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Economics, Education, and Policy: Review Article

Difficulties and Challenges Associated with Literature Searches in Operating Room Management, Complete with Recommendations

Wachtel, Ruth E. PhD, MBA*; Dexter, Franklin MD, PhD*†

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doi: 10.1213/ANE.0b013e3182a6d33b
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Multiple methods are used to make decisions in operating room (OR) management. Intuition generally performs poorly1–3 because humans cannot perform statistical calculations in their heads. A literature search can be used to learn principles that have been shown by scientific methods for appropriate implementation. Absent such a search, management efforts are sometimes of limited value to the individuals applying OR management decisions1–3 and may be detrimental to the facilities they govern. The purpose of this article is to teach OR managers and financial analysts how to locate articles they need in the areas of OR and anesthesia group management. These techniques are especially important because certain subject areas of OR management science are often so specific that only 1 or 2 articles address the topic of interest.

Three hypothetical examples suggested to us that the fundamental challenge in identifying OR management science articles is that the appropriate vocabulary must be known before doing the search:

  1. Staffing is planned from 7:15 AM to 3:30 PM. At 1:00 PM, cases have finished in OR 3 and OR 4. The next case in OR 3 is scheduled to end at 3:15 PM. The next case in OR 4 is scheduled to end at 4:15 PM. Which room should housekeepers and other personnel target for initial preparation? Answer4–6: The case in OR 4 is scheduled to finish past the end of the scheduled working day, possibly resulting in overtime pay for surgical technologists, nurses, and housekeepers. That room should be readied as quickly as possible. A PubMed search of {(overutilized OR over-utilized) AND “operating room” AND (hours OR time)} yields 20 articles, 10 of which are of interest. Quotation marks indicate that the search should be performed on a phrase, not the individual words within it. A Web of Knowledge search of {Topic=(overutilized OR over-utilized) AND Topic=(“operating room”) AND Topic=(hours OR time)} yields the same references. We tried multiple variations on this search. To get the answer, the searcher needed to know the vocabulary phrase from 1997: hours of overutilized OR time.7
  2. A neurological surgeon needs the OR with the microscope for a 6 hour case beginning at 7 AM. The following case also needs to use the microscope and requires preceding transport under general anesthesia and coordination of multiple specialties and surgeons. What is the earliest you can reasonably expect the first case to be finished so you safely schedule the second case that also needs the microscope to begin in the same OR? Answer:4,8–11 Allow enough time for the 6 hour case to account for the 80% to 90% upper prediction bound of the duration of the case. The upper prediction bound can be calculated accurately, from historical data on the duration of the procedure by that surgeon, using the exponential of a student t distribution.8,10 As an approximation, 1.5 times the scheduled duration of the case may be used to estimate the maximum duration of the case.8,12,13 A PubMed search of {“upper prediction”12 AND “operating room”} yields the appropriate papers, as does a Web of Knowledge Search. In preparing this review, we tried multiple other approaches. The manager would not find useful article(s) without knowing to look for an article about upper prediction bounds.12 This concept was first applied to OR management in 1996.14
  3. Two surgeons in different services at the same hospital bring in gross revenues15 of $4.5 million and $6.3 million dollars to the hospital. Both want more OR time. Which should receive it? Answer:16–20 Gross income is irrelevant. Contribution margin for each surgeon is the sum of revenues minus the sum of variable costs.16 Net profit is the difference between fixed costs and contribution margin.16 Assuming strategic objectives include improving the hospital financials status, more OR time should be given to the surgeon with the highest contribution margin, taking into account both linear programming17 to account for constraints such as limited intensive unit beds and quadratic programming21 to eliminate outliers. The best solution would be to give both surgeons access to first-come first-scheduled open OTHER overflow time.20,22 A search of {(“contribution margin” OR “contribution margins”) AND (surgeon OR surgeons)} is sufficient, as is {(“contribution margin” OR “contribution margins”) AND “operating room”}. Once again, we failed to identify a way to find relevant studies unless the manager knows to look for the phrase “contribution margin.”

We urge readers to open PubMed ( and repeat these searches themselves using their own keywords to see the challenges associated with searching the literature in OR management.

With the understanding that vocabulary is somehow integrally related to the challenges managers have in searching the scientific literature in OR management, this article reviews library science articles that consider the importance of knowing vocabulary in a particular field. Eight hypotheses are stated in Table 1. We will show that each of these hypotheses is supported by studies of how most people currently perform (and should perform) management literature searches. Table 2 shows the plethora of databases that can be searched to find scientific articles.

Table 1
Table 1:
Hypotheses Tested in this Article
Table 2A
Table 2A:
Electronic Databases for the Retrieval of Medical Information

Most of the citations in our article are from the past 5 years, since search technologies have changed substantially over longer periods. Our article is not intended to be a systematic review on searching the scientific literature, but focuses on finding OR management articles. Only articles in English are included. Throughout the paper, curly brackets are used to indicate search parameters.

In the few articles with multivariate analyses, the authors’ listed P-values are reported. Otherwise, we used the raw data to compare incidences to 50% using the exact binomial test. “Most” was used only when numbers justified a 1-sided P value of < 0.05 for exceeding 50%. “Substantive” was used to indicate a number between 10% and 50%. Although we only report “substantive” when the 1-sided P value of < 0.05 for exceeding 10% was satisfied, we do not list the P value.


