SMS ("Stanford Medical School") Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.
A recent survey published in H&P, the Stanford medical school magazine, asked twenty graduating students to recommend books to read during the clinical rotation in internal medicine. Surprisingly, the top vote-getters weren’t books at all. The two most popular resources were both banks of practice questions, while the next two included a review book and a pocket handbook. (The top four resources: MKSAP question book, USMLE World question bank, Step Up To Medicine review book, and Pocket Medicine.)
“Is this how our students learn the subtleties of sickness and health? What happened to textbooks? We had to read Harrison's Principles of Internal Medicine cover to cover!” remarked one professor after reading the survey.
For what it's worth, Harrison's did receive one vote in the survey. But the results reveal a profound generational change in how medical students are learning the fundamentals of human health and disease. The recent explosion of printed and digital resources offers students alternatives to the classic texts that previous generations swore by. As a result, medical tomes are no longer the primary means by which students learn medicine, but just one piece of an increasingly complex puzzle.
Medical school is often compared to drinking from a fire hose; the student’s job is to imbibe as much knowledge as possible without getting bowled over. This is not a new phenomenon. Western physicians have been producing vast compendia of knowledge for millennia. The ancient Greek physician Galen published hundreds of treatises, aided by an army of scribes and students who recorded his every word while he saw patients.
The modern academic physician also leads an entourage of student doctors during daily rounds. But instead of scribing away on scrolls or stone tablets, today’s trainees scroll through their web browser on tablet devices. While one resident looks up drug dosing on UpToDate, her colleague consults Diagnosaurus to make sure he didn’t miss anything in the differential diagnosis. Meanwhile, the medical student quickly does a practice question on the USMLE World online question bank to test if he really understands the treatment algorithm.
The shift away from voluminous texts starts early in medical school, when the first exams come up before any of us has made it all the way through Gray’s Anatomy. Students opt for streamlined review books and digital resources in part because they are, well, streamlined and digital. Instead of reading about each step in the Krebs cycle, download an app with vivid pictures and animations. Instead of lugging a cardiology textbook to the library, go for a run while listening to a podcast about congestive heart failure. And if Google doesn’t have the answer, consult the online version of Robbins Pathology (soon to be powered by Google).
Students also point out that reading textbooks is "passive learning," which many studies have shown to be less effective than "active learning" such as answering quiz questions. Others may want to tailor resources to their individual learning styles; visual learners frequent websites like SketchyMedicine and Picmonic, audiophiles stock up on lectures from iTunes U. Medical schools (including Stanford) even collaborate with web-based platforms like Khan Academy to digitize their curriculum.
The generational shift in learning styles is a source of consternation to at least a few senior physicians. I recall one clinician who helped us examine a patient in respiratory distress and then quipped, “There is NOT an app for that.” In another instance, an exasperated consultant asked a resident, “Do I need to draw you a picture?!” – and was shocked when the resident replied (without a hint of sarcasm), “That would be great; I’m really a visual learner.”
I have also heard faculty say that trainees must "earn it to learn it." Wading through Robbins and Harrison’s makes students confront the sheer depth and breadth of medical knowledge, and ultimately imparts a more nuanced understanding of human disease. As one surgery faculty put it, “would you really want your life in the hands of a doctor who aced his multiple-choice boards questions but hasn’t read a textbook?”
The truth is likely somewhere in between. Innovative digital resources are vital for helping students retain knowledge and simplify difficult concepts. As long as there are multiple-choice board exams, there will be demand for streamlined review books that distill high-yield content. But Harrison’s isn’t going away anytime soon, nor should it. There will always be a need for textbooks to provide comprehensive information. And even the most committed app aficionados among us will eventually make it through those books – just maybe not during internal medicine rotation.
Mihir Gupta is a third-year medical student at Stanford. He grew up in Minnesota and attended Harvard College. Prior to writing for Scope, Mihir served as co-editor in chief of H&P, the Stanford medical school student journal.
Photo by NatShots Photography