Medicine’s Alternative Universe

luckyby S. Goldberg, Med’Toons, Medmaster

An alternative universe is an unseen dimension. When we round and enter the patient’s room, we don’t experience this hidden dimension, just our own world with its medical technicalities.

The hidden dimension is the hospital experience from the patient’s point of view. The patient is not necessarily thinking what the therapist is thinking. I entered this dimension recently after undergoing triple coronary bypass surgery.  Here are my impressions of the physician’s dimension as opposed to the patient’s dimension during evaluation and treatment:

On being wheeled in a bed to angiography and by-pass surgery that night:
PHYSICIAN: Wheel the patient to the procedure room, adequately sedated.
PATIENT: Nervous; too late to change my mind. As one patient put it “Imagine someone sawing your chest in two and pulling you asunder and then doing some crazy shit to your heart?”  Lying in bed, I don’t have to do any of the wheeling. I’m a VIP from Hell.

Immediately post operation:
PHYSICIAN: Family visitations OK in ICU.
PATIENT: Family scared looking at me recovering from anesthesia. They heard a lot of moaning (which I don’t remember) and thought I might die. I can’t engage in meaningful conversation with them. I don’t look so great the rest of the hospitalization either.

PHYSICIAN: After admission to ICU; remove endotracheal tube (I don’t remember that); monitor vital signs; chest tube should be draining; Foley catheter in place; measure urine volume; IV drip with correct medication flowing at an optimal rate; nasal cannula in place with adequate flow; arterial line from angiography remains in place in groin in case arterial access is needed.
PATIENT: Groggy; pain on respiration largely from chest tubes; have to stay still and supine so as not to disrupt arterial line in right groin. Uncomfortable. I’m used to turning from side to side when I sleep. Can’t do that now.

During 6 days of hospitalization:
PHYSICIAN: Throughout each night, draw blood tests; check oxygen saturation; give medication; check BP, pulse and ECG.
PATIENT: At 3AM every night? Can’t sleep well as is, especially with the background noise and light; try sleep mask and ear plugs; can’t find good sleeping position; have to frequently call nurse to adjust body position; after a few days, need to sleep in chair part of night. So many pills; should I take them all at once or one at a time? Better take one at a time so I don’t choke. What if I arrest? Would they give me chest compressions with this fresh chest wound? Bed pan no fun. You never hear about bed pans in movie plots.

PHYSICIAN: Respiratory therapy – instruct patient how to use volumetric spirometer; administer respiratory inhalant in the middle of the night.
PATIENT: The respiratory therapist is encouraging, but I’m not going to break any Olympic records for volume of inspiration with this spirometer.  Inspiration with the device difficult due to coughing.

PHYSICIAN: Have patient sit in chair, not in bed all the time.
PATIENT: Need warm blankets, since I’m cold. The staff is busy. Not me. Nothing of interest on TV. I specialize in staring into blank space. Can’t work; depressed. Life is accelerating downhill. What about my family? My work? I don’t want to be a burden.

PHYSICIAN: Ambulate patient after 1 day.
PATIENT: Legs feel heavy; hard to stand or walk; in danger of fainting; need assistance in walking short distances, with shuffling. Need a walker; who, me? I’m a patient now!  I think the only difference between being sick and dying is that you don’t get better with dying. I’m walking a little better each day.

PHYSICIAN: Be sure patient receives colchicine to reduce cardiac inflammation.
PATIENT: Colchicine causing diarrhea. Hard enough getting out of bed with assistance to go to toilet, and, with all these IVs, need my butt wiped by the nurse.

PHYSICIAN: Time to remove 2 of the 3 chest tubes on day 2; leave one of them in, maybe until tomorrow, since there still appears to be significant fluid in the lungs.
PATIENT: Please take out that last tube tomorrow so that I can breath better with less pain.

PHYSICIAN: Surgery group says chest incision looks good.
PATIENT: It may look good, but it feels more like in the Alien movie before the alien burst from the chest. I guess it’s “better to look good than to feel good.” But I’m glad I’m still above ground. I’m growing a beard; look scruffy and old.

PHYSICIAN: Apply automatic inflatable cuffs pumping continually on calves to help prevent clotting.
PATIENT: Helpful, but another restriction to moving.

PHYSICIAN: Take frequent BP readings, with cuff remaining in place.
PATIENT: Cuff causes an irritating blister under my left arm and has to be moved to the right.

