How a medical student uses an iPad for patient care and education

iPads have been introduced into medical education mostly during the pre-clinical years. I’d like to share my experience using an iPad during my clinical year. I’ve found it to be exceedingly useful and versatile.

I have an entire medical library in my pocket. With the touch of a button I can pull up essential texts such as Harrison’s Principles of Internal Medicine or William’s Endocrinology. I get these books and more through my school’s subscription to MDConsult and AccessMedicine. Some other ancillary material that I have as PDFs can be stored and viewed with ease on the iBook app. I’ve also been using the beautiful e-reader app Inkling to keep full copies of popular texts such as Bates Guide to the Physical Examination stored on my device. Several times a day, I use these sources to look things up that I encounter in the patient-care setting.

When it comes time to write my H&Ps, I use native such as UptoDate, Medscape and FirstConsult to help me formulate my assessment and plan. I also use Papers to find and organize journal articles that also make their way into my write-ups. I use epocrates to find out the appropriate dosing for patients I’m caring for and to check for any contraindications.

Recently, I started a radiology rotation. Needless to say, I’ve needed to brush up on my anatomy a bit. Rather than having to lug Netter’s Anatomy around with me in my bag, I now just pull up the whole collection of anatomy plates on the Netter’s app for iPad. This has been a huge boon.

iPad also helps me ensure that I don’t forget all the things I’m seeing on the wards. Since last year, I’ve been using a digital spaced-repetition flashcard program called Anki. Adopting Anki as my primary mode of study has paid tremendous dividends. I recommend it to everyone. I used it last year for the basic sciences, and I use it this year to capture all the nuggets of knowledge from the wards. If I hear, see or read something, I make a card on the spot and add it to my library. When there is downtime, I just pull out my iPad and review those and other cards to keep things fresh in my head. I’ve found this process invaluable. On the wards, study time is distributed in small chunks throughout the day, rather than in large blocks as it was in the pre-clinical years. Anki and iPad have allowed me to take advantage of those little moments in a way I wouldn’t be able to otherwise.

Basic tools such as email and calendar help me stay connected and organized. I use the note program Evernote to capture thoughts or impressions I generate from my experiences. I also use this program to make to-do lists for the patients I’m carrying.

I’ve tried to incorporate iPad into patient care and education as much as possible.

One salient example is from my recent pediatrics rotation. Our team cared for a newborn who was showing signs of what appeared to be benign neonatal sleep myoclonus. The baby’s mother was very disturbed by the sight of her new (and first) daughter contracting during her sleep. When I was presenting this case on rounds, I pulled up a Youtube video of benign neonatal sleep myoclonus and showed it to the parents and the rest of my team. When the mom saw the video of someone else’s baby twitching like her own, she was reassured that her daughter’s condition was fairly common and of little concern. Likewise, the rest of my team, which included residents, medical students, nurses and attendings, got a better view of what benign sleep myoclonus looks like. This particular experience showed me the great power that iPads and similar technology can have at the bedside.

Accessing medical records is also a big part of patient care. Most patient information is electronic at Duke and we have a dedicated system for managing that info. With the Citrix receiver program, I can tap into our EMR system via my iPad. This ability has been most useful on rounds. There have been several times where key patient labs were still pending at the time when we started rounding. With my iPad, I’m able to periodically check for lab values; more than a few times, I’ve been spared from having to omit lab values in my presentation because I was able to retrieve them while on foot.

There are some ways where I’ve been less than impressed with iPad and I’d be remiss to not mention these points. On the whole, iPad has been a terrific consumption tool, but not a very good input tool. I’ve tried to use it to record notes during patient interviews, both by typing and with a stylus, and neither is satisfactory. By both methods, I lack the speed and accuracy to capture the information I need. Paper and pen is still superior in a lot of cases. In the instances where I’ve tried to use my iPad during patient interviews, I’ve felt like it was a barrier between me and the patient. I could sense that my patients felt like I wasn’t completely paying attention to them. Truth be told, I wasn’t. I was too busy making sure that the lines I scrawled or notes I pecked were accurate. I asked myself, “Who wants a medical student (someday physician) who focuses more on a computer than on the person?” And with that, I put away the iPad. For now at least. When the technology gets better, I do think iPad and tablets in general will be the preferred method of information acquisition, but until then, a notepad will suffice.

