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Previously, I discussed the merits of the ClamCase, an innovative and useful keyboard case for the Apple iPad. Of all of the higher end and pricier keyboard cases, it definitively remains one of the best options available for the production of written content on the iPad. During the past seven months, I have written numerous admission, consult, and progress notes every day I have worked in the hospital, and I have additionally written weblog posts and numerous e-mails. I often had a hospital computer open to an electronic patient record while having the iPad open to a new word processing file which would allow me to type notes and read simultaneously. Unlike a laptop, the iPad with a keyboard case allows for instantaneous access for quick tasks at the bedside and while rounding (such as typing in an order in tablet form with one hand holding the device and the other hand tapping the screen and typing) while also allowing for comfortable word processing and reading. The combination of the ClamCase and iPad 2 essentially replaced my old laptop (a previous generation of MacBook of the black plastic variety) except for the occasional Photoshop task or for iTunes file synchronization and backup.

However, there are a few important disadvantages of the ClamCase which may or may not be generalizable across the product line. First and foremost, the battery life of the device is variable. Initially, I did not have to charge the keyboard for days at a time, but about five months into its lifespan I discovered that it was losing its charge during the course of a day’s work. After some weeks of experimentation, I have not found consistent behavior of the battery in response to overnight charging and roughly comparable usage each day, leaving me with some degree of anxiety as to whether or not it will keep its charge during a particularly busy day of consults and admissions. I suspect that this is the result of me not treating the battery correctly, but most people do not maintain good battery charging practices which makes me wonder how often customers have difficulty with the battery for this keyboard case.

There are a few other additional small and surmountable issues. The case is heavy: the weight of the device essentially doubles the weight of the iPad. The four protective pads on the keyboard side of the case which elevate the keys off table surfaces when flipped into a video viewing mode quickly lost their adhesive and tore off easily. The keyboard additionally has very nice laptop-style keys, but some do become slightly sticky with time, sometimes causing the keyboard to produce a string of repetitive letters which sometimes would require exiting from an app to interrupt. Over time, this has become a more frequent occurrence. Lastly, on a purely cosmetic level, my white version of the keyboard case very easily stained on the bottom surface within a week of ownership.

In summary, the ClamCase has been an incredible boon to my productivity on the hospital wards, but after seven months my particular device has aged and is starting to run into difficulties. Some user reviews have commented on issues with maintaining the battery’s charge and not being able to trust the green/amber indicator light. If I had assurance that the battery issues has been fixed, I would certainly purchase another ClamCase, but in the mean time, I have started to look into alternative options.

The Context

Today, one of the our attendings gave a solid overview of the major families of dementias. With the skills of a talented and effective instructor, he queried the audience of residents and students to help him fill out the content of a table designed to help differentiate between the presentations, test findings, and treatments for the different types of diseases. He was able to keep the audience actively engaged and participating, but at one point he asked a question that was met with silence. I volunteered the answer, and he turned to me, somewhat surprised that anyone knew the answer. I explained (that he shouldn’t be so impressed): he had mentioned the answer in a previous talk given several months ago, and I just happened to have a set of notes from that discussion open on my iPad which I was annotating and expanding with the lessons learned from today’s talk.

While it’s not so impressive that I was able to ascertain the answer, impressing someone was not the point for me: the fact is that I had that information and was able to quickly access it, even if it wasn’t readily accessible in my own brain’s memory bank without the assistance of my notes. This raises a major question for lifelong students of medicine: Is it better to try and store as much information in one’s memory as possible knowing that there will be limitations on the amount of information that can be remembered, or is it better to store some (perhaps a large proportion) of that information somewhere it can be easily and quickly referenced? If secondary storage of information is worthwhile, then should clinical information be trusted to a few easily-accessible resources (e.g. a pocketbook, online medical search database) or should it be digested and recorded into a personal notekeeping device (i.e. a notebook)? To approach these questions, we must first understand the nature of knowledge and how it is gained.

