Opinion piece: ‘Medical students – learning from textbooks or electronic media?’


  • Conflict of interest: CMM is a regular reviewer and editor of relevant paediatric chapters for ‘UpToDate’. In return for this work, he receives a free annual subscription to ‘UpToDate’, together with a small honorarium for specific work done.

Correspondence: Professor Craig Mellis, Central Clinical School, Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia. Fax: +612-9036-5474; email: craig.mellis@sydney.edu.au

How do current medical students learn, and what educational resources are today's medical students using? In particular, do students prefer textbooks or the Internet? In short, what do students find is the optimal way to access the mountain of information that must be processed in order to progress from student to practising clinician? Furthermore, how are students' expectations and technological advances impacting on the delivery of the medical curricula? These are questions asked by generations of medical students and medical educators. These questions are just as relevant to teaching and learning in the many post-graduate specialty programmes, which are now far more structured than in the past. This opinion piece is based upon the experience of a graduating student, an executive officer of a clinical school and an associate dean of a clinical school, as well as the published literature.

Medical students must now negotiate a labyrinth of e-resources, iPhone and iPad apps. These range from the useful, such as ‘UpToDate’ (Wolters Kluwer Health, Clinical Solutions, Waltham, MA, USA) and ‘BestPractice’ (BMJ Evidence Centre, London, UK) for those who can afford it, and ‘Medscape’ (WebMD LLC, New York, NY, USA) for those who cannot, to the downright bizarre, such as an ‘i-stethoscope’ that claims to read a person's heart rhythm when placed on the chest. As new technology develops and becomes more affordable, it has become a case not of which resource to use, but which combination of tools is most effective in delivering the right information in the most efficient way to an individual student. Moreover, different students will learn in different ways, and what suits one may not suit another.[1] Despite the enormous volume of electronic and Internet resources now available, students are still encouraged by the faculty to purchase prescribed and recommended texts on entry to medical school, at a cost of at least $500 – some of which are never opened.

Print versus Electronic

There is now considerable literature on this increasingly relevant question. For example, a working paper from Monash University Library highlighted the numerous advantages to students (and librarians) of electronic media over print media.[2] These include remote access, on-screen browsing, cut and paste of downloaded text, tables and figures, selective printing, far better search facilities, plus cost and space saving. Many recent medical textbooks have attempted, with limited success, to overcome these disadvantages by including a CD (or restricted access website) with the entire contents in digital form.

Evidence-based learning and clinical decision making demands ready access to easily searchable and valid clinical data in electronic databases such as the Cochrane Library. Paradoxically, however, the Cochrane Library has its own problems. In particular, health professionals have major difficulty both locating the site and its contents.[3] User experience with websites has been extensively studied. Using a ‘honeycomb’ model, Morville et al. has described seven facets of user experience.[4] Namely, is the website findable, useful, usable, valuable, accessible, desirable and/or credible? Clearly, these are the questions all students should ask when using any Internet site for learning, particularly concerning ‘credibility’.

Online Resources

Most students currently consider ‘UpToDate’ (available by paid subscription, Wolters Kluwer Health), the ‘gold standard’ e-resource for providing reliable, current medical information. ‘UpToDate’ is a multi-authored electronic textbook, updated extensively every 4 months. It is evidencPrince of Wales Hospitale based, comprehensive and current, providing clinical information to aid decision making. The answers to a huge number of clinical questions are available in an easy-to-navigate, standard format. Quality of the evidence is graded with links to Medline abstracts. Treatment recommendations are made according to the ‘GRADE’ classification.[5] At its current price, $195 AUD per year for medical students (with proof of enrolment), ‘UpToDate’ is comparable with the price of many textbooks. Students are also aware that personal, departmental or health district subscriptions to ‘UpToDate’ are widespread in hospitals and medical libraries and readily available for their use. A new, comparable product, ‘BestPractice’ (BMJ Publishers), is now available to all students at Sydney Medical School. This is a similar, evidence-based decision support tool, which incorporates the well-known ‘Clinical Evidence’ (BMJ Publishers), and is designed for delivering valid information at the point of care.

