting patients on the
ward and reading aloud, “story telling, and generally exploiting the
library in ways that have greatly increased its usefulness” [24].
Nebraska, Indiana, and Vermont soon followed Iowa's lead, funded by
those states and operated under the auspices of either the state library
associations or the state boards of control [8].
In
1911, Jones conducted a study of library services available in 121
institutions for the insane, using her results to urge greater
involvement by the national library associations in the reading
facilities already available in the hospitals. Addressing the ninth
annual meeting of the League of Library Commissions, Jones passionately
reminded that body of the dire need for materials and services, saying:
I wish I could say this loudly and emphatically enough to be heard over the whole country, the insane are not imbeciles and they are not children. If the old ladies like to read the stories they loved when they were young, so do old ladies everywhere. [25]
Though Jones's plea was not ignored, it was not until 1915, when a second, corroborating study [26]
conducted by Julia Robinson (then secretary of the Iowa Library
Commission), that the American Library Association moved to establish
the first institutional library committee [8].
Members of the Committee on Library Work in Hospitals and Charitable
and Correctional Institutions actively promoted library services through
both library and medical journals, including a column called
“Institutional Libraries” in the journal Modern Hospital, and then created the Manual for Institution Libraries, whose purpose was to aid the organization and management efforts of a growing number of librarians nationally [8].
Beginning
in World War I (1917), the American Library Association's War Service
worked to distribute materials and provide services to wounded American
soldiers worldwide, proving that such services helped the healing
process by encouraging patient well-being. Based on that premise and
with government support, the American Library Association placed
hundreds of librarians overseas throughout both wars. Publicity was
overwhelmingly positive, and the American Library Association viewed it
as an opportunity to acquaint citizens with the types of materials
available through libraries and their functions of providing
entertainment and even education. Efforts were made by librarians to
establish bibliotherapy as a medically beneficial therapy, and the
medical profession supported those efforts. In an article published in Modern Hospital in 1925, Josephine Jackson expresses her view that:
the right book is an active therapeutic agent … since it actually affects the body chemistry of the invalid. As the sick man's fancy is thrilled with high hopes for the hero … that very mood proves a stimulus to his glands of internal secretion—thyroid, adrenal and others—which respond by pouring out an increased supply of their dyamogenic secretion, making the heart less sluggish, the diaphragm more vigorous, and the digestion livelier. [27]
Jackson's
words lent strength to the hypothesis that librarians were supported in
their bibliotherapeutic practices by physicians, as well as that the
rationale for such activities (and the attitude toward patients) was
likely grounded in medically based claims about the salutary health
effects of carefully selected reading materials. Such claims were
unsupported by anything but anecdotal evidence and occasionally were
roundly criticized. For example, a 1939 Library Journal article complained that:
So far most of the work in bibliotherapy seems to be based on untested assumptions rather than upon systematic scientific observation and controlled experimentation… If we are to have a science of bibliotherapy we must pass beyond the anecdotal stage in formulating principles and proceed to scientific experimentation. [28]
In
a 1934 article, “Closed to the Public,” Farrow provided library
anecdotes that seem amusing now, but that mirrored prevailing views of
the health care profession toward the general public. Her narrative
tells of a woman who came in with lists of requests, spent hours
researching, and then used the library's telephone to call people
(apparently her customers) with prescriptive advice. The author's
evident frustration with this state of affairs and her satisfaction with
the decision to close the door to public access exemplifies the
attitudes of some medical librarians toward serving the general public
throughout this period [29].