free your mind

The Student’s Dilemma

While we would like to think of knowledge learned as being the truth and that truth is an absolute, for better or worse the learning of medical knowledge is not this simple. Since medicine is based on scientific principles, there is a constant effort to strive for refinement of knowledge towards the best approximation of the truth, but in the mind of a humble scientist there is also the necessary acknowledgment that a better or more truthful explanation may arise to refute his or her prior claim. Simply stated, medical knowledge changes, evolves, and hopefully improves with the advance of medical science. Nonetheless, there is also the knowledge derived from practical experience (or story or wisdom) that enters the learner’s mind in the form of a “gospel” taught by more senior physicians. In many ways, this information is equally important and perhaps carries equal weight because this information is based on direct encounters with individual people that have the full force of a clinician’s mind reviewing the entirety of their unique cases. Nonetheless, something that is gospel must be preached (with strong language, without wavering, and lacking an acknowledgment of uncertainty), and one only has to preach when there are those who do not believe what is being said. In other words, truth does not need to be questioned, but this does not fit the description of anything in medicine. As such, physicians and patients alike must live and function with great uncertainty regarding what is known, what is not known, and whether or not what is “known” is actually meaningful (or “truthful” as charted against a constantly changing measure of what is true).

I will give an example here: I remember either a Neurology attending or fellow once explaining to me that the mild weakness found on ipsilateral limbs in a patient with a unilateral stroke could be explained by involvement of the fibers descending in the anterior corticospinal tract (which travels ipsilaterally and does not cross in the medulla). This descending fiber tract contains somewhere between 10-20% of the corticospinal tract fibers, varies in size between individuals, ends in the thoracic cord, and likely provides innervation to muscles of the neck and upper limbs. Anatomically, this explanation seems to make some sense. I asked another senior Neurology attending this question in a different patient with a similar presentation, and he stated definitively, “It never happens.” In perusing various Neurology textbooks, I cannot find any information corroborating the first explanation. The traditional textbook that most clearly addresses this question, Neurology: A Queen Square Textbook”, states “Of corticospinal fibers, 10% remain uncrossed, their neurones of origin outlining an ipsilateral somatotopic map, a point of little apparent clinical significance.” Why then, does this fiber tract even exist? There are some studies that suggest that the presence of this “accessory” pathway may aid motor recovery from lateral corticospinal tract damage as in stroke [1] or spinal cord injury [2].

A common response among learners to these conflicting messages is to give up. The tendency is to lose faith in attempting to achieve the ability to “know.” Accordingly, many choose to defer to those who do “know,” or at least believe they do. The appeal of following guidelines stems from this tendency: in theory, a panel of “experts” have pooled together their knowledge and provided recommendations to follow. In this climate of uncertainty, most people choose to follow. But what makes the experts “experts” in their fields? Often they are the physicians, scientists, or physician-scientists who are pursuing active research or have extensive experience with a particular clinical issue. At best, they are driven in their desire to know by the awareness of the incompleteness and changing nature of knowledge and also by the idealistic hope that it is possible to improve knowledge and thus improve the practice of medicine. Ideally, they additionally generate new evidence to contribute to the current knowledge of disease and treatment in the form of clinical trials, updated reviews, case series, and more. At worst, they may be the ones who are simply preaching the loudest and most forcibly.

I, and many others, would argue that this method of learning and practicing medicine is too passive and not sufficiently adaptive. Consulting (to the exclusion of other sources) searchable databases such as UpToDate potentially leaves one’s mind at the mercy of a few opinionated authors. It is not enough to practice medicine as directed by the Cochrane reviews alone. It is no longer enough to practice medicine based only on the anecdotal and experiential wisdom passed down by prior generations of physicians. And it is largely impractical for any individual physician to stay abreast of the latest developments in every field of medicine, let alone in his or her own field with regards to the numerous studies being published every week. Not surprisingly, it is important, then, to find a balance between all of these sources and types of information and information acquisition.

