[LHNCBC AUDIT]

[Reprise of 2001 Janet Doe Lecture, June 27th, 2001]

Or about Janet Doe in the course of the lecture, but I just thought I would tell you that the Janet Doe Lecture is a lecture that has to be given on a topic in the history or philosophy of medical librarianship.

It's been given about every year at the Medical Library Association annual meeting since 1967.

And the lecturer is chosen more than a year ahead of time so that he or she has plenty of time to obsess about the lecture, and I have been no exception to the rule of obsession over the Janet Doe Lecture over the years.  [Slide: Adjusting to Progress: Interactions between NLM and Health Sciences Librarians, 1961-2001. The Janet Doe Lecture. Betsy L. Humphreys, Annual Meeting - Medical Library Association, Orlando, Florida - May 28, 2001]

So, to begin, when I arrived at NLM in 1973, one of the first things I learned is that health sciences librarians are not always pleased with NLM.

Most health sciences librarians would agree that overall NLM's leadership and its services have been highly beneficial to the field. This does not prevent some NLM actions or lack of action from annoying or infuriating some health sciences librarians.

The problem may lie with the substance of what NLM is doing or, even more likely, with the way it is done or communicated.

In my twenty-eight years at NLM, I have lived through a number of highs and lows, some of them simultaneous in the remarkably productive and resilient relationship between health sciences librarians and NLM.

The invitation to present the Janet Doe Lecture gave me a welcome excuse to examine the history of NLM's interactions with the health sciences library community in greater depth,

to look for some underlying patterns, and to think about what it all means for our collective future.

Other Janet Doe lecturers have spoken of difficulty in selecting a topic. For me, it was the title. Here are a few I considered and rejected. It was while I was trying out one of these on my husband that he began referring to me as the Doe nut.  [Slide: NLM is from Mars..., Sleeping with an Elephant..., Our Best Friends Do Tell Us...]

[Laughter]

This lecture will focus on interactions between NLM and health sciences librarians over the past forty years.  [Slide: NLM Budget - FY 1961-2001 (Dollars in Millions)]

It will describe how these interactions were affected by additions to NLM's mission and services, the expansion of NLM's direct user groups, and the growing range of possible relationships between health sciences librarians and NLM.

I will pay particular attention to the way things stood at decade intervals beginning in 1961. To provide some perspective, I will touch briefly on selected developments in NLM programs.  [Slide: Online MEDLINE Searches at NLM]

I apologize in advance to all of you for the many NLM accomplishments that will not be mentioned.

In her centennial review of the Janet Doe Lectures, Alison Bunting noted that the histories of MLA and the National Library of Medicine are inextricably intertwined, and many of their joint efforts are documented in the Doe lectures.

By my count, only five of the previous thirty-four lectures make no mention of NLM and its services.

All of the previous lecturers had one or more relationships to NLM as users, advisors, grantees, trainees, NLM or RML staff members, and/or developers of innovations that were incorporated into NLM services.

These are exceptional people, but they are not unusual in having ties to NLM.

In the second half of the twentieth century, it was difficult, if not impossible, for any U.S. health science librarian to avoid having some interaction with NLM.

As a quintessential NLM insider, I approached the examination of NLM's relationship with health sciences librarians with a sizeable inherent bias.

I cannot claim to be objective, but I have examined many sources of blunt opinions about NLM and its programs, including MLA oral histories, the archives of NLM, MLA, and the MEDLIB LISTSERV, and the published literature.

I have also heard more than a few unvarnished opinions of NLM.

At my very first MLA meeting in 1975, Dr. Estelle Brodman, one of the true giants in medical librarianship, introduced me as a speaker in a session on serials automation.

She used roughly the following words" "Whenever I travel around the world, I am always struck by how fortunate medical libraries in the United States are to have the leadership of the National Library of Medicine.

It's a shame that NLM has never shown this leadership in the field of serials automation." [Laughter]

Janet Doe's own important interactions with NLM provide a useful prologue to the last forty years. In 1943-44, as librarian of the New York Academy of Medicine, Ms. Doe was a member of the committee of distinguished librarians who surveyed the state of the Army Medical Library, as NLM was then called. [Image: Head and shoulders photograph of Janet Doe]

The survey was commissioned by the American Library Association...excuse me, was commissioned from the American Library Association by Colonel Harold Wellington Jones, director of the Army Medical Library, using funds obtained from the Rockefeller Foundation.

ALA's initial proposed list of members of the survey committee contained only one medical librarian, and no women.

When it was sent to MLA president Mary Louise Marshall for review, she supplied the names of ten medical librarians topped by Janet Doe and pointed out that quote, "Many outstanding librarians in the medical field were women."

Although she did not recommend herself, Ms. Marshall, Ms. Doe, and Thomas Flemming of Columbia's Medical Library, ended up on the survey committee,

which produced a highly critical report with recommendations for major changes and improvements, including a new building.

Over the next sixteen years, Dr. Jones and his two immediate successors, Dr. Joseph McNinch and Dr. Frank Bradway Rogers, used this outside report and its forthright recommendations to garner additional resources and to justify sweeping changes in staffing, operations, and products. [Image: photo of Dr. McNinch and Col. Rogers standing side-by-side]

Ms. Doe continued to serve NLM's predecessor institutions, first on the Committee of Consultants on Indexing for the Army Medical Library, and then on the Armed Forces Medical Library Advisory Group, [Image: group of people posing at a table, titled "Committee of Consultants for the Study of the Indexes in Medical Literatur, published by the Army Medical Library"]

a precursor of the NLM Board of Regents. She testified before congress for MLA in favor of the act that transformed the Armed Forces Medical Library into NLM and later worked for NLM's grantmaking authority.