In science, technology, and medicine, 25,400 journals and 1.5 million articles were published in 2009.23 PubMed cited >20 million papers. Each year the number of journals is increasing by 3.5%.23

Systematic reviews are a scientific exercise aimed at generating new knowledge and they provide a summary of relevant primary research.24 Many physicians do not make use of systematic reviews for clinical decision-making.25 Although evidence-based practice has been widely discussed in the literature over the last several years, most nurses said they were not familiar with the term (P = 0.032, 350/760).26 When each diagnosis at a hospital27 was paired with the therapy administered, most pairs had no evidence (P = 0.014, 16%, 24/150) or nonexperimental (usually anecdotal) evidence (P < 0.0001, 32%, 48/150), 41% of pairs (61/150) had systematic review level evidence supporting the therapy and 11% (17/150) randomized controlled trial evidence). Approximately half of diagnoses lacked scientific evidence for their treatment (50%).27 Research evidence was not used routinely for clinical decisions among rehabilitation practitioners treating carpal tunnel syndrome.28 Of Norwegian physicians,29 substantive numbers (40%, 366/916) considered that their practice was always evidence based, yet 19%29 (174/916) did not accept the distinction between evidence based and other types of medical practice. Following training in evidence-based practice, faculty and residents still lacked the skills to formulate clear OR management questions.30 Librarians were consulted for <5% of searches of evidence-based practice.24,25

In a study of nurses, “journal articles, research reports, and hospital libraries” were seldom used as sources of information.26 Most nurses reported not using research reports at all to support their practice (P < 0.0001, 58%, 441/760).26 A substantive proportion of the respondents stated that they needed information to support their everyday practice only occasionally or seldom (39%, 297/760).26

Qualitatively, nurses were generally unaware of gaps in their knowledge and ignored or did not believe information from research.31 Interviews with nurses revealed that they thought it was not their job to look up research.32 Almost ubiquitously among surveys and qualitative studies, nurses reported that they did not have the time during regular working hours to perform literature searches.24,32 Many nurses expressed a lack of confidence in their critical appraisal skills to interpret the research.24,32,33 In addition, most did not have the medical or statistical knowledge to evaluate findings.24,32,34 Semi-quantitative and qualitative studies uniformly showed that nurses felt this was the job of physicians or librarians.24,25,33Among Norwegian nurses 407 rating sources of evidence used for supporting clinical practice, articles published in nursing journals were 18th in importance and articles published in medical journals were 19th.33

In an Irish study, a substantive proportion of clinicians reported difficulties in keeping up-to-date with evidence-based practice due to numerous barriers (65%, 13/20).35 Physicians were frequently unaware that they lacked clinical information, had gaps in understanding, and exhibited anxiety when searching for information.31Physicians who were risk-avoiding tended to use resources that provide answers and summaries, such as Cochrane or UpToDate, less than risk-seekers did.31.36 Physicians who reported stress when faced with uncertainty showed a trend toward less frequent use of MEDLINE when compared with physicians who were not stressed by uncertainty, because MEDLINE did not readily give the clinical answer.31

A survey of physical therapists in the United States showed that most performed 2 or less on-line searches per month (P < 0.0001, 65%, 317/488).37 Of resident trainees in Australia (the term residents was substituted for registrars where appropriate), substantive numbers (30%, 32/106) performed 2 or less on-line searches per month.38 In the Montana Department of Public Health and Human Services,39 most public health professionals indicated that they had not used an online bibliographic database to search the literature in the past year (P = 0.0013, 69%, 48/70). Respondents who did search were looking for review articles and articles regarding evidence based practices for a specific topic. Most respondents rarely or never sought a librarian’s assistance (P < 0.0001, 83%, 631/760), did not use the hospital library (if one existed) (P < 0.0001, 82%, 623/760), and had never received instruction in the use of electronic resources (P < 0.0001, 77%, 585/760).26

Primary care physicians were asked to select resources of their own choice to search for the correct answers to multiple-choice clinical questions.40 Each chose any 2 of 23 questions to research. They were able to locate the one correct answer out of 3 possible choices for only 43% of questions (P < 0.001 statistically different from chance of 33%, 10/23), illustrating their poor searching skills.

Evidence supports Hypothesis 1 that physicians and nurses do not search effectively for evidence-based practices.


Reviews of cognitive behavioral models and methods of knowledge transfer41 conclude that colleagues are the primary source of information when people have a question. Management stakeholders for international companies reported that their major sources of information were general internet searches and colleague knowledge.42 Both of those sources of information were used by most respondents (P < 0.0001, 88%, 36/41). Scientific journals were also used by most (P = 0.0002, 78%, 32/41).42 More commonly, most medical students in Malaysia43 preferred to consult another individual (colleagues, lecturers, hospital staff) first for their clinical queries (P = 0.014, 61%, 62/101). In a Norwegian study of physicians,29 the most frequently reported information sources (score 4 or 5 out of 5) for making decisions about individual patients’ health were “colleagues” (P < 0.0001, 86%, 788/916), “other specialists one trusts” (P < 0.0001, 78%, 715/916) and “medical textbooks” (P < 0.0001, 76%, 696/916). Mexican medical students44 reported that they used textbooks very often, residents and teachers often to very often, and journal articles rarely or occasionally. In a contrasting Irish study, colleagues were used as the primary information source only 17% of the time (8/47), with professional clinical informationists being favored instead (see below on professional librarian informationists (see Trained Librarians in Hypothesis 8).)35

Information was sought regularly. Each resident physician generated an average of 1 to 5 clinical questions per week.35 Most nurses said they needed to seek information at least once a week or several times a week (P < 0.0001, 61%, 457/749).26 When asked how they found the information they needed, most said they always or frequently sought information from a colleague (P < 0.0001, 67%, 509/760). Nurses obtained information from experienced nurses and discussion with physicians.31,33 Articles published in medical, nursing or other research journals were among the least frequently used sources of information by nurses for supporting clinical practice.33 Physicians surveyed sought information to make clinical decisions for treating patients an average of 0.75 to 1.845 or 2 to 3 times46 a day. Most physicians used the internet (258/444), not PubMed (36/444) (both P < 0.0004).46

Sources of information for governmental pharmaceutical policy decision-makers determining public policy in Canada were determined through semi-structured telephone interviews.47 Human expert sources were universally cited as the first source of information. The decision-makers said that nonhuman sources such as those in electronic format were less popular. Ultimate and final sources were trusted organizations with quick and easy websites or online publications.47 Results support the concept of bias (see Search Bias in Hypothesis 3).

