The failure of modern textbooks
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2132 (Published 07 May 2010) Cite this as: BMJ 2010;340:c2132
All rapid responses
Dear Michael, good question.
To function at a flat-footed doctor one does not need to
know quantum physics, differential calculus, Latin, Greek
or understand Darwinian theory. However we are
professionals trained at universities,some of which still
have a semblance of the old university tradition of
intellectual rigour,curiosity and dare I say savoir faire
and polish. Being an intellectual is about being curious
about the natural world and its workings, about playfulness
and extending one's boundaries and being enriched with new
insights, not just being a medical tradesman.
In my country, medical students are selected as the
intellectual crème de la crème. One does not need to know
why oxygen is so called or who discovered it. It is a
spirit of intellectual curiosity that makes good teachers.
Such insights then translate into new ideas about the
development of the art you practise so you see yourself as
a continuum instead of at one point in time ie now.
I can sail my wooden boat without knowing about
meteorology, the proper name for the four timbers on her,
and who Colin Archer was, but I know all and I sail better
and more enriched. I appreciate it all much more. It is the
gourmet rather than the gourmand.
I just started learning Norwegian. Suddenly my eyes are
seeing Norse words everywhere in English. My eyes have been
opened and they can never be closed and this is oxygen for
my soul.
Kind regards,
Roger Allen
Competing interests:
None declared
Competing interests: No competing interests
I cannot see why a doctor needs to know who discovered oxygen and
where the name comes from. Roger K Allen may be confusing a degree with
medicine with one in chemistry or the history and philosophy of science.
Competing interests:
None declared
Competing interests: No competing interests
It is interesting to hear the response by a student who is
under the pressure of time to slurp up facts to be
regurgitated in exams. But this is my very point that a
good book should assist in the teaching process and not
just be some Guide Michelin to medical fine dining.
The other problem is there are so few good examples that
most of us are used to eating medical gruel and not
anything palatable let alone enjoyable to read.
Medical text books and books in general are monolithic
edifices which have changed little since papyrus and velum
were discovered. They are inflexible, costly to produce, of
short life-span and have a limited audience; even best
sellers. The advent of the book over the scroll mattered
little to the content.
However with the electronic age (viz, Kindle and Ipad) it
should be able to buy an edition suited for the reader i.e
a tailor-made version. Whereas one might like footnotes and
notations telling us who Charcot was and with various
teaching points, another might like the pared down version
more like a compendium. Others might prefer an edition with
annotations. It will be possible to have an interactive
book with two and fro communications with other registered
readers and even with authors and editors. The book grows
beyond its material confines of paper and binding.
I think this century will see a revolution in publishing
equal to the advent of moveable type and the invention of
paper. It may even translate to medical publishing and
journals too.
Competing interests:
None declared
Competing interests: No competing interests
Fresh from the textbook drenched nights of medical school, I present
the student perspective.
The modern medical student remains time pressured. A fundamental
imbalance exists; an unrelenting requirement to acquire masses of facts
inextricably linked to incessant formal assessment yields little time to
simply enjoy medicine. The concise, pragmatic layout of the ’typical’
modern textbooks, that readily double up as revision notes, are much
appreciated and easily devoured by students hungry for only essential exam
facts. Such texts may be considered the academic equivalent of a microwave
meal; the basic bodily requirement is fulfilled but much editing and
processing curbs both intellectual nourishment and academic pleasure. This
perhaps brings into question the educational establishment and the type of
doctor we are attempting to generate.
I believe it crucial for a scientific text to be crisp, partly due to
the nature of the material conveyed and largely due to time constraints.
Acquiring clinical knowledge in itself can be most fulfilling, having that
conveyed with literary flair could, indeed, boost the learning experience.
I advocate moderation. Perhaps medical textbooks also require labels
showing carefully determined portions or ‘Recommended Daily Amounts’ of
wit, anecdote and ‘additional’ knowledge amidst the indispensable
information. I deem the Oxford Handbook of Clinical Specialties as a
modern text partly on its way to satisfying the requirements of the more
desirable ‘holistic’ text; dominated by clinical knowledge and punctuated
with a little introductory anecdote, a few snippets of medical history and
even some lines of humour acting as pleasant surprises in a sea of
evidence based fact.
Competing interests:
None declared
Competing interests: No competing interests
Dear Roger
I was attracted by the title of your delightful article, and I was
not disappointed by its content. I was further fascinated by the fact that
you have taken up Greek, my mother tongue. Well done, and keep up the good
work!
Medical textbooks were not always as dreary and as bland as they are
now. Two examples of lively, first-person didactic tomes that come to mind
are Bailey & Love¢s Short Practice of Surgery and J. L. Burton¢s
Essentials of Dermatology. The former has plenty of footnotes explaining
all the eponyms in the text, while the latter contains pearls such as ¡The
Lord Privy Seal is neither a lord, nor a privy, nor a seal, and
¡seborrhoeic¢ warts have no relationship to seborrhoea¢. Elsewhere it
explains that ¡The simultaneous occurrence of scabies in a doctor and a
nurse may mean that they have shared nothing more exciting than a patient
with Norwegian scabies¢.
