Welcome to Dr Roger K.A. Allen’s Blog

May 18, 2010

The failure of modern textbooks

Filed under: Medical — Tags: , — Dr Roger KA Allen @ 3:21 pm

I was recently asked by a colleague overseas to coauthor a chapter on the treatment of sarcoidosis for a book on interstitial lung disease. However, the task competes with a book I am writing about my early childhood and in which I am very much aware of the “voice” of the book. I have not yet started the chapter of the textbook but have looked at some early editions.

The overwhelming thing I observe is the failure of most modern textbooks to convey personal experience, except by virtue of a citation of some prior publication. The voice, by convention, is scientific, impersonal, passive, and not active. It is far off. The patient and the medical process are viewed like an enemy frigate through a spyglass at a league’s distance, only even less emotive. A handbook I own, Evidence-based Medicine Toolkit (no definite article), is the medical equivalent of a metre long bar of platinum held in a vacuum in Paris by which all metres and hence evidence in the medical cosmos is to be measured.

I believe the duty of a textbook is to be enjoyable to read. Most, however, have the linguistic flair of a German car manual; they have no sense of engagement with the reader, no real human “voice,” no guides for the novice, no hints to help you remember indigestible facts, no etymology to explain words, no history of the disease, treatment, or investigations. In short, they are written by idiot savants devoid of wit and soul. Their words are not used like notes, and their sentences are constructed with the finesse of an amateur brick layer. This is pedestrian prose at its worst. Harrison’s Principles of Internal Medicine reads like a medical version of the Larousse Gastronomique only with less appeal, and the only way I find it interesting is to read the French version, which then subserves my two needs: consciousness and information.

We have thrown the baby out with the bath water. If I wrote a chapter on the treatment of sarcoidosis I would like to include information about the history of the drugs used, the problems I have personally encountered over 30 years, and the pitfalls and costs – and not just lifeless lists of studies and facts like a Metro timetable. I wish to engage with my reader and share the passion I have for the subject of sarcoidosis. Alas, I am sure the editors would fillet the fish, leaving only the skeletal remnants, in accordance with the doctrine of Cochrane and the medical and political correctness of the time.

Carl Jung, in his Psychology and the East, stated: “Science is the tool of the Western mind, and with it one can open more doors than with bare hands. It is part and parcel of our understanding, and it obscures our insight only when it claims that the understanding it conveys is the only kind there is. The East teaches us another, broader, more profound, and higher understanding—understanding through life.”

The history of our craft is missing, even as a preamble, from our textbooks, which are preoccupied with the latest creations–advances and the studies and trials that led to them–and give no sense of the fertile swamp from which these new reptiles have arisen. This year’s textbook will be next year’s door stopper and no more readable.

I recently asked a final year medical student whether he knew who discovered oxygen, the derivation of the word “oxygen,” and the first man to describe how the lungs work. He did not know. Thus I believe that the current teaching of medicine perpetuates the existential, mechanical style of modern journals and textbooks.

Let us rediscover charm, linguistic style, and humour to breathe new life into these dreary reductionist manuals on the human machine. Be like Dr Johnson, whose Dictionary of the English Language stands out from all dictionaries that followed not just by his vast eclectic knowledge but by its humour, prejudices, and views of life.

So don’t give me the chaff of a modern textbook to read. Nay, Sire, give me a bushel of oats.

Published on BMJ 2010; 340: c2132.

___________________________

Rapid Responses on BMJ

We need a new recipe for a new era (Published 16 May 2010)

Dear David if I may use my colonial informality, I observe that we have entered a computer age where the consumer is used to a more interesting and creative medium; interactive, palatable and alluring and not a Metro time table.

My son at junior high school now has a Toshiba tablet on which all his work is done, with the teacher being able to see any tablet in class as they are all linked. They are not sitting down as I did as a kid with a slate or pen with nibs and ink.

