Results
Measuring outcomes of experiments in education is difficult. The two
charts provide some graphic data. The top graph
indicates results on the final exam given in our course for which we use
the Miniboard (an examination purchased from the National Board of Medical
Examiners, Philadelphia, Pa) which allows comparisons with a national base
of medical students. 1985-86 was the last year of the traditional lecture
course. In the years that have followed since lectures were nearly eliminated,
the performance of the weaker students (<380 score) did not signficantly
change. The performance of the stronger students (>600 score) significantly
increased.
The lower graph shows the performance of the second year class on the
formal National Board Exam, Part 1, given at the end of the second year.
The Pathology exam is indicated by the vertical arrow. It is apparent that
the students taking the exam in 1987, the first class to have gone through
the new curriculum, performed as well in pathology as in the other subjects,
much like in the prior year. The same can be said for 1988. 1989 was an
unexplained drop in overall student performance. Nonetheless, in this year
where all preclinical subjects were below the national mean, pathology was
the only subject which was above the national mean. In 1990, the entire
class had a much improved performance and pathology was 2 standard deviations
above the national mean.
An update of
the Pathology course as of July, 1995, and two brief abstracts (Abstract #1) (Abstract #2)
from 1996 are appended. Top
of Page
Eliminating lectures
through reading, discussion and computer based self-assessment
An update as of July, 1995
Robert L. Trelstad and Jana Raskova
Department of Pathology & Laboratory Medicine
Robert Wood Johnson Medical School
Piscataway/New Brunswick, New Jersey
Summary
Lectures were eliminated as the primary means of conveying information
in the second year course in Pathology. In place of lectures, the content
of the course was obtained by the students through reading a textbook and
selected articles from the literature. Elimination of lectures altered the
ways in which students organized their time and study habits to meet their
individual needs. Small group discussions, in existence before instituting
the lecture-free curriculum, assumed new importance in the interactions
of students with faculty. Addition of case based learning further increased
the importance of discussion and self-learning. Extensive self-assessment
and self-learning tools were provided on computers to assist students to
acquire and use new information. The performance of the students on internal
and national examinations improved under the new curriculum.
Introduction
The lecture is certainly the oldest tool employed in teaching. Before
the advent of writing in any form, individuals were teaching others by verbal
and visual means. The lecture is a powerful tool in the present day. It
allows individuals with general knowledge and/or particular expertise to
convey that knowledge in an efficient manner. In the medical school setting,
the attention of a class of 150 students can be riveted on a subject for
an hour or more with the lecturer conveying not only content, but attitude
and approach.
The lecture, however, has deficiencies which may outweigh its strengths.
In the medical school curriculum, lectures often follow upon lectures, straining
the attention span of students. Not all lecturers are well prepared or stimulating.
Many lectures are accompanied by a handout with content similar to that
presented verbally. Lectures obligate students to be attentive at specific
times and places and are not necessarily in tune with an individual student's
learning rhythm. A measure of the lecture's worth can be gotten by attending
any lecture at any medical school about half-way through the course. The
attendance at the lecture will generally be less than 50%. A tape recorder
will be recording the event and this tape will be transcribed by a student
and distributed by a 'note taking service.' Those students present at the
lecture will likely have copies of the previous year's notes open in front
of them as they listen.
In 1984 the American Association of Medical Colleges released its recommendations
for the curriculum for educating the physicians of the next generation.
In it was the suggestion that lectures be reduced by 20%. In 1986 we decided
to implement the recommendation in what we thought would be a significant
manner, viz., virtually eliminating the lecture as a means of communicating
course content. In this report we review that experience with attention
to the politics as well as to practical and pedagogic details.
Course Description
The second year course in Pathology occurs in the first semester of
the second year. It is attended by approximately 150 medical students. It
is the major course of the semester, occupying 205 hours of the curriculum.
Several short courses are given by other departments during the semester
including one in infectious disease and another in hematology. The pathology
course lasts 14 weeks with approximately 14 hours scheduled per week.
Each week begins with an optional 'Overview' at which the faculty member
responsible for that week presents a broad outline of the subject, often
through the use of a clinical case. No information is presented at this
session which must be heard, recorded or read from notes to be able to answer
an examination question. The faculty member in charge of the week is available
at all reasonable times throughout that week to meet with any student who
has difficulties with or special interest in that week's subject.
