86Doctors
6 Doctors and books
Derek Law
Medical education
Medicine is one of the great vocational disciplines and as a result students come to it with a sense of commitment and purpose not always found in other subject fields. Further, the medical profession has systematized a highly developed and examinable progression through undergraduate and postgraduate syllabuses, which moves the doctor from his first degree to registration and then from generalist to specialist. Thus the tiro medical student comes to university knowing that he is embarking on a course of study which will last upwards of ten years.
The new student will also have a sense of some achievement from simply being accepted by a medical school. There are 31 medical schools offering registrable first degrees, of which 12, including many of the best known, form part of the University of London. The intake of the schools varies between 80 and over 200 each year with a typical minimum entry requirement of three A-levels at 'B' grade in Chemistry, Physics and Biology. In practice there are ten applicants for every available place and this severe competition means that only the very well qualified and well motivated are accepted.
Undergraduate medical education is controlled by the General Medical Council (GMC) which keeps the Medical Register, and no one may practise medicine in the United Kingdom unless his name is on the Register. The GMC both publishes recommended guidelines for undergraduate medical education and approves the curricula of individual institutions. This approval also involves periodic visits to universities to ensure that facilities, from laboratories to libraries, are adequate. The first two years of a five-year course are spent studying the basic medical or pre-clinical sciences and are broadly similar in most respects to the ordinary pattern of university life in science based faculties. The final years are spent based in the teaching hospital or hospitals attached to the medical school and move abruptly to a 46-week teaching year. When students graduate they must then do a further year of supervised work while living in a hospital before registration by the GMC. This consists in general of two successive 'six-month appointments as a junior doctor in a 'firm' headed by one or more consultants.
Although the GMC has a statutory "duty to determine what constitutes suitable experience, the doctor's development over the year rests mainly with his medical school which must certify that the pre-registration service has been satisfactory. After this pre-registration year the aspiring doctor will seek membership and fellowship of the appropriate Royal College. The Royal Colleges largely set their own standards and qualification is by examination, although prescribed periods in approved posts are also dictated. These junior training posts In hospitals are considered for suitability by the Royal Colleges, and one of the criteria is access to adequate library facilities.
The general pattern is three years of general training and three to five years of specialist training to become qualified in this way. In passing one should also note the University MD degree which is awarded sparingly for advanced original research. In sum then, the new medical student knows that he is embarking on a course of study which may last a decade or more, and knows that an investment of time and effort in learning to use the library properly and efficiently will be of long-term advantage.
The medical library
When the student arrives in his university, he will usually find a medical library physically separate from the main library and sometimes from the campus. Such libraries are usually large enough to ensure the availability of adequate opening hours and a full range of library services, while not being so large as to lose the personal relationships between library staff and readers which smaller size encourages. The libraries range in size from those of Birmingham, Manchester or Edinburgh with over 100,000 volumes of stock and over 1,000 journal subscriptions to the smaller London schools which may have 300-400 journal subscriptions and a correspondingly smaller book stock. With so fewjournals, they may well be arranged alphabetically by title, whereas the books will probably be classified by a specialized scheme such as that of the National Library of Medicine. The library will have an author and title catalogue and perhaps most important of all a subject catalogue. This last is much more necessary to the medical student than to many other students. Medics require ready access to factual descriptions of 'things - a condition, an organ or a treatment - more often than to a specific title or to one author's particular viewpoint. Because the medical library commonly is separated from the central library it becomes the library for staff and students. This in turn means that the medical library will try to meet wider areas of library provision and will have as a minimum a general reference collection and in some cases will stretch to what may loosely be called recreational reading.
