A drug company reports that taking their new drug Dammitol results in half the number of heart attacks compared to those not taking the drug. Fifty percentage less sounds pretty good. However, if a population of 100 is what is being studied and normally there are only 2 heart attacks in that population, a 50% decrease in heart attacks is not as impressive. It means that the number of heart attacks has only decreased by one out of the 100 people studied, or 1%. A 50% decrease in heart attacks is the relative decrease. A 1% decrease in heart attacks is the absolute decrease. The drug company reported the relative, rather than the absolute, decrease in heart attacks, thereby making the results look better.
The same company also reports that there is only a 1% increase in the side effect of splitting headache from Dammitol compared with a placebo. However, if two people get the side effect on the drug, and only one gets it on placebo, this means a relative 100% rise in side effects on taking the drug. The drug company would not report a 100% increase in splitting headache, but phrase the results differently, namely that the drug causes only a 1% increase in the headache, from 1% off the drug to 2% on the drug, the absolute increase.
The problem is that drug companies sometimes report only relative results when it comes to making the drug look effective, but absolute results when referring to the side effects. It is important to distinguish whether the results are relative or absolute. When unclear, it is best to look at the raw data of number of patients rather than just the percentages.
For further information see Clinical Biostatistics and Epidemiology Made Ridiculously Simple, by A. Weaver and S. Goldberg, Medmaster.
1. Shoe size is directly correlated with neat handwriting. Does this mean that there is something about increased shoe size that causes neater writing? Or is it because older children wear larger shoe sizes and by virtue of age, are more mature and write more neatly than toddlers? The correlation does not mean causation.
2. The number of drownings is highly correlated with the time of year, namely summertime. This does not mean that summertime causes drownings. There are more drownings because more people swim in the summer.
3. Myocardial infarctions are correlated with elevated troponin levels. This does not mean that troponin levels cause myocardial infarctions. It would be a mistake to try to treat heart attacks by lowering troponin levels, when in fact it is the MI that causes the elevated troponins, which leak out of damaged myocardial cells. Too obvious? How about the following:
4. Elevated blood homocysteine is correlated with increased risk for myocardial infarction. Does elevated homocysteine cause heart attacks? Studies designed to decrease homocysteine have not demonstrated any lessening of the risk for MIs. Perhaps a third factor causes a rise in homocysteine as well as a susceptibility to MIs.
5. Elevated LDL cholesterol is correlated with increased risk of cardiovascular disease. If a third factor (e.g. stress, heredity) is the cause of both cardiovascular disease and elevated LDL, it may not help to try to control arteriosclerosis by taking years of anticholesterol medication. Current medical opinion leans heavily toward LDL cholesterol as a causative act in cardiovascular disease, but there are those who disagree.
6. Hypertension is believed to cause arteriosclerosis. But could a third factor (e.g. stress) be implicated as a cause of both?
6. According to a 2005 study in Finland, women who have abortions are more likely to commit suicide. Do abortions cause suicide, or are women who have abortions more likely to be in social situations that in themselves are more likely to promote suicide? Women who have abortions also are more likely to be murdered and die in accidents. If they are already high-risk for murder, suicide, and accidents, they may be more likely to be in situations where they choose an abortion.
7. People often are quick to judge patterns and often attribute causal importance to patterns that are only coincidental. I had an elderly patient who was sure he knew what caused Parkinson’s disease; he had purchased his home from someone who had Parkinson’s disease, and a year later he, too, was diagnosed with Parkinson’s disease. In his mind, it must have been communicable. However, about 1 million people in the USA have Parkinsonism, mostly people over 60. The chance that the person purchased the home from someone with Parkinson’s and also would acquire the disease is not so unreasonable, given the number of people who buy homes and the prevalence of Parkinson’s disease. In addition, there are thousands of other diseases that both buyer and seller might have had coincidentally. The chance that at least one of those diseases could have occurred in both buyer and seller is high. The clincher here was pointing out that the spouses of patients with Parkinson’s disease do not have a higher incidence of the disease than those not married to someone with Parkinson’s. One of the biggest mistakes in research is confusing correlation with causation.
8. A study indicated that smiling a lot is correlated with a longer life. Should we then go around forcefully smiling at everyone like the Burger King king? Maybe good health induces people to smile more.
9. If people who take Dynamo MaxiForte vitamins have a lower risk of illness, is it because of the vitamins or because they take care of their health needs in other ways, too, such as exercise and a balanced diet?
10. Teenagers who spend a lot of time texting and on social network websites have a higher incidence of sex, stress, substance abuse, depression, and fighting. Should texting therefore be decreased? Which variable causes which?