PHYSICIAN: Keep IV going.
PATIENT: IV is infiltrating, blowing up around the needle. Will the nurse come? I’m running out of veins. Was that the last vein available? What will they do if I run out of veins?!

PHYSICIAN: Keep controller near patient to control TV, adjust bed, and enable patient to call nurse.
PATIENT: Help, I can’t find the controller. I’m doomed, unless I yell for assistance. Would they come?

PHYSICIAN: Keep track of urine volume.
PATIENT: I find the bed urinal difficult to use. Which way? Up or down? I wet the gown and bed; hard to pee when supine; need to stand up.

PHYSICIAN: Administer prescribed diet.
PATIENT: Not hungry; ate little.

PHYSICIAN: Do direct stick for arterial blood gases.
PATIENT: More like several painful sticks; apparently harder to get arterial blood than venous blood; also I’m collecting an assortment of ugly purple patches from blood leaking under my skin. I’m looking more like a patient.

PHYSICIAN: Incisions in right leg to get vein for grafting is healing well.
PATIENT: I forgot that I have more incisions.

PHYSICIAN: Take patient down for x-ray.
PATIENT: I’m down in Radiology, but no one is coming. How long will I wait?

PHYSICIAN: Once outside ICU, arrange consultation for the Surgical team, Pulmonary, Internal Medicine, Cardiology, Physical Therapy, Social Services.
PATIENT: I’m losing track of all the consults. Nursing care very good, but more attentive in ICU where there is higher nurse-to-patient ratio. Medical consult passes through quickly. Does he really care, or has the bedside just become routine and impersonal? Does he know anything about me other than the lab values?

PHYSICIAN: Pain Medication PRN.
PATIENT: I don’t want to take any more meds than necessary. Pain improved on removing chest tubes, but have pain in back, shoulders, and neck, maybe from awkward sleeping position or the surgery itself. Maybe just Tylenol.

PHYSICIAN: Discharge patient, 6 days post-op.
PATIENT: On 11 different medications!!?? Discharge group conference discussed diet, activity, nursing and physical and occupational therapy visitations for 2 weeks, followed by cardiac rehab in 1 month post-discharge. Regarding depression, the group answered any questions and pointed out that I would feel better in time. They did a good job.

Start cardiac rehab 1 month post-op. Exercising more in Rehab; feeling better than I have in a long time 2 months post-op. I am grateful for a new heart. Another benefit: weight loss.

I wrote this blog entry to remind the student and physician that there is another dimension to making rounds, that of the patient’s feelings and point of view. Regretfully, empathy with the patient often diminishes in the latter years of medical school, probably due to lack of time and the mass of technical information that has to be absorbed, in addition to the stress of being personally involved with patient and family. Rather than quickly passing by the bedside on rounds, sit down for a minute with the patient to empathize at the patient’s level. That is also therapy. Do you know who your patient is? Is he/she just “the coronary bypass in room 612?” The patient “won’t care how much you know until they know how much you care.”

Two New Medmaster Books: 1. Alternative Medicine 2. Allergy/Asthma

SNAKES

Are You Afraid of Snakes? A Doctor’s Exploration of Alternative Medicine, by C. Scott Mahan

The many books comparing alternative medicine to Western medicine tend to be biased in one direction or the other. Are You Afraid of Snakes? A Doctor’s Exploration of Alternative Medicine offers a balanced view. C. Scott Mahan, M.D., an infectious disease specialist, is co-author of the best-selling “Clinical Microbiology Made Ridiculously Simple.” Are You Afraid of Snakes? describes his 5-year medical journey from Africa to Appalachia, as he encounters many alternative approaches to medicine (voodoo, naturopathy, homeopathy, chiropractic, acupuncture, hot yoga, barefoot running, performance enhancing drinks, titanium necklaces, magnets, hypnosis, detoxification diets, and ayurvedic medicine). Dr. Mahan relates his personal and often humorous experiences in the dual worlds of alternative and Western medicine. He offers an unbiased analysis and opinion of the differing approaches to medicine. 257 pgs; ebook $9.99; print book $16.95.