By 1961, Dr. Rogers, a physician and a librarian, had been NLM's director for twelve years. NLM was celebrating its one hundred and twenty-fifth anniversary and the fifth anniversary of the National Library of Medicine Act.  [Image of a group of men at a construction site, titled April 1960 - NLM Board of Regents visit Bethesda construction site]

The Board of Regents, then NLM's only advisory committee, included one medical librarian, Thomas Keys of the Mayo Clinic.

The staff was getting ready to move the collections from Washington DC and from Cleveland, where the History of Medicine Division was then located, to a new building on the campus of the National Institutes of Health in Bethesda, Maryland.

In 1961, NLM was already a high-volume operation known for its innovative use of technology.

The request for proposals for a contract to develop the Medical Literature Analysis and Retrieval System, or MEDLARS, had been issued, and the contract was about to be awarded to General Electric, using funds provided by the then National Heart Institute.

In 1961, health sciences librarians were the primary direct users of NLM's products and services.

With the important exception of those who visited the NLM reading room, health professionals, researchers, educators, and students obtained NLM services via another health sciences library.

In comparison to today, NLM had only a few critical services: Index Medicus, the annual NLM Catalog, historical catalogs, the NLM classification, MeSH, and interlibrary loan.

In 1961, NLM was not a major source of training for health sciences librarians. NLM did have an internship program, a precursor of today's associate program. Irwin Pizer, who you will hear more about later, was an NLM intern in 1961.

Use of NLM's bibliographic tools and ILL service was not very intrusive. It did not require librarians to change procedures or learn new skills.

In contrast, a decision to use the NLM classification or its subject headings in local cataloging required substantial effort, changes to existing practices and staff training.

In the preautomation era, there were fewer compelling reasons to adopt the NLM classification or its subject headings, and many health science libraries continued to use other systems.

The state of other U.S. health sciences libraries in academic centers and hospitals was pretty poor in 1961. Serious underfunding had prevented libraries from keeping up with the massive increase in biomedical research after World War II.

Nonetheless, the proceedings of the 1961 MLA annual meeting give an impression of a profession that is optimistic and growing rapidly.

There is a sense that increased spending on research, strong interest in translating research into practice, new information technologies, and the application of business management principles offer exciting new opportunities to improve the quality of U.S. health science libraries and their services.

Evidence of a strong, collegial, and mutually supportive relationship between MLA and NLM appears throughout the 1961 proceedings and the MLA bulletin.

Dr. Rogers often discussed NLM plans and problems informally with leaders in the field. In 1961, this meant he discussed them primarily with library directors from academic centers and large medical societies.

Rogers was elected MLA's vice president/president-elect, and also received the Noyes Award in 1961.

In recognition of NLM's one hundred and twenty-fifth anniversary, the July 1961 issue of the bulletin sported a metallic gold cover and a special National Library of Medicine section, which actually included an article by Janet Doe describing the survey and what had been done at NLM as a result of it.

In addition to being discriminating users of NLM products and services, health sciences librarians had become accustomed to serving NLM as advisors and advocates.

In 1961, Ms. Doe and the other leaders of the profession knew that their advice and advocacy had helped to make NLM a reality.

They looked forward to the expansion of NLM's legislative authority and budget to encompass an extramural program that would improve medical library resources across the country, and they were ready to help make this goal a reality.

The decade from 1961 to 1971 was the era of Martin Luther King, Jr., the Vietnam War, and Woodstock.

It finished up with the Watergate break-in. In 1963, MLA established the Federal Relations Committee, a precursor of today's Governmental Relations Committee, in part to advocate for the establishment of NLM's extramural authority.

When Dr. Martin Cummings succeeded Dr. Rogers as director of NLM in 1964, Dr. Estelle Brodman, MLA president-elect, suggested setting up an MLA/NLM liaison committee because she thought something more formal, quote "than having a gin and tonic with Brad Rogers" might be necessary.

Dr. Cummings expanded NLM's mission and programs dramatically during the 1960s. In 1964, NLM implemented MEDLARS and began batch search services.

In 1965, congress passed the Medical Library Assistance Act, MLAA, which gave NLM authority to award extramural grants and the mandate to establish the Regional Medical Library Network, now known as the National Network of Libraries of Medicine.

NLM's Toxicology Information Program was established in 1966. In 1967, the National Medical Audiovisual Center was transferred to NLM from the Communicable Disease Center, and the first Regional Medical Library was established at the Countway Library of Medicine in Boston.

In 1968, NLM's fledgling internal research and development program was officially named the Lister Hill National Center for Biomedical Communications.

That same year, NLM was sued by Williams and Wilkins publishing company for systematic copying of journal articles.

Of course, NLM's contention was that all of its interlibrary loan activity fell within the realm of fair use and was therefore permissible under U.S. copyright law and guidelines.

In 1970, the eleventh and last RML in the first set was established at the McGoogan Medical Library at the University of Nebraska.

By 1971, the easy collegiality between NLM and health sciences librarians was gone, a victim of the NLM extramural program, which the library community had so strongly advocated.

There was a built-in tension and a requirement to maintain a certain distance between a funding agency and its grantees and contractors.

