Dominic King

So, you have your smartphone in your pocket, loaded with medical apps, and you have your computer in front of you, housing the latest update of your EMR. You can quickly look up the next diagnostic step for elevated lab values, you can cross reference medication interactions with the Epocrates application, you can send e-prescriptions wirelessly to the pharmacy, and you can enter every detail from a medical encounter with the click of a mouse. The only thing these devices 

do... is talk to your patient. That is your job: to communicate with patients and help facilitate healing.

Patients drive hours, wait hours, and spend their money just to hear our advice. We should spend every minute of a patient encounter talking, listening, teaching, and bonding with our patients. Instead, we are busy trying to use our smartphones and our computers.

There is no doubt that the medical technological revolution is allowing medicine to be more accessible, but has the revolution also caused medicine to be more impersonal? As a medical student, I have had the ability to watch many physicians adopt EMRs and see how they try to balance the difficulty of recording everything on their computer, while still trying to include the patient in the process. I have witnessed multiple situations in which a patient clearly feels like the smartphone or computer was a complete interruption of the encounter, and their frustration was very evident. Because of this unique issue, I have outlined a sort of “etiquette” for using medical technology during patient encounters:

1.     The most important first step in including a patient in the encounter is ensuring 

. Make sure that the computer is not placed against a wall, where you will have your back to the patient, and make sure that you are taking time to look up from your computer to make eye contact with the patient, especially when they are giving you the history of their problem. This would seem to be common sense, but I have seen enough physicians stay glued to their screen during the entire encounter that it bears mentioning.

at the desk in your office, at the nurse’s station, and in each of the patient rooms. When you enter each room, plug in your computer. Losing power during a patient encounter is distracting, embarrassing, and immediately stops you from continuing with the encounter. Again, I’ve seen it happen many times, and it is easily preventable.

to the patient that you may be using your smartphone to look up medications and using medical applications to help out with the diagnosis of their problem. If you do not make them aware of this, many patients will think that you are sending a text message. To take that a step further, responding to e-mails, text messages, or answering phone calls with your smartphone during a patient visit is widely considered to be very rude. If you have to take a call, excuse yourself and exit the room. Remember, it’s the 

time. Also, make sure to put your phone into the 

mode before you enter the room. You don’t want to be halfway through a physical exam when 

. Many tablets can run software that can easily interact with your EMR and e-presciption service. They can also run applications similar to your smartphone, which eliminates the need for switching between devices. Tablets also have applications that are unique to their larger screen, allowing for more interaction between you and your patient. Tablets typically have much better battery life than standard computers, eliminating the need to constantly plug them in, and avoiding loss of power during an encounter. Finally, some tablets are very light and portable, allowing you to sit next to your patient or place the tablet on the examination table and easily integrate the device into the encounter.

5.     The most interactive way to use all of this new technology lies in the 

of these devices. Data is constantly being entered into the EMR, and that data can be manipulated and displayed in many ways. Most programs allow for a graph or some pictorial representation of this data, and we can use that to show our patients how they have been progressing. For instance, we take a blood pressure reading every visit. Why not use the program to display a line graph of how your patient’s blood pressure has changed since they began dieting and regularly exercising? This way, the patient can see their progress with their own eyes, and you can show your continued interest in the improvement of their health.

6.     After the encounter is finished, place the computer and smartphone to the side and close the encounter by sitting in front of the patient and describing the plan of action with them, 

. Patients truly respect that you have taken an extra second away from information gathering with the computer to make sure that they understand your plan.

Hopefully, these points will help you to approach the unique challenges that are presented with incorporating new technologies into interacting with patients. There is a happy medium that exists, but finding it can be frustrating and time consuming.

the crisis fleeting; experience perilous, and decision difficult.

The physician must not only be prepared to do what is right himself,

but also to make the patient, the attendants, and externals cooperate.

~ First aphorism of Hippocratres, c. 400 BCE

Let us ensure that our modern technological externals continue to cooperate with our efforts to communicate and relate to our patients.

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How to use all of your medical gadgets without forgetting about the patient in the room.