 

Allergy and Asthma Made Ridiculously Simple, by Massoud Mahmoudi

Allergy

Allergy and Asthma Made Ridiculously Simple is a brief, clear, and practical guide to the diagnosis and treatment of allergies and asthma. Dr. Mahmoudi practices internal medicine, allergy, and immunology in California. He has published or edited numerous scientific papers and 9 books related to allergy and immunology, including the best-selling “Immunology Made Ridiculously Simple.” He was a medical columnist for local newpapers and the San Francisco Chronicle, has spoken locally and nationally on allergy and immunology, and appeared on local television and Fox News. Dr. Mahmoudi is currently president of the American Osteopathic College of Allergy and Immunology and on the faculties of the University of California San Francisco, Rowan University, and Touro University. 72 pgs; $22.95.

New Medmaster Editions 2016

psychiatrist-evil.jpg

“And how long have you been, in my opinion, evil?” (From Med’Toons, by S. Goldberg, Medmaster)

Medmaster is pleased to announce the following new editions:

Nelson: Psychiatry Made Ridiculously Simple (Ed. 5). Includes the newer DSM-5 terminology in the diagnosis of psychiatric illnesses.

Board Reviews Books:
Carl: USMLE Step 1 Made Ridiculously Simple (Ed. 7)
Carl: USMLE Step 2 Made Ridiculously Simple (Ed. 6)
Carl: NCLEX-RN Made Ridiculously Simple (Ed. 4)

Each Board review book presents the material in a rapidly read chart format, plus Internet links to 1000+ review questions.

Pattern Recognition In Diagnosis

XBalloon-passed gas

Previous blogs have discussed memory techniques for rapidly learning and remembering information in medical school:

•  Understanding

•  Visualization

•  Ridiculous Associations

•  Substitute Words and Pictures

•  Ditties

•  The Linking Method

•  The Peg Method

•  The Memory Palace

•  Chunking

•  Acronyms

•  Hands-On

Apart from these memory methods, there is another aspect of learning that requires more time to acquire, the ability to quickly recognize disease patterns; this depends on experience.

Often a patient presents with a number of symptoms and signs that may all point to one particular disease; or they may be the result of more than one disease; or some signs and symptoms may be red herrings.  Without experience, there may be a tendency to create a differential diagnosis that is too large or too small, and without proper assignment of correct probabilities to the various potential diagnoses.

For instance, my wife not infrequently experiences headaches in the middle of the night. When I look up the differential diagnosis for this in one of the computerized programs for differential diagnosis, the leading diagnosis comes up as “massive intracranial hemorrhage.” Obviously, this is not true, but the computer program spins this out because the data was collected from hospital admissions, not outpatient visits.  Someone admitted to the hospital with headaches arising in the middle of the night likely has something more serious than someone who is not admitted.

The ability to correctly formulate a differential diagnosis depends on the physician’s experience — whether it is outpatient or inpatient, and even which area of the country or world, where certain diseases are more prevalent than in other areas.  Gaining experience  requires time. That is why the medical student’s differential diagnosis is often so long, and not necessarily listed in order of disease probability.  Eventually, though, the physician learns to quickly determine the most likely diagnosis, based on known disease patterns.  It is important, though, that the physician does not become sloppy and superficially misinterpret patterns by rushing to a diagnosis in the midst of a busy office (or, to save time, simply adopt a shotgun approach, ordering unnecessary tests that may be invasive or expensive).

Humans are expert in recognizing patterns, but often come to the wrong conclusion when they read too much into a pattern (e.g. a face on a pizza).  The ability to efficiently arrive at a medical diagnosis comes with learning on a longer time scale than the memory techniques listed above.

Should USMLE Step 1 Be Eliminated, Modified, Or Open-Book?

XBalloon-injection-[Converted]

“Now this shouldn’t hurt a bit!”
From Med’Toons, by S. Goldberg, Medmaster

At first glance, Step 1, which emphasizes basic science knowledge and is taken after the second year of medical school, would seem necessary to insure that medical students have achieved the proper level of knowledge to proceed in their education.  However, there is another consideration.

I cannot help but notice the great amount of time spent by students discussing how to pass the medical Boards; students are compelled to spend a great deal of time in rote memorization of esoteria for the exam; otherwise they may not pass.  In my view, this emphasis interferes with the need for students to acquire a proper understanding of the topics discussed in the first two years, understanding that is vital in taking care of patients.

Today, it is relatively easy to electronically search for isolated points of information through apps and the Internet; there is less need for rote memorization, which computers do best, and greater need for understanding, which humans do best.  Despite the information explosion, surely there is less need to memorize so much and greater need to promote understanding of the clinical material as a whole.