In 1971, the funding relationship between NLM and health sciences librarians was still new and quite uncomfortable for those who remembered previous informal collaboration with the NLM senior staff.

The purpose NLM defined for its extramural program, to evolve a national information apparatus founded on existing medical libraries, was not seen as a problem nor were the objectives of the various types of grants.

In fact, the 1966 description of these objectives is remarkably forward-thinking. For example, NLM was urging, quote "examination of the possibility that the library be designed for the recovery and transmission of information to scholars at the point of use."

As is ever the case, the devil was in the implementation details. In the early years of NLM's grant program, competing with peers for grants was a new experience for many health sciences librarians.

In 1966, NLM had announced plans to provide assistance for the construction of forty to fifty libraries, and many fundable proposals were received.

Unfortunately, the appropriated funds covered only eleven library construction projects. Library directors and institutions that did not receive construction funds were understandably upset.

Few of the librarians competing for any NLM grant would have previously served on federal grant review committees. Some were highly suspicious of the process used to select the winners.

Problems that arose between NLM and the health sciences library community over construction grants, resource grants, and research grants were destined to diminish, if never to disappear completely, as everyone, including NLM, became more comfortable with the grant process.

In any event, these problems pale in comparison to the upheaval caused by the implementation of the Regional Medical Library Program as the National Network of Libraries of Medicine was then called.

Most of the objectives of the RML program sound uncontroversial -- to provide prompt access by any health researcher, practitioner, or student of the health sciences in the United States to library materials he may need and to equalize opportunities for access despite accidents of geographic location.

The initial regional configuration was not dictated by NLM but was to be determined by librarians and health professionals in the field.  [Image: Map of U.S. Regional Medical Library Network, 1967-1981, each region displayed in a different color.]

The general strategy to strengthen the resources of existing institutions and to build on existing cooperative patterns among health sciences libraries seems eminently reasonable.

Grant funds were to be used to subsidize document delivery. So what was the problem? I encourage you to consult Alison Bunting's excellent history of the network from more details. I'll just hit the highlights.

At bedrock, the implementation of the RML Network required academic health sciences librarians to work with people and institutions they had never worked with before,

to adhere to policies they might not agree with, to serve users outside their customary clienteles, and, maybe worst of all, to make changes in internal procedures.

To give a concrete example, many academic libraries could no longer send ILL requests directly to NLM after the regional configuration was put in place.

Given the level of appropriations NLM received for the program, each regional medical library had to be responsible for a large multistate region.

Existing cooperative arrangements among medical libraries were more loosely defined and generally on a smaller scale.

Even the Regional Medical Programs, initiated at roughly the same time and prompted also by the report of the president's commission on heart disease, cancer and stroke, even the RMP programs covered much more restrictive geographic areas.  [Image: Map of U.S. Regional Medical Medical Programs]

Absent relevant models, it is not surprising that there were major disagreements on how to proceed, not just between NLM and academic health sciences librarians, who were chiefly involved in planning the initial programs, but also between leading librarians in the field.

In some regions, the competition to become the RML was intense, an added source of stress that remains with us today. NLM was the RML for the Mid-Atlantic states, which was seen as a distinct disadvantage by the academic libraries in that region.

As libraries in a given region worked toward agreement among themselves, NLM quickly became convinced that some basic level in quality of service should be uniformly available in all parts of the country.

NLM expected the RMLs to provide document delivery service for health professionals who currently lacked access to a medical library. We have been pretty consistent about that.

NLM also wished to establish uniform policies regarding its own backup role in the network and RML service standards for MEDLARS searches and interlibrary loan.

From the librarians' perspective, there were far too many occasions when NLM essentially dictated how network programs would operate.

NLM had been a federal agency for all of its long history, but it was not until the passage of the MLAA and the initial implementation of the library network that some health sciences librarians began to see NLM as the embodiment of the insensitive and misguided federal bureaucracy interfering in local affairs.

As Bernice Hetzner, the first director of the Regional Medical Library for the Midcontinental Region, commented, "some people involved in the Regional Medical Library Program looked upon the National Library of Medicine as an adversary. In fact, one region threatened to secede from the whole program."

Some directors of large medical libraries resented the fact that NLM's top management team, which in 1971 included no librarians, did not give greater weight to their professional counsel.

Some were offended by the notion that NLM funding should influence the way services were provided in their institutions. At varying levels of intensity, these views have remained part of the substrate for NLM's interactions with health sciences librarians ever since.

As always, there were strong personalities on all sides, and Mrs. Hetzner was one of only a very few diplomats involved in the whole process. I am not sure there were any here at NLM.

During the 1960s, the addition of new NLM programs had brought new categories of direct users of NLM services, but these additional groups had relatively little impact on NLM's interaction with health sciences librarians.  [Slide: 1971 - NLM's Direct Remote Users: Librarians and information specialists, Historians, Non-print media producers, Chemists/toxicologists, Information scientists]

The key to these slides is that the white stuff is what has been new since 1961. While the RML wars were being fought, NLM had been developing new services that were generally seen as advantageous to librarians, although they also increased the potential points of friction between NLM and the field.

Responding to repeated requests from the MLA-NLM Liaison Committee, in 1971, NLM was offering its authoritative cataloging and indexing data in multiple forms. NLM cataloging records also became available by a commercial catalog card service in 1971.

The rapid availability of NLM cataloging data had a standardizing effect on cataloging practices in health sciences libraries. Increasing numbers of libraries were switching to the use of the NLM classification in MeSH.