The Notebook

In my opinion, a notebook is the most essential piece of a physician’s armamentarium. It is more important than the stethoscope, scalpel, or any other tool. Why? The notebook represents a projection of the physician’s mind, and no matter the specialty, the physician’s mind is still his or her greatest asset and most effective tool in treating patients. The notebook serves a number of important roles for the physician:

[1] Facilitation of memory encoding

A lot of educational theory and research is based on the many ways different individuals learn, particularly with regards to methods emphasizing visual, auditory, and tactile sensation. Incorporating multiple modalities, such as writing notes while listening to a lecture and watching a slide presentation, is thought to improve memory retention. Accordingly, it helps to write down what is learned, whether on the wards, at the white board, during morning report or noon conferences, or at grand rounds or conventions, as this should help you more firmly implant the knowledge into your hippocampi.

[2] A database of references and the knowledge “family tree” (e.g. lineage)

Because of its origins and the way knowledge works within medicine, the lineage of knowledge remains an important distinction that marks one’s identity as a physician. Since much of medical teaching is based on the experiences of physicians whose careers may last half a dozen or more decades, one’s teachers inspire considerable reverence from the trainees who follow them. However, physicians may encounter several “schools of thought” throughout different stages of training and may find that their own minds are battlegrounds between competing ideologies. Accordingly, I find that it is very important to chart and document from whom one learns a new tenet of medicine (be it a resident, fellow, senior attending, clinical trial, visiting lecturer, clinical trial, review article, textbook, etc.). In the aforementioned example, I cannot remember who asserted to me the notion that damage to the anterior corticospinal tract can result in ipsilateral weakness. As such, I cannot ask him or her how that knowledge was obtained, and it thus holds little water against the assertion of the other attending or my current review of the available literature. If you keep track of your learning and keep references to your sources (e.g. the name of a physician who gave a lecture), it is possible to track how your thinking and understanding of the field evolves over time, particularly when new data is incorporated from new studies or encounters with physicians trained in another school of thought.

[3] A launchpad for inquiry

Sometimes the hardest thing to remember is a question. And yet, as physicians, questions arise in our minds constantly: much of our role as clinicians mimics the modus operandi of the detective. Furthermore, the ingrained abundance of intellectual curiosity is one of the distinguishing features that differentiates physicians from other health care providers. Nonetheless, our attention is also constantly bombarded by numerous competing interests (pages, e-mail messages, patients and families, other care providers, etc.). There are countless times that I had a question I wanted to ask someone giving a talk which vaporized prior to the talk ending and also numerous occasions when I identified something I wanted to look up which I later forgot about. In order to help further develop your own knowledge base, improve the care of your patients, and perhaps even generate questions that might advance the field as a whole, it helps to write down the questions that come to mind as soon as they arise. This can help identify knowledge areas that you can expand and enrichen, detect problems in your clinical practice that might be useful to address (e.g. Why isn’t there a standardized protocol for (blank) here?), and develop potential ideas for research.

[4] A map of the mind

Last but not least, the notebook can serve as a measure and organizational tool for the knowledge one has already acquired. Keeping one’s thoughts and memories organized is a very important precursor to developing an easily and quickly accessible knowledge bank. The primary objective is to make your brain an efficient and effective database of knowledge and to use that knowledge to guide actions (e.g. the practice of medicine) in a meaningful way. The notebook should not serve as a replacement for the mind’s memory stores, but rather, it should serve as a visual aid (to trigger memories of learning from direct visualization and also to help guide a mind-only “memory palace”-style search if the notebook is absent) and as a hierarchical “site map” or “table of contents” that helps you keep track of what you know so far and what you don’t know.

I hope I have at least begun to convince you that the notebook and the active engaging and recording of lessons learned are essential for physicians at all levels of training. In my next installment of this series (The Battle for Your Mind), I will discuss different methods modern physcians can use to keep notebooks.

References:
1. Shelton, F, and Reding, MJ. “Effect of Lesion Location on Upper Limb Motor Recovery After Stroke.” Stroke. 2001; 32: 107-112.
2. Priestly, JV. “Promoting anatomical plasticity and recovery of function after traumatic injury to the central or peripheral nervous system.” Brain (2007) 130 (4): 895-897.