The medical and popular literature is rife with examples of confusing correlation with causation. One must be on the alert not to confuse the two.
CLINICAL MICROBIOLOGY MADE RIDICULOUSLY SIMPLE (ED. 8)
This best-selling, updated approach to clinical microbiology, brims with mnemonics, humor, summary charts and illustrations; includes all the classic and emerging infectious diseases, with a brand new chapter on the SARS-COV-2 virus, its diagnosis, treatment and immunization. In regular, spiral-bound, or ebook format. ISBN 9781935660484
CRITICAL CARE & HOSPITALIST MEDICINE MADE RIDICULOUSLY SIMPLE (ED. 2)
The new second edition of this best-seller includes a separate chapter on the diagnosis and treatment of COVID-19 in critical care settings. Now in ebook format.
“Now this shouldn’t hurt a bit!” From Med’Toons, by S. Goldberg, MedmasterAt 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?
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.
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.
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.
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?
Having taught medical students for 25 years, practiced in several different medical fields, edited all the Medmaster titles in the basic and clinical sciences, and received feedback from many instructors and students through the years, here is how I would revamp the medical curriculum:
1. I would continue learning the basic sciences in the first two years, followed by 2 years of clinical experience, as opposed to the idea of learning the basic sciences and seeing patients right from the start. While one may want to see patients as soon as possible, it is better to first learn the basics, since you can then approach medicine with overall understanding, rather than scattered facts. It is like the juggler, who needs to combine a number of different skills to perform, such as simultaneously juggling 6 balls, twirling 3 hoops around one foot, and balancing a stick on his head. He would do better by first learning each skill separately and then putting them together, rather than trying to learn by practicing all of them together from the start. The basic sciences, though, should not be taught without reference to clinical medicine; they should be taught with a clinical emphasis, showing the clinical relevance of each subject as it is taught.
2. While small group discussions of clinical cases in the first two years can be an excellent source of learning for a given case, they tend to be an inefficient way to learn. They are time-consuming and cannot get into the vast amount of medicine that has to be learned. Also, when scheduled in the basic science years, they are presented too early for an adequate understanding of the topics, since the student has not yet learned the underlying basic science. While case discussions in the basic science years provide a way to introduce clinicians into the discussion (as most basic science courses are taught by PhDs, rather than clinicians), clinical relevance can be introduced more efficiently through well-designed reading, audio, and video presentations.
3. There is an overload of information in the medical curriculum today. We need to focus on general principles and understanding as opposed to numerous esoteric facts. People are much better at understanding than rote memorization, while computers excel at memorizing detail. The game-changer in today’s education is that it is easy to search for facts as needed on electronic media such as the Internet, in contrast to the past, where one had to rely on the latest reference texts and printed journals or go to the library to search through tomes of Index Medicus for relevant articles.
By the end of medical school we forget many of the facts that we learned. And we do not acquire an overall understanding of many topics because of the deluge of information that we are hit with over the four years; we do not see the forest through the trees. It is better to acquire overall understanding and know where to search for further detail. Learning general principles with understanding is in itself a fulltime job.
4. I would, for the most part, eliminate classroom lectures. Lecturers vary in quality, and even when there is an excellent lecturer, it can be difficult keeping up with note taking and grasping what is being said in a fast-talking delivery, especially when tired after staying up late. Why sit through a classroom lecture when one can learn the same thing through a YouTube or other video venue, at one’s own time and pace, and stop and go back to review points for clarification? I think the best use of the future instructor will not be to deliver a lecture in a classroom, but as a facilitator in pointing to the best educational sources for the student and responding to student questions. Where an instructor has something special to relay to the student that cannot be found elsewhere, it often would be better to present it as a personal reference video than as a classroom lecture. The instructor should, however, be available for individual questions from students, whether in person or by electronic communication. This will not only be better educationally for the student, but for the basic science instructor, who in many cases would prefer to spend more time in research activities. Rather than repeating the same lecture many times, the instructor can point to a well-designed video that can be accessed by different classes.
5. There should be a detailed list that the student receives on entering medical school as to what material in the basic sciences to learn, with recommendations as to where to find the information. The student should largely learn independently. There should be periodic tests to insure that studying is not crammed in toward the end, when the tests are given.
The same should apply in the clinical years. The student should have a list of the most important clinical conditions, with suggestions as to the most reliable learning resources to diagnose and treat them, whether they are books, apps, or videos. As is, education in the clinical years is often not organized, with the student left on his/her own to determine what is important to learn. As in the basic sciences, there should be periodic tests of knowledge. Learning through direct patient care is also very important, perhaps the most important way of all to learn. After seeing patients in the hospital each day, the student should seek out information as to differential diagnosis and treatment of the conditions seen that day. The student cannot learn everything, but by focusing mainly on the illnesses of the day, at the end of the four years the student will have studied the most common diseases.
