A Textbook Case: Making the Transition to the Online Universe

January 28th, 2017

With this blog, IDPodcasts inaugurates its new online presence. At its inception in 2007, our original goal was to make our division’s infectious diseases teaching available via a simple web site to a broad online audience. Since then, IDPodcasts has followed the pace of technology, explanding its reach to smartphones, tablets, YouTube, and to social media. In 2017, we celebrated our tenth anniversary. Recently, the development of our new web site led me to reflect again on how far online medical education resources have progressed since the beginning of this decade. For instance, In 2010, one of Oxford University’s “great medical legends” received a long awaited transplant. Long the close confidant and trusted aide to generations of doctors and medical students, it had become impersonal, grossly overweight, and unwieldy. Oxford University Press’s Textbook of Medicine, 5th Edition, first published in 1983, long regarded as perhaps the most comprehensive medical reference in publication and an emissary for evidence-based medicine around the world, was launched as a complete online edition. The project, five years in the making, brought the entirety of its massive twenty-five pound, three-volume, six thousand page print edition to the web, complete with all of the text, figures and illustrations. Though available to hospitals, universities and individuals as a paid subscription, the move to an online edition offered an unexpected benefit: inexpensive and even free access for more than 3,500 institutions in less-developed countries sponsored by the U.K.’s Wellcome Trust. 1

Oxford’s initiative, following a trend established by many medical publishers in the last decade and a half, reflected not just a gesture of altruism to third world countries but also a matter of contemporary professional and economic necessity. Since at least 2600 B.C., when Imhotep is said to have written his first papyrus on ancient Egyptian medicine 2, heralding the age when medical knowledge could be shared and adopted by others, clinicians have attempted to codify the practice of medicine onto the printed page. For more than 4500 years, the tradition of the paperbound medical text thrived, surviving the destruction of the Alexandria library in Egypt, the austere anti-intellectualism of the middle ages, and even the emergence of the new broadcast media of the second half of the 20th century. But as the practice of medicine now approaches the third decade of the new millennium, the bound medical textbook, so symbolic of the scholarly traditions that form the basis of our craft, is facing extinction. The solidification of electronic media, from online peer-reviewed information resources, medical web portals and search engines, to personal smart phones and tablet computers has now supplanted the hardbound textbook for many health providers.

In an original informal January, 2011 survey of internal medicine housestaff I conducted at my institution, only 15% had consulted a hardbound textbook in the last month, preferring instead to reference online resources such as “Up to Date,” “Harrison’s Online, “ and “Emedicine.” Less than half (47%) had reviewed a printed reference of any kind, underscoring the waning popularity of the softbound handbook or pocket guide. Now, seven years later, that number is probably close to nil. The migration that medical publications have made online reflects a societal shift away from the printed page, especially in basic and secondary education. Having a son and daughter, in both college and high school, respectively, I know that it is possible for my tablet and notebook-laden kids to never open a physical text if they wished to do so. For those of us who have been in practice more than twenty years, the transition away from the printed textbook in the last decade has presented some unexpected problems. No longer is a clinical question or controversial medical decision between clinicians resolvable via an obsolescent, forlorn text in the corner of a nurse’s station. Many resourceful clinicians now consider even a newly published hardbound volume to be out of date, questioning the validity of any reference that is not updated continuously. In an era where every question seems to be answerable via an online query, use of the search engine may have even superseded Pubmed or the National Library of Medicine, with sometimes variably reliable results.

In the past, the immutability and permanence of the printed page added certainty to hardbound textbook-based medical decisions. With the increasing reliance on online resources, it has become more difficult to distinguish credible from less credible sources of medical information, especially for patients who are sometimes forced to seek online medical advice in an era of “fake news.”. For less technologically adroit clinicians, clinging to hardbound medical resources they have used for decades, adaptation to electronic media may present formidable obstacles to reaching the information they once felt comfortable obtaining.

Yet, the online transition has had far more positive than negative consequences. Online reference sources are easier to produce and distribute, and for subscribers, often more affordable to obtain. In many medical facilities equipped with an electronic medical record, online medical references have been integrated with desktop, mobile or handheld devices at the point of care, permitting instantaneous access to evidence-based information critical to medical decision making. In fact, the growth of the evidence-based medicine (EBM) movement is likely to have been fueled since the turn of the millennium by the rapid growth of online medical resources. For many providers, the availability of medical blogs, subscription online content, YouTube videos, podcasts like our own, online access to full text medical journals and even social networking sites (e.g., Facebook and Twitter) ensure that no major medical advance, clinical trial, drug recall or outbreak can escape our awareness. In less developed countries, where medical reference resources were once limited to antiquated or donated textbooks, online resources offer resource-challenged providers with access that can level the playing field of medical information with wealthy countries, a development that is likely to be crucial to improving the quality of medical training and care in the third world. In the U.S., health information companies have also increasingly begun to acknowledge the promise of the new online frontier. Both Emedicine and Up-to-Date, among the most popular of the online peer-reviewed sites, began as struggling start-up firms in the 1990s, attracted an sizable user base, and then were ultimately acquired by large multimedia conglomerates. 3,4 For traditional publishers, almost every major hardbound text now coexists with an online edition, many enhanced for portable devices.

Like audiophiles who still extol the tonality, sonic imperfection, and nostalgia of the vinyl LP in an age of digital music streaming, there will always be those who cherish the great joy inherent in un-wrapping a new-edition hardbound text, resting its weighty spine on one’s lap, and thumbing through its unwrinkled and carefully typeset pages. Although classic medical textbooks may never completely disappear, they may be relegated to the novelty of display cases.   The ongoing transformation of medical information to the online universe will continue to affect the discipline of medicine in many ways and may even alter the foundation of what it means to be a physician. For if healthcare providers can now have access to a portal that can instantly provide them with unlimited online knowledge, updated constantly, and personalized to their patient’s individual needs, at what point could the physician, like an out of print textbook, also become obsolete, replaced by an artificially intelligent machine? It seems unlikely that this will happen anytime soon, one might think, because it is not what we know that endears us most to our patients.   “The art of medicine,” the 16th century Renaissance physician Paracelsus once wrote, “cannot be inherited, nor can it be copied from books.” 5




  1. Moisse K. A medical classic gets a 21st century makeover, going online and low cost. Scientific American https://bit.ly/dpVuEk. Accessed February 2, 2010.
  2. Breasted JH, ed The Edwin Smith Surgical Papyrus: published in facsimile and hieroglyphic transliteration with translation and commentary on two volumes. Chicago: University of Chicago Press; 1991; No. 3-4.
  3. Emedicine.com. https://emedicine.medscape.com.
  4. Uptodate.com. https://www.uptodate.com. Accessed 01/15/2018.
  5. Jacobi J, ed Paracelsus, Selected Writings. New York: Pantheon books; 1951.