Medical libraries are a curiosity in the university system in that their user population is often doubled by external use. Not only will NHS staff be heavy users of library services, but the local health authority may make a substantial financial contribution to the running costs of the library. Library staff may be universally sure of their importance, but as Matthews says 'Few, however, would claim with the medical librarian that their concern is with life itself'.1 The presence of on-call phones, bleeps and even, according to legend, of gowned surgeons dashing in to check a reference, gives an air of urgency not always found elsewhere in the academic library. It also provides a tension between the requirements of different groups of users whose major needs vary widely over such basic points as opening hours and lending policies. The physical separation of the medical library may also be echoed in a sort of intellectual distancing. Medicine is an ancient study and most of the medical schools are older than their parent institutions, with records of formalized instruction going back to at least the 18th or early 19th century. The medical faculty may regard itself and be regarded (often with a degree of envy) as somehow apart or aloof from the rest of the university.
The medical degree
The subject matter of the degree falls into two clearly defined halves. If one looks at a typical degree course, as for example at the University of Newcastle upon Tyne.
The course of study extends over two academic years and is concerned with the study of Human Structure, Function, Development, Inheritance and Growth, Social and Behavioural Science, Medical Statistics, Laboratory Medicine (including the principles of Pathology, Haematology, Clinical Biochemistry, Microbiology, Virology and Pharmacology) and an introduction to Clinical Practice.2
This first period of basic or pre-clinical sciences is similar in nature to the routine of a typical science faculty with a mixture of lectures, laboratory work and tutorials giving full days during a 30-week teaching year. Indeed some of the basic texts may be the same as for students in the veterinary or science faculties.
During this period the student is involved in acquiring a broad grounding of fact and of background knowledge which will underpin his later studies. Much of this will be assimilated directly from books, which will be a prime source of information and education. For the next three years the typical Newcastle student moves into the hospital where, as well as a clinical clerkship,
“he must also attend instruction in the principles and practice of Medicine, Obstetrics, Gynaecology and Surgery ... [then] students will be appointed for prescribed periods as senior clinical clerks to selected departments including Anaesthesia, Medicine, Obstetrics, Paediatrics, Psychiatry, Surgery. “, Instruction will also be given in Forensic Medicine.3
Although this type of instruction remains the norm, several schools have introduced an integrated curriculum designed to bridge this strictly demarcated gap between pre-clinical and clinical areas. Most medical schools provide an opportunity for their students to undertake one or more periods of study (called electives), usually at the end of the fourth year, in order to gain more varied experience. Traditionally, students spend these away from their own school, sometimes abroad, and the library will have the minor administrative problem of dealing with both incoming and outgoing students for these periods.
After the pre-clinical years, the medical student diverges markedly from the norms of student life. The teaching year increases to 46 or more weeks and the base moves to the teaching hospital, which may be still further distant from the main campus. In some instances the student may spend time in a number of scattered hospitals in order to gain the necessary exposure to the wide range of subjects which is required by the GMC.
Use of the medical library
The library becomes an ancillary activity, a place to be visited briefly to borrow and return books en route to and from the hospital. There is little time for wide reading, only enough time to cram the basic facts of each particular speciality. The greatest boon the medical library can offer at this stage is long opening hours to allow access to books in the short spells which can be snatched away from the hospital. Mann's study4 showed this dearly, with 74% of medical students spending under five hours a week in the library while the same figure of 74% had 25 hours or more a week of classes and a colossal 43% of medical students had over 30 hours a week of classes, four times as many as in any other faculty. This obviously reduces the time available for work in the library. The medical students also had few books
on loan, 50% having none and 20% having one. On the other hand they were excellent book purchasers, spending only fractionally less than the law students who topped the expenditure table. To this can be added some evidence on photocopying. In the Erskine Medical Library, University of Edinburgh, in the
1983/4session, medical readers made over 108,000 photocopies.5 Thus a picture begins to emerge of students using the library for reference rather than for reading, but requiring access to material whether by purchase or photocopy, which can then be studied outside the library. Another factor here is that various combinations of restricted opening hours, physical separation of the teaching hospital, restrictive lending practices and strict fining policies may so complicate the life of the medical student
as to make regular book borrowing a near impossibility. It is a curiosity of medicine that it remains the last bulwark of the subscription library, whether in the guise of Lewis's Lending Library (now mainly aimed at institutions), the Royal Medical Society's postal lending service or the traditional service of a
bookshop such as Ferrier's of Edinburgh. Perhaps each of these services in its own way comes as close to meeting the student's need for books as does a traditional university library service.