These results for clinicians support Hypothesis 2. Many nurses and physicians first turn to their medical colleagues for assistance with both medical and computer-related questions.


  • Why Some Physicians Do Not Search the Literature Regularly
  • Finding Information in the Literature is Sometimes Difficult
  • Most Users are Reluctant to Use Electronic In-Line Help Files
  • If They Do Search the Literature, Some People Do Not Read the Articles
  • Search Bias Is Commonplace

Why Some Physicians Do Not Search the Literature Regularly

Table 3 contains a list of reasons why many physicians and nurses do not search for information on evidence-based practices.24–26,32,33,39,45,48–52 Perceived lack of time and lack of training and knowledge in how to perform a literature search are the main impediments. In a review article of 25 papers that pooled the results of 10,218 respondents,24 a substantive proportion of studies mentioned each of the following barriers to use: knowledge, attitudinal, and behavioral (14/25); lack of awareness (12/25); lack of access (7/25); and lack of application to a clinical problem (7/25).

Table 3
Table 3:
Factors Compiled from Articles Describing Why Health Care Professionals Become Discouraged from Performing Literature Searches of Evidence-Based Studies, Systemic Reviews, and Meta-Analyses

Lack of searching for information is not restricted to medicine.53 The observation that few people take the time to read instructions and learn needed vocabulary when faced with technology questions is a problem for many industries, including manufacturers of computers,54 automobiles,54 and home appliacances.54 One in 5 calls to a brand name customer service center was for a question answered in the owner’s manual.54 Among the calls to Gadget Helpline55 in 2009 for technical support, most men (P < 0.0001, 64%, 48000/75000) and a substantive percentage (24%) of women had not even opened the booklet that came with their consumer electronic device before calling for help. Among the 1 in 7 mobile phones returned as faulty by subscribers within the first year of purchase, 63% had no fault.56 Analysis of monthly calls arriving at the specialist retail returns/diagnostics telephone line showed that most (P < 0.0001, 64%) represented calls in which no fault was present.56 Users did not attempt to understand the manual because they had not learned the vocabulary needed to use their devices. This behavior is analogous to medical professionals who claim they do not have the time or expertise to perform a literature search.

Finding Information in the Literature Is Sometimes Difficult

We compare literature searches for 2 problems, a management question and the search for articles on how to perform a literature search.

Suppose a manager wanted to calculate the number of nurses needed to staff a postanesthesia care unit (PACU).57 There are 10 ORs. Do you need 10 PACU beds? To find studies on the appropriate number of PACU beds, the knowledge needed is the vocabulary that this is a “staffing problem.”58 In PubMed, entering {“post-anesthesia care unit”} in quotation marks, the number of citations was 280. (Entering {PACU} returned 1414 articles.) Adding the term {AND staffing} resulted in 4 pertinent articles. In an ambulatory surgery center allocated for 8 hours a day based on minimizing the inefficiency of use of OR time, the number of PACU beds can be calculated using simulations incorporating variables such as the mean lengths of PACU stays.59

A key issue is that the manager had to know the word “staffing.” In the section of Hypothesis 5 on the use of specialized web sites, we rely on as an example. The site has multiple lectures on “staffing” and sample PACU “staffing” reports. The word “staffing” is used prominently and deliberately to match the scientific literature, and should be recognized as significant.

The need to know technical vocabulary before doing a search is an issue for OR management and other specialties, but not necessarily for searches in general. For example, a search of literature searching (the topic of this article) is an open-ended iterative process where the topic or research question of interest is first identified generally, then pinpointed more specifically over time as the nature of the evidence becomes more apparent from preceding searches.60 We first searched PubMed with the phrase {literature search[TI]}, the “[TI]” restricting the phrase to the title, resulting in 198 articles. We tried multiple ways to narrow down the search, but no strategy was successful. Using the PubMed Limit feature to restrict the search to review articles yielded 44 articles. Only 8 were relevant, 5 of which were published in 2006 or later and 3 of which were published in developing countries. In contrast, manual sifting through the 198 original articles revealed that 106 were relevant (literature searches of clinical topics were excluded), 81 were published in English, and 31 of these were published in the past 5 years. One hundred ninety eight articles were searched by hand because no specialized database was available (Hypothesis 5).

Most Users Are Reluctant to Use In-Line Help Files

Researchers discussing help files in a column on the World Wide Web associated with the research journal Technical Communications reported that users expect software packages and search interfaces to be as easy to use as web-based applications, in which icons with simple names guide mouse clicks.61 Software tasks are expected to be intuitive and not to require specialized knowledge of the software application.61 However, users of software applications often needed assistance but encountered frequent episodes of frustration when using help files.