Even the best physicians may have trouble with questions on the Boards. We would like to gear medical education to turning out the best physicians.  But what constitutes an excellent physician?:

• Most cases a physician sees are common situations rather than zebras.  Good medicine is largely a matter of applying common knowledge and principles to diagnosis and treatment, without getting sloppy, rather than coming up with a roundsmanship coup. The excellent physician does not, to save time, routinely order, in a shotgun fashion, all manner of rare, invasive, and expensive low-yield tests.  Nor does the excellent physician hastily rush to decide on a diagnosis based on a too-quick, superficial initial impression. The best physician is not necessarily the one who has the greatest knowledge base, but the one who consistently and meticulously applies common knowledge.

• Patients do not care so much about the physician’s medical school or residency diplomas as they do care about how the physician responds to them as individuals, whether the physician is compassionate, and allots the patient the necessary time.  “Patients do not care how much you know, until they know how much you care.”  This aspect of medicine is also important, just as is the knowledge base.

• The good physician, unless there is an emergency, schedules reasonable office waiting times, promptly notifies patients of lab results, follows up on the patient’s progress, and adopts more than just a cookbook approach to diagnosis and treatment. Medical education needs to emphasize understanding of important concepts, as well as familiarity with where and how to search for isolated points of information, which have grown too large for anyone to remember.  This is not emphasized on the Boards.  Emphasizing understanding, something Medmaster has focused on for the past 34 years, may seem to be a minimalistic approach to education, but in fact it is a maximal approach, insuring that the student acquires the greatest degree of understanding. Every patient is different, and a cookbook approach may not work for all patients; understanding  what one is doing is critical to good patient care.

So, should Step 1 of the USMLE be eliminated, or modified? Perhaps Step 1 should be an open-book exam; this would more resemble everyday practice, where physicians now have ready access to point-of-care information. What do you think?

Steven Goldberg – In Memorium

Last week Steven Goldberg (no relation), a former student of mine at the University of Miami School of Medicine, passed away of lymphoma at the age of 42.  After 25 years of my teaching at the U of M, his name stands out in my mind, not because of similarity of name, but because of his brilliance and character.  He was a true mensch.

Steve was born with transposition of the arteries, which required surgical correction.  When he advanced in medicine, his goal was to become a pediatric cardiac surgeon and offer to other children what had been provided to him.  He did just that, training at the same institution that had operated upon him as a child.  He specialized in difficult cardiac procedures in children, including the kind of congenital defect that he had, as well as cardiac transplantation.

You can gain a better glimpse of his character through the YouTube video he prepared for LeBonheur Children’s Hospital last year. Within only a few days of his passing, there were hundreds of facebook postings by people whose lives he had touched.

Steve was also a skilled artist who illustrated significant parts of my books on Clinical Physiology Made Ridiculously Simple and Med’Toons. Here are three of my favorite cartoons that he drew:

Emphysema in wolves

From Med’Toons, by Stephen Goldberg, Medmaster

Immune-picture

T-helper cell function in the immune system.
From Clinical Physiology Made Ridiculously Simple, by Stephen Goldberg, Medmaster

Steve will be greatly missed.  He was the personification of the ideal physician.

Drawing The Patient Into the Decision-Making Process

From Med'Toons, by S. Goldberg, MedMaster

From Med’Toons, by S. Goldberg, MedMaster

Should the patient and family participate in the decision-making process as to whether or not to pursue an aggressive course of therapy?

Of course, there are those patients who say “Whatever you think would be best doc.”  And there are others who are so mentally incapacitated as to not be able to render an intelligent decision.

But what if a patient wants to help decide on the course of therapy? There are two points of view.  There are physicians who feel that patients and family should not participate in decision-making in aggressive treatments, such as surgery, radiation, and chemotherapy, as they are too emotionally involved and may not think rationally.  I feel otherwise.  Apart from the patient having the right to agree or not agree to a particular treatment, there are situations in which the patient may be in a better position than the physician to decide.  For instance, say a patient has a tumor of the arm and the statistics indicate that there is a 90% chance of survival if the entire limb is removed, but only a 70% chance of survival if the tumor is removed locally, but leaving the function of the arm intact if successful.  What should one do?  Leave the decision up to the physician, or seek the patient’s opinion?  The physician may opt to remove the arm to improve the chances of survival but the patient may want to take the gamble, in order to keep a functioning limb. The patient’s choice may well be the better one; it suits the patient’s individual needs.  The patient and family may be willing to gamble, while the physician may not.

