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Monthly Archives: December 2008

Previously, I began adapting my iPod Touch to be used as a medical PDA during my clinical clerkships and beyond. Thus far, the results have been rewarding and are in part supported by the notable rapid spread of iPhones (and a handful of iPod Touches) that I have seen in the workplace among attending physicians, residents, medical students, and even a few nurses. (I chose an iPod Touch instead of an iPhone because of the cost of AT&T phone and data plans and the poor reception of its network in the hospitals where I work; I felt that it would seem unprofessional to not be reachable by cell phone since Tulane medical students are not provided with pagers.) Riding the popularity of the iPhone as a revolutionary device, the iPhone/iTouch platform has attracted a variety of medical resource publishers and software developers that have turned them into indispensable devices. In honor of those people who have made this early stage of my medical career so much easier with the power of knowledge and technology, I would like to list my top 10 medical resources for the iPhone/iTouch and the ways they have empowered me.

10. Apple’s Calculator – INCLUDED

When your last math class was sophomore year of college, nothing beats having a calculator to aid one’s atrophied mathematical skills (especially when they were questionable in the first place). In particular, having a calculator is essential during the Pediatrics clerkship when calculating nutritional balance (whether with infant formula or total parenteral nutrition) in the NICU, assessing urine output and fluid intake, and determining the amount of fluid with which to replenish and maintain a pediatric patient. Fortunately, there were plenty of calculators at each bed in the PICU and NICU, but resources on the Pediatrics general ward (including computers, chairs, and flat surfaces) were always scarce.

Replaced: a pocket calculator

9. Translator – FREE when obtained

This one would be higher on the list if I had an iPhone (i.e. a dedicated internet connection) and had discovered it sooner. However, I have only been using it for the past few days, and I am delighted to note that translations within the program are saved until manually cleared. The program accesses Google’s online translation engine so it is less useful for iPod Touch users, but the retention feature is an advantage. I can keep an entire Obstetrics/pregnancy workup in Spanish on hand while on my Ob-Gyn rotation during which I have encountered many patients who only speak Spanish. ¿Se ha sentido contracciones? ¿Ha tenido sangrado vaginal? Náuseas? Vómitos? I’m not entirely sure that the wording and grammar is entirely correct (I will need to check with my fluent Spanish-speaking fiancée), but it is enough to get the right idea across.

Replaced: a pocket translation book (Translator + PDF viewer with medical Spanish PDFs does the trick for me)

8. Games – variable

So, this has nothing to do with medicine, per se, except that there can be downtime during the medical student training experience. Ideally, downtime should be spent studying and reading up on information regarding the illnesses of one’s patients (and others cared for by your team). However, when you’re on-call for 24 hours, your resident is asleep, and you are switching off with her for the q2 hour laboring notes that have to be done on the Labor & Delivery patients overnight, you sometimes want something else to do besides reading in Blueprints or First Aid or Case Files. Also, while I seem to now have the amazing ability to read Neurology textbooks for fun, I have to work very, very hard to remember anything about the types of urinary incontinence and their treatments. At times like those when one feels daunted by the task of reading about urinary incontinence, it’s nice to break out a delightful few minutes of Tap Tap Revenge or win another battle in Reign of Swords.

Replaced: being painfully bored and miserable, melting brain cells watching VH1 reality shows (e.g. Scream Queens) on the call room TV

7. Eponyms (for Students) – FREE

This is an excellent resource that helps ameliorate one age-old problem in medicine: the tendency for pioneering doctors to name things after themselves or their mentors. Frankly, I find eponyms annoying and try to avoid using them (in lieu of more explanatory medical terms, e.g. “low transverse abdominal incision” instead of “Pfannenstiel’s incision”) whenever possible to avoid confusion. However, many physicians continue to use eponyms in their teaching, often in deference to the great physicians of yore. This app (the student version is free) provides concise descriptions of the numerous medical eponyms that plague clueless medical students everywhere.

Replaced: constantly asking attending physicians to clarify eponyms or wasting time looking them up on Google

6. Apple’s Calendar – INCLUDED

During the clerkships, it is essential (even more so than during the preclinical years) to manage your time well and to know where you need to be at each moment in time. I can’t imagine going through each day without having a detailed, updated calendar (whether in paper or electronic form): there are far too many training sessions, preceptor teaching sessions, meetings, changes in location and unpredicted reschedulings to account for. One underlying concern of medical students (and their evaluators) during the clerkships is the appearance and demonstration of “professionalism,” and it generally enhances the professional component of your conduct when you have a good handle on each situation.