Table 4 summaries the results of numerous studies of the various sources of information that people use when they have a software problem.62–69 Asking colleagues for assistance and using trial and error were mentioned frequently. Most users did not use the help files (P < 0.0001, Table 4).62–71 In one article, most users did not resort to help unless they were “really stuck.”70 When completing tasks using Microsoft Publisher, use of help declined monotonically because users considered the help not to be useful.70,71 In multiple site visits, use of help features was not observed.70 Although users of computer applications encountered a usability problem on average about once every 75 minutes and typically spent about a minute looking for a solution,66 users consumed more time than needed because they used ineffective methods.66 Users tended to read system documentation only when they were in trouble,72 regardless of the high quality and helpfulness of the documentation.73

Table 4
Table 4:
Most People Do Not Rely on Instructions, Especially Help Files, When They Encounter an Acute Frustration with a Software Package

Table 5 lists multiple reasons from qualitative studies in which people reported why they did not use help systems.62–70,74–78Table 6 lists the reasons people reported that help systems were not useful.62–64,68,71,74,76,79–84 Most novice computer users who tried to use the help systems at least once found them to be frustrating, and gave up completely.71,79 For 25 frequent users of Microsoft Office applications who suffered 79 episodes of severe frustration (mean frustration level of 3.38 of 4), the mean time since last use of on-line documentation was 1.64 months.66

Table 5
Table 5:
A Compilation of Reasons People Give for Not Using Online Help Associated with Software Applications
Table 6
Table 6:
Compilation of Reasons Reported Why Online Help Associated with Software Applications Is Not Helpful

One study tested 10 PhD chemists, 5 novices, and 5 experts, at using chemical compound database software.62 Subjects were assigned to complete search scenarios that were sufficiently complex to make it more likely that the test subjects would need the online help, which had been carefully designed. The test subjects subsequently ignored the help as much as possible during the tests and most were unable to complete the tasks during multiple attempts. “What we did not expect were the extreme lengths to which our test subjects would go to avoid using the Help menu.” (emphasis original) When the chemists finally went to the help for assistance, even the simplest instructions were misread.62 Their attitude seemed to be: “I don’t want to read all this information that you have so carefully designed and written.” In a study of text readability, most (P = 0.010, 79%, 15/19) users reported that they always approached unfamiliar web text by trying to scan it before reading it.85

If They Do Search the Literature, Some People Do Not Read the Articles

In 2006, most Principal Investigators and their research teams at the National Institutes of Health50 reported pursuing answers to questions that arose in their work during a period of 6 months to 3 years that they thought could be answered by a search of the literature (P < 0.0001, 79%, 84/106). They read 9.2 hours per week on average.50 Other NIH team members, such as research and staff nurses, data managers, statisticians, nutritionists, and pharmacists sought information when they had a question at a substantive but significantly smaller (P = 0.004) rate of only 38% (5/13).50

PubMed logs for a month included 58 million user queries.86 The average number of mouse clicks per session was only 1.5. The number of abstract views per session was just 3.6. Most users (P < 0.0001, 80%) selected abstracts only from the first 20 references (i.e., the default number displayed on the first web page). In a study of risk factors for bladder cancer87 in which 260 relevant articles were identified from 39847 based on a large number of synonyms, the authors reported, “Few users have the patience to look through all the article titles that PubMed retrieves. Many users do not make it past the first 10 or 20 results.” For most PubMed queries, only the first page of 10 articles was viewed on 1121 patient-related problems (P < 0.0001, 82%, 2625/3205 queries).88 In Canada, a survey of nephrologists established that most did not scan >40 references (P < 0.0001, 80%, 80/100).89,90

Search Bias Is Commonplace

Search bias is a process by which a user navigates repeatedly toward preferred sites, even when other sites have more valuable information.46,49 If a search engine indicates that a preferred site may have appropriate information on the required subject, biased users navigate directly to that preferred site. This method was used by a substantive proportion of physicians (48%, 213/444).46 Because of search bias, some clinicians may rely on a few ‘favorite’ resources while lacking the expertise to effectively search other more appropriate resources for the particular information needed.91 For example, a physician who usually searches UpToDate, a consolidated database of recent articles, may not realize that it often is not current.92 UpToDate lacked the most current information for a substantive proportion of topics (52%, 104/200).92 Of course, current literature is not always correct and consensus opinions do not always represent best practices.1,3,48,49,93

Evidence supports Hypothesis 3 by explaining the more common reasons that some physicians and nurses are reluctant to use the electronic help resources available to them.


  • Examples from OR Management
  • Automated Solutions for OR Management

Examples from OR Management

In our experience, there are 2 categories of OR management searches: (1) Words searched are not unique to the field and performing a literature search on the words does not result in citations relevant to OR management. (2) The terms are specialized and unique, and one must simply know them.

Table 7 lists much of the specialized vocabulary in OR management. Terminology can also be obtained from lists of definitions in articles7,94,95 and review articles.96–100,a

Table 7
Table 7:
Vocabulary of the Operating Room Management and Related Terms from our Lectures and Sample Reports at

The challenge of knowing the vocabulary appropriate to perform a search is not unique to OR management articles. For example, the most common reason that PubMed Help fails to assist users, resulting in literature searches that are unsuccessful, is lack of knowledge of the correct vocabulary or terminology to use when searching.64,67,71,74 As another example, oncology does not have standardized meanings for “palliative care” or “hospice care.”101 The literature contains at least 1 erroneous report about the frequency of congenital division of the atrium because not all synonyms were included when the authors performed a literature search.102 Another example is that the American Society of PeriAnesthesia Nurses (ASPAN) developed Standards of Perianesthesia Nursing Practice103 to create a comprehensive dictionary that includes the critical data elements crucial for inclusive and consistent perianesthesia nursing documentation,104 yet terminology to describe key nursing assessments varies widely by locale, workplace culture, and individual discretion and practice. These variations in use of vocabulary contribute to lack of uniformity, measurability, and, at times, disparate interpretations of clinical documentation.103

Examples of morphological variants affecting PubMed searches in OR management are “theater” and “theatre” and permutations of both “anesthes” and “anaesthes.” Another example of variants are the different uses of the word “practice.”b Computer software can use statistical measures of other words in close proximity to “practice” to help disambiguate the term.105