If the patient and family are well-informed of the facts, the therapist should encourage their participating in the decision-making. The patient and family not only have the right to do so, but their input may be helpful, even invaluable, in making the right decision.

Student Preferences For Ebooks Versus Print Books

curses---120

Curses – the leading cause of death in patients age 120 years. (From Med’Toons, by S. Goldberg, Medmaster)

Previous posts (A, B, C) discussed the pros and cons of digital versus print books.  A survey of students by Bowker Market Research (June 11, 2013) indicates that only 3% of college students in the previous semester used a digital textbook as their main course material.  Publishing Business Today  (Jan 21, 2015) confirms the student preference of print books over ebooks.

The Bowker survey of 1,540 undergraduate college students found that students overwhelmingly prefer print, at both four-year and two-year institutions of higher education.  The reasons include students preferring “the look and feel of print,” the greater ease in highlighting and note-taking, and the fact that they can’t re-sell digital textbooks.

Among those few students who prefer digital textbooks, the reasons include price, ability to search the text, and ease in carrying around.

As of March 2013, laptop computers are by far the most popular device for students reading digital textbooks. The iPad is No. 2:

Laptop computer: 51%
iPad tablet: 21%
Desktop computer: 8%
Android tablet other than Kindle Fire: 6%
Kindle Fire tablet: 5%

The topic continues to evolve.  We welcome your continuing thoughts on the use of ebooks in medical student education. In the meantime, Medmaster is working on the best ways to present its books in both print and ebook formats.

A Few More Medical Apps

bp cuff-money

From Med’Toons, by S. Goldberg, Medmaster

In addition to the popular medical apps listed previously, here are a few more to consider:

1.  MedPage Today.  This app connects you to the top breaking medical news stories that the public is reading.  While these news reports are not necessarily written by medical professionals, they do give you an idea of what your patients are reading and may ask you about. For iOS, Android, and web view.  Free.

2.  Unbound Medline.  This excellent app connects you to over 20 million journal articles.  You can also instantly email articles of interest to your colleagues.  For iOS and Android mobile devices. Free.

3.  Wasting time trying to find the right usernames, passwords, and PINs among an ever growing list?  One way is to have a single app to access all your passwords and PINs.  Some key ones are reviewed here.  A very simple (and free) password protection, though, is to simply list your usernames, passwords, and other codes alphabetically in a Word document that has a single password to access the file.  Security is easy to set up in Word’s Preferences, under Security.

Frustration In Medical School

Surgeon-divining

From Med’Toons by S. Goldberg, Medmaster.

The huge amount of studying that medical school demands can at times be so frustrating as to make one question medicine as a career.  The following illuminating story is reproduced with permission from the interesting blog WaitingForMd.

“It was a beautiful sunny day as everyone filed into the windowed room and took seats around a large, oblong table and scattered seats along the wall.  Medical students chit chatted about needing to get back to class and wondered when the main attraction, free Thai food, would finally arrive.  Meanwhile quietly in one corner a young woman sat with her hands neatly folded in her lap with a white lab coat.  She didn’t make conversation but smiled politely.”

“The meeting began after everyone was done scooping little heaps of pad Thai into their plates and shuffled back to their seats around the table.  Some introductions of board members were made and the general idea of the student organization was described.  At the close of the meeting they asked for any questions or comments and after some expected questions the young woman in the corner raised her hand and said ‘could I please share a story with the group’.”

“The club president smiled at her and replied ‘of course’.”

“‘I had always wanted to be a doctor; it was just something I never thought was possible for me.  I was married very young.  I spent most of my life in Africa and when I came to the United States I did not think that even going to medical school was an option for me.  I was always one of the brightest girls in my class and I even went to college but it all seemed so far away. By that time I was already a mother of two young children, which made a very busy schedule for me.  Somehow I managed to secure admission into a program that allowed me to do some coursework, and upon successful completion they would allow me to go to medical school.  I could not believe my eyes or ears and I worked hard, so hard to make sure I could do it.  My grades were all very good.  But then I started to notice that my youngest son was not speaking as he should be; he was not developing at a proper pace. The doctors said that he had autism.  He would need speech therapy and physical therapy.  Hours of individual attention were needed but my husband worked.  He told me he could not do anything; we needed the money; he had to go to work.  I was left with no choice and I had the acceptance letter in my hand and I declined my admission to medical school.  After all of that work, someone had to take care of my son.  I had to care for my child and I had to give up my dream for it.  I wish my husband had supported me more, so I could achieve my dream.  Even today when I walk on the sidewalk and I am walking in one direction and one of you, a medical student, is walking the opposite direction and passes by me in a white coat, I stop and I turn around and I look at you walking away. I see my dream that I had walking away from me.  I am so happy for each of you and I am so sad for myself that I did not find a way to make my dream.’”