Replaced: a pocket calendar book

5. Apple’s Mail – INCLUDED

The primary mode of communication by my school’s clerkship coordinators and directors to students is via e-mail: all of the important (scheduling and assignment) information is provided through this venue, and it is expected that we check our e-mail frequently. Even though I don’t always have access to free wireless on my iPod Touch, I usually have enough opportunities to grab a connection (which is especially useful when clerkship coordinators relocate a lecture half an hour beforehand). Furthermore, location assignments and rotation assignments are sometimes provided on a first-come, first served basis, and having access to e-mail is essential at such times.

Replaced: using the hospital or library computers to check e-mail

4. Apple’s Clock – INCLUDED

In the absence of a wrist watch, I currently use my iPod Touch as my timekeeper (and have developed a decent sense of the passage of time; there are, however, usually many clocks in patient rooms and throughout hospitals and clinics). The included Clock app, however, has served me in a variety of functions: the Stopwatch has been useful for counting fetal heart beats (using a fetal heart monitor, often in the 140 bpm range) or adult heart beats, the Timer is useful when I am budgeting time between clinical duties, and the Alarm is useful when I don’t trust having just my cell phone alarm to wake me up while on-call. Like they say, “Time is of the essence.”

Replaced: a wristwatch, stopwatch, and alarm clock

3. Datacase – $6.99 when obtained

Datacase has been a very useful, adaptable resource for me: it is a file storage program that allows me to read a variety of file times, most importantly PDF. A variety of medical resources are available in PDF format, and Apple computers allow one to “Print to PDF” when viewing webpages. Apply this ability to the “Print Chapter” features on the Access Medicine website (for which my school has a site license), and with a few hours work one can have a digital copy of Harrison’s Internal Medicine, Current Medical Diagnosis and Treatment, and many more on an iPod Touch or iPhone. The one disadvantage is that the program does not automatically resize pages, so one may be stuck with reading text in a small font on the relatively small screen; however, you can increase the font size of the web pages before “printing to PDF” in order to overcome this issue.

These, along with other medical resources and texts in PDF format, have provided me with a library of medical knowledge at my fingertips at all times. While I prefer accessing resources such as UpToDate on the hospital computers when possible, there are many more instances when having access to medical knowledge during rounds, lectures, and on the move has made the investment in a file storage and viewing program worthwhile.

Alternatives: Air Sharing, Files, etc.

Replaced: carrying a horde of books in my white coat pockets (especially ones that make some clinical preceptors unhappy, such as review books)

2. Mediquations – $4.99 when obtained

I can’t overemphasize the utility of a medical equations calculator, and these programs are some of the most popular medical apps I have seen on the iPhones and iPod Touches of students and doctors. There are numerous medical equations and algorithms that dictate patient care, and instead of Googling the equations on a hospital computer or memorizing all of the equations, it is much easier and faster to use one of these apps to accomplish the task. Some of my frequently used equations: Temperature Conversion and Urine Output. Next month on my Internal Medicine rotation: FENa, Corrected Sodium, GFR, etc.

Alternative: MedCalc, MediMath, Medical Calculator

Replaced: wasting neurons memorizing equations and wasting time searching for equations on Google

1. Epocrates Rx – FREE

Lastly, Epocrates has been the golden fleece of iPhone/iPod Touch medical apps: until my Ob-Gyn rotation, I was accessing it more than twenty times per day (on Neurology, Psychiatry, and Pediatrics). For a medical student who has only recently delved into the endless sea of generic drug names and trade names, Epocrates Rx is a godsend: I use it to figure out the indications for a medication, to determine its real spelling (since patients often mispronounce the name) and alternate name, to determine the dosages for writing orders or prescriptions, to determine the cost, to determine contraindications and adverse reactions, etc. Also, Epocrates Rx has an excellent Interactions Checker that allows one to input multiple medications.

The program allows for frequent updates, and it evens provides brief one paragraph summaries on major clinical studies affecting the use of pharmaceutical treatment. In the age of evidence-based medicine, access to up-to-date knowledge is vital.

Replaced: a pocket Pharmacopeia, especially an ugly one (not mentioning names) that you actually have to pay for

Runner-Ups:
• Netter’s Neuroscience Flash Cards ($39.99 when obtained) – These are beautiful and nicely organized and will likely be more useful in the future when I need to reinforce my knowledge of neuroanatomy. However, I rarely had time during my Neurology rotation to consult these cards. They would be useful prior to a Neurology clerkship as a refresher, especially if it is a long time since one has taken the USMLE Step 1 exam (and if one didn’t have quite as many Neuroanatomy questions as I did on mine).