About 50% of the time for pathology for the week is assigned to self-study.
These blocks of protected time are managed at the students' discretion and
range from reading alone at home to participating in joint studying with
colleagues. All students have available the services of an Education Office
where the staff are skilled in addressing the tasks of organizing, managing
and studying information. Approximately 5% of the class has one or more
encounters with this office during the semester.
Two different discussion groups are mandatory both with 16 student to
one faculty: PathTalk and CaseBase. PathTalk takes four hours every week;
in an interactive setting the morphologic and pathophysiologic aspects of
the assigned topic are discussed. This group also features journal article
presentation by a student of a recently published, clinically relevant article.
The other small group, CaseBase takes three hours and is based on the analysis
of clinical cases, written by the faculty, and focuses on the meaning and
interpretation of laboratory tests, and on the correlation of abnormal laboratory
values with pathophysiology and morphology.
Gross pathology is presented weekly through closed-circuit television
so that the demonstrator can provide clinical details and show organs to
all individuals at one time. At the end of the presentation, students can
go to the laboratory to handle the specimens directly. Attendance at the
gross sessions is optional.
Attendance at one autopsy and preparation of a final autopsy report,
including a discussion of clinical correlations was required until the most
recent year, when it became optional for reasons of insufficient cases during
the time alloted to the course.
Computer usage is optional. At the beginning of the course approximately
6 hours were devoted to demonstrating and discussing the various uses of
the computers. In 1989 several first year courses adopted our approach with
computer based quizzes. Accordingly, when the students entered the second
year they were familiar with the computer resources. In 1995 essentially
all student are computer literate and approximately 50% own a personal unit.
The required textbook was chosen in the spring of each year prior to
the next year's course. Three texts have been employed: Robbins Pathologic
Basis of Disease (Cotran, Kumar & Robbins, eds.; 3rd Edition; W.B. Saunders);
Pathology (Rubin & Farber,eds;, 1st Edition; Lippincott) and Robbins
Pathologic Basis of Disease (Cotran, Kumar & Robbins, eds.; 4th Edition;
W.B. Saunders); The information embodied in the text was that for which
the students were held responsible. While the journal reviews in the large
discussion groups were mandatory, questions on the exams were only taken
from the text. Approximately 20 articles from the primary literature were
read during the course.
Once or twice, during the course, the department hosts a late afternoon
party for the students and at the end of the course, a reception for the
Honors students.
Implementation and Maintenance of the Curriculum
The decision to implement the new curriculum was made by the course
director (JR) and chairman (RT) after thorough discussion. The plan was
then presented to the faculty for comment and input and adjustments were
made. The students were notified in the summer before their second year
of the new curriculum plans. This notification was not necessary in subsequent
years. The first day of the course each year is devoted to a discussion
of the philosophy and logistics of the entire course. This session includes
a presentation by the Educational Resources office. The course is monitored
by weekly meetings of the course director and/or the chairman with one of
the small groups for one hour. This hour is taken from the four hour weekly
session of that group. Four meetings with the teaching faculty are held
throughout the 14 weeks.
Outcome Assessment
Traditional assessments involve multiple choice questions based on image
identification and understanding (20%) and theoretical questions (80%).
Faculty prepare a short written comment on each student's performance in
their small groups which are read and integrated into a final descriptive
statement which becomes part of the student's record. Three examinations
are given during the course and are written by the faculty and edited by
the course director. The final examination is the Shelf Examination of the
National Board of Medical Examiners. The final grade for each student is
derived from examination scores, with judgements about honors including
comments by the discussion group leaders and the quality of the autopsy
report. At the end of the course a questionnaire is given to each student.
Computer Based Learning Resources
In conjunction with the elimination of the lectures in 1986, we introduced
a variety of self-testing and self learning tools on the computer. These
initially were MS/DOS based questions using the QuizMaster program from
Dr. Thomas Kent of the University of Iowa and the videodisc series from
the National Library of Medicine created by Dr. James Woods and Dr. Robin
Jones of the University of Kentucky. Subsequent software developments have
been done on the Macintosh, initially authored in Hypercard by one of us
(RLT). At present our students have access on both Apple and MS/DOS platforms
to the full texts of Robbins Pathologic Basis of Disease; Sherris' Medical
Microbiology; Junquiera's Histology; Theoharides' Pharmacology; the Merck
Manual; and Roitt's Immunology. In addition there are interactive exercises,
quizzes and an annotated and selected guide to the Slice of Life Videodisc.