More than most libraries, those in medicine are constantly faced with the fact that no matter how good or how well regarded, they can never be more than a secondary activity for those whose primary concern is patient care; but by embracing the role of a support service, the medical library adopts an attitude to readers which is more clearly marked than in even the most progressive libraries. It is not so much that they are tolerant of the vagaries and whims of readers as that, apart from requiring a certain basic reasonableness, library staff connive at recognizing that the administrative minutiae of the library is
largely irrelevant when compared to the common purpose of the medical community.
Library stock
With law, medicine is the home of great editions of great texts. Few can be unaware of Gray's Anatomy, now in its 36th edition, but the pace of change in medicine is so fast that the regular updating of texts means that many classic works are republished with great frequency. From Churchill-Livingstone's catalogue6 alone one can cite Taylor's Principles and Practice of Medical Jurisprudence now in its 13th edition, Weir's Immunology in its 5th edition, Holland and Brews Manual of Obstetrics in its 14th edition and many more. These textbooks are informative rather than contentious and normally present standard views. Monographs feature rather less prominently, at least in the life of the undergraduate.
As with science, the journal is the main forum for publication and the specialized monograph drawing together the strands of a subject is too detailed for general use. The medical library will also contain large definitive reference works. Picken7 cites the example of Duke-Elder's System of Ophthalmology in 17 volumes. It demonstrates well the complexity of medicine in that 13,000 pages can be devoted to the eye alone. The final area of the bookstock with which the student will become acquainted are the various review publications. Review articles are scarcely new, but medical publishers such as Year Book Medical Publishers and Annual Reviews Inc. subsist on such volumes alone while series such as Churchill-Livingstone's Recent Advances and W. B. Saunders' Clinics have refined this form of publication. They obviously vary both in nature and content but all appear more or less regularly and attempt to review and report on developments in a particular field since the previous volume of the title appeared.
Lying part way between books and audio-visual material are medical atlases. Medical illustration enjoys a distinguished pedigree stretching back to Vesalius, and the traditional type of anatomical atlas is now best typified by the enormously popular and successful series of Wolfe Colour Atlases. Other works of a visual nature exploit the results of the electron microscope, ultrastructure and the stereotaxic instrument. The importance of audio-visual material in medicine has long been recognized and the British Medical Association set up a film library as early as 1946. Some aspects of medicine are
particularly well suited to this type of material. It is perhaps enough to mention sound recordings of heart defects, slides of dermatological conditions and video or film to show movement, whether in the recording of a psychiatric interview or the diagnosis of the causes of a limp. While the student may survive without such aids, it is desirable that the medical library both has adequate equipment to show or play back audio-visual material and does not erect technical or administrative hurdles which makes its use difficult. Where audio-visual stock is actively promoted by the medical library, a willing audience will be created quickly. Helen Harrison demonstrates the uses of audio-visual aids more fully in chapter nine.
The last area of stock with real relevance to the medical student is abstracting and indexing tools. Of course the sine qua non for medical libraries of all sizes is Index Medicus and it is impossible to over-rate its importance. The modern indexing of medical literature goes back to 1865 when John Shaw Billings was given charge of the library of the Surgeon-General’s Office in Washington. His enormous energies were thrown into preparing both the Index-Catalogue of the library (whose direct descendant is the National Library of Medicine Catalog) and, in 1879, beginning the publication of Index Medicus itself. It can be criticized on several counts - its timeliness, its thesaurus, its coverage - but in 192 it covered 2,700 journals and published over a quarter of a million citations.8 No serious student of medicine can hope to survive for long without learning how to use the Index and it is, in fact, a pleasant and readily-used work.
Its main competitor is Excerpta Medica which is an abstracting rather than an indexing tool; published in over 40 sections, its value is mitigated by its price and it will be found in only the wealthiest libraries now. Possibly the second most important reference tool in the medical library is Science Citation Index.