In turn, the growing reliance of health sciences librarians on NLM cataloging copy would have a substantial impact on NLM's cataloging decisions over the next three decades and on its contributions to national bibliographic standards.

In 1971, many recurring bibliographies were published from MEDLARS in addition to Index Medicus. Abridged Index Medicus had finally been launched in 1970 with MLA's cooperation following years of prompting from MLA members.

In April 1971, the MEDLARS tapes became available on subscription. The Lister Hill's Center successful AIM-TWX experiment, which demonstrated the viability of online retrieval via nationwide telecommunications networks, led to the implementation of MEDLINE on the ELHILL retrieval system in October 1971.  [Slide: MEDLARS: MEDical Literature Analysis and Retrieval System. MEDLINE: MEDLARS Online]

Both AIM-TWX and MEDLINE built upon the experience of the SUNY biomedical communications network, which had been providing online access to MEDLARS data for a limited number of libraries since 1968.

This was a spectacular example of a recurring pattern in NLM's interactions with other health sciences libraries. NLM has often obtained good ideas from successful local or regional initiatives led by health sciences librarians.

Usually, when an idea is co-opted in this fashion, NLM changes some parameters to accommodate the larger national scale and to build on previous investment in related NLM products or services.

This is a positive and healthy process, but it has a bittersweet side. The national implementation may sometimes exclude helpful features that cannot be scaled up efficiently.

As time goes on, the successful NLM service may obscure the contribution of the pioneers who preceded it, although, fortunately, this hasn't happened in Irwin's case.

NLM's direct involvement in training health sciences librarians had gradually increased in the 1960s. The NLM internship program had been revamped into the associate program, but still involved only a few good people, you might recognize some of the ones in this picture, each year.  [Image of three men and three women posing, titled "1970/71 NLM Associates, with Joe Leiter and Carol Long"]

Beginning in 1965, a relatively small number of librarians from MEDLARS search centers in other U.S. and international institutions came to NLM for months to learn batch-searching using punch cards.

The first two MEDLINE classes were held at NLM in the fall of 1971. These were three-week classes.

Although NLM's big involvement in direct training of librarians lay just ahead, the library had been a significant funder of education since the passage of the MLAA in 1965.  [Image: About 20 peopled seated and standing at a long conference table, titled "Early MEDLINE Training Class (1972)]

In 1971, a total of a hundred and twelve people received training support through seventeen NLM-funded training grant programs, included master's degree programs in library science, post-graduate library internships programs, and doctoral programs.

Nearly all of the trainees were librarians. In 1971, health sciences librarians were still serving NLM as advisors.

In NLM's formal structure, Bernice Hetzner and Susan Crawford of the American Medical Association, joined MLA's board that year.

There were medical and other librarians on the Biomedical Library Review Committee, which reviewed NLM's grant applications, although many health sciences librarians were apparently unaware that their profession was represented in NLM's grant review process.

In MLA's formal structure, the MLA-NLM Liaison Committee was in full swing. It had two all-day meetings with Joseph Leiter, then NLM's associate director for library operations, and other senior NLM staff members in 1971.  [Slide: 1971 - Librarians vis a vis NLM: Users and testers of products and services; Advisors - formal and informal; Advocates; Recipients of training/education; Grant applications>Grant recipients; RML contractors; Network members]

Both technical and policy matters were discussed, and the frustration and irritation on both sides comes through in the committee's annual reports, and I quote, "The committee believes more written information on NLM's policies, activities, staff programs, and plans is very much needed."

Dr. Leiter commented that "communication is a two-way street. When information is needed, the librarian should ask for it. All letters to NLM are always answered. Some committee members believe that even when information is requested the answers are nonproductive or evasive."

NLM's director, Dr. Cummings, was in fact a member of the MLA board in 1971, just as Dr. Rogers had been in 1961. However, Dr. Cummings saw a conflict of interest with his position as head of the chief funding agency for medical libraries, and he felt constrained from active participation on the board.

In retrospect, it is surprising that he agreed to serve at all, although no doubt it would have been a very difficult invitation for him to refuse.

The level of animosity toward NLM prompted MLA officers and NLM management to discuss how to move communication between the two organizations to a higher, more productive plane. This has recurred a few times since then.

As a group, health sciences librarians continued to be strong advocates for NLM and its extramural programs in the political arena, despite the disappointment and anger of individuals in the profession.

MLA's Committee on Legislation, as the Federal Relations Committee had been recently renamed, had a busy year in 1971. It joined forces with the Association of Research Libraries in submitting an amicus brief to support NLM's position on fair use in the Williams and Wilkins case.

In 1972, the Committee on Legislation would send a memo to every MLA member urging them to continue current photocopying practices. In part, it said, "Libraries may soon be deluged with offers from publishers to provide copyright protection with royalty-paying arrangements.

It would seem to be premature to accede to any of these before the Williams and Wilkins case has finally been decided. Such action could severely damage the libraries' case and weaken their ranks."

Most health sciences libraries were better off in 1971 than they had been a decade earlier. Institutional support...and as I said at the meeting, a lot of the people in this picture are better off that I cut the picture off at the waist. [Laughter]

Institutional support of health sciences libraries had increased in the positive economic climate of the 1960s.

Disagreements notwithstanding, NLM's expanding intramural services, the Regional Medical Library Programs, the extramural funding, and extramural funding of other federal agencies had benefited health sciences librarians.