The students now have access to literally thousands of multiple choice questions
with learning responses in histology, pathology, microbiology and pharmacology
and immunology.
The number of computer workstations required for the course is approximately
1 per 10 to 15 students. For a class of 150, we presently have about 10
MS/DOS instruments and 10 Macintosh. Videodisc players with separate monitors
are necessary for using the Slice of Life videodisc and a minimum of 4 to
6 such units is necessary for a class of 150. The management and uses of
the computers are under rapid evolution and their governance, security,
maintenance and content are under review.
RESULTS
Student reactions
As predicted, the first year of implementation was the most difficult.
Uncertainty on the parts of the students and faculty was high. By the sixth
week, however, student comfort with the realization that the body of knowledge
to be mastered was primarily within the covers of the textbook began to
take hold. In subsequent years, the initial surprise at the expectation
of self-learning was muted by discussions with the older students. Many
students had not seriously read a large textbook prior to this course, however,
and the need to adopt a productive learning strategy became a major concern
during the first weeks.
The weekly meeting of the course director with each of the large discussion
groups provides an outlet for student fears, frustrations and accomplishments.
The mutual support of the students for each other in striving to adjust
their learning pattern to an independent mode is fostered at this session.
The anecdotal information and that which comes through the questionnaires
has been strongly supportive. Because the questionnaire is not obligatory
and yields less than a 50% return, it is difficult to reach rigorous conclusions.
We consider it significant that students have not complained to other faculty
or the administration about the course and regularly speak in its favor.
In a recently completed LCME study of the medical school, the pathology
course was singled out as a model by the students.
Faculty Reactions
The faculty embraced the idea after full expression of both hope and
doubt. The doubt was born from fears that curriculum time would be reduced
if lectures were eliminated; that students wouldn't be motivated to self-learn
and read the text; that computer based self-assessment was insufficient
to measure suitability to become a physician; that faculty were hired to
'teach'; that students would overwhelm them with office visits out of panic
and desire to get unique insights and information; that role modeling for
potential recruitment into pathology would be lost by eliminating the visible
and dramatic lecture platform. None of these concerns could be addressed
at the outset and during the discussions of the curriculum change on the
basis of any direct experience. However, these concerns failed to materialize.
The hopes were equally based on conjecture, rather than experience, and
included expectations that the new curriculum would eliminate the concern
that students were not attending lectures; that lectures often focused on
minutiae or special interests; that dialogue with the students would occur;
that developing independent learning skills would be promoted to the future
physician's best interests; that computer based assessment might lead to
better uses of this new tool; and that improvements in student performance
might be effected by giving them more active reading/learning time. Many
of the hopes have materialized.
Faculty Requirements
The number of faculty to staff the course as currently constituted include
the need for 10 instructors for PathTalk and 10 instructors for CaseBase
(8 regular and 2 reserve for each group). Some faculty serve for both small
groups. The department has 28 full time faculty and about 15 volunteer faculty
from which to draw. The volunteer faculty are not paid for their efforts.
The department also has residents, fellows and visiting faculty and/or fellows
totaling approximately 15 to 20. For the past two years, at least 3 residents
have assumed responsibility for one of the small groups, much to the delight
of the students, the residents and the faculty.
The central requirement for all faculty involved in the course is to
enjoy teaching. The intensities of the discussion group exposures assure
extensive faculty-student interactions and the pleasures and problems that
devolve from that process.
Student Performance
The attitudes of the students toward the course is strongly positive.
Because of the care and consideration given to the effort by the faculty,
the course director and the chair, this is to be expected. One objective
outcome is the performance of the students on National Board Examinations.
DISCUSSION
The role of the lecture in teaching has a long history and the uses
and abuses of lecturing as a mode of teaching in medicine, in particular,
has an interesting legacy in the history of Robert Wood Johnson Medical
School, the oldest, episodic medical school in America (1792-93 Queens Medical
College, 1812-16 Rutgers Medical College, 1826-30 Rutgers Medical College,
1962-1986 Rutgers Medical School, 1986-Robert Wood Johnson Medical School).
