Preferred Book Formats in an Academic Medical Center*

Learning more about when and why medical students , faculty, and clinical staff use e-books, as opposed to print books, is an expanding area of research for health sciences librarians. Several studies have highlighted the heavy use of health sciences titles in campus e-book collections [1–5] and the book format preferences of medical and other health sciences students [2, 6, 7]. A recent case study by Shurtz and von Isenburg is one of the first to explore e-book use in both health sciences educational and clinical settings [8].

Learning more about when and why medical students, faculty, and clinical staff use e-books, as opposed to print books, is an expanding area of research for health sciences librarians.Several studies have highlighted the heavy use of health sciences titles in campus e-book collections [1][2][3][4][5] and the book format preferences of medical and other health sciences students [2,6,7].A recent case study by Shurtz and von Isenburg is one of the first to explore e-book use in both health sciences educational and clinical settings [8].
As of June 2010, The Ohio State University (OSU) Prior Health Sciences Library offered more than 6,000 health and life sciences e-books.E-book usage has increased every year driven by Core25 Books, a browsable e-book promotions tool developed at the Prior Library, the ability to link to e-book chapters via the online course management system, and the distribution of the latest in mobile device technologies by OSU to incoming health sciences students and residents.During recent patron-driven e-book selection projects conducted at OSU, medical and life sciences books ranked at the top of subjects selected.Even with the growing emphasis on e-books at OSU, many questions remained about format usability and customer preferences.
This exploratory study proposed to: (1) identify the book format preferences of customers in education, research, and patient care settings of an academic health sciences center; (2) discover factors that influence customer format selection; and (3) offer suggestions to librarians involved in the selection and delivery of health sciences books.

METHODS
A convenience sample of sixteen participants from OSU-two faculty members from the college of medicine, two faculty members from the college of nursing, four nurses, four medical residents, and four medical students-were recruited via email communications to campus email discussion lists asking for volunteers to participate in an e-book study in earlymid 2009.The email indicated that the print books used in the study as well as gift cards would be offered as incentives.Fifty-five individuals responded to the request, and sixteen were chosen, representing a crosssection of primary library customers.Participants were not required to be experts in the use of e-books but were expected to be familiar with handheld devices and online tools.After completing a baseline survey and introductory interview, participants completed a question-and-answer exercise using three book formatsprint, web-based, and handheld-and then took part in a closing discussion and completed a post-study survey.
Exercise questions were compiled from two sources: assignments from an OSU clinical skills immersion class and a study guide for the United States Medical Licensing Examination [9].The survey and exercises were pilot tested on two Prior Library staff members to ensure feasibility.During the pilot test, it was determined that the various formats used, combined with the complexity of the questions used in the assignment, did not warrant controlling the order in which the formats were searched during the study exercise.There appeared to be little in the way of knowledge transfer from one book format to another.
Print books, web-based books, and e-books preinstalled on a Palm TX handheld device (the device being issued in 2009 to OSU medical students and residents) were provided to study participants.The selected titles, based on availability in all three formats, were Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, Ferri's Clinical Advisor, Harrison's Principles of Internal Medicine, Manual of Laboratory and Diagnostic Tests, and The Washington Manual of Medical Therapeutics.Web-based versions were accessed through MD Consult, Ovid, and STAT!Ref, and handheld versions were provided by SkyScape.Participants' prior experience with the titles used in the study was not a consideration.
Prior to beginning the study, participants met with the authors to review study requirements and compete a baseline survey (Appendix A, online only) to measure prior use of e-books.They received handheld devices preloaded with the study books along with the print books.Participants not familiar with the Palm TX device were offered a demonstration and instructed to explore the device on their own.
Participants were then asked to answer a series of questions as if they were caring for patients or studying for examinations.Ten identical questions (Appendix B, online only) were given to each participant, and participants were instructed to spend a maximum of 10 minutes on each question using books in all 3 formats, completing the entire exercise in 2 weeks.After searching for answers to each question, participants recorded the books, page numbers, relevant chapters or sections used to answer the question, and the time needed to answer each question to satisfaction (Appendix C, online only).Participants also rated each format overall for ease of navigation, readability, and searching efficiency on a 5-point Likert scale, where 5 was ''Strongly agree'' and 1 was ''Strongly disagree.'' In the study's final phase, participants met with the authors, turned in their exercise forms, completed an exit survey (Appendix D, online only), and summarized their study experiences.

Baseline survey
All 16 participants completed the baseline and exit questionnaires (Table 1, online only).At baseline, 11 participants (68%) reported owning a handheld device.Fourteen (87.5%) indicated they were aware that the library offered e-books.The 2 who were not aware of the e-book collection were both nurses, 1 nurse faculty member and 1 clinical nurse.Nine (56.2%) participants reported they had previously used e-books, and 1 participant was unsure.Of these 9, all had used web-based e-books and 3 had used handheld e-books.Six participants found e-books easy to use, and 3 were unsure.All 4 clinical nurses reported no previous use of e-books.The reasons reported for not using e-books were a lack of awareness and a preference for using journals.