Yet the proceedings of the 1971 annual meeting and the 1971 issues of the Bulletin of the MLA indicate that librarians were bracing for a period of retrenchment.

The U.S.economy was weak, government subsidies for research and education had been cut with predictable effects on some academic health sciences libraries. The decade from 1971 to 1981 saw the end of the Vietnam War, the resignation of Richard Nixon, and double-digit inflation.

It was a much less expansive era for the federal government than the 1960s had been. No major new program areas were added to NLM but existing activities were modified in ways that had an impact on NLM's relationship with health sciences librarians.

In 1971, NLM established a resource improvement grant, which could be used to establish new hospital libraries. In 1972, NLM revamped its training grant programs to focus on PhD and post-graduate fellowship training.

Funding for master's training in library science and library internship programs was eliminated, and a new training program in computers in medicine was established. NLM-funded research on workforce requirements by David Kronick and Alan Rees, had indicated a declining demand for new health sciences librarians.

The addition of the Computers in Medicine program was recommended in a 1971 report entitled "Educational Technology for Medicine: Roles for the Lister Hill Center," produced by the Association of American Medical Colleges and commissioned by NLM.

The Stead Report, as it was known after its editor, Dr. Eugene Stead, father of Bill, also led to the establishment of AVLINE as well as other changes in NLM's audiovisual and research programs.

This was the decade when the great majority of health sciences libraries went online. NLM built many other online databases, starting in 1973 with CATLINE, SERLINE, and TOXLINE.

NLM instituted charges to defray the growing telecommunications costs. In 1975, NLM implemented consortia grants to simulate local cooperation, primarily among hospital libraries.

In 1977, NLM's Lister Hill Center began its influential work on a minicomputer-based integrated library system appropriate for academic health sciences libraries.

The Association of Academic Health Science Library Directors was established, and the first Symposium on Computer Applications in Medical Care was held. It has since become the Annual Symposium of the American Medical Informatics Association.

In January of 1978, eleven hospital librarians, one from each region in the network, met with NLM staff to discuss the needs of hospital libraries and how hospital librarians could have more input into NLM and regional network decisionmaking.

Three past or future MLA presidents were present among the Bethesda Eleven, as they came to be known, Barbara Coe Johnson, Judy Messerle, and Jackie Bastille.

The meeting led to changes in NLM's plans for online training, serial holdings data, and grant programs as well as NLM and RML advisory mechanisms. In a statement issued after the meeting, the hospital librarians captured the essence of the enduring communication problem between NLM and health sciences librarians:

Quote, "Since the environments in which we function and the places from which we come are so different, we feel that regular opportunities for direct communication are necessary if we are to achieve the genuine understanding of one another's problems and concerns that is essential for progress."

As NLM expanded its online training program and the RMLs increased training opportunities in their region, concern arose over the invasion of MLA's territory as a provider of continuing education to health sciences librarians.

In 1978, agreement was reached that MLA would provide CE opportunities for professional health science librarians, sometimes using courses developed by NLM or RML staff.

NLM would restrict itself to training in the use of NLM databases and systems, and the RMLs would focus on training for nonprofessionals with responsibility for managing hospital libraries.

In 1980, NLM completed the functional specifications for MEDLARS III, which was to provide both greatly enhanced user functionality and also more rational and integrated data creation in library processing capabilities.

I think we finally achieved the last piece of functionality described in these specs this year. One long-term effort that did reach fruition in 1980 was the opening of the Lister Hill Building.

You can just make out Lois Ann on the right. She was actually representing MLA as its president when the building opened. Compared to a decade earlier, relations between NLM and the health services library community were considerably less strained in 1981.

During the 1970s, there had been no fundamental changes in the relationships between health sciences librarians and NLM.

Health sciences librarians were still very discriminating and demanding users of NLM products and services, and, of course, online databases were harder and more expensive services to use than print.

They required training equipment and new procedures. NLM had introduced many new services, but with a few exceptions, they could be characterized as much more of what had been available a decade before.

NLM's involvement in national bibliographic programs had expanded dramatically. The SERHOLD database debuted in 1981. NLM was now able to generate union lists considered useful by health sciences librarians.  [Slide: 1981 - Major NLM Services (1): Bibliographic Data; Other Databases; Classification and Subject Headings; Interlibrary Loan; Standards Development; Training - Associates, online]

In 1981, health sciences librarians were still the primary user group for most NLM services, but medical informaticians were now the major beneficiary of NLM training grants, even though they didn't call themselves that then.  [Slide: 1981 - NLM's Direct Remote Users: Librarians and information specialists, Historians, Non-print media producers, Chemists/toxicologists, Information scientists, Medical informaticians]

Since 1978, some research grants had also been focused on computers in medicine with earmarked funding added in 1980. NLM's grant programs continued to fund the development and testing of innovative library services, including circuit rider and clinical librarianship programs.

By 1981, a large percentage of health science librarians had received training in the use of NLM's online databases, either from NLM or at NLM or at an RML training center.

Michael Homan, the immediate past president of MLA is one of the two in plaid here in the meeting. [Laughter]

The cadre of former MLA associates working in other health sciences libraries had continued to increase.

By 1981, the Regional Medical Library Network had improved document delivery considerably and also provided training, consultation, and other support to many libraries, especially in hospitals.

RML and resource library staff members continued to see NLM's management of the program as heavy-handed. The recompetition of the RML contracts continued to be stressful.