Since an ontology vocabulary allows using synonyms and homonyms, the meaning of some terms in a query will inevitably be ambiguous.106 Informatics researchers and terminology developers have therefore devised a number of methods to audit terminologies in systematic ways to distinguish between actual meanings and the human-interpreted labels with the intention of conveying meanings.107 Consequently, the first step in good help software must be the disambiguation of the meaning of the terms in a query.106 Good software packages often aim to disambiguate logic in a query, because every software package has its own vocabulary.106 For example, to help users better understand jargon, acronyms, and specialized scientific terms found within articles, one search database compares all words to Wikipedia page titles and examines its pertinent links.108

Automated Solutions for OR Management

Customized wording during the creation of OR scenarios is an approach we developed and validated to convey the correct meaning of a vocabulary word in OR management for individual facilities.109 The scenarios are adapted automatically from information systems data to the keywords (cues) at each facility.109–114 Thus, the method applies when performed during or after relevant statistical analyses of OR information system and/or anesthesia information system data. The scenarios are then used by the OR manager to learn the OR management decisions made by the anesthesiologists and nurse managers (i.e., “needs assessment”). For example, many facilities use the same names to label ORs (e.g., OR 1 and OR 2), and these names are not interchangeable among facilities. Whereas a nonadapted prototypical scenario may refer to a retina case in OR 1, OR 1 may be a trauma room at the hospital where the scenario is being considered. The name of the OR thus provides a cue to the type of procedure being performed, the surgeons, the equipment, etc. A crucial point is that the vocabulary has been chosen automatically to refer to the characteristics of the procedure site. Explanations are then included with the corresponding vocabulary for use in searching.109

Another approach to providing automated feedback on vocabulary is immediate adaptive responses to answers to questions. Specifically, several times a year we host a course on Operations Management for Surgical Services that is designed to teach anesthesiologists, CRNAs, OR managers, and financial analysts the principles of OR management.115 For this course, we developed a series of cases studies with questions that are answered in an Excel workbook.116 The workbook has been designed with many thousands of hidden Boolean formulas to give feedback to assist the class participants (students) in the proper vocabulary to answer the questions.116 Cell entries are marked automatically as correct only when participants use correct vocabulary in the proper context.116

Evidence supports Hypothesis 4 because people often need to seek assistance due to frustration over limited knowledge of the vocabulary.


Many databases are available for searching scientific and social science articles. For example, Medlinec includes over 19 million references to journal articles in life sciences covering 1946 to the present. PubMed, a service of the United States National Library of Medicine, provides free access to Medline. PubMed does not search results according to relevance, although Medline results can be grouped according to topics.117 Detailed instructions for using PubMed can be found in help files, published papers,118 or on the web. Instructions also exist for Medline119 and Google Scholar.120

Medline has limitations, and many other databases have been created for specialized purposes. Some of these are listed in Table 2B. Except for Medline and PubMed, most of the search engines are designed to be complementary (i.e., will give different search results,121,122 especially when different keywords are used). The importance of searching multiple databases cannot be overemphasized. Six databases were queried in a study of rehabilitation of people with severe mental illness.123 Most of the studies included in the systematic review were identified from these 6 databases together (P < 0.0001, 89%, 85/96). However, each database uncovered only 29% to 44% of the studies.

Table 2B
Table 2B:
Specialized Databases for Answering Clinical Questions

Clinicians and hospitals searching OR management articles will not find PubMed to be complete, and neither will companies and engineers seeking quantitative methods. PubMed focuses on clinical journals, not statistics and operations research.

A complete bibliography of peer-reviewed articles on OR and anesthesia group management is at The bibliography page has been subdivided into topics.d Titles are searchable from the home page. Researchers performing a comprehensive search or trying to find a specific paper in OR management will find this bibliography more useful than PubMed because it also includes articles taken from statistics, social science, and engineering databases. Articles have also been screened for relevance to OR management issues, meaning that the bibliography can be perused efficiently in search of an article of particular interest.

Evidence supports Hypothesis 5 that specialized databases can be searched for articles on OR management, and these specialized databases are especially important for researchers.


  • Definition of MeSH
  • Advantages of MeSH
  • Disadvantages of MeSH
  • MeSH Terms for OR Management
  • Use of Other Text Words

Definition of MeSH

MeSH is the National Library of Medicine’s controlled vocabulary thesaurus used by PubMed. MeSH consists of sets of terms naming descriptors in a hierarchical structure that permits searching at various levels of specificity. MeSH topics can be identified at Each scientific article is indexed using an average of 10 to 12 MeSH terms. There are currently 26,853 descriptor MeSH terms and >317,000 concepts that assist in finding the most appropriate MeSH heading.e

Advantages of MeSH

Searches using MeSH terms are useful for clinical questions because they have a higher sensitivity and precision (Table 8) than generic keywords.124 In automatic term mapping, PubMed searches for a match between the search term, journal title, author, and the MeSH term. Synonyms and word variants will automatically be included in the search by PubMed if a MeSH term is used. MeSH terms therefore often avoid ambiguous clinical abbreviations.125,126 In addition, “heart” will search for “cardiac” in All Fields (title, abstract, key words, etc.). “Anaesthesia” will be searched in addition to “anesthesia.”