“The entire room sat in silence. Sitting in that room with nothing on my mind besides needing to get back to class at the end of the lunch hour, this woman’s story really touched me.  I could feel tears welling up in my eyes.  This story just serves as a stark reminder that this is an opportunity that we were lucky to have been given.  It sucks sometimes.  It’s really hard.  It makes you want to punch the wall.  But no matter why you did it, there was something that drove you.  If you can keep a piece of that with you and remember back to the time when you would have traded anything to be where you are today, everything gets a whole lot easier.”

On a personal note, I was at the bottom half of my class in medical school and there were many frustrating times.  I was a slow reader.  What I have learned is that under such circumstances, it helps to simply keep going.  In the end, it will work out. Small steps each day add up.  When it appears that you are hopelessly behind, you are not as far behind as you think.  And just like a hiker cuts through the obstacles of a dense forest underbrush, but eventually arrives at a clearing with a brilliant panoramic view, there will be a time when you no longer have the continual pressure to pass exams.

Information Overload x 2

primitive laser surgery

Primitive laser surgery
(From Med’Toons, by S. Goldberg, Medmaster)

Apart from the information overload of medical school study, modern technology adds to the problem.  While technology has made it easier to find information, its distractions can be time-consuming.

We depend on the Internet but sometimes it is down. There is the beloved “Error” message that punctuates computer illnesses of unknown origin. Email, texting, Facebook, Twitter, blogs, Google searches, the same news multiple times per day, and a zillion different apps compete for our attention. It is as if we have taken a step backwards in the way we read, switching from the centuries long efficient and easily grasped format of print books to the variable ways of reading books electronically, with smaller pages on mobile devices. Certain ebooks can only be read on certain tablets, and some tablets only allow certain reading apps, and certain ebooks are listed in only certain ebookstores.  This can be upsetting to students who would like their ebook library to be available in ebook format on a single tablet or computer and available from a single source.

Hopefully, the way we read electronic books will become standardized so we can purchase and read ebooks anywhere, and not depend on a particular reading tablet, ereading app, or ebookstore.  Personally, I think the optimal way to read ebooks in the future will evolve toward reading on the web.  In that way, ebooks can be read anywhere in the world by anyone who has internet access, on any computer or tablet, and will not depend on having a particular brand of reading tablet, a particular reading app, or a particular ebookstore.  There would be little concern about the time and expense of shipping print books, and books could be updated continually.  At Medmaster, we are looking into the most optimal ways we can offer our books in electronic format. Presently, the field is not yet ready for prime time, due to different format issues with complex books, publisher terms with ebookstores, and the great variety of competing, often mutually exclusive reading apps and tablets.  We receive inquiries from students as to when Medmaster will have all of its books in ebook format.  While we have done so for a few books, we are exploring the evolving ways of presenting them and hopefully we will shortly be able to offer the remainder of Medmaster titles in ebook format as an alternative to print for those who prefer that way of reading.

The Best Ebook Readers And Reading Apps For Med Students

Einstein's-x-ray-[Converted]

Einstein’s X-ray
(from Med’Toons, by S. Goldberg, Medmaster)

Previous posts discussed the pros and cons of print books versus ebooks.  This post discusses the pros and cons of the various eReading devices and eReading apps.  Which tablet (or computer) should you use to read ebooks?  Which reading apps?

Choosing the best way to read ebooks can be confusing.  There are many different reading tablets. Some ereading apps work with some tablets and not  others.  There is also  the growing ability to read books directly from the web, whether from a tablet or a computer.

While it may seem obvious that publishing companies should simply list all their books on every eBookstore (e.g. Amazon, Barnes & Noble, etc.), it is not that simple.  The particular ebookstore’s terms to a publisher may differ depending on the size of the publisher and the price of the book.  Thus, a publisher may opt to place certain titles  in only certain ebookstores.  Also, some books do not presently lend themselves well to ebook format.