The old recipe for a text book has reached its “used-by date”. I think this applies to journals too but that is another matter. The recipe has been reached because editors are conforming to what they see as a scientific recipe but is is more than that; it is “safe” and boring to boot. The crême brulée has no caramelised sugary crust and the taste is bland. We are getting Spam instead.

As one who has participated in writing textbooks as an author, one is given blinkers and hobbles and told to stay within the guidelines. The remuneration is also abysmal for the work it takes. If medical publishing is going to succeed, it has to attract back the disaffected like me.

I cannot see why a book cannot teach as most currently don’t. They present facts and that is not teaching. The reader either has the stuff taught by an external source e.g. medical teacher/tutor or learns to navigate the stuff and works out a teaching method himself.

I am currently learning Greek and have a teacher and observe that the book which is all in Greek (no English), teaches up to a point but could be made so much more useful with specific teaching points, footnotes, reference to words in English, Ancient Greek, or how to remember a word which seems impossible to remember; sort of aides mémoires. The editor and author are not putting themselves in the shoes of the reader who is a novice. In a nutshell, it’s all Greek to me.

It is also possible now to have a website attached to textbook for further reference, footnotes etc. Teaching takes more intellectual input than just presenting facts and what may appear to be patently simple and clear to the boffin writing the book, may be less than simple to the novice reader. Just look at the chapter on pseudo- pseudohyperparathyroidism etc or porphyrias and see how the authors fail to show you how to remember them.

Rapid Responses is just one example of the change in publishing. We can now discuss “live” rather than writing a letter with quill and ink six months after the BMJ arrived by clipper ship to Australia and long after you Poms had read it.

Kind regards, Roger Allen

Competing interests: None

Humour and rhyme in medical texts; why not? (Published 12 May 2010)

Since I started medicine as a student in 1970, I have only read two textbooks that taught medicine. The first was my late father’s and was called “The Acute Abdomen in Rhyme” by Zeta (a nom de plume) with illustrations (H.K. Lewis & Co. Ltd, London, 1949. I still have it and have considered having it republished. It is humorous and the message sticks.

The preface starts as follows;

“The use of rhyme in teaching is quite small,
Its limitations great and plain to all
But use it has, although it may be merely
To put some things more quaintly or more clearly”

and in the opening chapter on General Principles he says with prescience,

“The diagnostic problem of to-day
Has greatly changed – the change has come to stay;
We all have to confess, though with a sigh
On complicated tests we much rely
And use too little hand and ear and eye.”

The second book was a short primer (pronounced “primmer” for Gen Y) on head injury and neurosurgery by the late Ken Jamieson, a Brisbane neurosurgeon who was instrumental in car seat-belt legislation. It was called “A first notebook of head injury” (1965) and is a must for any intern. I attended his funeral the month I started as an intern at the Royal Brisbane Hospital in January 1976.

http://adbonline.anu.edu.au/biogs/A140633b.htm

He used humorous cartoons. I remember a drawing of the brain, side-on with another drawing below to resemble an Oxford don smoking a pipe (the pituitary). It was full of rhyme and limericks and with extracts from the Bard. He was not above humour or colour to get the message across. How sad it is that I have spent countless hours with humourless text books, written and edited by witless fools who are too pompous to teach or to convey a message other than as verbal chook food and about as interesting.

Competing interests: None declared

More discursive stuff on death by textbook (Published 11 May 2010)

I have been heartened by the three responses so far which support my own iconoclastic observations of life.

My late father who was a G.P. taught me Senior French (matriculation) as an extra subject and was a Classics Scholar. He knew how to teach. He alerted me of the pitfalls, the false friends, went over my weaknesses, told me the gender rules and the exceptions, and guided me through a seeming maze of the subjunctive which as I went started to seem less intimidating. Books can do this too.

It just takes imagination and caring about the reader who has bought the kilogram of diced pine pulp to advance his or her knowledge. Try that when reading the section on porphyrias.