Today marks the end of the 2012 American Academy of Neurology annual meeting. I spent this past week (also my final week of vacation as a junior neurology resident) attending courses and lectures, perusing posters, meeting other neurologists, and trying to absorb as much neurology as possible in this short amount of time. AAN hosts the largest conference for neurologists around the world and is typically attended by 10,000 to 20,000. While some of the more advanced and groundbreaking science may gravitate toward the specific subspecialty society conferences (e.g. stroke, epilepsy, etc.), this conference is a fantastic opportunity for neurology residents to broaden their perspectives on the field.

These are the highlights from my week at the AAN annual meeting:

Monday:
[1] Acute Central Nervous System Infections – Infectious Diseases – This course organized by Larry David of the U. of New Mexico provided a brief overview of acute meningitis and encephalitis, the approach to diagnosis and treatment of these diseases, and the practical wisdom and experience used to help one differentiate between various syndromes. In particular, I found value in the emphasis on poor sensitivity of the classic signs of meningitis in elderly patients, the relatively high incidence of undetected nosocomial and multi-drug resistant meningitis in ICU patients with fever and altered mentation, the use of fluid resuscitation in preventing cerebral ischemia in meningitis, and an outlining of an approach to selecting diagnostic tests in encephalitis.

[2] Stroke in Children and Neonates – Vascular Neurology – This course organized by Lori Jordan of Vanderbilt University spanned the current body of knowledge on pediatric stroke as well as provided insight on the interventional trials being pursued, including the use of intravenous thrombolysis in acute stroke in children. While this course was primarily for the benefit of my wife (who is training as a pediatric neurologist), it was interesting to see what lessons the pediatric neurologists drew from the experience of adult stroke neurologists. In particular, the notion that stroke units (one of two interventions in acute stroke that has evidence for outcome benefit, the other being intravenous thrombolysis) were developed as a result of the use of IV tPA (a medication with limited effectiveness and very limited use throughout the country) is an interesting perspective.

[3] Catching up with Tulane’s Neurology department – It was nice having a few hours to catch up with Sheryl Martin-Schild (the director of the Stroke Program at Tulane University Medical Center) and some of the residents and attendings of the Neurology department, the program within which my interest in neurology initially developed. When I was a student, the department was in a state of recovery but appears to be growing quite nicely now. Perhaps not entirely surprisingly (given the high number of acute stroke and hemorrhage cases), several of the residents are pursuing further training in critical care.

Tuesday:
[1] Presidential Plenary Session – Stroke Prevention – While there were several interesting talks at this session, the one of greatest relevance and interest to me was a relatively straightforward statement by Ralph Sacco who recently stepped down as the President of the American Heart/Stroke Association, the first neurologist to hold that position. He spoke at length about both medical and lifestyle risk factors for stroke. He made the logical statement that racial/ethnic disparities in long-term stroke outcomes can be eliminated by addressing these risk factors, and he showed the evidence to prove this.

Wednesday:
[1] Neurotoxicology – General Neurology, Neuromuscular – This was a very interesting talk organized by Herbert Schaumberg of the Albert Einstein College of Medicine that introduced me to several clinical entities I was not well aware of before including cobalt neurotoxicity from metal-on-metal hip prostheses, drug-induced myoclonus in end stage renal disease (including with gabapentin, morphine, and even propofol), bismuth myoclonic encephalopathy, and fibrous myopathy from intramuscular injections. I also finally learned how to differentiate between ciguatera and scromboid toxins.

[2] Contemporary Issues Plenary Session – Immunology, Vascular Neurology – 500 cases of NMDA encephalitis, Imaging in Acute Stroke – Any talk claiming data on the outcomes for over 500 patients with NMDA encephalitis can easily capture the interest of a room full of neurologists, which this one did – a very, very large room. The other talk that caught my interest was a brief discussion by Maarten Lansberg of Stanford University of the current imaging modalities used in acute stroke. While this talk did not provide much new data, it was refreshing to have a focused review of the current recommended approach to using noncontrast CT scans, perfusion imaging, vessel imaging, and MRI in the acute setting.