Along the lines of paying attention, I’ve also sensed that some of my preceptors don’t appreciate my use of the iPad. I think they assume I’m goofing off on facebook or tweeting or something like that. I think that perception will change with more and more people bring tablets into the clinical setting, but for the time being, medical students should be sensitive to this. I’ve found that just asking before using my iPad helps avoid any hurt feelings (and poor evaluations!).

So there you have it. That is my experience with the iPad. There is no doubt that I’m learning more and better because of this incredible device. I’m very grateful that I get to be a medical student in 2011. I am excited to see how the iPad and similar technology continues to transform and improve medical education in the coming years.

Alex Chamessian is a medical student who blogs at Dr. Willbe.

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  • Alexander Chamessian

    Hi all,
    This is Alex Chamessian. I invite you to post your comments and share how you use the iPad to improve your clinical work or education. I’d love to get the discussion going.

  • Jackie Feinberg

    Hi Alex,

    I’m a first year medical student who uses an iPad for (almost) all of my work at school. As you said, clinical years will of course be different, but I’ve challenged myself to find a way to use the iPad for data input as well as consumption. 

    My most recent endeavor has been with the Jot stylus (http://adonit.net/store/jot/) which is a fantastic new stylus that actually feels like you’re writing with a pen. It still has minor issues picking up everything (like the top of an ‘s’!), but overall has been great. I use the stylus with Note Taker HD (a note taking app with handwriting smoothing and PDF annotation options) loaded with the lecture slides to take notes in class. Since I got the stylus I actually have ceased using paper even when doing practice questions or writing out anatomy schematics outside of class. As you said, the convenience of having all of your notes and books in one place is unbeatable. I even take my iPad into anatomy lab in a Ziploc freezer bag so I can have access to them there! 

    Thanks for your article – I enjoyed hearing about how you use it in the clinical setting!

    –Jackie Feinberg

  • http://twitter.com/katellington Katherine Ellington

    iPad platorm increases our capacity to approach interactive and enganged learning.  The new NEJM platform is a great example of a multimedia that enhances the material, making it more accessible as well as appealing. 

  • http://www.facebook.com/people/Marcos-Renato-Assis/100001647363819 Marcos Renato Assis

    I agree with you Alex. There are many advantages of using IPad support except input data during patient interview. It is still a gap to be filled. However if you need to use a standardized questionnaire or other assessment tool, let’s say DAS-28 or Roland-Morris, it could be very practical with the appropriate applicative. If your Institution’s register are computerized you can launch these data after through a Bluetooth system. In fact, I’m trying to implement a more practical operating in my rheumatology clinic, but for now, due to availability, we are using IPhone for this purpose of clinimetry.

  • http://www.facebook.com/people/Marcos-Renato-Assis/100001647363819 Marcos Renato Assis

    Hello, Jackie. It was a new for me. I have searched for different types of inputing information. I looked for the tool you mentioned at the internet. I found two adonis device (jot and writer) and both seems to be good. I guess they are light, sufficiently portable. Did you use the writer also? Is there a possibility to convert the text you make with the pen to a digitalized text? I would also like to see progress with the voice recognition systems but until now any accent in the speech has been a barrier.

  • http://twitter.com/jill_mccormack Jill McCormack

    Alex – is your device supported by the University and/or do you have the password function engaged?  The reason I ask is to make sure your if you have patient’s information on the device, that it is protected.  It’s amazing what technology can offer clinicians from brand new to experienced learners, but we are all struggling to balance ease of use with security.

