TEACHnology in Medicine

Focusing on the incorporation of technology into medical education and the future of medicine
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Check out this new app by Epocrates, called Bugs and Drugs.  This app is a partnership between Epocrates and athenahealth and leverages their microbiology data for urine, blood, and skin in the cloud.  This allows you to see the most common bugs and antibiotic sensitivities in your area. 

Similar to the reports that most institutions put out on their own isolates, this takes advantages of larger data sets to provide a better insight.  

For example, using our region here in Irvine, we’re looking at 2,000 urine samples and 1,200 blood samples.  

The only downside is that the geographic region is pretty broad (Irvine pulls up the surround 300 miles for urine, 1200 miles for skin).  I’m not sure what the geographic variation of bugs is in the surrounding 300-1200 miles, but it may not be truly specific to the area.  This is where the hospital’s own data may be more useful.

Overall, great concept and makes a great introduction to leveraging cloud data for the average physician user.  Hopefully physicians will spend some time checking out the methodology to learn more and start thinking about the cloud as an option for healthcare!

I had the great honor of speaking about Digital Professionalism and Digital Literacy today at the Information Technology in Academic Medicine conference and have had a number of great conversations afterwards.  

I wanted to put a couple of thoughts down to further frame this discussion of digital literacy and the evolution of medical education that needs to take place.  

When I get asked “What Can I Do?” to get more involved, I tend to answer with the story of how I got started in this space and how I became passionate about digital literacy…

Get Inspired! The first time I heard of many of these concepts and ideas was at the Medicine 2.0 Conference and Stanford Summit in 2010 and it completely blew my mind.  I had been fixated on the minutia of implementing technology and iPads that I didn’t understand the role of technology and medicine on the grand scale.  This conference helped me see that and provide CONTEXT for technology and what we do.  All of you should attend one of these conferences - here’s a short list: Medicine 2.0 Congress,  Health 2.0, Doctors 2.0, Stanford Medicine X, and TEDMED.

Find Role Models and Follow Them!  My next step was figuring out how to actually get involved and how to learn more about these tools.  Unlike most of my educational experience, there was no course for this, no book to follow, and I felt a very overwhelmed.  So I found people that knew what they were doing…and watched, and read, and learned.  You can look at my Twitter profile to see who I follow, but here are the people that inspired me when I got started:

Ask for Help…those of us who use social media and other emerging technologies in medicine and medical education do so because we are passionate about it, and we love to talk about our passion.  Reach out and you’ll be surprised what can happen.

Participate, Share, and Collaborate Forward!  Just because your students and residents are young doesn’t mean that they get it.  Teach them and engage them in these discussions.  Open their eyes and show them what is out there and what is possible and what COULD be - the medicine they will practice when they graduate will likely be very different than it is today, and it is our obligation to help them prepare for that.  

Engage and Recruit!  Engage with the decision makers at your school or hospital.  This is important, not just for students/residents, but for any practicing healthcare provider from tech/medical assistant to physician.  The leaders need to see your passion and understand why this is important and how their support can make a difference.    

"Tell me, I’ll forget, show me and I may remember, involve me, and I’ll understand" - Chinese Proverb

Here are the resources from my Keynote presentation given at the inaugural Mobile Computing in Medical Education conference:

Data from Mary Meeker of Kleiner Perkins Caufield & Byers

Pew Research Center’s Internet & American Life Project.  Just-in-time Information through Mobile Connections.  May 7, 2012

Cell phone activities over time

Endless Alphabet by Callaway Digital Arts

Finger paints, picture books and iPads — the newest classroom tools for some preschools, kindergartens

Given Tablets but No Teachers, Ethiopian Children Teach Themselves

An ailing UK school makes an incredible transformation

Students with iPads do better on USMLE, UC Irvine iMedEd initiative wins Apple educational award

UCI’s iMedEd Initiative named a 2012-13 Apple Distinguished Program

Inkling Interactive Textbooks

iTunesU Collections at UC Irvine

iTunesU Courses at UC Irvine

Anki Interactive Flash Cards

Septris by Stanford

Surgical Improvement of Clinical Knowledge Ops (SICKO) by Stanford

Resuscitation! App

UCSF Neuro Exam Tutor

Areo Saffarzadeh - Pharmacology Podcasts

A Complete Guide to the Physical Exam

Sketchy Micro

Med AppJam

iMedEd International


Scanadu Scout

Camera Oximeter

Mobisante Ultrasound

ViSi Mobile


Welch Allen iExaminer System

AliveCor Heart Monitor

The Economist - Squeezing out the doctor

The Atlantic - Are Doctors Becoming Obsolete?