I have yet to find a modern textbook which has even an inkling of teaching in it. It is as if the author is not engaged with the reader, or is such a nerd that he or she is completely disinterested in the needs of the reader. It is like buying an orange with no juice.

There are the occasional case studies which give an answer at the end but even they fail to show you how to walk the tight-rope, how to cross a bar on an ebb tide (probably foolish) etc.

Much of the problem is that the editors are nerds too, who are totally divorced from clinical teaching and even the lofty title of professor is not worth a pinch of salt when it comes to being an intuitive teacher.

Most people I have known who rise to the rank of professor or a book author breathe a rarefied atmosphere and have never done a course on teaching not that this really qualifies one to teach either.

Good teachers I believe are born and not bred. The book author or expert may be able to drone on endlessly about biphenyl-polywaffletransferase at the Annual Scientific Meeting in Copenhagen, but take some No-Doze before you enter the room. It is all breathtakingly boring.

I think there needs to be a complete rethink of medical textbook publication. All boring authors and dullard editors should be put in front of a firing squad or for those of your like us without capital punishment, be sentenced to medical conferences for eternity. I think the BMJ is a lone beacon in the medical publishing gloom but even it has a long way to go. This very article of mine was rejected by an Australian physicians’ journal as it was “too discursive”. I was clearly not singing from the official medical hymn sheet. It is all a bit too much in your face.

Fancy the audacity of challenging the very plinth of the columns holding up the Temple of Hygeia. The sky might fall in and barristers would be aghast in a medico-legal case. Wigs might slip off and heads might fall. Anything that gets into a textbook, well it’s truth itself even if soporific.

I predict that medical textbooks will soon be restricted to museums and torture chambers if the current trend is not arrested. Perhaps the princes were not suffocated to death in the Tower of London, but their nanny read them a few pages of that famous American medical text. I use mine for doorstops and haven’t bought one for years.

Medical publishing is at the cross-roads as the textbook is out of date by the time the ink is dry. It is only powerless students who are sentenced to expensive drudgery by textbook. For a more discursive version of my paper which started off with Dr Johnson’s dictionary see my blog on www.sarcoidosis.com.au. It was also on doc2doc, another light in the Great Despond.

Competing interests: None declared

March 24, 2010

On Dr Johnson, Sarcoidosis And Medical Writing; More Oats, Sire

Filed under: Literature,Medical — Tags: , , — Dr Roger KA Allen @ 4:44 pm

“Why Sir, you find no man, at all intellectual who is willing to leave London? No Sir, when a man is tired of London, he is tired of life; for there is in London all that life can afford”.

Samuel Johnson’s greatest legacy is “The Dictionary”. Born in 1709, he grew up in Lichfield, Staffordshire but fell in love with London, where, with the aid of six amanuenses, numerous goose quills, much paper and ink, he worked from 1746 when he signed the contract, until MDCCLV which finally appeared at the bottom of the frontispiece of the huge first edition.

Johnson’s “A Dictionary of the English Language”, stands out from all dictionaries that followed not just by his vast eclectic knowledge, but by its humour, prejudices and views of life. Before he started on the work he was confronted by the fact that the French had achieved their dictionary only after forty years by a committee of forty men of the Académie Française. Johnson’s responded in essence was that one Englishman was equal to 1,600 Frenchmen and that he could complete the task in three years. It was to take a bit more. Although the first edition had its critics, it was heralded as a national treasure. For the first time someone had brought order to the chaos of Georgian English including spelling, grammar and word usage. It was the linguistic equivalent of the standard gauge railway to the bickering state governments in colonial Australia but that may be a bad example as we still remain divided by gauges not to mention time zones.

An example of the charm of his dictionary is exemplified in the famous definition of the word, “oats; a grain, which in England is generally given to horses, but in Scotland supports the people. While this may leave the reader bemused, it illustrates that the author is a human being with prejudices and opinions. In reference to his unpleasant experience with his would-be patron, Lord Chesterfield who offered to come to his aid only after seven lean years of slog had paid off, he defines the word, “patron” as such; one who looks with unconcern on a Man struggling for Life in the water and when he has reached ground encumbers him with help”.