In 1813, the College of Physicians &Surgeons had adopted a policy of
giving students "the liberty to attend any course he may think proper
with the professors passing upon the attainments of the candidate, and not
upon the number of courses, nor the number of years he may have attended
the University". This program in 'self-learning' was opposed by a number
of faculty and became the focus of formal complaints. In 1822, a document
was drafted which stated: "It is a well ascertained fact that young
men generally speaking, will not perserve in the labor of long application
and study without some degree of compulsion. Coercive means, adopted to
their age, but conducive to the acquisition of knowledge are necessary,
such as a certain period of study and attending upon lectures in several
successive sessions. The argument continued that lectures were necessary
and a superior form of education. "The Professor reads for the students,
and gives him the result more beneficially than he could collect it for
himself until his judgment is matured." The Faculty squabbled for some
time over this issue of curriculum and the leader eventually became David
Hosack, who turned to New Brunswick and, gaining the sanctions of Rutgers
College in 1826, opened Rutgers Medical School at 68 Duane Street in Manhattan
and had 152 students in contrast to 90 at P&S.
The studies in the 20th century on the relative merits of lectures versus
self-learning in medicine have demonstrated that the two approaches are
relatively comparable. We do not contest this conclusion. Because our curriculum
revision did not involve a comparison of a lecture intensive versus a lecture-free
curriculum running concurrently, we do not believe we can directly address
this issue. We do conclude, however, that the performance of our students
has improved by the shift to a non-lecture, small group format and we believe
there are arguments for adopting this mode of teaching in departments other
than pathology.
The most significant issues which have developed in our lecture-free
curriculum which warrant its consideration as a model for other disciplines
are: 1) the students are required to be self-learners and print literate;
2) learning time for students increases by the implementation of a self-study
curriculum; 3) faculty-student interactions are maximized through attention
to discussion groups; 4) computer literacy can be introduced and emphasized
and review, retrieval and reference skills with textbooks and literature
on computers is acquired; 5) time flexibility is added to the life of the
student; 6) the expectation that students will continue as self-learners
and strong performers is being borne out.
The expectation that students must master the body of knowledge embraced
within any and all of the major preclinical knowledge domains, by whatever
name, is very real. A sampling of curricula at various institutions; a review
of the expectations of clinical services vis a vis the students' prior learning
experiences; and a review of national certifying examinations all attest
to this expectation. In pathology, the knowledge domain required for student
mastery is well circumscribed and presented in either of two major textbooks.
Robbins pathology has been a standard for generations of medical students.
It contains 30 chapters and 1463 pages of text, with figures and tables.
Most American medical schools attempt to survey this material in a 200 to
250 hour course which is minimally one semester in length and rarely longer
than 2 semesters. Most schools choose to cover only a part of this body
of information and at RWJMS we expect the students to read approximately
60% of the book. This means that the most compressed courses, such as ours,
requires the students to cover a chapter a week. This is a large body of
new information to read, integrate and master. We believe that the most
efficient manner for students to do this is to do so by themselves, at their
own place and time of choosing and at their own pace.
Since implementing the lecture-free program, we have had the opportunity
to discuss our experience with a number of different schools. It is immediately
apparent that the raw volume of material placed in front of most students
at other schools exceeds by a factor of 2 to 4 that which we give our students.
Last year's lecture notes, this year's lecture notes, handouts, outlines
and the like are added to the text, in most courses. Few course directors
will admit that their students neither own nor read the texts. But few courses
require, as is the case at RWJMS, that the students read the textbook. The
quality of the notes from which students at most schools study are never
greater and usually less than the information found in a textbook. As a
matter of sheer volume, therefore, the lecture-free course puts less in
front of the student to master. As to quality of learning materials, we
have yet to see a course syllabus which is not extracted heavily from the
textbooks and which adds clarity to content or presentation. The converse
is generally the case.
So why do we lecture? The reasons are bound up more in politics and
personalities than in pedagogy. The lecture provides a forum for faculty
to provide nuances and insights; the lecture offers the opportunity for
students to be exposed to the thoughts of experts; verbal presentations
can be inspiring. Under the pressure to speak to the student the essential
content of the textbook, however, these goals are often missed. Second year
students are confronted with a substantial vocabulary test when reading
or listening to a lecture. We believe the apprehension of the basic facts
and processes of the pre-clinical sciences are more efficiently gained by
the student by reading and then discussing.