Doctors Like Electronic Medical Records, as Long as Patients Can’t Touch Them

Most U.S. Doctors Believe Patients Should Update Electronic Health Record, but Not Have Full Access to It, According to Accenture Eight-Country Survey

Mobile Technology Etiquette

Doctors have the medical techonology, now they need to cultivate the human touch with patients

Health 2.0 and Digital Literacy Course

Derek Sivers - How to Start a Movement

I’ve got some issues with the original article that are only amplified by the fact that it was picked up by the Washington Post.  The original article, available at the Journal of Medical Internet Research (http://bit.ly/16t3GjJ) looked at one academic ER in Florida and tracked their Facebook usage via SurfControl monitoring over 15 days.  Here’s what they found:

  • 68 workstations in the Emergency Department
  • 15 days = 360hrs of data collection
  • Total cumulative time on Facebook was 72.5 hours
  • 72/360 = 20%, hence the 12 minute/hour average or 1 in 5 minutes as the Washington Post article describes

My issues with the article:

  • Did not track any specific users, nor did they comment on the total staffing of the Emergency Department…this makes a difference because if the ED has a staff of 12, then the results become “each user spent an average of 1 minute/hour on Facebook.”  That becomes more meaningful to me and changes the “1 in 5 minutes” statistic to “1 in 60.”  Without this perspective it gives a TERRIBLE impression of poor patient care
  • There are 68 workstations in that Emergency Department, so if you re-ran the calculations:  12 minutes (720 second)  / hour on Facebook across 68 workstations = 10.5 seconds/workstation/hour.  This suggests that 12 minutes isn’t actually a significant proportion of time!
  • Back to the users point - my Emergency Department is an extremely busy place with consultants and other non-ED staff in the department using our computers.  The study workstations also did not have any site access restrictions - in our hospital, the ED is one, if not the only place, where there is open web access.  This is commonplace knowledge in the hospital and we often get staff/physician “visitors” to the department to access the web.  This study fails to account or comment on these factors and their potential inflation of Facebook users.

Why do I care?

  • The conclusions drawn from this study are not the complete picture and therefore, the public gets a terrible impression of the kind of care that they will receive in an Emergency Department.
  • Hospital administrators or CMIO/CIO types may see this data as the justification for restricting web access to hospital users.  I agree that the internet should be minimized as a distraction to patient care, but the logic has to be sound.

Just my 2 cents.  

As Emergency Physicians, unexpected deaths are part of our job.  Telling families that their loved one has died does not get any easier over the years.  Each time you do it, you have to remain stoic, you have to be the “rock” in the room.  I often find my mind racing through pathophysiology to keep myself a little emotionally detached - sounds like a reasonable coping mechanism, right?  A fatal accident or coding patient is not a loved one or a friend, but a patient with multi-system trauma or a massive MI unresponsive to treatment.  This way I can compartmentalize that remaining bit of emotion so I can get through the family discussion and the rest of the day.  It works most of the time.   

But what happens when that patient is one of your own?  A physician, a colleague, a friend?

This past weekend, the UCSF-Fresno Emergency Medicine family lost one of our own.  Dr. Melissa Dowd, one of our interns, was killed after she was struck by a car while crossing the street.  I had the pleasure of working with her a number of times this year and she was great - bright, full of potential, eager, loved learning, loved taking care of patients, and was just fun to be around.  

But we are not invincible…we get sick, we get hurt, and sometimes so badly that we can’t be saved.  We are not always stoic…we have sadness and we can feel loss.  

It is times like this these that make you stop and re-evaluate.  Tell your friends and families that you love them, cherish your time together.  Life is random and sometimes, bad, unexpected things happen to good people, even to physicians.

Melissa, you will be missed.

Last week, Apple announced the release of the iPad mini, their new 5.3” x 7.8” answer to the growing market of smaller tablets and readers such as the Kindle Fire or Nexus 7. Since its release, I’ve received many questions as to the potential role of the mini in medical education - would its smaller size improve adoption rates, specifically in the clinical areas where the existing iPad may be too big? Or, should medical schools continue to stick with Apple or move to another device like the Kindle Fire or the Nexus 7?  And possibly the most important question of all…do you have your iPad Mini yet?

Well first off…no iPad Mini yet - we purchase them through our campus computer store and our order only arrives next week.  So with that in mind, this whole post may be invalidated as soon as I pick mine up.  :)

Let’s look at its potential for Medical Education through the lens of the basic sciences experience and the clinical experience, since these two uses are quite different in their technology needs.