There is also a definite difference in writing style between British
and American textbooks, though this may be getting increasingly blurred
with today¢s globalised book markets.
Competing interests:
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Competing interests: No competing interests
Dear David if I may use my colonial informality,
I observe that we have entered a computer age where the
consumer is used to a more interesting and creative medium;
interactive, palatable and alluring and not a Metro time
table.
My son at junior high school now has a Toshiba tablet on
which all his work is done, with the teacher being able to
see any tablet in class as they are all linked. They are
not sitting down as I did as a kid with a slate or pen with
nibs and ink.
The old recipe for a text book has reached its "used-by
date". I think this applies to journals too but that is
another matter. The recipe has been reached because editors
are conforming to what they see as a scientific recipe but
is is more than that; it is "safe" and boring to boot. The
crême brulée has no caramelised sugary crust and the taste
is bland. We are getting Spam instead.
As one who has participated in writing textbooks as an
author, one is given blinkers and hobbles and told to stay
within the guidelines. The remuneration is also abysmal for
the work it takes. If medical publishing is going to
succeed, it has to attract back the disaffected like me.
I cannot see why a book cannot teach as most currently
don't. They present facts and that is not teaching. The
reader either has the stuff taught by an external source
e.g. medical teacher/tutor or learns to navigate the stuff
and works out a teaching method himself.
I am currently learning Greek and have a teacher and
observe that the book which is all in Greek (no English),
teaches up to a point but could be made so much more useful
with specific teaching points, footnotes, reference to
words in English, Ancient Greek, or how to remember a word
which seems impossible to remember; sort of aides mémoires.
The editor and author are not putting themselves in the
shoes of the reader who is a novice. In a nutshell, it's
all Greek to me.
It is also possible now to have a website attached to
textbook for further reference, footnotes etc. Teaching
takes more intellectual input than just presenting facts
and what may appear to be patently simple and clear to the
boffin writing the book, may be less than simple to the
novice reader. Just look at the chapter on pseudo-
pseudohyperparathyroidism etc or porphyrias and see how the
authors fail to show you how to remember them.
Rapid Responses is just one example of the change in
publishing. We can now discuss "live" rather than writing a
letter with quill and ink six months after the BMJ arrived
by clipper ship to Australia and long after you Poms had
read it.
Kind regards,
Roger Allen
Competing interests: None
Competing interests: No competing interests
Dear Dr Allen
I enjoyed reading your article in this weeks BMJ.
I would have to disagree however.
Whilst there is no correct way to write a textbook, nor learn or
practice medicine, surely the purpose of a textbook is to present the
information with objective brevity and clarity, not subjective bias or
confusion.
The black and white script of the textbook is and always has been
coloured by anecdotes from clinicians, from the students own experience
and from the patient narrative. The etymology of words and the history of
medicine is fascinating to some, myself included, but not all and where
would one stop, the textbooks could become overwhelmed, hence the need for
books on the history of medicine etc.
There are good medical books out there, those which teach an art and
a science, with warmth, humour and humanity, whilst these aren't
textbooks, I would consider Macleod's and the Oxford Handbook as
superlative to most.
Best wishes
David
Competing interests:
None declared
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If there is a dilemma, which is not uncommon in practice, I delve
into medical textbooks of 70s or even earlier for a comprehensive
description of clinical history, symptoms and signs. I have collected
these old textbooks from a local library when they were discarded to make
room for the new ones.The next step is to pick up one of the popular
handbooks for a synopsis and this is supplemented by the modern textbooks
for management including investigations and treatment. Searching web and
journals complete the information gathering particularly in terms of
research and practice, which have not yet included in the most recently
published textbooks.As the saying goes "a place for everything and
everything in its place".
shah.tauzeeh@barnet-pct.nhs.uk
Competing interests:
None declared
Competing interests: No competing interests
So true, yet, how would it be if we had no modern text-books to read
and refer to? How would students learn if not through modern text-books,
despite the suggestion that these are outdated before the ink has dried,
which is so true.Without modern textbooks,how would we know the modern
terminologies? the old diseases now seen as modern diseases i.e.those that
had no name/s, no tests,and such.
Disease pathology, disease imaging and so many more aspects of diseases
not able to be accessed because there was nothing to access in the past,
have taken on a different significance when read about in modern text-
books.
To cite one example:The Carcinoid Syndrome is becoming increasingly
manifest yet, poorly recognosed. Another example is the word 'clastogen',
used in the pharmaceutical industry, to described some of their products.
Competing interests:
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Re: Old vs New
Sir
One example of a gem is 'The Diseases of Occupations' by Donald
Hunter (1898-1978). This book was first published in 1955, and the 6th
(and last) edition in 1978. It is a fascinating book, a joy to read, and
is highly recommended for occupational health professionals in developing
countries, especially those from the "Factory of the World" where many
workers have to re-live the tragedies of the Industrial Revolution more
than 200 years ago. Unfortunately, the 8th edition of the book that bears
the name 'Hunter's Diseases of Occupations', reverts to the format of a
conventional medical textbook.
Tze Wai Wong
Professor
School of Public Health and Primary Care
The Chinese University of Hong Kong
Competing interests:
None declared
Competing interests: No competing interests