Tag Archives: medical students

Medicine in the Age of Mobile Technology: How Tablets Are Transforming the Patient Encounter

Medicine is becoming mobile.  Physicians, nurses and other healthcare providers must be able to quickly assimilate and react to an overwhelming stream of data.  Tablet technologies, such as the Apple iPad, have been incorporated into the workflows of many clinics, emergency rooms and hospitals.  Medical Schools and Residency programs are quickly adapting the technology for teaching.  While tablets do present some security challenges, most clinicians who are currently using them tout them as revolutionary and efficient. Moreover, there appear to be many new medical uses for tablet technologies in the pipeline that may forever change the way medicine is practiced.

Tablet Utilization:  Pros and Cons

Many hospitals are now using tablet technology to help physicians and other treatment team members prepare and interact with patients while on the move.  With healthcare reform and cost containment strategies, many hospital systems are looking for ways to streamline care and cut costs.  Potential advantages of tablet use include the ability to improve workflow on rounds, reduce staffing requirements, and increase productivity and efficiency without compromising patient outcomes.  In many centers, physicians are able to “sync” their devices wirelessly or via sync stations located throughout the hospital.  Rather than moving to a computer terminal to sit down and review labs, consult notes, test results, etc, a team can move through the hallways and discuss these findings via an interaction on the iPad.  There is virtually no downtime and less staff is required to see patients in an efficient way.  When interacting with patients in their room, caregivers can actually show them images and results and discuss findings with them.  In fact, a recent study from the University of Sydney showed that secondary review of radiology study images on an iPad was just as good as a standard LCD computer screen.  For patients, it improves education and engagement in the care plan when they are able to see an image or test result as they discuss the finding with their providers.  When patients have a better understanding of their medical problem and are able to participate in their treatment plans, outcomes improve.  Tablet technology helps facilitate this type of engagement.

Some centers are incorporating their EMR (electronic medical record) into the tablet via a mobile application and this allows for quicker documentation and immediate record of the day’s plan for the patient–available for all team members to access “real time”.  The EMR mandates put in place by the federal government have become a burden to many facilities and providers–by interfacing with these technologies via tablet technology, adoption of EMR and efficiency of documentation may improve.

As with any computerized medical record or medical application, security and HIPPA regulatory compliance are always a concern.  In addition, the small size and mobility of the iPad device makes keeping the devices in the hospital a challenge.  Although several major academic medical centers, including Massachusetts General Hospital have begun to incorporate tablet technologies into their practice, many others have not due to the cost of stocking the institution with the relatively expensive devices.  Now, many EMR companies, including EPIC (a major EMR player in academic centers) have created secure applications for tablets and other mobile devices that protect privacy and are HIPPA compliant.

Tablet Technology:  Future Applications in Medicine?

At this point, we are only seeing the tip of the iceberg when it comes to mobile technology in medicine.  Tablets are very powerful, portable, and user friendly.  I believe that these devices will become standard issue in medical schools across the country.  Rather than spending 1000 dollars per student on printed materials for a year of medical education, schools such as the Yale University School of Medicine are now issuing iPads to all students and utilizing the iPad for nearly all curriculum related materials.  According to the AAMC, tablet technology is being adopted all over the country and is being used to replace reams of learning materials on paper.  In a recent survey of medical students published in the Journal of the American Medical Library Association, most students go utilize electronic based medical resources at least once a day and over 35% use a variety of mobile devices to access information.

Applications continue to be developed that have important educational roles in medicine–apps for learning EKGs, reviewing histology, learning pharmacology and others are becoming mainstream and will likely be an integral part of medical education going forward.  A recently published study in JAMA: Internal Medicine evaluated the changes in resident efficiency when using iPad devices for clinical work.  In the study, the authors found that the utilization of mobile devices improved workflow and both perceived and actual resident physician efficiency.  In fact, orders on post call patients were placed earlier–before 7am rounds–likely resulting in improved care and more timely delivery of medications, treatment plans and orders for diagnostic studies.

For patients, tablet technologies may improve their visit experience and may help reduce medical errors.  I can foresee a clinic where patients check in for their appointment and are given an iPad to fill out forms and answer a wellness screening questionnaire prior to their visit with their primary care doctor.  With more “meaningful use” requirements imposed by government bureaucrats, these electronic screening opportunities will allow clinicians to not only meet regulatory requirements but also continue to spend meaningful time with their patients during a visit.  In addition, patients can have the opportunity to review imaging with their clinician at their side and actually “see” what the doctor is able to see.

For physicians, the possible applications of tablet technologies are endless.  Ultimately, I believe that these mobile technologies will revolutionize medicine and allow for care to be provided to patients who have previously been underserved.  Tablet based electronic patient encounters are on the horizon.  As physicians we must ensure that we continue to embrace technology and we must not resist change–medicine remains both a science and an art.  We must continue to strive to incorporate BOTH technology and human touch into our patient encounters.  Change is coming–we must adapt and embrace these technologies in order to provide our patients with the healthcare and caring that they deserve.

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Guest Post: Musings on General Medicine at a Teaching Hospital

The Following Post is Written by Dr Deborah Fisher, Associate Professor of Medicine, Division of Gastroenterology at Duke University Medical Center.  Dr Fisher is both a brilliant clinician, writer, and researcher…and also happens to be my wife. http://www.durham.hsrd.research.va.gov/cv/Deborah_A_Fisher_MD_MHS.asp

Usually I spend about 65% of my time in clinical Gastroenterology and 35% in research, but 4 weeks a year I put on my General Medicine hat and supervise the housestaff.  General medicine is more challenging than ever because of resident time restrictions, multiple patient care hand-offs, and the increased administrative burden for all physicians (in-training and supervising). For readers not familiar with the academic calendar, it runs roughly July to June rather than January to December. This past General Medicine rotation I drew the lucky card of July.  Or so several administrators would have me think.  “Residents are enthusiastic in July, no burn-out” “They don’t argue with you” “They treasure every clinical pearl you offer” and the like.  Perhaps.  I must admit that residents rarely argue with me during any month and often General Medicine induces burn-out in even the newest residents.

