An ongoing dialogue on HIV/AIDS, infectious diseases,
January 25th, 2024
Printed Medical Textbooks — Going, Going, but Not Quite Gone
Take a look at the things behind my desk at work:
- cute photos of family and dog
- a bunch of sentimental objects, gifts from grateful patients or colleagues
- a smattering of miscellaneous plaques and clocks
- pictures of our current (awesome) first-year ID fellows and other stuff
- a bunch of books, several of them many inches thick
You may not be familiar with item #5 on this list — those hefty books — so allow me to remind you what they are. Those are medical textbooks. Because if you’re like me, there’s a decent chance you haven’t opened a medical textbook in months, or even years. It’s these that we’ll be chatting about today.
There was a time when consulting these heavy tomes fortified our approach to clinical care on a regular basis. Now, many of us barely ever open them; instead, we look online to recently published papers, comprehensive reviews, the latest treatment guidelines, or other sources to stay up-to-date.
(See what I linked there? Full disclosure, I’ve been a contributor to UpToDate since its very early days, as I’ve detailed previously.)
For evidence supporting this move toward online sources and away from print textbooks, take a look at the results of this poll:
Granted, those who respond to polls on Twixter already live much of their lives online, and hence least likely to turn to an actual printed book. That’s why I repeated it below — different audience, maybe a different response. But still, if you’re a doctor, nurse, pharmacist, or student, chances are excellent you own one or more textbooks, but they’re sitting somewhere in your office, their hundreds (or even thousands) of pages as fresh as the day they left the publisher.
Here are some representative comments I received related to this post:
I literally never use paper textbooks for anything and haven’t for about a decade.
I’m 35 and have a deep nostalgia for physical print books, so I have all my old textbooks (including Harrison’s), but I never use them.
Textbooks in print? Never. Last time over 15 years ago. I do read from the textbooks online.
Have these books in my office shelf for the sentimental value. I have used them twice in last few years.
Wrote a chapter in a textbook. Received free copy. Can’t find a med student around here who will take it off my hands.
Several of these textbooks might include outdated information, pointing to a critical problem with printed books highlighted by Dr. Michael Calderwood:
They look pretty on a shelf but are already outdated by the time that they arrive. Knowledge is changing quickly, and we need readily accessible, expert curated, living documents.
Even worse, how many of us replace the old versions? Guilty as charged — I checked the publication dates on some of the textbooks displayed on my shelf. One is from 2003! Another, 1997! No doubt there are some clinical pearls in these old books, but my advanced math skills calculate that they are decades outdated. Reader beware!
Or maybe your textbook serves another function:
In our fellows’ room, we have an old version of Mandell holding up a computer monitor (which occasionally displays the electronic pdf from the new version). That’s how we use it.
Importantly, there was a vocal contrasting opinion, no doubt representing the 10-28% from the poll. And it’s so interesting that it’s not just older doctors who have this favorable view of printed textbooks! Dr. Courtney Harris, a recent graduate from our ID fellowship program, weighed in with this comment:
I love them. I probably pull one out once a month for hard clinical questions or when I just need a deep overview of something I feel like I really don’t have a good grasp on. Plus I love physical books in general – having a few in my office just gives me joy.
This minority but opinionated group must help sustain the traditional textbook market. Some who continue to use print textbooks say that they can’t learn things as deeply from online sources — a reminder that there’s no right way to learn, just that people take different paths to their own education.
But going back to the numbers from the poll, I maintain that print medical textbook users represent a small (and I suspect shrinking) group. I wonder how long this fragile relationship will continue, especially because writing, producing, and publishing these books isn’t cheap — and neither is their price tag should you want to purchase one.
I confess that exploring this topic fills me with a tinge of nostalgia, one almost reaching melancholy. It has a similar emotional effect to hearing the accounts of other print media dropping in popularity and becoming decreasingly viable economically. Newspapers and magazines (in particular) have been decimated.
Augmenting the sadness is my longstanding participation in writing for some of these texts. For generations of doctors, an invitation to contribute to these pivotal books signaled a true honor. You felt a deep responsibility to research and know the topic thoroughly, to get it just right. After all, someone reading it could make treatment decisions based on your summary of the existing literature. Authorship in these well-known reference books acted as a good way for academic physicians to plant a flag that reads, “I belong.”
Today? A colleague of mine recently submitted a revised version of a chapter to one of these pivotal texts, one that I co-author with him. As it was being revised, I seriously wondered who would ever read it. I can’t imagine the numbers would come anywhere close to a comparable topic in UpToDate, or as covered in a treatment guidelines paper.