• Apple’s Video Player (INCLUDED) – NEJM has a variety of excellent procedural training videos available on its website that provide instruction on how to insert peripheral venous lines, intubate a patient, incise and drain an abscess, perform a pelvic examination, and more. I have viewed some of these videos on an as needed basis. I think this will become more useful during my fourth year of medical school and during my internship/residency when I will be more involved and also required to perform these procedures.

Not Yet Explored:
• ReachMD (FREE) – a CME resource with downloadable, 15-minute mini-lectures and quizzes redeemable for CME credit

• SkyScape (FREE) – a multipurpose resource including a drug database, evidence-based “outlines” for medical practice, and a medical equations calculator

• Netter general anatomy, musculoskeletal anatomy, and surgical procedure flash card – similar products to the neuroscience flash cards I purchased, but I’m not sure I need to spend $40 on each one; the anatomy cards are probably more useful for first and second year medical students

• BRS flash cards – information cards from a popular review book series

Future Gems:
• Epocrates Essentials ($149 for one year) – One highly anticipated software package is the Essentials diagnostic and treatment resource provided by Epocrates that has been used by many physicians on their past PDAs. Some medical schools actually provide this software free for their students (using their site licenses), so take advantage of it if you have that option available! I’m not certain I will spend the money on this resource when it arrives (especially if it is provided through my residency program) as my Pocket Medicine binder has proven to be a useful, expandable complement to my iPod Touch.

It is with a deep sigh of relief that I welcome the electoral victory of the Obama-Biden ticket as a symbol of the (majority of the) general public’s acceptance of intelligence as an asset. While I know of no scientific evidence or study proving a link between the anti-intellectualism and charismatic ignorance of the Republican presidential administrations in the recent past (Nixon, Reagan, and the Bushes) and the public perception of higher education (or any education) as being undesirably “elitist,” I would be willing to wager that the public celebration of outwardly unsophisticated leadership to some degree inspires a lack of confidence in doctors in the level of intelligence of their patients, a sampling of the general public. I’m not sure I know of any doctors who generally think of most of their patients (if they see a variety from all walks of life) as being on par with themselves. By necessity, even if they try to repress the outward impressions and implications of their educational background, physicians are generally very well-educated and are almost automatically counted in the ranks of the intellectual elite. Some patients do overcompensate for their prior lack of knowledge by becoming experts on their diseases or those of their loved ones (courtesy of the internet and bookstores). However, as one might expect, the educational differential between doctors and their patients is often vast: during the past two months, most of my patients have been either on Medicaid or lack insurance, and their highest level of education has usually been either sometime in junior high or in high school. Despite my lack of exposure to Obstetrics and Gynecology before November and the notion that some of my veteran patients knew much more about the physiology and management of pregnancy than me when I first started this clerkship, I should not have been surprised that recently I have often had to abandon any assumptions about what my patients know about their own bodies.

There does seem to be a decent correlation between level of education and intelligence, but I do not think that my patients lacking higher education do not have the ability to understand the information I can offer them about their health and diseases: rather, I just have to try harder, and perhaps all physicians should. I think some people forget that progression through the American education system does not select only for intelligence; socioeconomic status and cultural attitudes toward higher education play significant roles (or perhaps even more important roles) in the decision-making process. I think physicians shouldn’t take their own educations for granted: it would do themselves (or those who paid for those educations) a disservice to waste the opportunity to build a bridge of knowledge between the patient’s current understanding and the functional stage between the doctor and patient.

At some points, I have felt a little frustrated trying to break through barriers of ignorance and incomprehension, but it is stories like this that convince me to keep trying. Patients don’t need to know as much as doctors do: we’re here to help them make decisions with our specialized knowledge of health and disease as well as provide treatments and counseling. However, we do need to make sure that they know enough to make intelligent decisions. I hope that the next four years (and hopefully, beyond) will help dissolve the cultural attitudes that celebrate the uneducated maverick, the rebel without a clue: there’s no reward in being ignorant and stupid when it comes to life-changing decisions. In the meantime, it’s my job to educate: to help women select the right method of birth control for them, to convince them to keep taking their prenatal vitamins during pregnancy to prevent birth defects and anemia despite the common complaint of nausea, and to help them figure out how concerned they should be at this time about irregular bleeding and what we plan to do to figure out the cause. Even though it takes up more of my time, it’s the least I can do.

Fight the stupids! – Maple Street Bookstore bumper sticker, New Orleans

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