Education Unplugged: In Defense of Paper


books rmPhysical medical reference books (remember those?) still hold an important place in many EPs’ hearts… and in their pockets

Physical medical reference books (remember those?) still hold an important place in many EPs’ hearts… and in their pockets


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Smartphone apps have found their way squarely into medical practice, helping doctors communicate with one another, monitor patients’ vitals and look up medical conditions and treatments. In fact, according to the British Medical Journal, there are close to 100,000 health-related apps for smartphones, between iOS and Android.

If that number sounds overwhelming – or if you’ve ever been in the middle of a drug reference search when your phone died – you might be among the cohort of doctors who still believes that the old school is the best school. Sure, smartphone apps come with lots of bells and whistles, but sometimes you just need a trusty dog-eared drug reference guide shoved in your pocket. Here, amidst the sea of app reviews and tech reports, EPM takes a moment to talk about the value of paper.


On one end of the spectrum you have the true old school docs who simply trained and practiced in a world devoid of app stores and push notifications. For instance, it should surprise no one that EPM columnist Greg Henry prefers a physical reference guide over an iPhone app any day of the week. Dr. Henry – who still writes with a quill pen and considers any book with a ring binder a radical abomination – is the first to admit that he is from the old school. But it’s not just a lack of familiarity that breeds contempt. For Henry, the difference between electronic and paper references as the difference between the ephemeral and the permanent. Or even deeper, the difference between a friend and a stranger.

“When you shut the power off on the computer, it’s gone,” says Henry. “But I have books that I literally love. The friendship that you can feel with a physical book is not something I take lightly. They become our connections with people, with the past.” Even something as seemingly mundane as a drug reference guide can contain meaningful notes from the past year, says Henry; “Last time I gave that the patient died.”

Dr. Brady Pregerson, a staff emergency physician at Cedars-Sinai Medical Center in Los Angeles, is decades younger than Dr. Henry, yet he’s passionate enough about pocket reference guides to have made them into a side business. Pregerson has authored three medical reference pocket books that are jammed with charts and stats – diminutive almanacs for diagnostics and treatment options for a myriad of ailments.

Pregerson first got the idea for making pocket books during his residency in 1998. “I started making review notes for myself and walked around with these folded up pieces of paper,” he said. Brady showed the notes to one of his friends who was amazed by all of the information they contained and suggested he turn them into books. To tech-loving, early-adopting skeptics, Pregerson points out a few ways that paper beats smartphone. One, pocket books cost less – PEPID Emergency Medicine Suite costs $299.95 per year. Two, they won’t break if you drop them. Three, they never run out of batteries. Four, if you want to talk “upload speed,” the pages can be “instantly” flagged for future reference.


“I still carry around an antibiotic handbook,” says Greg Henry. “You can tag a couple pages and jump to that data faster than going through an algorithmic program.”

Finally, with a paper reference guide you never have to worry about being some start-up’s guinea pig. Why get stuck using the first iteration of an untested software, says Pregerson, when you can use a tool that has been honed over more than five centuries.

To be fair, Brady’s not a complete luddite, embracing technology in other ways throughout his day. He’s a recognized expert in bedside ultrasound education. But he represents a group of mid-career doctors who didn’t start using smartphones until relatively recently and who may have trouble swiping, tapping or scrolling to access important medical information in a hurry. For these docs, pocket books might be a helpful alternative.

Of course, for Generation Yers and Millenials, iPhone apps and websites are still the more intuitive and comfortable method for finding essential medical information. They are also updated more frequently than books of any kind. But even for younger docs, online medical referencing can have its drawbacks. For example, it can be hard to know which websites and apps are accurate.

Dr. Lynette A. Scherer is chief medical officer at Surgical Affiliates Management Group, a surgical hospitalist company. Scherer said that when she was the medical residency program director at UC Davis she saw most students working solely on their iPhones and spent a lot of time teaching them how to determine if a reference is credible.

“It’s hard to beat peer reviewed literature,” Scherer said. “It’s easy for someone to write a PDF and post it online, but then you’re at the whim of author. The peer review process adds clarity and emphasis to the work, so whenever you choose a site or app, you just want to make sure the material is good and the data is accurate.”

Of the tried-and-true online references that have been vetted for accuracy, such as UpToDate and DynaMed, Brady’s biggest complaint is the problem of information fatigue. A doctor might be overwhelmed with results after searching for a particular condition or medication online. Links, video procedures and auto-updated content could slow a user down in the fast-paced emergency room setting, and will make the app more likely to crash. In that way, the page limitations of print publishing can end up working in its favor.

Dr. Melissa Barton is an attending physician in the emergency department at Sinai-Grace Hospital in Detroit and an associate clinical professor at Wayne State University. She has been carrying around the Tarascon Pocket Pharmacopoeia for over a decade. “I can highlight drugs during an emergency and I write my own notes in the pages,” she said. “I don’t know how you can do that on an iPhone app.”

Essentially, Barton prefers pocketbooks because they are an easier transition from the textbooks she was trained on. To Barton, paper is just faster than trying to locate information on a cellphone. She also noted how impractical apps would be for her because her phone does not work in all hospitals, which prevents her from accessing the Internet or apps. “Depending on what hospital or hospital system you’re in, you will be dependent on their Internet speed on the phone.”

Barton does not feel like her preference of paper keeps her in the dark as new medical information becomes available because she purchases updated versions of pocketbooks every year. “My drug reference book has gotten thicker over the years, but it still fits in my pocket.”

Amy Kraft is a science reporter based in New York City.


  1. For defending a decision – whether in court or in practice – paper is going to win the battle. Electronic information can change instantly, but if you ask a physician why he treated someone a certain way five years ago, he could point to a print source that was the “gold standard” at that time. It would be tough to get a 5 year old electronic reference.

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