The verb “to take” encompasses 5,500 words with 134 senses and even the verb “to fall” is expanded into sixty-five nuances. For more examples may I commend the most entertaining book by Henry Hitchings (1).

In 1979, when I was a medical registrar, the professor of medicine, asked me if I would do a study on angiotensin-converting enzyme as fellow called Jack Lieberman in the United States had serendipitously found it was elevated in sarcoidosis. As I was about to start training to be a thoracic physician it seemed a bit left field but I complied and did the work in his department which was a hot-house of hypertension research. This task which was to take six weeks resulted in my life-long interest in sarcoidosis, my doing doctoral thesis on the enzyme and becoming a member of executive of the world body called WASOG (World Association of Sarcoidosis and Other Granulomatous Disorders).

When I first became involved in WASOG in the early 1980s, it was led by that Pied Piper, the charming and ebullient Englishman, the balding bow-tied D. Geraint James, known by all as “Gerry James” and although his wife was the famous hepatologist, Dame Sheila Sherlock, he did not sit in her shadow. On my bookshelf sits his book, Sarcoidosis and Other Granulomatous Disorders, published by W.B.Saunders in 1985 and although only 254 pages in length, it hold pride of place (2). Inside it just says,

“With affection and admiration. Geraint James, September 1990”.

He signed my fading copy one memorable night at a dinner with him in Brisbane in a charming Queenslander owned by his old friend, the Brisbane pathologist, the late Dr Bruce Gutteridge. Until late, we drank red wine heady with bonhomie from fine Venetian glasses while the flying foxes squabbled in the palm trees lining the front drive and the scent of jasmine permeated the night air. In that bygone era, WASOG was vibrant and his book effervesced with his unique enthusiasm like that of an eccentric school boy with a collection of pinned beetles. His book is replete with his own black and white photographs taken over the years of his wanderings like a medical Odysseus.  From his book, I get the feel that he has been courted by the Sirens and attacked by Harpies and that he had blinded Polyphemus on his sarcoidal epic armed on with the honed bronze blades of hydroxychloroquine, corticosteroids, methotrexate and a few less trusty weapons like azathiorprine and time.

In the editions that have followed the voices of the authors become hard to make out, the language increasingly impersonal, the diction more turgid andreflections about life, the disease, the patient and the doctor more uncommon. In this first edition, he reflects on the first world conference on sarcoidosis in 1958 when I was only seven. He states;

The Olympic torch was lit and the first conference was held from June 30 to July 2, 1958, in London. Until that time the clinicians had read each other’s articles but did not know one another. They met in a spirit of cordiality and camaraderie, and this spirit has pervaded all subsequent conferences. (2)

There were twenty-two participants then including one woman but by 1966 the International Committee on Sarcoidosis in Paris included amongst others Dr Tom Hurley (Melbourne), Louis Siltzbach (New York), D. Geraint James (London), Sven Lofgren (Stockholm), Harold Israel (Philadelphia) and Martin Cummings (Washington D.C.), the then Director of the National Library of Medicine and who later established MEDLARS and MEDLINE.

I was recently asked to co-author a chapter on the treatment of sarcoidosis for a book on interstitial lung disease by a colleague overseas. However the task competes with a book I am writing about growing in the house of a country doctor in the fifties and in which I am very much aware of the “voice” of the book.  I have not yet started the textbook chapter but have looked at some early editions. The overwhelming thing I observe is the failure of most modern textbooks to convey personal experience except by virtue of a citation of some prior publication. The voice by way of convention is scientific, impersonal, passive and not active. It is far off. The patient and the medical process are viewed like an enemy frigate through a spyglass at a league’s distance only even less emotive. A handbook I own called “Evidence-based Medicine Toolkit” (no indefinite article) is medical equivalent to a metre-long bar of platinum held in a vacuum in Paris by which all metres and hence evidence in the medical cosmos is to be measured.

