Anticipating a Future We Never Anticipated

During the summer of 2017, my first summer as Director of the National Library of Medicine, Joyce Backus—our then-NLM Associate Director for Library Operations (ADLO)—approached me with a wild idea: “How about we engage an architectural firm to guide renovations of our library space?” Joyce was a forward-thinking ADLO and had already done much to spearhead important renovations to protect our collections and make them accessible to the public.

As you may know, NLM has 66 miles of shelving that house our expansive collections: from books to journals, audiovisual recordings to unique papers of medical and public health pioneers, to rare and unique manuscripts and volumes spanning ten centuries and originating from nearly every part of the world. From 2014 to 2019, NLM worked with the Wellcome Trust to digitize and make freely available via PubMed Central, or PMC, thousands of complete back issues of historically significant biomedical journals along with their human- and computer-readable citations; the availability of this important biomedical literature began the joint investment to advance research, education, and learning.

Fast forward to 2022 when we entered the third year of a global pandemic. Libraries around the world served as essential resources not just by providing up-to-the-minute, trustable access to COVID-19 information, but also by providing innovative and accessible free spaces to work, study, and gather safely. Many businesses and services had to turn on a dime to figure out how to protect their assets and deliver their operations remotely, but NLM was prepared for the challenge and already familiar with strategies that preserve our past and make our holdings available to people who may never set foot in our building.

Now—I would like to claim clairvoyance as an essential skill of the NLM workforce, but of course that would be foolhardy! No one can see into the future, including NLM staff. Almost 200 years of serving the public has engendered in our workforce an ability to serve increasingly diverse stakeholders in the present while keeping an eye to their future needs and anticipating ways to meet them. Libraries are essentially a human enterprise and designing spaces to make the best use of our excellent workforce is critical for our future.

So, it’s not too surprising that as the COVID-19 pandemic overtook the world, NLM in particular and libraries in general stepped up to the task! NLM expanded its terminologies to include new ones representing the emerging vaccines, therapeutics, and diagnostic tools; expanded the resources in our Network of the National Library of Medicine to support outreach and locally congruent information resources about the pandemic; and improved access to digitized versions of our holdings in an on-demand fashion. We planned new workspace arrangements to make the best use of our existing buildings to anticipate their suitability for hoteling, hybrid work engagements, and on-site meetings to bring teams together.

I am inspired by how we anticipated a future we never anticipated, and I spent the year reflecting with my leadership team to discern how this success will provide us with the guidance to anticipate the next future we never anticipated. Please join us in this process to make sure that we have the space and access to reliable biomedical information for your needs!

When You Stand on the Shoulders of a Giant, What Do You See?

This blog contains my remarks from the 2022 Lindberg-King Lecture and Scientific Symposium: Science, Society, and the Legacy of Donald A.B. Lindberg, M.D., which took place on September 1, 2022. Watch a recording of the event here.

I had the great fortune of becoming the director of the National Library of Medicine immediately following the 30-plus-year tenure of Donald A.B. Lindberg, MD. I am sure that each of you here today treasures your own recollection of Don, maybe from a conversation or a laugh you may have had with this great leader, teacher, visionary, and colleague (and husband to Mary, father, grandfather, and friend). I am both proud and humbled to stand on the shoulders of this giant as I lead this incredible organization.

I know more viscerally than most about Don’s legacy as NLM director. I sit in the office he occupied, I walk the halls he walked, I work with the people he hired, and I see and experience the fruits of his judgement, investments, and vision.

I now sit where Don once sat, representing NLM at the leadership table of NIH with the other Institute and Center directors. With Don paving the way, I have a platform to extend NLM’s thought leadership and technical knowledge to guide NIH’s continued efforts to advance data-driven discovery. The good will and collaborative spirit engendered by Don across NIH opened doors for me and helped me continue his legacy to deliver on the promise of science accelerated by broad access to literature and data.

Don and I share a deep commitment to ensuring that the public benefits from NLM’s efforts to assemble, organize, preserve, and disseminate biomedical knowledge for society. It was his early vision that made MedlinePlus a trusted resource for consumer health information and ensured that the PubMed citation database and the PubMed Central full-text literature repository were open and accessible to everyone, everywhere, with an Internet connection, at any time and place.  

Don’s commitment to the public was also evident in his efforts to educate the next generation of biomedical informatics scholars. Frankly, I believe that of all of the aspects of his job, engagement with trainees was his favorite!

When you stand on the shoulders of a giant, you have a great advantage. The foundation Don built and the relationships he established provided me, the 4th appointed director of NLM, with a playbook right out of the gate. It is not enough to solely rely on his vision to guide our future as Don also inspired innovation; in one of our last conversations, he said to me, “This is your game—make sure you play it well!” In order to do that, I cannot simply stand on the shoulders of a giant; I must also keep my head up and my eyes forward to the future to envision new pathways and find new opportunities to bring forward the riches of NLM to the future benefit of science and society.

I close by inviting all of you to stand on the shoulders of this giant and meld your sights with his, for it is not by holding tight to that which he could see, but by using his vision as a stepping-off point for our own that will serve his legacy.