As well as being frequently updated, the major advantages of e-textbooks such as ‘UpToDate’ and ‘BestPractice’ as learning resources are their reliability, ease of searching and portability of access (including via iPhones, Androids and iPads). Students report they often use these resources to check whether the information in their textbooks is up to date, and they are proving to be very useful adjuncts to their lecture material. In addition, these resources acquaint medical students with evidence-based medicine in a very practical, clinical context, which can be immediately integrated into clinical practice. This provides students with an excellent demonstration that evidence-based medicine can be applied at the point of care. However, since both ‘UpToDate’ and ‘BestPractice’ are essentially clinical resources, they do not provide sufficient information for use as a basic sciences text and are far more appropriate for senior medical students. A further disadvantage of ‘UpToDate’, common to many currently available resources, is that it is written largely by North American authors and recommendations target North American patient populations. Although ‘BestPractice’ is of British origin, it does attempt to be more global by including various guidelines and treatment recommendations from other countries.

‘Medscape’ is a free electronic database, operated by WebMD, an American-based provider of health information services. Medscape connects to an excellent ‘iPhone app’ and is used almost universally by those medical students who possess a smartphone (now virtually 100%). Students use this resource to look up concise information about uncommon conditions and to provide an overview of the pathophysiology and management of many common conditions. ‘Medscape’ is neither as comprehensive, nor as current as ‘UpToDate’ or ‘BestPractice’, but students find it very useful and readily available for on-the-wards fact finding, and for clinical, problem-based learning.

A major thrust of all medical programmes is the encouragement of self-directed learning, with the active exploration of information, rather than the passive receipt of information handed out by teachers. In medicine, more than any other field, the amount of new information generated is rapidly accelerating. This explosion of information will continue long after students have graduated. Students need to be able to identify required new knowledge, find it, appraise it and apply it appropriately. Thus, competency in both evidence-based medicine and information management is now absolutely essential competencies for new graduates.[6]

Online Courses

Rapid advances in information and communication technology (ICT) are continually changing learning and teaching practices within medical education. Students are embracing new technology and are changing the way they learn, resulting in new theories and practices in student teaching. ICT now forms the backbone of 21st century learning as an ever-expanding learning tool, being utilised to support new pedagogies involving complex problem solving and enhancement of the learning process. Most medical courses now include problem-based learning programmes, supported by online applications and systems such as recorded lectures, clinical investigations, images and pathology, multiple choice tests and interactive simulation programmes. A recent systematic review sought to determine what types of Internet-based medical courses ‘work’, for whom and in what circumstances.[7] From the 249 articles that met their inclusion criteria, these authors generated a list of five questions for prospective learners (and website developers) to ask of an Internet-based course. These fell into two broad areas: technology acceptance and achieving interactive dialogue. Firstly, Internet-based courses must strive to engage learners to use the technology, and secondly, in order to promote effective learning, interaction and feedback are absolutely essential.

Use of Handheld Computers in the Clinical Setting

A 2006 systematic review of the use of handheld computers in medical education found that approximately 60–70% of medical students and resident doctors use some form of handheld electronic device for education and/or patient care.[8] However, the impact on either learning or patient care was not addressed. Among our current graduating students at Sydney Medical School, the use of smartphones is almost 100%, providing immediate access to the Internet and numerous medical apps.

Advantages to learning

The use of handheld computers in accessing information for delivery of care is suggested to be of benefit to both teachers and students.[9] Reported advantages described in recent studies, including efficient information management, portability, immediate Internet access, efficient use of time and ease of communication.[10, 11] Further to this, having immediate access to information while on the wards gives students a better scaffolding for the comprehension and accumulation of new information that will also enable more efficient retrieval in the future,[12] facilitating ‘opportunistic’ learning opportunities for students.[13] Additionally, when students access information frequently, they learn through repetition, repeated active application and consolidation of knowledge.[11, 14]


There are a number of challenges identified to the use of handheld computers in the clinical setting, including reliability of sources, distraction, professionalism, information privacy, superficial learning15 and negative perceptions from medical staff and patients.[9-11] A particular concern regarding such easy and rapid access to information is that this may inhibit the internalisation of knowledge, with students may rely too heavily on being able to access information, rather than memorising core knowledge.15 While handheld computers currently provide a useful additional tool for students and are increasingly used in undergraduate medical education and training, it remains unclear whether this will result in improved student skills, increased learning opportunities and better acceptability by medical staff. Students would likely benefit from faculties developing policies to provide guidelines on the professional use of handheld computers in medical education.

In conclusion, the resources discussed above, as well as many others, are widely available to students and currently being used by many but not all of any given cohort. It is within the scope of educational institutions to harness the availability of such information and guide students towards choosing the resource that is right for them, thus fulfilling what is arguably the most important role of the educator: to teach students to learn for themselves. It appears that while e-learning and e-resources will replace traditional textbooks for many medical students, others prefer written media and will continue to favour textbooks.