I wouldn’t give up on the printed stuff completely, though. Not only are there still people like Dr. Courtney Harris who still value the concrete, real thing you can hold in your hand, but perhaps there’s a burgeoning market: my 20-something-year-old daughter told me recently how much she loved subscribing to the print versions of two high-quality magazines.
They arrive in her mailbox each week — her actual mailbox, not the electronic one. Imagine that.
36 Responses to “Printed Medical Textbooks — Going, Going, but Not Quite Gone”
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Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
Learn more about HIV and ID Observations.
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I am an internist and work as an out pt primary care doc. I love my dermatology book and refer to it regularly. I also enjoy the images and other information I “bump” into while looking for what I am looking for. I personally experience a different state of absorbing information from a screen vs a book. One is a “snack” the other is more of a meal. They would be ideally complementary. Text books were never inexpensive but we managed when it was our only option.
I remember in the early days of pediatric AIDS being handed a 1930s? textbook about pediatric TB written by the doctors at Bellevue. I made 5 photocopies of more than 300 pages for our team. That has probably not been digitalized.
If we don’t use textbooks, or pay for them in some way, the Low Income World would really suffer.
A few can get Uptodate, but that isn’t the only thing they need, and it is very expensive in LMICs, like all such resources, despite subsidy programmes. A lot of the cost is locked into the electronic devices required, and into getting any electricity at all. My Malawian students borrowed phones or PCs on a shift sytem over 24h, with predictably harmful effects on their performance.
I wonder how may we enjoy our freedom to choose without hitting the poorest in our world?
Hi David! I’m in Eswatini and we can get free access to uptodate through the better evidence program – check it out! It’s free as long as you’re a HCW outside of the US. And you can download the content when you have internet access and use it offline. (I don’t get any money for saying this, just have gotten enormous benefit from the program and use up to date several times daily). Doesn’t solve all of the problems you mentioned, which we also face, but it’s very helpful to have it free and downloaded for the loadshedding/rural areas without internet.
https://www.better-evidence.org/
Paul:
As I contemplate retiring from my academic office (but not from patient care!) I am wondering what to do with my bookshelves packed with textbooks. I fear they will go into the dumpster–our medical school library doesn’t want them–in fact the “library” has very few books these days–just computers!
I’m in my seventies and haven’t opened a medical textbook in many, many years, but your wonderful column prompted me to review my bookshelf. I found: Gray’s Anatomy from medical school (1970) — those wonderful illustrations are not the same online. Cecil Textbook of Medicine (2004), the last time I purchased a medical textbook. And Zollinger’s Atlas of Surgical Operations (1975), awarded in medical school, with a hand-signed inscription from Robert Zollinger “Don’t let the boys scare you!” All priceless.
Hello. I am halfway between the person who just likes books and those that read online. I have my father’s copy of Gray’s Anatomy which I used to help me survive anatomy, since we used a different anatomy book. However, it is just taking up space on a bookshelf. I was able to show it to my daughter who is taking anatomy at veterinary school, but obviously she can’t use it to study from. But I also rarely use most of the books on my shelf. I do have a book on parasites that I inherited from my dad that I like for the diagrams of life cycles, which have not changed in years, so no need for up to date information. Given a choice I would prefer to read a physical text because computer monitors are not always easy to read as I get older. Thanks for your columns. C Bliss Jr MD
I am a fool for my older [and updated versions] of my hard cover texts. I admit I do readily use on-line resources, but still wander into my bookcases for additional in-depth info and pictuires/diagrams. I suspect we are a dying breed, and that the libraries refusing these tomes on our retirements will eventually create a small curated selection as collectors’ items. And for older versions of info that changes slowly, I donate these to others who can use them as a starting point or even curiousities.
I pity my children who will have to decide what to do with my dozen or so beloved texts when neither I nor those texts serve any purpose! Fortunately not in the near future….
When I retired from the practice of family medicine and downsized, I needed to dispose of several medical texts I had updated. This is how I did it: I used a razor blade to cut out the pages so they could go to paper recycling. Most of the boards went into the trash. I only kept a falling apart version of Netter’s anatomy, because it is beautiful. No one was the least interested in any of the medical texts but one secretary used a couple of the boards for room decor in her home.
I am now looking critically at the other thousands of books I own– fortunately they can go to a library book sale when I get tired of dusting them.
I love my print copies of medical texts, and love taking print copies of Journal Watch folded into my back pocket to read while waiting for my friends at restaurants. So much of medicine is online, my eyes find looking at paper restful. I love taking multiple colors of pencils to underline key passages in Harrisons & MKSAP and dread the day MKSAP is electronic only. I love carrying a MKSAP in my backpack hiking up to Lake of the Clouds hut on Mt Washington to read; they don’t have internet up there. Leave the screen behind: pileated woodpeckers and bobcats really exist independent of the internet, but you will never see them when looking at your phone.