6 Keys to Medical Technology Etiquette  

Writing medical application reviews for MDNG has allowed me to take a very critical look at the new age of accessing medical knowledge with technology. In these reviews I use the phrase ‘electronic medical bag’ to describe these devices, because of the daily usefulness they can provide. With the advent of medical applications, a smartphone or tablet is almost necessary for the new generation of health care professionals and can be a useful tool to even the most seasoned of physicians. These devices are compact and can give us access to more information than could fit in the pockets of our white coats. However, the competition is varied, new devices seem to pop up every day, and with the introduction of tablets, the decision on what to get can be very difficult and time consuming. If you haven’t delved into purchasing a smartphone or tablet yet and are timid about testing the waters, you have come to the right place. Here, I will provide a little assistance to those just jumping into the arena of portable medical resource devices.

First off, it is only right to mention that there are other devices available that also achieve similar goals as these three. Microsoft has their Windows 7 phone and with their partnership with HP will be delivering the Slate tablet. HP will have the Pre3 (originally developed through Palm) and the follow-up TouchPad running webOS. The reason why I am excluding these products from this post is a simple reason of familiarity. Microsoft has been absent from the smartphone game for a while and is just now starting to regain steam, and the offerings from HP are not yet available for a comparison. Future posts may be written about their usefulness as medical devices, but for now, we will stick with the big three.

For those of you who already have an iPhone, Blackberry, or Android phone and are considering getting one of the new tablets on the market, the quickest and most reliable method of choosing which tablet to get is easy: 

. Apple has the iPad, Blackberry has the Playbook, and Android has the Xoom. You will already be familiar with the operating system and interface, although they might differ slightly from the phone to be adapted for a bigger screen. If this is your first entrance into the exciting world of smartphones and tablets, the decision then to make is, “Which one do I get?”. For those new to the game, choosing a device is based on two things:

: Basically you are going to pay the same amount for each of these devices. The smartphones have contracts with cellular network carriers and the prices of the devices are subsidized through these contracts. Expect to pay $200-$400 for the smartphone with a contract running from $60-$100 a month, depending on phone service options and data usage. If you are in the market for a tablet, expect $400-$900 for the tablet and $30-$40 for cellular data access, or free for wifi access.

: This is where the lines are drawn. Having used devices offered by each of these companies, I can tell you that the interfaces are all very different and the ease of use is just as varied. The best way to see the difference is to head to an AT&T or Verizon store and check out each of the devices for yourself. Get an idea of how easy it is to open applications and navigate through the operating system. Notice the different build qualities of the products. Apple and Blackberry have their own software and hardware, whereas Android is software that runs on different manufacturers hardware. This results in consistent build quality of Apple and Blackberry devices, with a range of quality with the Android devices. You will immediately be aware of all of the differences, but here is my simple rundown of each of the devices:

-        requires some knowledge of using a computer for downloading iTunes for activation

-        Apple App Store is very expansive with great support for medical applications

-        moderate difficulty with learning the software

-        each of the devices have a good build quality

-        self contained with no need to use a computer

-        Blackberry App World is functional but not as impressive as the Apple or Android offerings

: (Motorola Droid X, HTC Incredible, Samsung Galaxy S, many others)

-        most difficult learning curve for new users

-        many customizable functions and interactions with computers

-        great synchronization with Google applications

-        build quality depends on the hardware manufacturer

-        Android Market is as expansive and as reliable as the Apple App Store

: I’m sure I will get some flack for generalizing this statement but, . . . “buy Apple”. I have an Apple iMac computer, an Apple iPhone and an Apple iPad tablet, and I like them because they are simple to use. If you are someone who is very comfortable with computers and likes customization, you may prefer the Android devices, and if you like the look and feel of the Blackberry, you won’t be disappointed either. Android is the biggest competitor to Apple right now, but to compare the two really is like comparing “apples to oranges”. However, if you are new to the smartphone/tablet game, save yourself a lot of time and frustration and just go get an iPhone or an iPad. The interface is ridiculously simple, placing all of the emphasis around applications and the customer support is the best out of the bunch. Each of the devices from these companies share a lot of the same medical applications, but it seems as though more applications are created for the Apple devices first, then released onto the others secondarily. Another point to mention is that if you don’t need the phone capabilities of an iPhone, and are not interested in the larger size of the iPad, you can get the iPod Touch, which is essentially an iPhone without the phone. These range in price from $230-$400 with no contract.