6. Exams, including the Boards, should not present ‘gotcha’ questions, but basic information highly relevant to practice. So what if the questions are so basic that nearly everyone can succeed at the tests. They should be designed to confirm that the student has the necessary practical knowledge base. With the time saved by teaching general principles and promoting understanding in the basic sciences, rather than an overload of esoteria, the student will have more time to review for the Boards and study medical topics of personal interest.
7. While this may seem to be a “minimalist” approach to education, it is not. In the end it would maximize a student’s overall understanding of medicine, while inculcating a lifelong method of seeking out detailed information as needed.
“It’s the most comprehensive book for the Medical Boards. Unfortunately, no one can carry it out of the store.”
Medical student forums extensively discuss study for the USMLE exams. While this is important, because you need to pass the exam, there is a problem with spending a lot of time on rote memorization of numerous facts, since it steals time from understanding the subjects.
Understanding is key to practicing medicine; it enables the physician to provide better individualized patient care than relying on rote cookbook facts. Understanding also facilitates memory and retention. For those of you who have taken large subjects such as Biochemistry or Physiology, have you at the end acquired a broad understanding of the fields, or are you left with isolated points that never quite gelled into a coherent whole?
There is a better approach to medical education than rote memorization of an impossible number of facts. The medical school curriculum should instead insure that the student gains an overall picture and understanding of each subject, rather than cramming in an overbearing number of facts that will later be forgotten, even by the best physicians. These days, it is relatively easy to find isolated points on the Internet and elsewhere. It is not as necessary to remember everything; computers do a better job at that. The USMLE should also focus on understanding, but students are still required to memorize tons of information.
Over the past 32 years, Medmaster has tried to assist medical education by focusing on understanding, rather than rote memorization, through brief, clinically relevant books.
Since one has to study for the USMLE, it is important to maximize the efficiency of study, so that a great deal of material can be reviewed and retained in a short time. Andreas Carl has written Medmaster books for the USMLE Step 1, USMLE Step 2, USMLE Step 3, and NCLEX-RN exams using a unique approach. Rather than just presenting isolated and unrelated points, he has made extensive use of charts that compare one point with related ones; this saves study time. For instance, the chart below compares the most common causes of infection. Apart from having few words, the chart quickly allows the comparison of one disease with another. All his books do the same. His supplementary USMLE and NCLEX-RN Question Banks (available as free downloads from the Medmaster website), make review quicker by combining a number of questions into one, so that 4 or 5 facts can be covered in the time that it ordinarily would take to cover one.
Alternative medicine refers to medical approaches to diagnosis and treatment that lie outside the province of conventional medicine and are practiced instead of, rather than alongside, conventional medicine. Complementary medicine, which may consist of the same treatments as alternative medicine, is practiced in conjunction with conventional medicine, as a supplement.
CAM includes not only Acupuncture, Homeopathy, Chiropractic Therapy, and Herbal Medicine, but many other approaches to diagnosis and treatment, including (in alphabetical order) Alexander Technique, Alternative Diets, Alternative Exercise Therapies, Anthroposophic Medicine, Aromatherapy, Ayurvedic Medicine, Bach Flower Remedies, Cellular Therapy, Chelation Therapy, Colonic Irrigation, Craniosacral Therapy, Crystal Therapy, Cupping, Detoxification, Ear Candles, Feldenkrais Method, Feng Shui, Food Supplements, Hypnotherapy, Leech Therapy, Magnet Therapy, Massage Therapy, Meditation, Naturopathy, Neural Therapy, Orthomolecular Medicine, Oxygen Therapy, Reflexology, Reiki, Relaxation Therapies, Shiatsu, Spiritual Healing, and Traditional Chinese Medicine.
There is some difference in opinion as to what should or should be not classified as CAM. In a semantic sense, there really is no CAM that has been shown to work, since once a CAM treatment has been found effective it becomes adopted as a part of conventional medicine, so it is no longer “CAM.” Some CAM treatments have been shown to be ineffective, but for others there is insufficient evidence as yet to make the case one way or the other, and they might be useful.