The concern that faculty-student interactions, role modeling and personal
interactions would be diminished by the lecture-free format have proved
false. The opportunities in the small group sessions to establish a meaningful
relationship with the students are extensive. Each faculty member deals
with his/her group as they wish within certain boundaries agreed to by the
course director. We have not rotated students through the groups so they
would get exposure to more than one instructor. It has not proved difficult
for the instructors to master the materials relevant to the topic of the
week.
The issue of expert's versus non-expert's levels of knowledge occasionally
arises. Our goal is not to make the students practicing pathologists, but
rather to lead them to gain insights into disease nosology and mechanisms
which will serve as a base for future clinical years. Accordingly, the best
of the lung pathologists are not needed to teach lung pathology to second
years students. Quite the converse can be the case: too much knowledge and
expertise can preclude the simplification which the students need to apprehend
the subject on their first iteration through the topic.
Textbooks on Computers
We now have over six year of experience with textbooks on computers.
From the efforts begun through our course at Robert Wood Johnson Medical
School, a new approach to medical textbook presentation and utilization
has evolved. This has included the founding (by RLT and others) of Keyboard
Publishing.
Of relevance to the present discussion is the value of textbooks, and
other learning resources, on a computer platform. As usage of computers
for daily tasks accelerates and computer literacy is becoming commonplace,
it is not hard to realize the power of books in digital form. In the Keyboard
Publishing series, all books are on a common platform and can be searched
simultaneously. This is, without doubt a powerful and compelling use. We
do not recommend that students initially read the text on the screen. The
purpose of the text in digital form is for re-reading, for reviewing, for
searching. Our students can simultaneously search textbooks of histology/cell
biololgy, pathology, microbiology, molecular biology, immunology, pharmacology
and medicine/pediatrics/psychiatry/obstetrics (Merck Manual) in a Boolean
manner within seconds. In essence, nearly the entire knowledge domain of
the pre-clinical curriculum can be integrated by the student in such a manner.
While these digital textbooks are just becoming available, it is likely
that all major medical textbooks will be available in similar forms within
two to three years.
By eliminating the lecture and presenting the textbook in a rapidly
searchable form we have been able to simultaneously decrease the students'
dependence on the spoken word for information transfer while increasing
their access to those words. Thus the first year student studying protein
folding and beta-pleated sheets can immediately leap without jeopardy into
Robbins or Roit or Sherris or the Merck Manual and read about amyloid. The
cell biologist talking about clathrin and coated vesicles can leap into
these same texts and explore explicitly the details of the LDL receptor
and atherosclerosis. This integrative capacity has just begun to have an
impact on the ways by which our students now explore these texts. It is
also just beginning to have an impact on the clinical decision making process.
Putting the student in charge of the access to information by reducing
or eliminating the lecture has been a success. That the technology of digital
publishing happened concurrently is, in part, unexpected and, in part, of
our own doing. We would like to think this was all planned through a rational
approach to the curriculum. However, it was not, and therein might also
lie an important message. We have engaged our students by whatever means
we had available and through that process we've all grown.
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Replacing Lectures with Reading,
Small Group Discussion and Computer Assisted Learning: Results after Nine
Years.
Jana Raskova,MD and Robert L. Trelstad, MD
Academic Medicine, 71:537-538, 1996.
Objective
To promote self-learning skills, problem solving and computer literacy
in the second year course in pathology in a manner which is applicable to
other preclinical courses. Description
Lectures were eliminated as the means of conveying information in the
second year course in pathology (Arch. Path Lab Med 113:204, 1989). Subject
content was obtained by reading textbooks and articles complemented with
case-based discussion groups. Self-assessment and self-learning tools were
provided on computers.
The pathology course is first semester, second year, 205 hours, 15 weeks
for 150 medical students. About 50% of the allocated time is assigned to
self-study, managed at the students' discretion. Two different discussion
groups, each with 16 students to one faculty, are mandatory. PathTalk requires
four hours class-time weekly and 2-4 hours preparation. Morphologic and
pathophysiologic topics are discussed, slides and unknowns studied and journal
articles presented. CaseBase requires three hours class-time and is an analysis
of clinical cases focusing on the interpretation of laboratory tests, and
clinical correlations with pathophysiology and morphology. Gross pathology
is presented weekly through closed-circuit television and in the laboratory
where students handle specimens.