Table 8
Table 8:
Definitions for Usefulness of Retrieval of Articles from a Database Search

Disadvantages of MeSH

MeSH has limitations that apply to many specialties. Searching MeSH terms can fail to retrieve relevant citations due to retrieval bias127–129 (e.g., from deficient indexing of an article or inadequate key words). Manual searches of terms130 will sometimes uncover another 5% to 10%127 of references not detected through MeSH searches.87 MeSH commonly adds search terms that are unrelated (e.g., “turnover” maps to “personnel turnover” but also adds the word metabolism), resulting in multiple articles identified that are irrelevant for OR management.131 Additionally, searching only MeSH terms will fail to retrieve references to recently published articles for which new MeSH terms have not yet been created.51

MeSH Terms for OR Management

Table 9 shows the MeSH terms for ORs, surgery, and related topics. Few are relevant to OR management. MeSH terms for searches on OR management do not contain the pertinent vocabulary that is specific to OR management. For example, “tardiness” is not a MeSH term. “Operating theatre” and “operating theater” are not recognized as synonymous. See Hypothesis 2, Table 5 and Table 7 on limited knowledge of vocabulary. See the examples at the beginning of the article of the importance of knowing specialized vocabulary in searching.

Table 9
Table 9:
MeSH Headings Relevant to Operating Rooms and Surgery

Use of Other Text Words

Text words are more effective in locating references than MeSH keywords not just for OR management but also for some other topics (i.e., the validity of our results are confirmed by being applicable to other fields). For example, MeSH terms used to search a specific aspect of adolescent health130 identified 17 of 41 studies, while a generic search of general terms identified 21 of 41 studies. As another example in a study on sleep of healthy humans,132 the use of MeSH terms resulted in 254 citations, with a sensitivity of 78% and a lower specificity of 66%. The terms “sensitivity” and “specificity,” along with “recall” and “precision,” are criteria for evaluating and understanding the effectiveness of a database search (See Definitions in Table 8.)

Evidence supports Hypothesis 6 that MeSH terms are not useful for searches in OR management and some other fields. Simple text words can identify pertinent articles.


  • Techniques for Searching
  • Creative Searching is Needed to Find OR Management Articles
  • Methods for Finding Obscure Articles

Techniques for Searching

In the technique of “citation pearl growing,” the user starts with a very precise search to find one key relevant citation. The goal is to elicit a reaction of, “That is exactly what I wanted.” Index terms and free text terms found in the relevant citation are then examined and incorporated into a new strategy. This process continues until all additional relevant terms have been included in the search strategy. Just as for vocabulary, the first “pearl” is likely to come from review articles,96–100 the lectures and sample reports at, and/or a search of Google Scholar.

In successive fractions (also known as ‘divide and conquer’ or ‘file partitioning’), the first step represents searching a major topic. Subsequent topics are added as AND conditions to the results set, making it progressively smaller. Eventually the number of retrieved references becomes manageable.

Other approaches include list checking and citation searching. In reference list checking, references in relevant papers are examined to determine whether they are also pertinent. In citation searching, papers that have cited particularly relevant papers, such as those identified as citation pearls, are identified. Citation searching can be performed to a limited extent without fee using Google Scholar.

Creative Searching Is Needed to Find OR Management Articles

For example:

  1. OR time has been assigned to various surgical services 12 weeks prior to surgery. Five days before surgery, 3 add-on cases must be fit into the schedule. Where should they be put on the schedule? Can they be added to the allocated but unused time reserved for one of the services, or would it be better to wait until the day before surgery before scheduling the add-on cases? Answer:133,134,135 The add-on cases should be scheduled into the time of the service that has the biggest difference between assigned time and already scheduled OR time.133,135 Because of case rescheduling before the day of surgery, there is negligible benefit to releasing OR time >5 days in advance,134 and generally 1 to 2 workdays ahead is sufficient.134,135 Keys to searching this question are knowing that allocated time is “released” when it is given away to another service, and similarly that “service” is used to describe the unit of OR allocation.7 A PubMed search of {“release allocated” AND “operating room”} yielded 4 results, all of which were relevant.
  2. OR managers fear that cases will not finish by the end of the scheduled workday, and that overtime wages will have to be paid. Suboptimal behavior occurs because of overcompensation for this naturally-occurring bias. How does one learn more about the bias? Answer:136 General reading will show that this bias represents a natural tendency to pull toward the center. It also represents a risk aversion.136,137 Information can be understood better by reading in operations research journals about the newsvendor problem,6,7,136,138 but the vocabulary word “newsvendor” probably would not be known in advance by clinicians. A PubMed search of {“operating room management” AND behavior} produced 8 results, one of which was an article that described the phenomenon. A PubMed search of {“operating room management” AND newsvendor} produced 2 results, both relevant.
  3. There are 3 add-on cases for the day. The first is expected to last 3 hours, then 2 cases are added for 2 hours each. Open slots include 4 hours, 2 hours, and 2 hours. Absent information about the subsequent 2 hour cases, a natural inclination137 would be to assign the 3-hour case into the 4-hour slot in case it runs late. Is this the best decision? Answer:4,6,139,140 Computer simulations were used retrospectively to analyze 10 different algorithms to schedule add-on elective cases into ORs based on 16,200 cases at one hospital. A case would be scheduled into an OR assuming the case is scheduled to be completed within the allotted period. Therefore, provided cases are scheduled in a manner so that the mean error in the time to complete the series of consecutive cases in each OR is zero, errors in surgeons’ predictions of the durations of their cases will not increase labor costs.139 The key to solving this literature search problem and identify the appropriate references is to realize that the issue is how to schedule add-on cases into the OR. A PubMed search of {“add-on” AND “operating room” AND scheduling} yielded 7 results, 4 of which were relevant.
  4. Should adjusted utilization (the percentage of the scheduled workday that the OR is in use) be as close to 100% as possible? Answer:20,22–145 No. (1) High utilizations can limit the flexibility of surgeons with high contribution margins to schedule longer cases. (2) If utilization were high due to the addition of cases with little or no insurance coverage, those cases would lose money for the hospital. A good start would be to examine the lectures at One is entitled “Strategic planning: financial impact of different types of surgery.” Paging through the lecture, one finds that “contribution margin” is a key term. A search of {“operating room” AND utilization AND “contribution margin”} yielded 7 references, 5 of which were relevant.