Exercise findings
Details of the responses to the study exercise are shown in Tables 2 and 3. Overall, the print format was rated the most intuitive and easy to navigate as well as most satisfying.Participants found the handheld format to be the least intuitive and easy to navigate as well as the least satisfying.Participants reported that it took the least amount of time, on average, to find answers in print format, followed by web-based, with the handheld format taking slightly longer than the web-based format.Nurse faculty members spent the least amount of time answering the questions across all formats with an average time of 1.98 minutes per question.Physician faculty took the most time answering questions across all formats with an average of 4.34 minutes per question.
When asked which format satisfied their needs most, students and nurse faculty indicated print, residents and clinical nurses indicated print and online formats equally, and physician faculty indicated print and handheld formats equally.
The exercise form provided space for comments, and comments regarding the handheld format focused on two issues: navigation complexity and price.Residents and clinical nurses reported problems searching for specific information using the handheld device.Several participants noted concerns about the price of subscriptions and devices with one nurse faculty member recommending this format be left to personal purchase.With respect to web-based ebooks, participants noted frustrations adapting to different provider platforms and stated a desire to have both print and web-based books available.Regarding print books, participants noted the inconvenience of carrying large books but a preference for using print books when reading large amounts of text.

Exit survey
At the exit meetings, all participants noted that study activities provided an opportunity to learn about e-books and discover their personal and professional format preferences.Presumably because their opinions were informed by their participation in the study exercise, participants' responses changed between baseline and exit surveys (Table 1, online only).At baseline, regarding purpose of e-book use, 7 (43.8%)participants reported using e-books for clinical care and 6 (37.5%) reported using e-books for course readings.At the exit survey, 15 (93.8%) participants indicated clinical care was also the most-anticipated reason for use, with 12 (75.0%)indicating they would anticipate using e-books as a general reference tool and The exit survey asked participants to indicate the format they would choose to use in the future for each of the 5 titles used in the exercise.Fourteen participants offered the following responses: (1) DSM-IV-TR, 5 of 14 predicted future use of the print and handheld formats and 4 of 14 predicted use of the web-based; (2) Ferri's Clinical Advisor, 6 of 14 predicted use of the handheld, 5 of 14 web-based, and 3 of 14 print; (3) Harrison's, 8 of 14 predicted use of the web-based, 7 of 14 print, and 1 of 14 handheld; (4) Manual of Laboratory Diagnostic Tests, 6 of 14 predicted use of both the handheld and the web-based formats and 2 of 14 predicted print use; and (5) Washington Manual, 7 of 14 predicted use of print, 4 of 14 predicted use of online, and 3 of 14 predicted handheld use.

DISCUSSION
This study supports the notion that there is a time and place for print as well as e-book formats.Similar to other findings, participants in this study found the electronic formats best for quick searches and brief reading and the print format more conducive to reading large amounts of material [2,7,10].
An initial assumption was that medical students and residents would prefer electronic formats because they have grown up using them, but this was only partially supported.The authors also predicted that health care professionals would prefer print books because of their comfort and experience with using this format, and this was also only partially supported.As to overall satisfaction, all groups indicated that print books satisfied their needs as much or more than the other formats.This finding suggests that libraries should continue to provide print books as well as ebooks during this time of transition.
Additional studies involving larger, random samples of participants would strengthen the evidence in this field of research.Other areas that warrant future research include conducting follow-up communications with research study participants for collecting information on the long-term use of e-books, exploring the impact of faculty and department leadership preferences and expectations regarding e-book use by their students and staff, and investigating which e-book education and communication techniques reach customers most successfully.

Study limitations
The authors' limited resources combined with the demands on participant schedules necessitated the small sample size, which limits the extent to which the results can be generalized to other populations.Web-based platforms were chosen for this study based on the required availability of titles in all three formats.The study's findings mght not apply to all commercial platforms.The order in which participants searched each format during the exercise was not controlled, and this might have resulted in some bias.Complications related to license rights, access to the handheld hardware and software, and lifechanging events among some of the participants slowed the completion of the study.

CONCLUSION
In the months since the authors conducted this study, interest in e-books and e-book readers has increased at OSU.In a very short time, e-book access devices have evolved from the popular Palms used in this study to the iPod, Android, Kindle, Nook, and most recently, the iPad.The authors theorize that most customers will soon come into the academic and health settings having personally used an e-book reader of one type or another.The ways in which libraries provide and promote e-book access is crucial.Library promotions, communications, and educational sessions must regularly highlight e-book resources, features, and functionality [11].
Companies such as Amazon, Barnes & Noble, Apple, and Google are revolutionizing how e-books are bought and read.Four trends are certain for the foreseeable future: (1) e-book publishing will continue to grow; (2) the evolution of e-book access methods and devices will continue; (3) licensing and archival challenges will persist in libraries; and (4) a time and place for print book usage will remain, albeit a diminished place for many customers.It will be exciting to see how these tools and resources will be utilized by health sciences populations and adapted by health sciences publishers.

Table 1
Overall level of satisfaction by status/format

Table 2
Minutes to find an answer by format/status