Another example was found in a 1949 article by C. Lamar Wallis,
librarian at the Rosenberg Public Library in Galveston, Texas. “What
does the public want in a medical book,” he asked (and so he titled his
presentation before the forty-eighth annual meeting of the Medical
Library Association):
Too often it is just what the old gentleman wanted—information on how to treat oneself without consulting a physician. We should like to believe otherwise, but too many conversations with readers lead right back to this conclusion. [30]
Wallis
continued by alternatively characterizing some lay medical information
seekers as curious, somewhat psychopathic, suspicious, looking to
satisfy morbid curiosity, or those abnormal few who seek anatomy texts
and even fewer looking for information about sex (here he explained that
such questionable materials were placed in a special collection, where
they were “administered by a librarian”). To be fair, Wallis did
eventually discuss the needs of the “normal” information seeker who
intended to:
simply know more about what is wrong with him or how he can avoid becoming ill. He wants a medical book to give him an honest, clear, forthright exposition of his physical makeup. He wants to be told as far as is possible in layman's language, what he can do to keep himself and his family healthy and what he must do in case of illness to aid in his recovery. [30]
Clearly,
members of the public were actively seeking health information, even
though their access to certain topics was deliberately impeded. However,
use of the hospital library for medical information was still not the
norm through the 1940s and even into the mid-1950s, when it was reported
by one librarian that “[o]ccasionally, we have a request from a doctor
for a patient to read a certain article and we do honor such a request
by having the article put aside and ready for the patient when he comes
in” [31],
although others allowed patients to circulate materials, if only
overnight, and noted the use of the library by in-house, nonmedical
staff:
Sometimes the office workers will come over to look at our books on nutrition and will sit down and copy a reducing diet of interest. Or perhaps a member of the family has been placed on a diet by a physician and they want to know more about it. Mothers who are employed by the hospital will consult our books on child guidance and child care. Girls who are engaged will ask for books or articles on “How to prepare for marriage.” We show them how to find journal articles on this subject, and allow them to borrow the books which are available. [32]
In
recognition of the importance of public health information and a rising
volume of such information requests, the National Health Library began
in 1933 to distribute a list of books on the subject of health to public
libraries, with the intended purpose of helping lay readers “choose
material that is factually correct and authoritative” [33]. By 1955, when the Bulletin of the Medical Library Association
published a series of papers presented at the fifty-third annual
meeting on service to the “lay public,” librarians were actively
debating what would develop, over the next thirty years, into consumer
health services. “I might say here that it does not seem to me that we
can brush aside the public entirely,” writes Beehler:
[w]ith practically every magazine which comes off the presses today containing an article or two on health matters or recent advances in medicine, the layman is becoming more and more aware of what is going on in these fields and is developing a growing interest in it. He no longer is satisfied with being given a pretty pink pill for whatever ails him; he wants to know the whys and wherefores. He wants an intelligent answer and there should be some place for him to go to get an intelligent answer. Naturally, he goes to a medical library. [34]
CONCLUSION
An
examination of the development of library services to patients from the
late eighteenth through the mid-twentieth century is as complex as the
examination of any other sector of society whose changes reflect overall
change in the environment. Considering these parallel events leads to
the tentative conclusion that the early role for medical librarians in
service to individuals for personal health information was largely
restricted to bibliotherapy due to a number of factors. These included
the lack of recognition by the medical profession of the value of
patient education until public health reforms found public health
education to be a crucial element in the alleviation of epidemics. Other
factors included the recognition by librarians that physicians would
readily protect their turf against incursion, as they had by the gradual
exclusion of all but Western medical practices, coupled with the
beneficent role of those same physicians, without whom medical libraries
would not have existed. Given these contributing elements, it was not
surprising that the practices of medical librarians tended to reflect
(as Anderson did, in her passionate assertion that patients or the
public were really not entitled to medical information [2]) the paternalism that characterized medical practice into the 1950s and beyond.
To
render this analysis more directly meaningful to the practice of
medical librarianship today, particularly with regard to the provision
of consumer health information, the review would need to extend beyond
the mid-twentieth century.
Additional complexities
enter the study at that point, embodied in the issues of consumerism,
medical ethics, insurance and litigation, contributions of the various
media to the national dialogue, recurrent (or resurgent) folk medicine,
and evidence-based medicine. Questions are myriad, and only a partial
list is provided here, because it is certain that others would occur, if
this review were extended. What legacy might be evidenced in the
approach to consumer health services? Did the practices and attitudes of
earlier medical librarians mirror those of physicians? How, over time,
has this been reflected in the library literature? Bringing it to the
present day, one might ask about the dominant discourses in the field of
librarianship with regard to consumer health information services—with
regard to information about issues (such as complementary and
alternative medicines, for example) that might not be supported by the
medical professionals they also serve. Directly related to these
questions, what are the discourses about the division between “consumer
health” and “patient education?” Are medical librarians (particularly in
hospital settings) empowered, as they might be in public or academic
settings, to freely provide information to individuals, or does the
awareness of political pressures to conform to expected practices act as
a barrier to the free flow of information?
It
is interesting to consider questions generated from reading the
historical literature of medical librarianship's development and to
attempt to parallel observations made by doing so with trends and
developments in the broader society. Issues in the medical arena include
well-explored power imbalances between patients and physicians, with
many researchers pointing to the possession of proprietary knowledge
(even to the extent of deliberately mislabeling diseases and drugs) as a
means by which practitioners exerted the control once believed
necessary to a successful therapeutic relationship. During a time when
evidence-based practice in medicine asks physicians to consider patient
values in treatment, thus continuing the trend toward righting
historically rooted power inequities in that relationship, librarians
are not exempt from examining their own practices.
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