American College of Physicians: Internal Medicine — Doctors for Adults ®


Medical textbooks are making their way to the Web

Electronic textbooks offer up-to-the-minute information, but is that what physicians really need?

From the March 1999 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

By Howard Wolinsky

When Jody L. Pettit, ACP-ASIM Associate, a general internist and faculty member at Providence Ambulatory Care and Education Center in Portland, Ore., needs to consult a medical text, she no longer turns to a book. Instead, she consults an online version on the Web.

Dr. Pettit, who has been in practice for just under two years, says one of her favorite Web texts is Harrison's Online ( and that she likes services like MD Consult (, which contains text from numerous medical textbooks and journals. "It takes a few minutes to log on," said Dr. Pettit, "but you can search more than one text or journal at a time."

Besides, she said, some sites contain features that printed text simply can't offer. For example, one site has an illustrated dermatology atlas that allows her to magnify an image of a rash to get a better look. And if Dr. Pettit finds something useful on a Web site, she simply prints it out and puts a copy in the patient's chart for later reference.

As a growing number of medical textbooks make their way onto the Web, physicians like Dr. Pettit are going to the Internet—not to their bookshelves—for answers to clinical questions. Web-based textbooks offer many of the advantages of print and CD-ROM versions plus up-to-the-minute information, access to massive databases and links to related Web sites. And while most physicians say they are still not ready to abandon the print copies of their classic textbooks, Web-based textbooks are already changing not only how doctors get clinical information, but also how publishers produce and update clinical texts.

"Harrison's Principles of Internal Medicine," for example, used to be updated every three and a half years. While the print version is still published on that schedule, Harrison's Online is updated nearly every day and includes practice guidelines, the latest news from clinical trials, drug approvals, reviews of new therapies and medications, editorials and links to related sites on the Web.

Harvard cardiologist Eugene Braunwald, MACP, editor-in-chief of Harrison's Online and a former editor of the print version, said he thinks of the Web site as a "living textbook." His staff regularly scours news sources like the Associated Press for information that will be relevant to the site and searches databases like Medline for news from the major medical journals.

Dr. Braunwald also monitors other Web sites for new drug approvals and reports from the FDA as well as new clinical guidelines from organizations like the American Heart Association and the American College of Cardiology. If he finds a noteworthy trend—he pointed to the approval of three drugs in the past year to block platelet function as an example-he might commission an essay or review article for the Harrison's site.

Another internal medicine standard, "Scientific American Medicine," is also available on the Web. SAM Online ( offers highlights from the monthly bulletins and contains most of the charts and illustrations from the print version. David C. Dale, FACP, editor of SAM Online and the College's Governor for the Washington Chapter, noted that as soon as important new articles from the print version are edited, they are posted on the site's "Fast Track" section. That gives online subscribers immediate access to cutting-edge clinical information.

New kinds of textbooks

While sites like Harrison's Online and SAM Online focus on content from one textbook, a number of other sites are providing vast repositories of clinical information from various sources.

MD Consult, a three-year-old site that is a joint project of medical publishing giants Lippincott Williams & Wilkins, Mosby-Year Book Inc. and W.B. Saunders Company, offers the content of 37 textbooks, including such notables as "Cecil Textbook of Medicine" and Sabiston's "Textbook of Surgery." The site also offers text from 47 medical journals, more than 500 clinical guidelines, drug information, medical news and online discussion groups. Officials from MD Consult estimate that physicians would have to spend roughly $20,000 to buy print copies of all the site's textbooks and journals.

Another Web site, Emedicine (, is positioning itself as a new kind of clinical textbook. The site, which bills itself as the first online, multiauthored clinical textbook, offers chapters on topics like dermatology, emergency medicine, neurology and pediatrics. Text on the site is written and edited by physicians and other health care professionals.

A quiz appears at the end of each section to test users' knowledge of the chapter they have just read, and readers can get in touch with authors and editors by clicking on a list of names. Readers are also encouraged to send editorial suggestions or pictures to illustrate the text.