  • Basic Sciences - primary functions are consuming large amounts of medical content, be it via PDFs, textbooks, podcasts, or apps.  For this task, I don’t see how the iPad mini would be less useful than the iPad.  Conversely though, I’m not sure that its smaller size would make it more useful than the regular iPad.  For students in their 1st and 2nd years of medical school, I have yet to hear anyone say “this iPad is just too big.”  Also, our students have gotten quite good at creating content while in lecture.  I wonder if the smaller size, will make annotating notes and creating diagrams more difficult?  Check out the great examples of student notes generated during lecture…
  • Reference Material in Clinical Rotations - primary functions here in the clinical setting are just-in-time learning, quick references, and exam preparation.  For the reference and study material, I can see the argument for a smaller iPad; however, most white coat manufacturers now make pockets for their lab coats.  We have a post on MacHealthcare regarding some of the vendors for iPad-friendly white coats here.  Some students and faculty have noted that at times, the iPad is more prone to bumps and getting knocked around in their coat, so they often add a protective case, which definitely adds to the heft and size.  Some even come with their own shoulder strap as an alternative to the white coat.  Is the iPad more bulky than all of the pocket reference materials students and residents have traditionally carried around in their white coats?  Hard to say…
  • Accessing the Electronic Medical Record in Clinical Rotations - now this is the area where the iPad Mini may have problems.  EMR’s with dedicated iOS apps have different functional versions based on the device - Epic has separate apps called Canto and Bento, Allscripts has Sunrise MobileMD that has different functionality based on iPad vs iPhone/iPod.  The iPad versions of each EMR provide a good deal of functionality because of the screen size - I worry that the iPad Mini does not have the screen real estate for looking at progress notes, lab trends, etc.  Also, for those Citrix users, the iPad screen size is at the minimum size necessary to really be functional since you are running a full Windows desktop.  The iPad Mini may have too much scrolling to be useful.  This could be problematic for programs like the University of Chicago that rely heavily on Epic and their iPads.  
  • Patient Education in the Clinical Setting - the larger screen size of the iPad is really great for educating patients and showing them the images of their radiology images and patient education apps like DrawMD.  The size is also great for sharing data during walking rounds - definitely easy to show trends in lab values, etc to a team of 5-6 people without too much squinting.  The iPad Mini may be too small for this…
  • Mixed platform deployments - iPads and Kindle Fire, iPads and Nexus 7?  Always a tough idea to institutionally support multiple platforms, especially if the goal of using a mobile platform is to consolidate all of your resources in one place.  There is a still a fair amount of digital textbook and app content exclusive to the iPad.  Also, many hospitals don’t allow Android-based devices on their networks since they lack built-in hardware encryption and security…
Final thoughts verdict - again, I don’t have one to make a more realistic determination, but based on what I’ve read and our experiences thus far, the iPad Mini may not have a distinct niche in medical education.  Would some students like the smaller format?  Possibly… Are we going to switch our iMedEd Initiative to iPad Minis at this time?  Not just yet.
That being said, I’ll keep you posted when I get my Mini!

This article from FastCompany is a little bit scary - medicine is becoming a very data driven field and even though we have all of these systems in place, data breaches and cybercrime still occurs.  

If you need a bit of perspective as to why we jump through all of the hoops of complex passwords, multiple logins, device encryption, HIPAA training, secure email servers, etc - then this article is worth your time. 

No solutions offered up yet, but it is good for all healthcare providers to be aware of these issues.  

At the University of California, Irvine, School of Medicine our philosophy on technology use during patient encounters is that mobile technologies, such as the iPad, are a useful patient education adjunct, though they should not distract from the purpose of the encounter. To assist in this endeavor, the iMedEd curriculum at UC Irvine has developed a list of 15 self-assessment questions to help providers better integrate mobile technology into patient encounters.

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A recent report from PricewaterhouseCoopers (PWC) entitled “Emerging mHealth: Paths for Growth” found that consumers are ready to adopt mobile health faster than the health industry is prepared to adapt.  As an interested observer and now participant, I would have to agree.  Much of what we’ve seen in the past few years has started at the consumer level with the field of medicine slowly catching on.  

However, this is not an unseen phenomenon - many smart medical thinkers and “philosophers” have picked up on this and are doing their part to educate physician colleagues.  This will seem like a “shout-out” list, but some of the big players so far are Eric Topol (Creative Destruction of Medicine), Jay Parkinson (Hello Health, The Future Well, Sherpaa), Wendy Sue Swanson (@SeattleMamaDoc), Larry Chu (Stanford Medicine X), Bertalan Mesko (The Social MEDia Course) - they have all done amazing things to help promote mobile health and patient empowerment.  

Ryan Faas from CultOfMac.com takes a look at the same study in an article entitled "Why Your Doctor Doesn’t Want You Using iPhone and iPad Health Apps." I will disagree with his interpretation of the data as it seems to spin physicians into a “tech-averse” group of individuals that do want to let their patients participate in their care.  