Citation indexing is a relatively recent concept but it has proved of particular value in medicine and although more difficult to use, both physically and intellectually, than Index Medicus it is again a necessary discipline for students. Larger libraries may also contain such standard works as Biological Abstracts or Chemical Abstracts, but these are not usually of daily importance to most readers.
Library services
It is perhaps worth interjecting at this point that reader instruction in the use of such tools and more generally in the use of the library is less a cause of soul-searching than in other areas of the library. Users of medical libraries mostly exist in a world which, if it leaves any time at all for the library, leaves only the bare minimum. Bureaucracy and petty administration cannot be tolerated and the medical library more than most wholeheartedly works to the end of serving the reader and ensuring maximum benefit from the time spent in the library. Further, the medical community is quite small, even in a large university, and it is easier to build personal relationships with most readers than it would be in larger library units. Thus reader instruction falls naturally into the work of both reference and issue desk staff and is generally conducted on a one-to-one basis, often without either party dignifying this interchange with the notion of instruction. That is not to say that the usual orientation tours and guidance on the mechanics of using the library are not needed or given, and in some cases teaching staff may even seek to include some library instruction in the curriculum. It is more normal, however, to give the reference service a high profile and to consider reader instruction as one of its functions.
Medicine has, in computer terms, a long history of on-line information retrieval. The great thrust behind this has come from the National Library of Medicine in Bethesda, Maryland. In order to speed up the' printing of Index Medicus a computer system was installed in 1964. A database was created as a by-product of this process and from it first MEDLARS and later MEDLINE were made publicly available. Other services have appeared and grown in importance over the years, but none has remained so firmly in the public eye. It would be idle to pretend that even a small minority of undergraduates will come into working contact with on-line searching, but such a service is now an in-built and natural feature of the medical research process and as such the student will become aware of it as a tool to be used at a later stage of his own career development.
In sum, the medical student is faced with a wide array of forms of material to assist his studies, each with particular attributes. The literature itself is and has been highly disciplined and has a long history of controlled exploitation. For most of the time, however, the undergraduate will rely on a small number of large, expensive and comprehensive textbooks.
Publishers, booksellers and budgets
Medical publishing and bookselling are well developed specialities, again unusual in being areas where specialist firms have managed to survive. Medical publishing is generally considered to be lucrative (at least from the outside), albeit an area where publication costs are bound to be high. Firms such as Churchill-Livingstone will have a reasonable number of titles guaranteed to sell in quantity edition after edition, while the rate of change in medical knowledge is such that new explanatory works are required with great regularity and always with the hope that a well-received title will achieve the status of a standard text. Specialized booksellers such as Lewis's, Kimpton's or Ferrier's appear to survive both because the medical profession is accustomed to book-buying and because its commitment to a decade of examinable work means that there is a need to buy books simply to learn.
Although the medical student will be largely wedded to the textbook, the medical library will probably spend the great bulk of its budget on journal provision. There is a tension between the needs of different user groups which can be caricatured as long opening hours for hospital staff, multiple-copy textbooks for students and journals for research staff. Medical libraries have borne their share of the cuts in university expenditure in the early 1980s and arguably have suffered worse than most, for two main reasons. Firstly, the rise in the cost of journals in medicine has consistently been as high, or higher, than in other subject areas; coupled with the performance of the pound this has led to price rises averaging up to 90% in the three years 1981-3. Secondly, in those libraries where significant funding has been received from the National Health Service, government pressure on NHS funding has often led to freezing of or a reduction in support for the library. Even at best, this funding too has failed to keep pace with inflation. Financial control for the last few years has therefore been coloured largely by thethe desire to protect the journal collection. Even then a decade of retrenchment has seen a steady erosion in the number of journal subscriptions placed by most libraries. Cuts in staff and often, by extension, in opening hours, and the maintenance of journal subscriptions at the expense of textbook provision have therefore led to a shift in the distribution of resources between the different groups in the last few years. As elsewhere in the library, one response has been to consider the introduction of charges for on-line searching or inter-library loans. In most cases decisions are perforce tied to the policy of the university library as a whole, but the debate is no less anguished.