A required textbook is chosen and students are responsible for the information
in the textbook. Three texts have been employed with equal success. Twenty
journal articles in the discussion groups are mandatory reading, but exam
questions are only taken from the assigned textbook. Students have available
seven digital textbooks, including Robbins, in a cross-searchable platform;
multiple question banks (pathology, immunology, microbiology, pharmacology,
cell biology); and several image intensive programs (histology, microbiology
and pathology), all from Keyboard Publishing..
Discussion
This curriculum warrants its consideration as a model for other disciplines
for several reasons: 1) students are required to be self-learners and print
literate; 2) learning time for students increases by the implementation
of a self-study curriculum; 3) faculty-student interactions are maximized
through discussion groups; 4) computer literacy is emphasized and review,
retrieval and reference skills with textbooks and literature on computers
is acquired; 5) time flexibility is added to student's learning opportunities;
6) the expectation is that students will continue as self-learners.
Evaluation
Putting the students in charge of the acquisition of information by
eliminating the lecture and making reading essential has been a success.
Students perform well on national examinations; they regularly rate the
course the best pre-clinical experience; and they continue to refer to Robbins
as clinical clerks, indicating that tools and references used during training
continue to be used at subsequent times. We have engaged our students by
a variety of old and new means and have emphasized the process of self-learning,
peer discussion and literature review. The need for healthcare providers
to be print and computer literate is addressed in our curriculum while the
students acquire the essential content to allow them to be skilled practitioners
and life-long learners.
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Digital Medical Textbooks:
Empowering Students, Providers and Patients
Robert L. Trelstad, MD
Digital textbooks for students, providers and patients developed from
an assumption that cross-searchable, interlinked references would appeal
to and empower the user. Several software platforms with medical textbooks
are available with an array of pre-clinical and clinical subjects. The assumption
that they are useful can now be tested in a variety of environments including
schools, offices, outpatient clinics, pharmacies, hospitals, and homes.
Description:
In 1986, digital self-testing and self learning tools for the second
year course in pathology were introduced in a shift in the pathology curriculum
from a lecture base to a discussion base (Arch. Path Lab Med 113:204, 1989).
In 1987 printer's tapes were obtained from W.B. Saunders of Robbins
with the help of Dr. Ramzi Cotran and Mr. Richard Zorab and tapes of the
15th Edition of the Merck Manual were obtained with the help of the Editor-in-Chief,
Dr. Robert Berkow.
Additional books have been added to both Macintosh® and Windows®
platforms so that users of the Keyboard Publishing® series can simultaneously
read Robbins, the Merck Manual, Sherris Medical Microbiology (Appleton/Lange),
Junquiera Histology (Appleton/Lange), Roitt Immunology (Blackwell), Theoharides
Pharmacology (Little Brown), and McClatchey Laboratory Medicine (Williams
& Wilkins).
Discussion:
Over eight years with digital textbooks confirm their acceptability
and usefulness. Measurements on student use show browsing patterns, directed
searching and inter-textbook linking. Marketing data show rapid growth within
and outside the usual medical environments.
Students, healthcare providers and patients ask questions when stymied,
querying peers, advisors or accepted standards. Textbooks are accepted standards
of distilled knowledge. Information, quickly obtained from an aggregate
of such independently written references, properly read and digested is
empowering and enabling to students in their semi-artificial world of problem
solving, providers in the real world of problem solving and patients in
the middle of a clinical problem.
In the May 3, 1995, issue of JAMA, Coleman O. Martin, a medical student
at the University of Kansas wrote "Recently I was assigned a patient
with Pompe's disease, a condition about which I knew nothing. I quickly
scanned some of my computer software and found in the Merck Manual that
Pompe's causes muscle weakness, while Robbins presented the biochemistry
of glycogen metabolism. Armed with this basic information, I gave a brief
overview during rounds".
Mr. Martin was empowered by his access to digital textbooks. With time,
healthcare providers, trained with digital resources, will come to rely
on them.
Evaluation:
We do not recommend initially reading a textbook on the computer. The
purpose of the digital textbook is for re-reading, reviewing, and reference.
Providing students with digital resources will eventually alter the way
they practice medicine and remain current. Continuing medical education
through this avenue is open for new development.
Digital textbooks will not replace printed textbooks. Printed books
do not require power, can be mishandled, magnetized, frozen, taken to the
beach or stored for centuries without loss of readability. Digital books
do not replace print books; they complement and extend them.