    • Alexander Chamessian

      Hi Jill,

      Yes, patient information protection is very important. My device is password protected. I also don’t keep any patient info on my device. It’s all through my school’s EMR, which is protected by another layer of passwords and encryption.

      Thanks for your comment.

      • http://www.facebook.com/profile.php?id=640631196 Jason Scott

        Hi,

        You mention you don’t keep patient data, yet in your post you said you keep to-do lists for your patients. Have you just pseudonymised the data?

        • Alexander Chamessian

          Hi Jason,

          Yes, I keep lists that are pseudonymized so that I know who’s who, but others wouldn’t know. Patient information protection is very important, and I hope some good solutions are found so that more docs can use tablets.

          Since this is your domain, let me ask. Docs and providers carry all kinds of non-electronic patient information on them – pads, loose sheets of paper with notes, sometimes printed case histories. To my mind, these items are even less secure than a password protected tablet. These can fall out or be found by the wrong people every day. The major difference I see between an electronic device and these conventional items is that the former houses a lot more data in one place. That seems to be the major weakness. Is that why there is much more concern about tablets and information protection?

  • John Smoot

    I totally agree with Jill while technology can really improve care and response times I really worried about security risks and leaks. Do any of you do anything to anything to help protect yourself?

  • http://twitter.com/RyanMadanickMD Ryan Madanick, MD

    Funny you mention the Jot stylus…I am still waiting for the company to adapt its stylus to the Zagg screen protector, which I have on my iPad.  The Jot will not work well with it on.  

    The med students are leading the faculty here!

  • http://twitter.com/RyanMadanickMD Ryan Madanick, MD

    Nice commentary Alex.  You are probably correct about preceptors.  Many preceptors do not yet see the advantages of iPads and other technologic advances in medical care and medical education.  Engage your preceptors before you use the device, and/or be transparent about what you are doing/have done.  That said, gaps do exist.  Thank you for helping to identify them.

    • Alexander Chamessian

      Glad you like the article Ryan. Honestly, I’ve been surprised by the reception of my iPad. More times than not, residents and attendings bring it up to ask me how I like it :)  One quick peek at UpToDate or our EMR and they’re sold. So even now, I feel like most people are accepting, but there are some from time to time who don’t appreciate it. And so I simply don’t use it in those context.

  • http://twitter.com/ProPerformLeadR Greg Jensen

    As a former medical school education administrator, I wholeheartedly applauded the introduction and integration of this technology when it first came out. I think that cost might have been a detractor at the time (begging to question what is more costly, a sentinel event, or harmful patient care – or a $600 I-pad?)
    Knowledge is both power and key to successful treatment, allowing any means to rapid acquisition of knowledge only benefits the patient. My only concern is HIPAA and security.

    Great Article……Thanks

  • http://twitter.com/dhildebrand Dave Hildebrand

    I’d have some worry about infection control as well.  Apple needs to offer Healthcare an anti-microbial version that is sealed to allow for cleaning.

    • Alexander Chamessian

      Dave,

      I thought a lot about this when I first was bringing my iPad into the clinic. The solution: I got a screen cover http://www.powersupportusa.com/accessories/ipad.html and back cover. I wipe down the screen and the back surface with alcohol wipes. 

      Consider something else. Everything we carry on us into patient rooms is a source of infection. Stethoscopes, pens, pads, ties, watches. So the iPad is no more dirty (and likely less so) than any other tool we carry on us.

  • Alexander Chamessian

    Hey Jackie,

    Great comment. I’m glad you’re getting use from the ipad in class. I’ve used a stylus on Notetaker HD. It’s not terrible but still too slow for me. I’ll have to check out the adonis Jot. 

    Best,
    Alex

  • http://pulse.yahoo.com/_PNPBGD57JTXHA2UB5QOOV4RHMM ajay M

    NO, YOU HAVE TO HAVE A BUG PROOF DEVICE, BE THIS  YOUR HANDS, STETH,WATCH AND PEN ETC.