Medical school libraries have always to some extent been self-renewing libraries. This is partly due to the rate of change in medicine itself: a true information explosion. Enormous new areas such as transplant surgery open up, new problems such as AIDS or Legionnaires' Disease are discovered and render areas of stock quite out of date, while new treatments or improved diagnoses render more stock obsolete in traditional subjects. There is also a small area of stock where dated information may be physically harmful to the patient. All of this makes weeding and stock control an endless but necessary task. Ideally the working collection will be under constant review to ensure that old editions and dated stock are withdrawn either for disposal or at least to a separate sequence. There is a perceived need to present students with a 'clean' collection where any book is guaranteed' accurate and current.
Book provision for students rests heavily on a supply of multiple copies. Although so much of the budget is spent on journals, they are on the whole peripheral to the students' needs. He will not escape from using them and indeed project work may often be based on specific articles, but the medical faculty is less likely than most to clash with publishers over copyright and the multiple copying of articles. The aim of the university medical degree is to produce a generalist in a very large subject field and the textbook is the ideal medium for this. Perhaps this is best exemplified in the minor industry of publishing multiple choice question crammers to supplement specific textbooks for examination purposes, such as 1200 MCQ's in Medicine by P. Fleming et al. (Churchill-Livingstone, 1980).
Prospects
Medicine and medical libraries have always been innovative and as substantial sums go into medical research we may expect that some of the money will continue to be used for the development of specialized information services for the researcher. It is to be hoped that such developments will continue to spread more generally into the library community at large. The most immediate developments may well come in the related areas of microcomputers and Prestel-type systems. Although many groups are experimenting with these, much medical information is ideally suited to such presentation. Whether relating to lists of drugs or antidotes for toxic substances, the physician's need is often for straightforward factual information. Further, the pressure on the time of practising doctors is such that any labour-saving device will find a welcome reception. It is a paradox that for all the change and adventure in medical techniques, medicine remains a deeply conservative profession and medical education seems set for slow evolution rather than revolution. A major review was undertaken by a Royal Commission under the chairmanship of Lord Todd9 in 1965-8 and apart from some moves to integrate the clinical and preclinical curricula in some schools, sudden change seems unlikely. Equally, since student numbers in medicine are controlled by government in a more direct way than in any other profession, a sharp fluctuation in student numbers seems unlikely.
In medical libraries, a number of developments may be foreseen but perhaps the most desirable is the full extension of the regional libraries system throughout the NHS. The regional librarians co-ordinate and develop NHS libraries in their areas and in some, most notably Wessex, strong links are developed with the medical school library. Such a network has been seen as increasingly necessary10 and as it develops it is easy to envisage as attainable the target of putting all qualified medical staff in touch at all times with some part of a professional library system which they will first learn to take advantage of at 18, then use for the rest of their professional life.
References
1 Matthews, D A and Picken, F M Medical librarianship. London, Bingley, 1979. 12.
2 University of Newcastle-upon-Tyne Calendar 1984/85. Newcastle, University of Newcastle,
1984. 329.
3 Ibid. 330.
4 Mann, P H Students and books. London, Routledge, 1974.
5 Edinburgh University Library Abstract of the annual report 1983/4.Edinburgh, Edinburgh
University Library, 1984.
6 Churchill-Livingstone Complete catalogue 1984. Edinburgh. Churchill-Livingstone, 1984.
7 Matthews, D A and Picken, F M. op.cit. 53.
8 Sutherland, F M 'Indexes, abstracts, bibliographies and reviews' in Morton, L T and
Godbolt, S Information sources in the medical sciences. 3rd ed. London, Butterworth,
1984.
9 Board of Education Royal Commission on Medical Education 1965-8 (Chairman, Lord
Todd). London, HMSO, 1968. (Cmnd 3569)
10 Morton, K 'An information network for health care' in Carmel, M. Medical librarianship.
London, Library Association, 1981. 79-80.