Resource constraints led to program changes such as the gradual phasing out of partial ILL subsidies, which was not popular.

In his 1981 Doe lecture, Bob Cheshier characterized the Regional Medical Library Program as a bureaucracy, "which uses inordinately large parts of the financial resources available to it." And as then constituted, "an idea whose time has passed."

His views were very controversial, and they elicited several letters from hospital librarians in defense of the program.

To quote Judith Topper, "One of the great successes of the RMLP has been to encourage the professional growth of hospital librarians. The RMLP has helped hospital libraries to demonstrate their effectiveness and broaden their user population."

Health sciences librarians continued to serve NLM as advisors. In 1981, Jim Williams, then director of the Wayne State Medical Library and an RML director, served on NLM's Board of Regents, as did Gwen Cruzat.

Nina Matheson chaired the Biomedical Library Review Committee, which also included several other health sciences librarians. The MLA-NLM Liaison Committee was now responsible for technical and operational issues only.

Policy matters were discussed between the NLM director and the MLA board. In 1981, the committee had few technical issues to raise with NLM staff, and it just continued to arrange an annual session on NLM programs at the annual meeting.

In 1981, health sciences librarians played a particularly important role as advocates for NLM and its programs. In the early 1980s, some commercial interests viewed NLM's online services as unfair competition for the private sector.

This led to several government studies of NLM systems and its pricing policies. At the same time, David Kessler, then on Senator Orrin Hatch's staff, had identified NLM's extramural programs as potential candidates for elimination.

This combination presented a serious threat to the NLM budget and the scope of its activities. At this critical juncture, Mary Horres was chair of the MLA Legislation Committee.

The outstanding work of this committee and of the legislative committees of MLA chapters across the country was invaluable to NLM.

In one example, which Kent Smith remembers vividly twenty years later, the legislation committee arranged for Priscilla Mayden, director of the Eccles Library at the University of Utah,

and Dr. Richard Polascek, director of the Welch Library at Johns Hopkins, to testify at a hearing chaired by Senator Hatch on April 1, 1981.

In addition to testimony from the Congressional Office of Technology Assessment, Dr. Eugene Garfield of the Institute for Scientific Information, testified that NLM's online pricing policy led to unfair competition with the private sector,

and also spoke in support of payment of copyright fees for materials supplied under interlibrary loan in the Regional Medical Library Network. Mrs. Mayden and Dr. Polascek made statements on the value of the Regional Medical Library Program and NLM's extramural programs.

In response to a question from Senator Hatch about whether NLM was competing with the private sector, Mrs. Mayden effectively ended the discussion when she said the following, quote

"What I think I find puzzling is the idea of it being competitive because the services are different.

I agree with Dr. Garfield. Dr. Garfield himself, within the last year on the occasion of the hundredth anniversary of Index Medicus, stated that his service and the Index Medicus do not compete but complement one another. I would not dream of trying to run my library without the services of the Institute for Scientific Information."

The 1980s began with the Reagan revolution in the US and finished up with the fall of the Berlin Wall and the release from jail of Nelson Mandela.

Personal computers first arrived in offices and homes in appreciable numbers, and internet access became commonplace in U.S. universities.

At the end of the decade, the combination of huge federal budget deficits and rising healthcare costs brought renewed interest in U.S. healthcare reform and a strong impetus for managed care.

NLM's extramural programs and its online pricing policies survived the challenges of the early 1980s, but the budget for the extramural programs was cut early in the decade,

and NLM was required to use a more inclusive definition of the cost of access, which increased charges for online services. The tight extramural budget led NLM to reduce the number of regions from eleven to seven in 1981.

This was a disruptive change for the seven regions that were combined into three larger ones. Beginning in 1982, the Midcontinental Region implemented Octanet, which built upon the pioneering serials system at Washington University at St. Louis to provide automated routing of ILL requests within the region and to NLM.

The Association of American Medical Colleges published the IAIMS report that same year, and NLM made its first IAIMS grants in 1983.

In 1984, Donald A. B. Lindberg, a physician and a leader in the application of computers to medicine, succeeded Dr. Cummings as NLM director and launched another period of great expansion of NLM's programs and mission.

In 1985, NLM implemented DOCLINE nationwide as a free service to RML network members. DOCLINE adopted Octanet's routing table design, which allowed libraries to take advantage of existing reciprocal borrowing patterns.

NLM completed its preservation plan in 1985, and subsequently established a new Preservation Section, a major preservation microfilming program, and in 1987, the permanent paper campaign.

Eighty-five was also the year that MLA and the Association for Academic Health Science Library Directors formed a joint legislative task force. Nineteen eighty-six was NLM's sesquicentennial anniversary celebration.

NLM introduced the initial Grateful Med search interface software designed for individuals without search training. The first Unified Medical Language System research and development contracts were awarded.

The Board of Regents published the long-range plan, to which many health sciences librarians contributed. The most dramatic outcome of the planning effort was the legislation that established the National Center for Biotechnology Information at NLM in 1988.

In 1987, the MLA-NLM Liaison Committee was disbanded due to a lack of substantive issues to address. As part of the agreement to disband the committee, the MLA board reserved at least one hour of each annual meeting for an NLM update.

In 1989, the NLM Board of Regents published an outreach plan, known as the DeBakey Report, after Dr. Michael DeBakey, its chair, the chair of the committee that produced it.