Buying print books is relatively simple: buy them any place; no need to distinguish between reading tablets, apps or booksellers.  For ebooks, though,with time-consuming usernames, passwords, and wrestling with computers, mobile devices, and reading apps, it is a wonder that a medical student can get any reading done at all.  Time is at a premium for medical students, and we need the most efficient ways to read.

I still prefer print books.  But others prefer ebooks for their ease of acquisition, portability, searchability, hyperlinking and multimedia capability, and generally less cost than print books. If you want to read using an ebook, which is the best tablet to purchase, and which ebookstores and reading apps should you use?  I have summarized my current understanding of the matter in the chart below, along with some general observations that follow.

Reader-devices

1.  Of all the tablets, only the iPad supports reader apps from the all the various ebookstores (iBooks, Nook, Kindle, etc.).  I suspect that is because Apple, although having its own ebookstore, is mainly interested in selling iPads and wants its readers to know that with a single iPad they can read any ebookstore’s books.  On the other hand, Nook (Barnes & Noble) and Kindle (Amazon) are mainly bookstores, and are more resistant to having other eBookstore apps on their tablets.  Thus, their tablets do not support the broad range of reading apps as the iPad.

It is interesting that while the iPad has its own iBookstore, you cannot read iBookstore books on a Macintosh computer (!), or for that matter on any other tablet or computer.  So if you want to read books from Apple’s iBookstore, you presently need an iPad.

2.  Medical students’ needs differ from that of the general public in that medical students, in addition to studying a lot, commonly want to highlight, and to a lesser degree take notes when reading. I found highlighting more awkward on the Nook tablet than on iPad, Kindle, or Android. While the Nook tablet otherwise has excellent reading features,  its somewhat awkward highlighting and lack of support for reading apps other than its own is a drawback.

While the Nook app for Windows Vista works well, it appears the Nook for Windows 8 does not presently have a highlighting or notes feature.  I found Nook for Macintosh buggy in that sometimes its menu does not appear when the application is opened.

3.  In contrast to tablets, it seems easier and quicker to highlight using a computer, whether Mac or Windows, using a mouse or trackpad.  The availability of relatively large monitors for Mac or Windows computers makes them easier to study from than the smaller monitors of  mobile devices.  And the external keyboards of Mac and Windows computers make typing, as for notes and other functions, quicker than on a tablet.

4.  There is an increasing ability to read books on the web.  Kindle, in addition to its reading app for computers and tablets, also allows reading directly from the web via its Kindle Cloud Reader, which makes it easier for the student to log in anywhere, even without a tablet or a computer that has the Kindle app.  Kindle Cloud Reader has good highlighting and note-taking ability.  Google Play, Inkling and Vitalsource (VS) also have tablet readers as well as web-reading functionality with good highlighting and note-taking. Nook for web allows direct reading from the web, but at this time it does not appear to support highlighting or note-taking.    Of course, the drawback of relying on the web to read is that the web may be down, or you may be out of range of wi-fi.

5.  In addition to the specific ebookstores, such as Apple’s iBooks, Barnes & Noble’s Nook, and Amazon’s Kindle, there are also many independent bookstores that have their own reading apps (help!), or whose books readers can access with what I will call “generic” readers.  Two of the best generics are Adobe Digital Editions (ADE, especially the latest edition), for Mac and Windows computers, and BlueFire (BF) for tablets, both of which can read ePub and PDF files.

There is now a Windows 8 Surface Pro tablet, which, unlike the Windows Surface RT tablet, has the full range of Windows 8 function, just like a regular Windows 8 computer.  It, however, is thicker and heavier than most tablets and does not presently have a large screen.  It also does not support the full range of reading apps as the iPad.

The bottom line: I suggest that the student, where possible,  use a computer (Mac or Windows) for ereading because of the easier ability to highlight, the larger monitors, and the greater ease in typing on an external computer keyboard.   But if you want to use a tablet, the iPad offers the greatest range of ebookstores to choose from, good highlighting and note taking features, and an intuitive interface.

[Update Jan 16, 2014: Apple now has an iBook app for Macintosh computers, which appears to run very well.  However, at this time it is not available for Windows or other tablets except iPad. One would have to purchase books from the iBooks bookstore.  It seems to me that the wave of the future, for those who prefer eBooks to print books, will involve reading off the Internet.  In that way, books will be  accessible to everyone who has Internet access, not requiring a specific reader or computer.]

The field of ebooks is changing rapidly and these opinions may change as well. What do you think?