From the report, here are the stats as presented:

  • 64% say that mHealth offers exciting possibilities, but there too few proven business models
  • Only 27% of physicians encourage patients to use mHealth to become more active in managing their health - 13% actually discouraged it.  You could make the assumption that the other 87% just aren’t familiar enough to make a judgement or recommendation

Naturally, my position and technology background make me biased and different than most physicians in terms of comfort with emerging technologies.  However, I feel that the statement “your doctor doesn’t want you using iPhone and iPad Health apps” is a little too broad and overstated - if this were a manuscript submission to a peer-reviewed journal, I would choose “Accept, pending revisions” since the claims don’t necessary match the raw data.

Yes, healthcare is slower to adopt, and yes, many physicians are unsure how to use technology best with their patients.  This is where the physicians and medical students who embrace technology need to step up and educate their colleagues.  

Medicine and healthcare are changing whether we like it or not - we might as well take advantage of the new opportunities!  

One of the first documented cases of harm from a mobile device - one caveat though, the device needs to be within 1-2.5 cm away from the VP shunt itself.  

For those of you rotating in a clinical setting, this degree of close contact between your patient and your iPad seems unlikely; however, for parents with children with VP shunts, please be careful about them falling asleep next to their devices as that 2.5cm buffer can easily be overlooked.   

Really great article about the context for technology and some thoughts on how to teach your young ones to use it responsibly.  As parents we often set boundaries for other behaviors - TV watching, eating healthy, sleep habits - we should do the same for mobile technologies such as smartphones and tablets.  

As medical educators, these are issues that we should take note of - even though our users are not children (though have been known to act that way -j/k) there is still a shortage of good information on how to best teach healthy usage of these devices within our daily lives.  Restrictions on texting and driving and in some places, texting and walking, are designed to prevent serious injury, but do we have any recommendations for prevention of injury and maintenance of health - repetitive stress injuries, hearing compromise, eye strain?

As physicians who work with children and parents, we will likely see more of technology usage by little ones in our practice environments - how can we best guide our patients for health habits?  Something for us to think about…

Highlights from the article:

  • Original source article about 3 year-old kicked off the plane for his temper tantrum after getting his iPad taken away from him - http://newsfeed.time.com/2012/06/02/3-year-old-kicked-off-airplane-for-crying/?iid=ec-main-mostpop2?iid=ec-main-mostpop2
  • Parents are lost about managing technology to fit appropriately into children’s developmental needs and family life” - Dr. Eitan Schwarz
  • "First, you are the child’s model and have the home-court advantage, so stop texting while parenting and straighten out your own tech life." 
  • "Enforce tech-free times and zones." 
  • "Teach that these are powerful tools, and learning their correct use is a careful long-term task, like hygiene and other self-care"
  • "While there is lots of debate about "screen time", not all screens are the same and no general rules can apply here except to use these devices only to benefit the young child’s development and family life"

Cool article and video about the use of smartphones to monitor your carseat! Interesting application of technology for injury prevention.

Physicians, keep an eye out for these coming your way and consider checking one out so you can possibly recommend it to your patients!

Here’s the link for the iTunesU course for UCI’s Clinical iPad Orientation.  Please review this material to help you get a better handle on how to use your iPad clinically. 

Please check this material frequently as new apps and clinical pearls will be distributed via this course!

Story from the AMA, adding more examples of physician adoption for tablets.  Has some interesting highlights:

  • Great example of patient use of iPads while waiting for providers at the clinic in Wake Forest Baptist Medical Center’s Downtown Health Plaza
  • The article also gives some examples of why the tablet is “more than a bigger smartphone” - EMR access and patient education with a shout-out to DrawMD.

Also some great data from Manhattan Research’s “Taking the Pulse US 2012” survey:

  • 3015 physicians in 25 specialities, surveyed in Jan-Mar 2012
  • 62% of physicians owned a tablet (up from 27% in 2011).  Of those 62%, half use them at POC
  • 81% with smartphones
  • Physicians with three devices (smartphone, tablet, computers) spend more time online on each device and go online more frequently during the workday than other physicians
  • Adoption of physician-only social networks (sermo, doximity) remained flat
  • More than 2/3 of physicians use video to maintain their knowledge base - no comment on if this is true CME or if this is the primary source for knowledge maintenance


  • Survey data from ZocDoc implies that younger users of healthcare are dissatisfied with the lack of access to healthcare appointments - i.e. in addition to prolonged waits to see a provider, there is the inherent difficulty in making an appointment 
  • Technologies employed in the healthcare setting have terrible usability and UI, which can lead to more errors and time consumption
  • Smart design means that it should be easy for patients to navigate the system and for doctors to exchange information
Good article by two emergency physicians!