Methods for Finding Obscure Articles

Table 10 lists the components associated with a good literature search and contains many ideas for locating obscure articles. Many techniques are used in combination.146,147 We have already shown that searching multiple databases produces different results (Hypothesis 5, second paragraph). Google Scholar is an especially good resource. Using different vocabulary (Table 7) and choosing a variety of keywords are necessary for a complete search. The citation index lists articles that have cited a particular paper, and is an excellent method for finding related articles. It is available also through Web of Knowledge, among other sources. Suppose a manager remembers reading a particular article on the economic value of improved case scheduling.4,148,149 but doesn’t know the author or title. A search of {economics AND case scheduling} yields over 300 articles. A citation search of any recent review article should identify the appropriate key words to search. Of course, consulting an expert is the ultimate method of ensuring that information is as complete as it can be, as considered below (see Need for Experts under Hypothesis 8 below).

Table 10
Table 10:
Methods for Conducting a Literature Search with Special Emphasis on Locating References That are Difficult to Find

Evidence supports Hypothesis 7 that creative methods are needed to find an appropriate number of articles on OR management, but such methods are available.


  • Training Is Useful
  • Training Does Not Persist Over Time
  • Trained Librarians Contribute to Success of Literature Searches
  • Experts Are Needed
  • Domain Knowledge Is Important

Training Is Useful

Training increased ability for medical students, residents, and physicians to perform their own searches of online databases.43,44,150–156 Training also increased their ability to evaluate information critically, improve clinical question formulation,154,155,157manage information collected or generated,155,158 and use information with understanding.159 Instruction in literature searching skills for medical students or residents160 generally resulted in improvement in clinical question writing, search strategy construction, article selection, and resource usage. The number of medical students who reported that they searched PubMed or Medline during clerkships >3 times per week increased from 10% (9.7%) to 32% (31.7%), and those who searched the Cochrane Library at least once a week increased from 8% (8.1%) to 18% (17.5%) (P < 0.001 for both items).43

Nevertheless, trained searchers were not always successful in locating information for which they were searching. A review of 27 studies,155 each describing at least one barrier to the uptake of evidence from systematic reviews, concluded that the transfer of important clinical knowledge is impeded by the amount and the ongoing growth of the biomedical literature. Principal Investigators at the National Institutes of Health50 reported that relevant information was difficult to find for a substantive proportion of topics (38%, 32 / 84). They were probably more experienced at searching than the average investigator.

Training Does Not Persist Over Time

Some follow-up studies showed retention of skills over time155,161,162 and others showed a clear decay.25,43,52,154,160,163,164 Six months after training, the median number of logins was increased by a factor of 2.1.155 This effect was not reproducible.160 Unless skills were being used soon and for work purposes, the relevance of the training was lost and the skills forgotten quickly.151 Of those who used their skills every week or once a month, most professed themselves satisfied with the results of their searches (P < 0.0001, 74%, 96/130). This falls to 56% (P = 0.002, 73/130) for those who rarely practice the skills learned.152 If managers are not going to perform literature searches on a frequent basis, they are unlikely to be successful.24,25,165 The assistance of a library informationist may be helpful (see next section). Teaching of literature searching skills appears to be moving away from formal courses and toward a direction of curriculum-integrated instruction that ties knowledge of literature searching to solving evidence-based practice problems.160,166 Providing a context for searching improves retention.164,166

Trained Librarians Contribute to Success of Literature Searches

Searching requires expertise in search. The best search protocols result from collaboration with subject matter experts and medical decision-making experts, coupled with search experts.167 Health science librarians who specialize in informatics91 represent a wealth of search knowledge within the biomedical domain.

Online searching skills were regarded as the most important technology skill for today’s reference librarians,168 followed by communication skills.169 Search skills are valued at institutions where the publishing record of librarians is important for determining promotion and/or tenure.170 Citation counts of research papers published by faculty librarians are considered important.170 Librarians are encouraged to perform research on searching and to publish the results of their studies of search strategies.170 Such activities enhance their skills and help make them valuable resources for OR managers needing help with searches.

Some libraries have services in which they briefly (e.g., 20 minutes) investigate patient care questions for the physician.171 A review article from the United Kingdom found that medical and surgical staff, including general practitioners, had an average of 0.23 to 1.27 questions regarding diagnosis or therapy per patient clinical visit.172 Librarians answer these questions. Such services173 save clinician time174 because the physician can see another patient while the librarian performs the search. Librarian searches prevent the necessity of a repeat patient visit and are cost-effective.

Clinical research activities175 require librarians to obtain new knowledge and develop new skills. The new role of the clinical librarian as an educator or “information managementist,” who passes information to clinicians for use as the basis of practice at the moment of care, or who performs longer-term literature searches, reflects the change that has taken place in library practice. We will think of such specialists as “library informationists,” but simply call them librarians with “informationist” implied.

