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.
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