The report called for expanded efforts by NLM and by a renamed National Network of Libraries of Medicine to reach health professionalswho lacked ready access to information services with special emphasis on those serving rural and intercity populations.

As one follow-up to the report, in November 1989, NLM sent the letter signed by Dr. Lindberg to U.S. hospital administrators, informing them about Grateful Med.

In a mistake that we would undo if we could, this letter did not mention hospital libraries or library services, and it elicited a storm of protests from librarians.

In 1990, NLM issued the first purchase orders for Grateful Med outreach projects. The Loansome Doc feature of Grateful Med was introduced to allow individual health professionals to submit document requests automatically.

NLM released the first experimental edition of the UMLS.

By 1991, librarians and other information specialists no longer constituted the majority of those who accessed NLM services directly from remote locations, although librarians continued to use a wider range of NLM services more frequently and heavily than other categories of users.  [Slide: 1991 - NLM's Direct Remote Users: Librarians and information specialists, Historians, Non-print media producers, Chemists/toxicologists, Medical informaticians, Health professionals, Molecular biologists and other researchers]

Some librarians thought it was a hostile act for NLM to develop and promote services designed for direct use by health professionals.

By my interpretation of contemporary comments, there were at least five underlying concerns.

First, individual health professionals did not have the time or the inclination to do effective searches.

Second, by implying that health professionals could search effectively on their own, NLM was belittling the expertise of trained librarians, and given the economic picture for hospitals, perhaps threatening the very existence of hospital libraries.

Third, by marketing directly to health professionals, NLM was inserting itself between librarians and their users, offering sometimes different, and less informed, advice on what tools were most useful in the local context.

Fourth, if health professionals did do their own searching, then librarians would lose a part of their work, which had both improved their status and been intellectually challenging and rewarding. They would be left with more mundane tasks.

Fifth, if NLM focused on products and services for unaffiliated health professionals, it would devote fewer resources to helping librarians to serve their primary clienteles and to other programs that might improve the status of librarians within their institutions.

From this perspective, NLM was adding insult to injury by asking librarians to promote NLM services, to train health professional outside their primary clienteles, and to provide supporting technical assistance and document delivery service, even if NLM was willing to pay for it.

Yet, involving librarians in outreach had become a major objective for NLM and for the National Network of Libraries of Medicine, as the Regional Medical Library Network was renamed in 1991.

At this point, New England reemerged as a separate region. Those who worked in the RML during this period have many stories to tell about the level of hostility they encountered from some network member librarians.

Words like Gestapo were not uncommon. On the other hand, NLM and the multidisciplinary advisors who developed the DeBakey Report saw the combination of new end-user services and active outreach as a powerful way for NLM to pursue its basic mission

of advancing medical science and the public health by enhancing the dissemination of medical information to help professionals who otherwise lacked library services. From this perspective,

the assumption was that many health sciences librarians would find outreach to underserved health professionals both personally rewarding and beneficial to their status within their institutions.

This eventually proved to be the case, but the first librarians who embraced NLM funding for outreach activities received considerable flak from some of their colleagues. On top of more basic concerns,

some health sciences librarians resented "NLM's cutesy naming tendencies," as they have been called on the MEDLIB LISTSERV.

Some also disapproved of expanded NLM publicity, which they saw as overstating NLM's contribution at the expense of theirs and exaggerating the utility of some NLM products.

Complaints about NLM's overblown publicity goes back, at least, to 1975 when Harold Bloomquist referred to the hucksterism surrounding MEDLARS in his Doe lecture.

Of course, health sciences librarians have never been a homogeneous group, so whatever NLM does, some librarians applaud the substance of what other librarians deplore.

In 1991, NLM activities were probably viewed more favorably by many academic health sciences librarians, although those in privately-funded institutions were generally not interested in outreach.

In academic environments with good networks, Loansome Doc could be used by affiliated faculty and staff. Other high-profile NLM initiatives like IAIMS, HPCC, etc., were seen as having important potential benefits by academic librarians.

These were all areas in which librarians might play important roles on multidisciplinary teams.

It is interesting to note that several of the 1991 participants in the NLM associate program moved directly into multidisciplinary research and development projects after finishing the program.

At this juncture, some health sciences librarians thought that NLM should be doing more to promote the education and training of health sciences librarians for these and other new roles.

In 1991, NLM's official advisory structure included many librarians, as you can see in this picture, and there were also seven on the Biomedical Library Review Committee and Pat Walter on the more recently formed Literature Selection Technical Review Committee.

NLM's board and its management agreed that the library should look for ways to highlight NLM services to librarians and should also take visible action to underscore the importance of librarians in enhancing access to health information.

The 1992 satellite broadcast on the importance of information services and librarians in the hospital environment was one such action.

On MLA's side, the MLA-NLM Liaison Committee no longer existed, as I said before, but MLA established a task force on MLA-NLM collaboration in 1992, which is sort of shades of what had occurred in 1971.

The 1990s saw the failure of the Clinton health care reform, the rise of managed care, the closure and merger of many hospitals and hospital libraries and changes in Medicare reimbursements that had a negative impact on academic health sciences centers.

Y2K, the federal health data standards, and privacy regulations became significant issues in the IT departments of healthcare organizations. The internet, the worldwide web, and electronic full text influenced NLM services and its interactions with health sciences librarians.

In 1992, NLM began its internet connections grant program, the week-long Woods Hole medical informatics course, and also applied informatics fellowships, which offered a format and a stipend attractive to some practicing librarians.