[3] Neuro-Ophthalmology and Vestibular Lab – The examination of the eyes is one of the hardest parts of the neurologic examination, and I recognize this as one of the areas where I need a great deal more practice and refinement. Fortunately, this session was there to serve this need. While the lab/workshop sessions are relatively expensive, this provided me with very useful practical knowledge and skills, more so than any other session during this conference. The workshop had about a dozen stations where those taking the course could work directly with experienced neuro-ophthalmologists to refine examination skills, develop methodical approaches, and pick up a few new maneuvers. For me, I was able to refine confrontational visual field testing, the head impulse maneuver, the Dix-Hallpike and Epley maneuvers, and pupillary reaction testing, and I furthermore learned a few new methods of demonstrating psychogenic vision loss.

Thursday:
[1] Neurologic Complications of Medical Disease – General Neurology, Neuromuscular, Vascular Neurology – This course organized by Neeraj Kumar of the Mayo Clinic was a very neat and extensive session covering a variety of medical conditions. I took this course knowing that next year as a senior neurology resident I will be running the consult services and will have greater involvement in directing the care of patients without primary neurologic disease but with severe neurologic deficits and symptoms related to the dysfunction of other organ systems. The course provided overviews of rheumatologic diseases causing peripheral nervous system dysfunction, neurosarcoidosis, nutrient deficiencies, gastrointestinal diseases with neurologic symptoms, systemic malignancies and cancer treatments causing neurologic dysfunction, and finally systemic diseases causing ischemic stroke and intracerebral hemorrhage.

Friday:
[1] Practical Issues with Botulinum Toxin Use in Neurology – Movement Disorders – I have had no direct experience thus far as a resident with the use of botulinum toxin in neurologic conditions, so I took this course with the hope of having an introduction to its use. Furthermore, as a junior resident with predominantly inpatient ward duties, I have minimal exposure to neurologic movement disorders (which is an outpatient subspecialty within neurology). One major caveat for this course was that the various speakers all had several financial conflicts of interest related to the pharmaceutical companies that manufacture formulations of botulinum toxin; many off-label uses of the medications were discussed. Nonetheless, I particularly found value in the introduction to various dystonias and an overview of the different presentations of spasticity after stroke. Listening to one of the principal investigators for the trials related to botulinum toxin as a therapy for chronic migraine was also very interesting, particularly in his discussion of the pathophysiology and the distinctions he made between chronic migraine and other types of chronic headache (chronic tension-type headache, rebound analgesia).

I presented at AAN two years ago as a medical student. I only had enough time and money to present my work and did not get to explore much to the conference’s many educational resources. This time, my goals were focused entirely on education and broadening my own perspectives, with regards to differential diagnosis (learning about less common clinical entities), approaches to diagnosis and treatment, and the development of a career pathway. For numerous reasons, I wish that all residency programs would send their residents to AAN every year as it is a fantastic opportunity for growth and learning.

Anomia is the inability to generate the name of an object or item presented to a patient. Confrontational naming is often tested as a standard portion of the neurologic examination of mental status. While there are several standardized tools for testing of naming ability (such as the Boston Naming Test and the NIH Stroke Scale naming cards), many Neurologists and other practitioners use readily available everyday objects to test patients at the bedside or in the office. There is a distinction made between “high frequency” and “low frequency” names; individuals with naming ability will lose the ability to identify low frequency objects first, meeting criteria for a “mild anomia” which may indicate a degree of subtle cognitive deficit.

The two objects I have seen physicians use most often at the bedside are wrist watches and pens (followed by eye glasses for those who wear them). The physician will first start by asking the patient to identify the entire object (e.g. watch, pen) and then ask them to identify specific parts. However, not surprisingly, there is considerable variation in the design of watches (especially between analog and digital watches) and pens (spring-loaded pens versus capped pens), and there is likely some variability in cultural knowledge regarding the ability to identify the “low frequency” components of each.