  • http://twitter.com/hospreviewmag Hospital Review

    More and more physicians are using tablets in the clinical setting, and there are a variety of benefits. However, tablets don’t always have the level of security necessary to protect patient information, especially if the tablet is not issued by the hospital. Check out this article to learn tips on how health care professionals should secure their tablets!

    http://www.beckershospitalreview.com/healthcare-information-technology/5-security-features-every-health-tablet-should-have.html

  • http://www.facebook.com/profile.php?id=675034719 Mary Lee Rossmaessler

    As an RN, I’m big on hand washing/sanitizing.  How do you sanitize the Ipad?  If you are cleaning your hands, I think it would still need to be cleaned.

    Big point – you are right – patients don’t like doctors (or any other care provider) that looks at the computer all of the time and not at the patient.  Difficult to do some say; however, I like the paper and pen idea.  There are also going to be times when equipment fails (ie, computer crash, etc.)  Don’t let people skills or handwriting suffer from lack of use.

    • Alexander Chamessian

      Hi Mary,

      As I said below, I use alcohol on all the surface which I touch. That might not be enough to satisfy some, but it’s the best I can do. I’ve asked the IT people and other docs, and this is what they do too.. So washing my hands and wiping with alcohol is what I do.

      • Benjamin Yee

        Another product you may be interested in to keep your iPad clean and sanitary is a product called, Monofoil.  One wipe and it will keep the iPad germ-free for 30 days or more.  Doesn’t leave any sticky residue and is colorless and odorless.  I am a distributor of the product and currently have several hospitals in my area doing an evaluation of the product.  If you are interested, contact me for more information. benyee at bkyconsulting dot net  

  • http://www.facebook.com/rvijaykumar Ragu Vijaykumar

    I’m curious as to how you use FirstConsult and UpToDate as they seem to only be available natively with a personal license and not an institutional one.

  • Anonymous

    Alexander,
    You should check out the app AnatomyLab. I nice real anatomy app that is full of information containing the real anatomy of a cadaver.
    Xerobates

  • Anonymous

    The iPad has tremendous possibilities as an input tool. The iPad has not been out that long and most EMR companies use the computer as their primary input vehicle. The term “Mobility First” is a term coined by the software industry to describe the concept that any user would want to use the iPad interface before the computer.

    The touch screen with hand gestures give the users power input tools with the iPad. Many software companies understand this and are developing “Mobility First” apps for their products. As an example during the HPI portion of a visit you could document pain with a  0 through 10 slider or show the smiley face chart to a pediatric patient. During the Plan part of the note for pain management, the display could show your favorite OTCs, NSAIDs or narcotic analgesics. After tapping your selection, it would not only document this in the note but send the Rx to the pharmacy.

    If properly designed the iPad would allow more eye to eye contact than if you were hand-writing notes. Again most EMRs are in the process of developing these. My company’s product Resonate is an agnostic mobility solution that will work with any EMR to accomplish what I discussed above.

  • Anonymous

    I am an RN in home care and I find your article informative.  I think it is very observant of you to realize that if you use the iPad during an interview the pt’s feel you’re not paying attention to them.  Let me also say, when you are a doctor in an office, and typing the info you’re getting from a pt into a computer, they also think you’re not paying attention to them.  Not only that, I’ve had several pts complain that the doctor has their back to them, putting info into the computer and talking away “at” them, but many of my older pts are very hard of hearing and they are not hearing a word they are saying.  So, the doctor thinks he has given all of this wonderful information to the pt, but they didn’t hear any of it and the older people are either too embarrased to say so, or, being from their generation, were taught not to interrupt or question the doctor, so they walk out not knowing what the doctor found or what he/she wants them to do.  And then the doctor wonders why in the world they don’t follow their instructions.

  • http://www.facebook.com/people/ونة-خفوق/100002675417019 ونة خفوق

    useful <3

  • http://www.facebook.com/freesunny Elena Kuznetsova

    Great material, Alex! Thank you!

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