In 1993, Congress established NLM's National Information Center on Health Services Research and Healthcare Technology. We put up our first website in 1994.

That same year, we began funding AIDS information projects and also applications of High Performance Computing and Communications. The first Visible Human was released, and NLM started system reinvention.

In 1995, NLM used funds from its AIDS information budget to provide free access. We went on to build upon MLA's educational policy statement to set up or publish a planning report on the education and training of health sciences librarians,

and we issued a set of challenge grants to support planning of innovative education programs. In 1996, Internet Grateful Med was launched. PubMed, and free internet access to MEDLINE followed in 1997.

A free access arrived just in time to facilitate outreach to traditionally underfunded public health professionals. In 1997, NLM funded health applications of the National Information Infrastructure,

emphasizing evaluation of the impact of telemedicine and approaches to protecting electronic health data. In 1998, we announced that the PubMed retrieval system, Entrez, would replace ELHILL on NLM's basic retrieval system for MEDLINE and other citation data.

This caused great concern among librarians, given the then-current state of PubMed features for expert searchers. In April 1998, NLM hosted a meeting of expert searchers from every region to discuss specific deficiencies and develop strategies for addressing them.

As had occurred twenty years earlier with the hospital librarians' meeting, everyone who participated found it valuable. Of course, there have been many subsequent improvements in PubMed.

Once NLM's databases were free on the web, the general public became a significant NLM user group. In 1998, we had the pilot Consumer Health Project with public libraries, and we also launched MEDLINEplus.

After looking at the results of the challenge grants, NLM added a second fall session of the Woods Hole course, expanded the NLM associate program, and added more slots for librarians in some of NLM's medical informatics training programs.

Online access to ELHILL ended in 1999, and by that time, at least ninety-three percent of network members had internet access, thanks in large part to special efforts on the part of the Regional Medical Libraries.

Web-capable workstations and connections supported access to new NLM services, including Profiles in Science and ClinicalTrials.gov.

And in 2000, we awarded more than fifty consumer health outreach projects through the network, new DOCLINE appeared, and PubMed Central debuted. We have arrived in the year 2001, and you can all be your own judge of the status of interactions between NLM and health sciences librarians.  [Slide: 2001 - Librarians vis a vis NLM: Users and testers of products and services; Advisors - formal and informal; Advocates; Recipients of training/education; Grant applications>Grant recipients; RML contractors; Network members; Outreach and Research Contractors]

There was no fundamental change in the range of relationships between librarians and NLM during the 1990s. Once again, the recompetition of the Regional Medical Libraries has been a source of strain.

NLM's services have migrated to the web, and there are many more of them. PubMed LinkOut and PubMed Central are the most visible of NLM's efforts to grapple with organizing and ensuring permanent access to digital information.

NLM now sees the light of day on the system reinvention project, which is totally replacing the systems that support NLM's basic services.

Because many NLM systems are integral to the work of health sciences librarians, there have been some unscheduled and unwelcome ripple effects in libraries across the country.

During the 1990s, NLM increased its support for training and educational opportunities for health sciences librarians, including the expansion of the associate fellowship program.

NLM has also partnered with MLA to increase scholarship opportunities for minority library students. NLM's new strategic plan calls for examination of the need for specialist librarians in such areas as bioinformatics, clinical informatics, and health policy.

Work is already underway to develop courses that would equip librarians to train students and researchers in the use of NCBI's advanced genomic information services.

The most significant developments of the 1990s were the addition of the general public and, to a lesser extent, publishers as target groups for some NLM services. These changes have generally been applauded by health sciences librarians, some of whom have been serving patients and their families for decades.

In 2001, librarians are serving on five NLM advisory groups, including the most recently formed one to advise on the PubMed Central Project. NLM continues to receive outstanding support from MLA's Governmental Relations Committee and from the MLA / AAHSL Joint Legislative Task Force.

In the era of digital information, intellectual property rights demand continuing attention from NLM and all health sciences libraries as do many other information policy issues, including privacy and security.

Once again, NLM needs a new building, and we are happy to have support from librarians for that too.

For the past forty years, the greatest friction between NLM and health sciences librarians has occurred when there has been a fundamental change in the way NLM carries out its mission,

a change that adds to the web of relationships that link librarians and NLM and prompts corresponding changes in the way other libraries do business.

To a lesser degree, each new service that connects NLM and health sciences librarians is another potential source of irritation, ready to flare up when the service is interrupted, changed, or eliminated.

Even a slight and positive shift in the NLM infrastructure that supports daily activities in other libraries can have short-term seismic effects in the local context.

Other factors, including strong personalities, mistakes, and poor communication add to, but do not cause, the intermittent problems between NLM and what are arguably our most loyal and engaged user group.

These problems are in essence the price we pay for the leadership and vision of NLM's directors and for NLM's success, all of your success, in developing useful services and in taking librarians' advice on how to make these services even more useful.

If NLM continues to lead and to provide services that are important to other libraries, then we can count on a future that includes episodes when NLM will be temporarily at odds with some health sciences librarians.

There will be lots of change in our collective future as the electronic health record meets the digital library and genomics continues to transform science and medicine.

This is my husband finishing a fifty kilometer mountain hike. This talk is finished too, and none too soon, but if we are lucky, NLM and health sciences librarians will never really be finished. We have many more mountains to climb together. Thank you.

[Applause]

You are all standing there. Do you have questions? [Laughter]

[Background voices]