Librarians perform more time-consuming searches dealing with complex questions, often using sophisticated algorithms.176 A substantive proportion of health professionals have asked library staff to search on their behalf (54%, 132/243).48 Respondents expressed a preference for retaining the option of performing management searches themselves or having a librarian do them.151 Training increased the number of searches that users requested be performed by librarians,52 presumably because users became educated about the complexities of performing a thorough search. Most health professionals were not prepared to spend >2 hours performing a literature search (P < 0.0001, 80%, 80/100).152 Few nurses performed their own searches, but relied on librarians to educate them about evidence-based practice.165

The assistance of a skilled librarian significantly improved the outcomes of searches performed by pediatric residents and interns177 or interns, residents, fellows, and faculty physicians in a wide variety of specialties.163 The technical skills of librarians provided significantly increased recall and precision of bibliographic searches.34,163

Domain Knowledge Is Important

One of the challenges facing librarians who assist with literature searches is domain knowledge, or training in the area of expertise of the search. Librarians providing rapid clinical question answering services were asked about the skills necessary to do their jobs.178 Besides literature searching, the next most important skill was understanding the context of clinical questions and clinical content.35,171,179

Domain knowledge is likely very important for OR management because the vocabulary is complex (Table 7). The average library informationist would not be familiar with OR management terms, and would need specialized training. They would need to read review articles4,5,96–100,136 or study the lectures and reports online at

An editorial in the Annals of Internal Medicine on clinical teams discussed an informationist trained in science or medicine as well as information management science.50 In 2001, the National Institutes of Health (NIH) Library began hiring information managementists, librarians (we will refer to them simply as librarians for simplicity) with extensive expertise in a clinical or research specialty. In addition to being expert information management scientists, some of the NIH librarians had doctoral degrees in basic biomedical sciences such as molecular biology, biochemistry, and neuroscience. All are expected to continue their education by taking graduate-level courses in the specialties they support.50 Principal Investigators at the National Institutes of Health50 were asked to rank 6 competencies that librarians needed to be effective team members. The first was “expertise searching information management sources relevant to my clinical/research area” and the second was “specific knowledge of my clinical/research area.” The librarian’s subject knowledge was recognized as necessary if all the perceived benefits were to be achieved.

An example of the need for an expert follows. Brusco180 published a tutorial of how to use PubMed using the example question, “What is the national average benchmark for OR turnover time?” Answering the question is straightforward because the question already contains the vocabulary of “benchmarking” and “turnover time.” However, the vocabulary used is unique to the situation about which the user is inquiring; there are not many synonyms or alternative meanings for “turnover time.” “Benchmark” is even a MeSH term (Table 9). These 2 characteristics of the question make it easy to search. The authors narrowed the search to {“operating rooms” AND “turnover time”} but that resulted in 46 articles, and the authors did not pursue the subject further. A search of {“operating room” AND turnover AND benchmark} would have yielded 4 results, 3 of which were relevant.181–183 Those articles probably represent the majority of literature pertinent to the subject.

A less experienced searcher may want to know the same thing, but might have phrased it: “What is the average time between cases at different hospitals?” We tried searching these text words {“time between cases” AND “operating room”}, which yielding 1145 references. Perusing the first few results, the abstract of the #13 citation contained the term “turnover time.” The first reference for the search {delay AND “operating room”} also contained the word “turnover.” An experienced library informationist might recognize this pattern and realize the need to search on “turnover time.” In order to perform a successful search, knowledge is required of both how to search databases and what key words in the field are important. Table 7 lists terms specific to OR management for which searches can be performed.

Experts Are Needed

Contacting experts to identify appropriate articles also is important.184 Searching electronic databases may uncover only half of all relevant studies. A substantive proportion of references identified by experts would have been missed if experts had not been consulted (60%, 24/40).184 In another study,184 while a substantive proportion of references pertaining to a particular topic were found using electronic databases (49%, 50/102), most were identified by people working in the field and hand searches (P < 0.0001, 70%, 71/102).

Experts are usually responsive to requests for assistance. Of 111 emergency medicine physicians with valid e-mail address, 70 responded to e-mail requests for information.185 Thirty of 39 gastroenterologists contacted by e-mail responded within 2 weeks.186

Evidence supports Hypothesis 8 that trained librarians and experienced knowledge of searching methodologies, in combination with experts in the field, improve results.


We tested 8 hypotheses about literature search for OR management articles (Table 1). A wealth of practical information can be found in the literature of OR management. However, experts in the fields of both OR management and searching the scientific literature are needed to locate pertinent references. This article explains some creative methods for locating OR management articles. Unusual measures are sometimes required to find articles that address the topic of interest, especially when the problem is very specific. The materials are presented broadly enough that the reader can extrapolate the findings to other areas of clinical and management issues in anesthesiology. E

Recuse Note

Dr. Franklin Dexter is the Statistical Editor and Section Editor for Economics, Education, and Policy for the Journal. This article was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Dexter was not involved in any way with the editorial process or decision.


Name: Ruth E. Wachtel, PhD, MBA.

Contribution: This author helped design the study, perform the study, and prepare the manuscript.

Attestation: This author approved the final manuscript.

Name: Franklin Dexter, MD, PhD.

Contribution: This author helped design the study, perform the study, and prepare the manuscript.

Attestation: This author approved the final manuscript.


a OR management. Available at: Accessed July 10, 2013
Cited Here

b Practice can be used as a verb meaning to practice medicine or to perform a skill repeatedly to increase proficiency. As an adjective, it can mean practice standards. As a noun, the word can be used to mean an anesthesia group practice, an action such as washing one’s hands, a habit such as practicing courtesy, a set of actions associated with something like a religion.
Cited Here

c Fact Sheet MEDLINE®, U.S. National Library of Medicine, National Institutes of Health, Available at: Accessed July 10, 2013
Cited Here

d Surgical services management; Anesthesia group management and strategies; Predicting the duration of elective cases;Post anesthesia care unit staffing; Add-on cases, staffing at the end of the day and on weekends, inpatient surgical beds; Pre-anesthesia evaluation economics, including case cancellation; Economics and mathematics of decreasing anesthesia, turnover, or surgical times; Policy related to OR management; Organizational behavior and psychology; Anesthesia Information Management Systems
Cited Here

e Fact Sheet Medical Subject Headings (MeSH), U.S. National Library of Medicine, National Institutes of Health, Available at: Accessed July 10, 2013
Cited Here


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