Monthly Archives: May 2011

I carry my iPad with me to work, the hospital, every day. Dozens of people have asked me whether or not I like it and have found it useful. This post is a detailed response to those questions and has a series of app recommendations.

My training in medicine is taking place during a major transition point with regards to information technology. While electronic documentation systems are in high demand but are lacking in quality, utility, and universality, personal information technologies are rapidly evolving. Many quintessential medical textbooks are now digitally accessible for medical students and residents through the libraries of their academic institutions, reducing the need to purchase or update textbooks. Rapid access to specialized and obscure medical information is now available through subscription services such as UpToDate, a medical encyclopedia with a powerful search engine that helps physicians at all levels of training access and share knowledge that might otherwise require consults or in-depth literature searches to obtain. And finally, many physicians now carry portable computers, whether in the form of smartphones, or more recently, tablet computers such as the Apple iPad. Previously, I wrote about my efforts in using an iPod Touch as a medical information device during medical school. During this year, my first year of residency, I have been greatly aided by the iPad I received as a wedding gift just prior to the start of my intern year: with it, I have been able to more rapidly expand my medical knowledge, build my teaching repertoire, and quickly access pharmacopeia and medical calculations, all of which have helped facilitate patient care. Below, I highlight the areas in which this device has helped me.

Building Knowledge

Aji Annotate PDF Reader – If you can save a digital document as a PDF file, then that can become a page in your digital library forever. Through a meticulous team effort during medical school, my friends and I managed to compile several medical textbooks through our university access to AccessMedicine and MD Consult, giving me instant access on my iPad to Harrison’s Medicine, the Osler Handbook of Medicine, Adams and Victor Principles of Neurology, and many more. This app has a smooth reading interface, but best of all, it SEARCHES THE TEXT. This app, with these customizable sources of information, have helped guide me many times with initial treatment decisions for a variety of my patients when I am confronted with a medical problem with which I am not very familiar.

Articles – Though not an information source designed to be relied on for making treatment decisions, Wikipedia still remains a rapid and useful resource for reminding oneself of rare clinical entities and eponyms and snippets of medical history. In many ways, it is like a Cliff Notes version of an entry-level medical school textbook. Of all the Wikipedia viewers, Articles may have the most beautiful and easy to use interface, and it is easy to save and organize bookmarks for future viewing.

Papers – When you need a high quality, evidence-based answer, one often must resort to the classic past time of gluttons for punishment: the literature search. This app designed by graduate students makes the process a lot easier and saves a lot of trees: it has a built-in composite search engine that searches several libraries (PubMed, Google Scholar, etc) according to your specifications for your search terms. When you find papers of interest to your question, you can import them into the app for storage and reading (it serves as a PDF reader). For me, whenever a resident or attending hands me a paper to read, I look up the paper, import and sort it into this app, then recycle the printed article. This is yet another helping hand to reducing the “too many pieces of paper in the white coat pocket” dilemma.

Videos – This built-in Apple app has at least one amazing, readily-accessible application: the storing and viewing of NEJM procedure instruction videos. Don’t remember how to perform a lumbar puncture? Haven’t placed a central line since intern year? Just go onto the NEJM website, download the videos, and then watch them when you need to to help prepare for the procedure to be performed (usually under supervision, of course, but it helps to have a reminder of the steps and the supply list).

Kindle – Though many textbooks are available through medical school libraries of training institutions, many other books are still not available. Some of these are available for the Kindle app, making this yet another portal for accessing advanced medical knowledge.

Everyday Tasks

Mediquations – The author of this app has done an amazing job of frequently updating his app with the most useful equations, scores, and data cards used in medicine. Of all the apps I use on a daily basis, this is one of the most frequent. Cheers.

Micromedex – This iPad-native app provides an excellent pharmacopeia for any medical provider. At this time, I actually prefer it to Epocrates with regards to faster and more automatic updating and also smoother operation (with no invasive “news bulletins” and notices). I use this app daily, either on the iPad or iPhone, to determine medication dosing and scheduling, adverse effects, drug interactions, and cost.

Citrix Receiver and similar apps – Several hospitals, including the two in which I train, are already beginning to use iPads to access the hospitals EMRs, allowing for quick access to laboratory and imaging data, placing orders, and even writing notes (perhaps somewhat more slowly unless one is adept with the glass keyboard, which I have grown accustomed to).

Facilitating Communication

Sign-N-Send – This app is definitive proof that the gods are merciful. To illustrate how firmly entrenched part of medicine is in the Stone Age of technology, fax machines still remain a primary form of hospital-to-hospital communication. Furthermore, residency programs and hospitals as employers send interns and residents dozens of forms to fill to be completed and faxed back. NOBODY HAS A FAX MACHINE AT HOME (except those of you who have physicians for parents). Normally, I would have to print out the form, fill it out on paper, scan it, and then email it back. This app allows one to open up, download, or import from the web forms in PDF, and it allows the user to type on the form or sign with a finger or stylus (allowing for zooming to make signing easier).

Mail – Academic medicine is firmly entrenched in the world of email – if you don’t check your email often, you fall behind very quickly. Forms need to be signed, rotation needs to be requested, and opportunities are offered without being advertised elsewhere. Check your email, often and much!