These things are so important whether you are a doctor or not. When everything is electronic, ephemeral, and rapid these physical things ground us in the years when we were learning and aspiring and at our most idealistic. They connect us to our best selves
Funny you should write about this, Paul. We moved and had bookcases built in our dining room. My medical school textbooks (pathology, micro, anatomy, parasitology, neurological, surgery, peds, physical diagnosis, etc) and residency textbooks (some of which were updated decades ago) didn’t seem to fit in the dining room. Couldn’t part with them, though, so, moved them to a bookcase closer to our shared home office. Looking at them still makes me happy, remembering what it took to get through those challenging years and the friendships I made a long the way. Only book I still consult is the classic DeGowin and DeGowin, but, having the others near reminds me of who I was and how I got here.
I love medical textbooks with photos such as those for dermatology, fungal pathogens and their appearance, and pediatric syndromes. There was a flood last February in my office and all of my textbooks were ruined. I took photos and was going to replace them… but still haven’t. And I really haven’t missed them. I’m with Dr. Courtney Harris though, I do love opening a book and reading. Thanks for this post!
I admit loving medical textbooks and yet rarely using one. (An Up-to-Date subscription will do that to you!) I guess that makes me in-between. I do struggle with whether I should continue to require textbooks for my undergraduate students and have come close to eliminating them as a requirement on multiple occasions. I’m never sure the cost is worth it to the students, and the publishers keep putting out new editions every 2-3 years. But the textbooks do go into more detail on certain topics than I am able to cover in class. It’s reassuring to be able to tell students to read a great explanation in their text. But still… I’d be curious to hear from other faculty who have or have not given up requiring textbooks for undergrads. Or graduate students, for that matter.
I have been a family medicine faculty member for 40 years. In the last 10 years I have noticed that residents and students study primarily by question/review products and are very good at trivia and yes/no concepts but have very little sense of the overview of diseases that textbooks used to provide.
I have recently had a major issue with my medical school Alumni Association providing $25k / year for a pathology study guide! for all first year students!With the advent of Pass /fail in medical education for the first 2 years in many schools and in some schools all four years,all one has to do is pass(70%) to become a physician..Dr. Novak ,you are 100% ( not pass/ fail)correct regarding the lack of knowledge of basic medical knowledge..Thank you LCME and AAMC for putting what students want ( student centered as opposed to Knowledge centered and DEI centered above all else)This approach ( Student vs knowledge centered )began in the 1980s or so in elementary and accounts for the US pathetic academic levels in the world, made worse of course by the pandemic ..30% of US 8th graders are at grade level in reading and math)
Forgive my tirade but I will stand by these comments.You are spot on in your assessment .
I have the last two editions of Mandel by my bed and sometimes just pick them up to read something . However for answering day to day questions it’s Uo to date , pub med and idsa or other relevant guideline z I have a copy of Goodman and Gilman pharmacology from my med school course 1972 . I bought a newer one ten years ago . I have the med school students lift one with each arm (if they can even lift the newer one they are going into ortho ) and then ask why med school curriculums are being shortened
I get the satisfaction of gaining medical knowledge mainly through Medical Textbooks. How can our generation forget Bailey and Love, Harrison, Samson Wright, Gray Anatomy, And Parson?
The younger generation may please try it.
Amazing coincidence for me as I am changing office locations after 42 years in practice as an internist and was looking at my bookshelves with textbooks going back to medical school from 1975-1979 and trying to decide if I want to even take them with me. The only printed text I seem to ever use is my ancient neuro-anatomy text showing dermatomes which I show to patients with Herpes Zoster as if to confirm the diagnosis! I could show them this graphic easily on the computer screen but somehow I like to go to the shelf, pull out the textbook, and turn to the page showing the dermatomes. After reading this column I decided to take all of my books with me!!
PS: Shout out to Dr. Dickey as I also save my printed Journal Watch pamphlets and re-read them at odd times…
Printed textbooks present information in an organized manner and serve as a one-stop shop. you have to read quite a lotof online resources with different access costs for you to research on one topic.
Printed literature was favourite source of gaining knowledge at time when inspiring teachers were out of reach in old days, now I am at 69, reading on tabs and desktop more with convenient and comfort, finding references and meaning flipping page with a click, less time consuming.