Emedicine differs from other Web sites not only in its content, but in that it accepts ads from drug companies like GlaxoWelcome and Genentech. That allows the site to give physicians and patients free access to the site. Most Web-based textbooks charge physicians an annual subscription; Harrison's Online charges $89 a year, MD Consult charges $199 a year (limited use rates are also available) and SAM Online charges $245 (free to subscribers of the print version).

Not surprisingly, some of the new Web sites have been the subject of criticism. Some physicians have voiced concern about the presence of ads on the Emedicine site. They worry that the ads may be particularly influential on patients who read about a condition and then see an ad for a related product at the top of their computer screen. Other critics have also raised questions about the review process that Web-based textbooks use to ensure their information is accurate.

Stephanie Manning, MD, publisher of MD Consult, acknowledged that new Web-based services will have to win over what can be a fairly difficult audience. "There's a healthy skepticism among physicians about the quality and authority of information on the Web," she said.

For the most part, however, analysts predict that that Web-based textbooks will receive a more positive reaction. Mark E. Frisse, FACP, director of The Bernard Becker Medical Library at Washington University School of Medicine in St. Louis and an expert on online publishing, said that MD Consult is like "a librarian on steroids." He added that "many doctors won't have to run to the library anymore."

Online aficionados are also quick to point out another bonus of Web-based textbooks is their flexibility, particularly when it comes to updating information. Web sites like Harrison's Online and Emedicine, for example, allow users to exchange e-mail with authors and editors. "Textbooks tend to be somewhat iconoclastic and authoritative," Dr. Braunwald said. "You can't talk back to a textbook."

The Emedicine site, also from Harrison's, allows authors to update their chapters throughout the year. "Our system allows authors and editors to write their topics online and update them with little effort," explained Scott Plantz, one of the site's creators and professor of emergency medicine at Mt. Sinai Medical Center in New York. "When they are done, all will share in a well-written textbook series that we all can use free of charge."

Too much news?

While no one argues about the flexibility of Web-based textbooks to stay up to date, some wonder how much breaking news most physicians really need. Dr. Manning from MD Consult said that practicing physicians do not necessarily need the latest data in making clinical decisions, since conclusions from the clinical literature can be a moving target. "Not that much changes in medicine," she explained. "Physicians need to know what is conventionally held to be the best evidence for practice. That's what they find in textbooks. They help doctors remember the important things that they forget."

Dr. Frisse agreed that the ability of Web sites to offer updates is often overhyped. "Most doctors don't need the latest and greatest. They just need the practical wisdom," he said. "They want to know what Dr. Braunwald said about a heart condition."

For these reasons, few analysts are predicting the death of print-based textbooks. "Online texts and textbooks have different functions," said Dr. Braunwald. "If a student wants to learn about congestive heart failure, the printed version is superior. But if you're practicing in an HMO and want the latest information on a drug, you can pinpoint that best online."

William C. Miller, ACP-ASIM Member, a general internist in suburban Cincinnati who has been in practice for more than 20 years, said he plans to replace his old paper version of Harrison's when it is released, but that he also likes to use Web-based resources like Harrison's Online and MD Consult.

When he is on a tight patient schedule and can afford only five minutes for a search, he uses the paper text. When he has more time, however, he likes to go online to look for information from newer studies and for new off-label uses of medications.

But Dr. Miller was quick to add that he finds traditional paper-based textbooks a bit easier to use and more comfortable—"like an old shirt"—when refreshing his memory on subjects where there has been little change in recent years.

Making physicians comfortable with their products is likely to be one of the biggest challenges that Web-based textbooks face. "If people don't find something really compelling at first glance, there won't be a second glance," explained Dr. Manning, publisher of MD Consult. "They'll just use what's been working for them all along."

Howard Wolinsky is a Chicago-based freelance medicine and technology writer.

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