Nonetheless, I thought it might be less pressure to teach in July.  The classic Chalk Talk is all but gone.  Allegedly, residents are all self-teaching basic pathophysiology and differential diagnosis during the time carved out by duty hour regulations, but the empiric and published evidence is not obvious to me.  My teaching goal is to bring relevant data to the clinical setting in the context of individual patients. Of course, I provide feedback regarding data collection, patient presentations, and plans for management, but I also emphasize the importance of communication: within the team, with covering physicians, with consultants, and with patients and their families.  I teach critical appraisal of guidelines. Guidelines can be useful summaries of the available data, but they can also be biased opinions and above all they cannot be applied to any patient without considering how that patient may have complicating comorbidities or other circumstances not addressed in a given guideline. Finally, in all clinical settings, I emphasize that in this age of technology we must connect with our patients and engage them in their own healthcare. I worry when in clinic residents only make eye contact with the computer screen or on the wards when, after morning rounds, they deliver all news to patients via bedside telephone (even when on the same hospital floor and wing). The Mantra from Administration is “Discharge planning begins on admission.” My interpretation is that we are not attempting to discharge as quickly as possible for its own sake, but that we must understand something of a patient’s social situation and other potential barriers to managing their health to start mobilizing resources to address these barriers. The sooner this is done the better.  We must tailor the evidence for an intervention with the individual needs of the patient.

To avoid taking myself too seriously in my role as a clinician-educator I will end by sharing my 2 super powers.  This is timely as July is also filled with superhero summer blockbuster movies.  My best super power is the ability to arrange endoscopic procedures with a single phone call.  My second super power is the ability to approve Miralax (polyethylene glycol) for constipation.  Oh the might! The glamor!  Of a Gastroenterologist on General Medicine.

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The Changing Focus of Medical School Admissions: People Skills Required!

When I was applying to medical school in 1991, a stellar GPA and near perfect MCAT (Medical College Admissions Test) score would almost guarantee admission to a student’s medical school of choice.  Typically, interview days consisted of meeting with one or two esteemed faculty at the school, a tour with current students and a brief talk with the Dean of admissions.  Sometimes offers of admission would be made “on the spot” by the Dean.  Little time was spent evaluating the social skills or personality of the prospective student.  The best medical schools focused on packing their classes with valedictorians, published researchers, and other scholars.  Activities outside of academics including volunteer work and service were important “window dressings” on the application but the real focus was on the numbers.  Today, more than ever, we need to train doctors who can effectively communicate.   As healthcare costs continue to skyrocket out of control, so much of healthcare in the future is going to focus on prevention.  As I have said many times before, prevention starts with patient engagement.  Engagement requires that physicians are able to interact effectively with patients via multiple modalities including good old fashioned face to face encounters as well as via electronics and other mHealth applications. Effective in person, patient interactions require that a physician is guided by ethics and is able to understand and apply the concepts of empathy and compassion.

Technology based education has become heavily emphasized over the last decade.  Recently, many physicians have expressed concern over the tech-bias of newly trained doctors. As I have referenced in a recent blog, many senior physicians worry that the ability to interact and relate personally with patients and colleagues may be missing.  An article in the New York Times from April 2012, reported on the new focus by the AAMC (Association of American Medical Colleges) on integrating social sciences into medical education.  The MCAT is has been redesigned to include a section on ethics, behavioral and social science.  This is a very nice thought, but how can we accurately measure empathy, compassion, and the direction of one’s moral compass through a standardized test?

In the Wall Street Journal this week, Jonnelle Marte discusses the fact that medical schools are now emphasizing “people skills” as they select students that will make up future classes.  Certainly grades in undergraduate school and MCAT scores remain important but many of the best medical schools are expanding the admissions process to include a full day of interviews with multiple faculty members.  Some admissions committees are requiring personality tests as well as interviews with trained psychologists.  Other institutions are creating “mock patient encounters” for prospective students in order to gain insight on the applicants ability to relate and interact with potential patients.  I believe that much of this is a move in the right direction.  Just as in most professions, “book smarts” and academic prowess isn’t always enough for success.  The most successful CEOs not only have a Harvard MBA (or equivalent) but also have the ability to make those around them feel good about what they are doing.  A recent global CEO study conducted by IBM found that companies in which CEOs embraced and fostered a culture of openness and collaboration outperformed others by nearly 30%.  It is clear that successful leaders engage followers and motivate them to function at the highest levels and reach potential.  These same principles arguably can be applied to produce more connected and interpersonally engaged physicians.

As healthcare continues to evolve, so must our ability to educate young doctors.  The US has one of the finest systems for medical education in the world today.  Students and doctors from all over the world come to America to train.  However, in order to select and train the best candidates our system must continue to evolve as well.  Now, more than ever, we must ensure that doctors are not only skilled healers but skilled leaders, motivators and communicators.  Although many of these interpersonal skills are learned over time, we must be able to identify potential and cultivate these abilities when selecting students to enroll in the medical schools of the future.  The new emphasis by the AAMC and MCAT on social and behavioral sciences is a move forward but we must remember that it is just one small step in crafting the caring, compassionate, empathetic physicians of tomorrow.