How Being an ICU Nurse Prepared Me to be NLM Director

In mid-May, at their 2022 National Teaching Institute & Critical Care Exposition in Houston, Texas, I received a great honor from the American Association of Critical Care Nurses (AACN): the AACN Pioneering Spirit Award. I was delighted to receive this prestigious award, which recognizes significant contributions that influence progressive and critical care nursing worldwide and relate to AACN’s values of integrity, inclusion, transformation, leadership, and relationships. I was humbled to receive this award for my work during my tenure as NLM Director, and it’s in large part due to the work that so many NLM employees do every day.

This acknowledgement from AACN is deeply meaningful to me because critical care nursing has been a part of my professional identity for almost 50 years! In 1974, while I was still in nursing school, I was assigned to work as a nursing assistant in the critical care medical unit at Lankenau Medical Center outside Philadelphia. After graduating in 1975, I became part of the nursing team in the surgical intensive care unit (ICU) at the very same hospital.

These early experiences have touched every part of my career, including my role at NLM—the epicenter for biomedical informatics and computational health data science research and the largest biomedical library in the world.

Then: Learning from My Teachers and Colleagues

I learned from Kathy McCauley, cardiac-care nurse extraordinaire, about the importance of the scientific basis of nursing. Nurses’ deep knowledge of physiology, pharmacology, and anatomy enables the bedside critical care nurse to almost instantaneously recognize vital changes in a patient’s medical status and determine just the right interventions to rebalance fluid or improve oxygenation. My colleague and ICU nurse, Nora Kelly, modeled respect for patient dignity that, to this day, shapes my work to support patient self-management using effective computer technologies. Nora showed me that even in the midst of an often hectic, fast-paced ICU environment, there was always time to provide a patient with comfort, help a person into a more comfortable position, or complete basic hygiene and grooming around tubes and monitor wires.

Now: Serving as Your NLM Director

What stands out the most to me now are the lessons about the importance of in-the-moment information processing; interdisciplinary teamwork supported by nurses, physicians, respiratory therapists, pharmacists, social workers, and others; and personal accountability that shape my everyday life as the director of NLM. Delivering high-quality care under extreme levels of uncertainty and risk is the hallmark of critical care. I learned early on that time was of the essence—there was rarely an opportunity to pause and read an article or two as one pondered how to intervene in a physiology cascade that could lead to sudden death.

The insights from these experiences taught me that for information to truly support in-the-moment care, NLM needed to make its resources open and available in machine-readable formats. It is our job to use machine-learning algorithms to make available NLM’s vast repository of biomedical and scientific literature that drives contemporary drug management or clinical guidelines interpretation. NLM invests in research that helps ICU professionals quickly interpret patient charts so they can predict the likelihood of pulmonary embolism diagnosis or track a patient’s probable health outcome trajectory using observations noted in their electronic health record.

NLM in the ICU

ICU patients in hospitals around the country are all supported by the best interprofessional teams that understand the unique aspects of patient care, whether that’s to advance the patient’s progress towards wellness or to provide alternative end-of-life care focused entirely on comfort. Because of the diversity of caregivers and professionals across hospital ICUs, we must acquire, organize, and disseminate the literature to all biomedical professional groups when they need it most.

It is in this spirit that each division in NLM—including our Library Operations team managing our NLM Collection, our MEDLINE Literature Selection Technical Review Committee to impanel experts across many specializations, and our PubMed and PubMed Central with the tools to index and catalog records—accelerates the dissemination of knowledge from many disciplines. Clinicians are required to have deep expertise and stay abreast of new research within their specialty and to recognize potentially valuable literature from other disciplines. In support of this requirement, we organize over 34 million citations by clinical problem and physiological underpinning. That way, no matter what your specialty, each search identifies literature from a wide range of perspectives and refines our “relevance-based results return” according to those patterns most valued by our patrons, as described by NLM’s Best Match algorithm.

Patients often find themselves in the ICU from somewhere else in the health care system and are frequently discharged not to their homes, but to other less-intensive clinical care units. To understand their conditions and efficiently guide their care in a vast, complex, and time-sensitive setting, health care interprofessional teams should understand all ICU clinical information and events so they can translate and transmit that information to the responsible post-discharge teams. This information flow relies on health data standards so that events that occur in one place are well understood in the next. NLM plays an important role by forecasting how health care settings like ICUs will use health data standards to promote interoperability and by shaping the public policies that protect patient records. NLM shares its expertise in data science, health information technologies, and computer science with our fellow federal agencies and with the private sector to make sure patient records are accessible while remaining private and secure.

Connecting the Dots

I remember the enormous intimacy involved in my ICU nursing experience, often including myself and a patient, at times the patient’s family, and certainly every time the rest of the care team. But teamwork only works when each member holds sacred their responsibility to the patient and the care that they require. Personal accountability does not occur in a vacuum; rather, it is molded and shaped through conversations with colleagues, collaborative care-planning rounds, candid postmortem reviews, and quiet heart-to-hearts in the staff lounge. Even these efforts are touched by NLM, from providing literature and guidelines that lay out the various roles of professionals to furnishing our citations repository with the contact information of those authors whose work guides clinical thinking. In this way, NLM becomes a partner for personal accountability.

If only that fledgling ICU nurse from 50 years ago knew that her entire cultural and practical experience was preparing her to direct the most important health science library in the world! Because of who she was as that nurse and who we are as NLM, critical care remains a cornerstone of health care information and systems in best support of all patients. If you have ideas for how NLM can better support the critical care of YOUR patients, please let us know!

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