Lovely post! Actually, I do think that the long editorial process due to produce printed medical books makes the outdated just at the arrive on the bookshop… anyway, I could not manage in reading from computer (or tablet, or smartphone) display… I do need printing online articles on paper and reading them underlining key passages, writing notes asides and ultimately keep them as a physical record of what I’ve studied… I read usually from the smartphone display as well, but I realize that it’s just to have a look and find interesting stuff, and then I need to print them and read them thoroughly on paper to hope to fix something…
In looking at the offices in our ID division you can almost predict the age of the member by the number of textbooks in their office. As an older member, I’m guilty of still having a larger library than most, and am also one of the few to still get print copies of at least some journals.
However, I have continued to wonder about the continued utility of textbooks for the third world. Even though smartphones are now ubiquitous, getting to an online medical text requires reliable internet service
Thanks for writing Paul, an oasis amid the chaos of practicing medicine in 2024.
I an an internist, who graduated from medical school in the Dominican Republic 35 years ago this month. Medical education there was difficult, but extraordinarily rich. Besides being taught and examined in Spanish, we were exposed to books I still treasure: We used the French anatomist Testus’s text with Rouvier’s amazing anatomy atlas, which still astonishes me with its detail, artistic style and precision. There was active leprosy in the orphanage across the street from where I lived. And there were my derm books who showed what it looks like, how it develops. There were no student accessible computers, no internet, and daily power blackouts, forcing me to study by a kerosene lamp some late nights. Even getting a land line phone was difficult in San Pedro Marcoris. But my books, our professors, and the people who entrusted their medical care to us students in the public hospital, all these carried us through, and enabled our dreams. The breadth, and depth of learning was immense: personally, socially, morally, and academically, But it was the books that enabled me to pass the tests and Boards, and allowed me to come home, to practice medicine. How could I not treasure them?
It was Testut’s anatomy text: Forgive the typo!
I am interested in Rheumatology books and internal medicine books
To what extent should the medical profession (as well as medical education and libraries) worry about the preservation of the information ecosystem? If publishers can’t make sufficient profit due to fewer people buying textbooks, could that mean an eventual end to high quality medical texts in any format? UpToDate is written by experts and updated regularly, but its high price tag can make it inaccessible to many and having all your eggs in one basket is not necessarily prudent.
I have several 19th and early 20th century textbooks such as Hansen’s on leprosy and another on smallpox. They were great for photos of (now) rare diseases and for nerding out!
I’m an Anatomical Pathologist, 74 years old who only reports on Dermatopathology cases. I have the online versions of all the current most commonly used textbooks in Dermatopathology, editions less than 3 years old. I use these virtually only for the illustrations, as the immunochemistry and genetics are out of date.
I suscribe to the NEJM for cutting edge information in general medicine. The dermatopathology and dermatology articles are my prime interests, of which the Review Articles are superb.
I also subscribe to the American Journal of Dermatopathology, for superb detail, illustrations, and Review Articles which are asup to date as you can get.
Lastly I also subscribe to UptoDate.com, for its excellent coverage of all aspects of current medical practice. The pathology descriptions and illustrations are also superb. They reference everything also.
I use my DeGowin and DeGowin physical diagnosis text because the electronic version is not preferable to me. But I do have both. I use it when teaching residents. But I confess I do not know where my last edition of Harrison’s even is.
I wonder if the days of massive all-in-one tomes are numbered, but I think there’s a place for a great writer/teacher to write a focused book, readable cover to cover, that helps a clinician understand key concepts. A great example is Practical Office Orthopedics by Ted Parks, which was clearly a labor of love and is highly readable. Others that come to mind are The Only Neurology Book You’ll Ever Need.
While used infrequently, access to comprehensive information conveyed in textbooks is still an effective rapid means of garnering needed information for both clinical and teaching situations.
As an older physician I have fond memories of studying my massive texts underling important items never to look at those marked pages again. They sit now in my office each one like a trophy to show off to younger doctors and a reminder that I’ve forgotten more than they’ve learned so far.
Even now I have become adept at rapidly finding the dosage of a med for a 20 kg child using one of my handbooks. When its slow I tell stories to new pa’s about how all docs used to receive a free PDR every spring with its dozens of pages of pills photo…and show them the shelf of them from 1994 to 2013 with a few missing of course waiting for a rate book seller in 20 years to come by and make me an offer.
After 50 years in medicine, before Kindle I had a very high percentage of my home and office space devoted to print books.
I now have about 3,000 books on my iPad Pro and almost no print books in my house/office.
It’s a much better way to do things, although I can see that this would not work as well in third world countries.
Almost never can I not find the book I want in digital form.
After reading all of these comments I feel a little selfish holding on to textbooks I never use when someone else might benefit from them. Any suggestions on where and how to donate old texts other than a public library? If I give them to the library I fear no one will use them.