I admit that I am a little biased because of the great experiences I have had with Apple products, but the main point to convey is the amazing utility 

of these devices offer a medical professional. The ability to sit by the bedside of an injured athlete, open the SCAT2 (sports concussion assessment tool) application, get immediate results and e-mail them to the team physician, all from one device is incredibly efficient. These programs have had such a great impact that the FDA is now approving some of them for use as regulated diagnostic aids. This kind of incorporation of technology and medicine is interesting and downright fun, but is it effective? How do we gage the impact of using these devices to improve patient health? Are we spending too much time using these devices, and not enough time with the patients? These advancements cannot be ignored, and I believe they will serve a very important role in the diagnosis and treatment of our patients’ conditions. However, it seems like we, the ‘NextGen Physicians’, are so focused on “what is the new diagnostic test”, that we are forgetting that medicine is not based around the disease, but around the patient.

Please comment below with any kind of feedback. I’m new to medicine and to blogging, and if there is a specific topic you would like me to address from the perspective of ‘The NextGen Physician’, I would be happy to start a conversation. Thank you for reading.

What smart device should you use as your electronic medical bag: Apple, Blackberry, or Android?

Apples, Blackberries and Robots, Oh My!

Years ago, a few thousand sheets of loose leaf paper, several pens, and a stack of medical books were the arsenal of choice when it came to medical education. Add in about 80,000 hours of lecture and study, several days of board examinations, and a countless number of lost nights of sleep . . . and you have a doctor. Today, however, advances in computers and technology have completely changed medical education. The 80,000 hours of lecture and study, several days of board examinations, and countless nights of lost sleep are still there, but the approach is entirely different. Notebooks and pens have been replaced by laptop computers, smartphones, and tablets, and the stack of medical books has now been converted over into eBooks. These technological advancements may seem “flashy” and “in style,” but they serve a very valuable purpose. 

Understanding the wealth of medical information in medical school has been described as trying to take a drink of water out of a fire hose. Converting all of this information into a digital format and compiling it into a useful interface has offered the new class of medical students opportunities not even imaginable 10 years ago. Let me take you through some of these advancements.

            1. Laptops/Tablets/Smartphones:

                Laptops are ubiquitous on college campuses, and medical school campuses are no different. All medical students use laptops, tablets, and smartphones to access daily lectures, read electronic medical texts, take notes, and attend electronic study sessions with other students and faculty members. Smartphones have become especially useful for medical students with the advent of medical applications for study, research, and diagnosis. A laptop is a necessity for a medical student. In fact, the entire application process for medical school and residency is now fully electronic and mediated through websites and e-mail. For this reason, most medical schools provide a laptop to incoming students and offer reimbursement for the student’s smartphone of choice.

            2. Fully recorded audio/video lectures:

                Depending on the school, every lecture, including questions asked by students, is digitally audio and/or video recorded and uploaded to a database that students can access later. This results in students spending less time in class trying to write down every single word of a presentation, and instead paying attention to the presenter and the lecture. Lectures can even be streamed live for those students who are on their rotations away from campus. Of course, because of the accessibility, this has resulted in schools having a requirement of a minimum number of lectures attended, so there is always an audience for the presenters.

Probably one of the most “fun to use” tools in medical school is the robot simulator 

. With the use of computer software, instructors can simulate a wide variety of medical complaints and complications. The simulators have breath sounds, heart sounds, peripheral pulses, pupillary reactions to light, IV access that can determine what medication was given, and many other features. Being able to simulate different scenarios under controlled conditions allows students an invaluable resource for practicing their clinical skills.

            4. Digitally recorded patient encounters:

                Standardized patient encounter rooms are outfitted with high definition audio and video recording tools for faculty clinicians to observe students as they work with both robots and standardized patients. From a remote control room, the clinicians can monitor and track all scenarios across a wall of LCD HDTVs. Every encounter is digitally recorded and tagged with the student’s name, so later review can be observed and points of education can be made.

These are just a few of the ways medical schools are evolving with technology, and that is also true of medicine in general. EHRs, digital imaging, and ePrescribing are quickly becoming the norm for medical professionals. Technology has made medical school, residency training, and medical practice more integrative and accessible. However, with all of these advancements, a dilemma presents itself.

: has the access to all of this electronic medical information made us diagnostic robots? How do we balance the un-emotive presence of technology with the ability to compassionately communicate with our patients? How can a computer help us improve our relationships with those for whom we care? More on that to come . . .

Med school now combines state of the art technology with ages of medicine for a whole new innovative educational experience.

Dominic King

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