Although as a sailor I know Moreton Bay fairly well, I still refer to the charts when I venture into unfamiliar waters. The channel to Cabbage Tree Creek shoals up with a shallow spot at dead low which lines up at right angles to the outer third of the Shorncliffe Pier about a mile to the north. This is not in the chart and nor is the old tractor engine at dead low half way up the creek where the cattle used to ford. Nevertheless some fools still run aground there and even rip the bottoms out of their boats. And thus it is like this with medicine but the textbooks don’t mention this unless there is a p value or a citation. I frequently see patients with sarcoidosis with painful balls of their feet but this is not in the textbooks and probably never will be accepted as it is hard to prove objectively. Indeed the obstacles to publication now are so formidable I think a lot of good material goes unpublished.

I believe the duty of a textbook is to be enjoyable to read. However most have the linguistic flare of a German car manual, no sense of engagement with the reader, no real human “voice”, no guides for the novice, no hints to help you remember indigestible facts, no etymology to explain words, no history of the disease, treatment or investigations. In short, they are written by idiosavants devoid of wit and soul.  Their words are not used like notes and their sentences are constructed with the finesse of a brick layer. This is pedestrian prose at its worst and worthy of a bottle of No Doz.

Harrison’s reads like a medical version of the Larouse Gastronomique only with less appeal, and the only way I find it interesting is to read the French version which then subserves my two needs; consciousness and information. By contrast my late father’s textbook, Tropical Diseases in Australia, by Sir Raphael Cilento, 1944 says on page 37 in reference to the use of quinine for malaria,

Soldiers are particularly difficult if they have heard the false rumour – widespread amongst troops – that quinine causes a diminution of virility. After malaria sexual vigour frequently remains diminished for a fairly long period…. (3).

I wonder if he had a p value and surely Cochrane would have dismissed this as baseless.

We have thrown the baby out with the bath water. If I wrote a chapter on the treatment of sarcoidosis I  would like to include information about the history of the drugs used, the problems I have personally encountered over thirty years, about the pitfalls and cost and not just lifeless lists of studies and facts like a Metro time table. I wish to engage with my reader and share the passion I have for sarcoidosis like Gerry James. Alas, I am sure editors will filet the fish leaving the skeletal remnants in accordance with the doctrine of Cochrane, as well as the medical and political correctness of the time.

Carl Jung in his “Psychology and the East” states;

Science is the tool of the Western mind, and with it one can open more doors than with bare hands. It is part and parcel of our understanding, and it obscures our insight only when it claims that the understanding it conveys is the only kind there is. The East teaches us another, broader, more profound, and higher understanding – understanding through life.

The history of our craft even as a pre-amble is missing in our textbooks which are preoccupied with the latest creations; advances based on studies and trials with no sense of the fertile swamp from which these new reptiles have arisen. This year’s textbook will be next year’s door stopper and no more readable.

I recently asked a final year medical student doing a term with me who discovered oxygen, the derivation of the word “oxygen” and the first man to describe how the lungs work. He did not know. Thus I believe that the current teaching of medicine perpetuates the existential, mechanical style of modern journals and textbooks. Let us rediscover charm, linguistic style and humour to resurrect these dreary reductionist manuals on the human machine. So don’t give me the chaff of a modern textbook to read. Nay, Sire, give me a bushel of oats.

References

  1. Hitchings H. Dr Johnson’s Dictionary. The extraordinary story of the book that defined the world. John Murray (Publishers), London. 2006.
  2. James D.G., Williams W.J. Sarcoidosis and other granulomatous disorders. W.B. Saunders Co, London. 1985, pp10-11
  3. Cilento, R. Tropical diseases in Australia. A handbook.  2nd ed. Smith & Paterson, Brisbane. 1944, pp 37.
  4. Jung, CG. Psychology and the East. Princeton University Press, Oxon. 1978, pp5-6

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