WordPress – Writing is one of my careers, and it is a personal commitment. Writing about medicine can be a dangerous past time, especially keeping a medical weblog as more conservative, old-fashioned physicians and others do not believe in sharing or expressing the medical and healing experience with the general public. HIPAA and “professionalism” are sometimes used improperly as a club to silence those who aspire to express something fascinating about this field and our unique roles in the lives of our patients. Nonetheless, those of us who seek to communicate across worlds need the tools to do so, and this is one of them.

Twitter – As with this weblog, I find that it may become increasingly more useful for physicians to communicate with the general public to improve health literacy, help them understand our intentions and our missions, and serve as leaders and movers in our communities, local and beyond. Twitter and other social networks help facilitate this form of communication, and I hope in some small way to take part in that process.


Elements – In medicine, we take an oath to teach – it is directly stated in the Oath of Hippocrates, the most classic mantra of medicine. When I learn, I take notes, and what I learn, I reformulate and build upon to develop my own lessons and methods of teaching. Moments of inspiration can be unpredictable, and so Elements serves me well: it is a text editor that imports my documents to my Dropbox account, a cloud data storage service. With my notes always accessible (on my iPad, iPhone, or computer), I can constantly build upon my personal rendition and ways of understanding medicine, and then I can share these with my students with one of these devices in front of me as an outline and reminder.

Aji iAnnotate PDF Reader – Not only does this app provide storage for text for me to read and learn, but I also have access to scanned anatomy images and other diagrams that can be used to teach students and patients. Visual aids are always powerful tools to augment learning, and there are a million ways one can use a data storage device to help teach (e.g. diagrams of treatment algorithms, presentation slides, anatomy images, etc.).

Of note, I am aided by the fact that I am a budding Neurologist, and I carry a small satchel with me to work at all times, thus allowing to carry the iPad. I had dedicated myself to the “only what I can carry in my white coat” doctrine of minimalism until I received this surprise present, thus prompting me to return to the tradition of doctors carrying bags of useful tools. This is a most useful tool, and one that will have increasingly more creative uses.

The words spoken by physicians carry weight and significance, but as first year residents we might not always appreciate and effectively use this fact. Too often we are prompted to go to the bedside of a patient by a nurse’s page or request stating “The patient wants to speak with you,” often without further explanation divulged.  At 3AM, it is easy for us to attribute these calls to laziness on the part of the nurse. However, nurses often feel disempowered: in many hospitals, physicians rarely take the time to share their treatment plans or diagnostic explorations with the nurses who are charged with handling the logistics and details of minute-by-minute patient care, and patients in these settings often do not trust or expect their nurses to have the answers to their questions. To further worsen matters, at my hospital nurses are typically given the task of discharging patients which includes reviewing medication lists and upcoming appointment times. “Discharging,” however, should also include debriefing patients on their hospitalization, their illnesses, and their immediate (if not long term) outpatient treatment strategies. Although sometimes quite experienced and knowledgeable, many of our nurses are not necessarily equipped with the general medical knowledge or knowledge specific to individual patients to carry out this task. Furthermore, my hospital’s Medicine service discharge paperwork does not include an area for patient instructions (the Emergency Room does include instructions in their discharge papers).  To make matters worse, interns receive little to no training on how to properly discharge or educate patients. As with the emphasis on the dismount from the balance beam in gymnastics, the discharge process can make or break a performance –  in this case, the performance is the sustaining of the patient’s recovery from illness beyond the hospitalization.

Patient education by physicians, even in brief measures, can be a powerful tool for enacting change. For example, in tobacco cessation counseling, the mere act of advising patients against tobacco use without extensive explanation or justification can significantly increase the odds of a patient quitting tobacco. In much the same way, most of the patient education I deliver on the inpatient services occurs through repeating teaching points during brief daily encounters. I would love to be able to spend fifteen to twenty minutes sitting down with each patient at the time of discharge to debrief and educate them, but in reality, the time demands of my intern year have only allowed me to debrief the patients with the most critical needs for further education. Fortunately, in my residency program, many of the second and third year residents are proactive and see patient teaching as one of their responsibilities, so most patients will receive some degree of teaching from either the intern or resident (and sometimes the hands-on attending).

I continue to search for my strengths and passions among my evolving roles as a young physician: by necessity we wear many hats, but we choose which skills to hone and use most often. There is much interest in medical writing and journalism at this time because for many years there was an incredible dearth of adequate, accurate reporting of medical science discoveries and treatment changes and their impact on health. There is a growing influx of medical writers who are better educated and more familiar with medicine. In theory, this should have a powerful impact on educating patients and the general public. However, I worry that just as physicians are spending more of their time in front of the computer screen instead of by the bedsides of their patients, we may also spend too much time writing words and advice instead of speaking to and educating our patients, their families, and our communities in person (except in the context of increasingly brief hospital stays and primary care visits).  A piece of paper or words on a screen do not carry the same weight as words delivered through the voice of a trusted advisor, a professional and known expert – your physician.

To this end, health education, through teaching patients and their families directly and through teaching students and medical professionals to teach more effectively, may become an important component of my personal mission in medicine. We need to get out there more, and by “out there,” I mean out of our offices and hospitals and into the lives of the people whom we are entrusted to treat and heal.

%d bloggers like this: