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Lament for the Passing of the Textbook

A first-year medical student I mentor recently asked me:  “What’s the point in buying textbooks? Sure, I could pull it from a shelf in the library – or save time and just Google it. But wouldn’t I learn more from a Google search or a Medline search than by reading all those pages?”

This seems to be the current thinking of students in general. Our medical book store recently removed a large portion of its shelves of books and replaced it with a bigger area for computer hardware and software; the store’s manager tells me that textbook sales have declined by 10-15% in each of the past several years. The medical library has replaced a major portion of its text reference section with computer carrels. Fewer new textbooks are being published, and new editions of standard texts are appearing less frequently. And the financial news tells us of the loss of profitability and financial difficulties faced by publishers.

In recent years, medical school curricula have embraced
efficiency-enhancing technologies. Syllabi, selective readings, videos
of lectures past and present, computerized lecture notes, and access to
high quality and frequently updated electronic library services form a
major part of the basis for current medical education. Why this came
about goes beyond the availability of the electronic technology. It is
driven by the exponential explosion in the volume of medical information
pertinent to becoming a physician and the speed with which this
information becomes available. Furthermore, electronic piecemeal
information retrieval is consistent with modern problem-centered or
problem-based curricula.

Many of today’s students are surprised
to learn that for centuries, dating back to Hippocrates and Galen,
textbook study combined with lectures and supervised patient practice
were the basis of medical education. In fact, until the 20th century
most American medical schools consisted of a library, a lecture hall,
and a dissection room. Early textbooks were sometimes written in rhyme
to facilitate memorization. In the 19th century, textbooks could remain
in print for 25 years or more before requiring a new edition.

the second half of the 20th century, textbooks were most often the
product of a single author, usually an experienced and authoritative
figure, who traced the historical aspects of medical topics and offered
an insightful and balanced view of medical controversies. As medicine
became more complex and specialized, textbooks became multi-authored
with each contributor addressing his or her area of expertise. Classic
texts such as Sir William Osler’s Principles and Practice of Medicine
went through multiple editions and remained in print from 1892 until
the second half of the 20th century. Likewise, Ernst Fuch’s Text-book of Ophthalmology went
through numerous editions from 1889 into the 1930s. Textbooks such as
these were translated into many languages and considered the “Bibles” of
their field. Until recent years, medical students built libraries
during their years in school that they kept updated and which served as
references and sources of knowledge throughout their careers.

of electronic searches as a source of learning maintain that performing
Internet searches actually improves a person’s ability to process
information and focus attention, and is a boon to learning. On the other
hand, David Brooks, in his NY Times Op-Ed column, writes that critics,
such as Nicholas Carr in his book “The Shallows,” cite research
indicating that the “multidistraction, hyperlink world degrades people’s
ability to engage in deep thought or serious contemplation” (The Medium is the Medium.  NY Times Op-Ed. July 9, 2010). Brooks goes on to state:

matters [in the Internet versus books debate] is the way people think
about themselves while engaged in the two activities. . . . The Internet
smashes hierarchy and is not marked by deference. . . . The new media
is supposedly savvier than the old media. The dominant activity is
free-wheeling, disrespectful, anti-authority disputation. . . . The
Internet helps you become well informed — knowledgeable about current
events, the latest controversies, and important trends. The Internet
also helps you become hip — to learn about what’s going on . . . But
the literary world is still better at helping you become cultivated,
mastering significant things of lasting import. To learn these sorts of
things, you have to defer to greater minds than your own. . . . You have
to respect the authority of the teacher.

What is
the relevance of this to those training for a career in medical science
or other branches of science? An important part of one’s education
consists of learning the facts, factoids, values, doses, tests, and
various and sundry other pieces of information that together form the
essential building blocks of knowledge of your subject. Whereas in past
decades, memorization of this information was to a large extent a
necessity, the Internet allows people to access it almost as rapidly as
if it were already in your own mind. But of no less importance in
training for a career in science is the ability to have a sense of
perspective and judgment, to independently evaluate, to accept and
reject conclusions and ideas, and develop original concepts and
hypotheses. This is a process teachers call “learning to think,” and
it’s what separates the technician from the scientist and the
professional. In this realm, viewing the latest studies and data, and
reviewing introductions and discussions in published papers and reviews
on the Internet are of real value. But, to my mind, textbooks are
extremely important for learning to think. A carefully written chapter
by one or more experts in the field that traces the development of
concepts, evaluates data collected over decades, points out strengths
and weaknesses of competing hypotheses, and addresses future needs and
opportunities is invaluable. A well-written chapter does so in a
carefully prepared, literate, and measured way. It’s an approach that
has been effective for centuries.

For these reasons, I believe
that as publishers adapt electronic technology to make textbooks
available, continuously updated, and financially feasible, I believe the
obituaries of the textbooks will prove premature.