While the same treatments can be used in alternative and complementary medicine, alternative medicine is more risky. By dismissing conventional medicine (e.g. many alternative practitioners advise patients not to immunize their children or use antibiotics), alternative medicine runs the risk of neglecting treatment for conditions that are highly treatable by the conventional approach. One plays Russian roulette with a child’s health by relying only on alternative medicine. Administering an ineffective remedy for a high fever in a child will be successful when the treater is lucky and there is a spontaneous cure, which usually occurs. But in the less common situation where there is a more serious illness, such as a meningitis or septicemia, the results may be disastrous. Hence, the importance of working together with the conventional system if one wants to try an unconventional approach.
You are taught conventional medicine in medical school rather than CAM. You will need to learn more about CAM on your own. You will be faced with patients who ask about or are using a variety of unconventional approaches. How do you sort through and evaluate all these options? The Internet is full of misleading information, as are many TV and radio shows, and tabloids that patients rely on from supermarket check-out counters. I suggest the following sites for trustworthy information:
Since so much of medical education involves reading, it is important to consider how eBooks compare with print books. Pros and cons of either method of reading have been presented in previous posts (A, B, C).
Which format do medical students prefer? Comparing medical student needs with those of general readers in other areas of interest is not necessarily useful. Someone reading a novel may have different preferences than a student who wants to underline, take notes, and study intensively for long periods.
The impression I have from medical students is that preferences differ considerably. Some prefer eBooks because they are easily portable and generally cost less than print books. Also, it is easier to acquire eBooks outside the country of publication, due to high costs of shipping print books. Ebooks also have an advantage of easy searchability and the ability to link to other areas. They can provide audio and video and are more easily updated.
Other students, however, prefer print books. Not every book requires audio and video. While an eBook can provide an impressive 3D rotation of the complex hemoglobin molecule, how important is it to know this structure? Is it educational or eye candy? While current eBooks allow for highlighting and note-taking, it is easier to do this directly in a print book, and one can easily just flip from one page to the next. Also, the screen glare is disturbing to some; it can be fatiguing looking at a screen for a long time, and there is a question as to whether reading speed and retention may be superior in print books. There is also an intangible; there is something “cozy” about a print book that is not found in an eBook.
In view of the differences in preferences, it would make sense for a publisher to publish the same book in both print and eBook format, so that readers can decide for themselves. Presently, several factors delay the publishing of eBooks: One is the different formats of eBooks; an eBook may be available on one type of reading tablet but not another, and even when books are available on a number of reading tablets, the interfaces may differ and the books may look different on one tablet as compared with another. Some books can be read on one’s computer desktop; others off the Internet, while others require a reading device. Also, some companies offer books using their proprietary reading applications, which are not available on Kindle, iPad, Nook, Android, or other reading tablets. This confusion is not the case with print books, where there is a single standard format; everyone knows how to use a print book and they are simple to use. If you want a print book, you can just go to a bookstore or major Internet distributor such as amazon.com or Barnes&Noble.com to purchase it. When the format and method of distributing eBooks become more standardized, this should increase the publication of eBooks, since a publisher can then develop an eBook in a single format and have it widely available, without having to prepare the book in a number of different formats for different eReading platforms.
Another factor holding up the production of eBooks is the evolving terms that eBook distributors such as amazon (Kindle), Apple (iPad), Barnes & Noble (Nook), etc. offer to publishers. These will need to be worked out and better standardized.
In addition, preparing an eBook that has many images and tables, particularly tables that spread across two pages in an 8.5″ x 11″ print book presents certain technical problems in trying to convert it to an eBook, since current eReaders offer a smaller viewing area, and there can be problems with the awkward reflow of text in tables.
Another consideration has arisen. Does reading on an eBook interfere with the remembering of what was read?
Some studies suggest that remembering may be harder with eBook reading (see Healthland and The eBook Skeptic) than with print books. The associations one makes with landmarks in print reading (the relative positioning the text and figures, whether the information was at the top or middle of the page, on a left or right-hand page or column, etc.) is not set with eBook reading when there is shifting of text flow with resizing of the page or font size. This relates to a memory technique called the Memory Palace (the method of loci) discussed in a previous post, where the context of the information, such as the surrounding visual landmarks, plays a role in memory ( also see Brier Dudley’s Blog). Ebooks that have text reflow have fewer such landmarks, and remembering may be more difficult.
Another issue is whether reading may be slower with eBooks than print books. Some of the earlier studies suggested this, but were done years ago when the computer screen had lower resolution, so it is unclear whether this is still a source of concern. It is also a question as to whether linking all over the place slows down reading and makes it difficult for the reader to keep track of all the links.
The issues of remembering and reading speed with eBooks require more study. If you have used eBooks, do you have any personal observations regarding your ability to remember, or reading speed with eBooks? Do you prefer eBooks or print books?
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