However, sometimes even physicians will make mistakes in identifying the individual parts of each object! If you plan to use either object for testing naming, use the following as a guide:

Watches (analog)
Physicians are more likely to wear analog wrist watches which are seen as more professional than digital watches (which typically are worn by children or for sport situations). I focus on analog watches here.

Band – also known as the bracelet or strap, this is a high frequency component that is used to secure the watch to the wrist

Face – medium to high frequency component, the part of the watch with the numbers and markers. The surface under the watch hands is called the dial.

Hands – medium to high frequency component, the linear bars that turn and point toward the individual numbers which are used to designate the current time

Marker – low frequency, the design element that designates time intervals (five minute intervals, fifteen minute intervals, hours), often a small dot or line

Crown – low frequency, the cap on the side of the watch that is pulled up in order to alter the date wheel or time setting. The cap sits atop the stem and tube.

Stem and Tube – very low frequency, invisible when the watch is in a normal functioning position. This component sits under the crown and is only visible when the crown is pulled outwards. This connects to the internal mechanisms that adjust the date wheel and time.

Crystal – low frequency, the clear covering sitting above the face of the watch.

Bezel – low frequency, the outer ring with indentations or numbers that count or providing markings from 0 to 60. The bezel holds the crystal in place and also provides a time reference for divers to help them determine how much air remains in their tanks. There is considerable variation in bezel designs which are sometime fixed or they can rotate clockwise, counterclockwise, or both.

Date Wheel – low frequency, an indicator for the date of the month. Sometimes the date wheel window will have a magnifying lens above it called the cyclops.

Lug – very low frequency, the metal pieces that project from the main body of the watch and secure it to the band (specifically, the band end piece)

Case – also known as the casing, low frequency, the back of the watch which is lifted off to access the internal workings of the watch and battery compartment. The casing sometimes will have the model and serial number listings (if not located on the lug).

Pens
There are many different pens used by physicians, the most complicated being fountain pens which have dozens of components (nibs, cylinders, ferrules, feeds, levers, derbies, screw rings, press bars, sacs, etc.). However, considering how often pens are lost and “borrowed,” most probably rely on a steady supply of cheap, disposable pens. For simplicity, I’ll demonstrate names with a push-button pen here.

Point – also known as the tip, high frequency, the part of the pen through which ink is delivered to the page

Clip – medium to high frequency, the part of the some pens that will hold the pen in place in a (white) coat pocket

Barrel – low frequency, the main body of the pen (with many different names depending on the type of pen)

Push Button – medium to low frequency, the part of the pen that is pressed to exposed the point

Joint – low frequency, the part between the upper and lower halves of the body of the pen which connects them

Since most physicians are unlikely to deconstruct their pens at the bedside, I won’t describe the thrust tube or ink cartridge.

Many senior physicians would have one think that young physicians are like their children: easily distracted and absorbed by the growing culture of electronic connectivity. These physicians fear that younger doctors are in danger of ignoring clinical responsibilities in favor of the social obligations that accompany these devices: social networking, instant messaging and texting. And yet, the rapid adoption of tablet computers (predominantly iPads) and smartphones among training physicians represents the entry into the next stage of information technology in medical care. Mobile technology now permits instantaneous access to the most up-to-date pharmacopeias, practice guidelines, clinical trials and reviews, and also electronic versions of medical textbooks, training videos, medical calculators, and in some cases, electronic medical records. The adoption of the last wave of technological evolution, electronic medical records, has proceeded at an achingly slow pace, particularly due to the high startup costs that necessitate initial investment by a well-funded organization such as a hospital, group practice, or a practitioner with seed money. How can one balance the benefits of connectivity with the detriment that might come from distraction?

As is the case with many other solutions to problems encountered in the practice of medicine, the answer must come from within: the cultivation of greater self-discipline. One of the most important skills learned by interns and later refined throughout residency is the art of time and expectations management. The expectations and time demands imposed on training physicians by program leadership, attending physicians, chief residents, nurses, case managers, hospital administrators, and (last but not least) patients and their families are inevitably unrealistic and conflicting. For example, training physicians are expected to be in multiple places at once, frequently criticized for poor attendance at mandatory educational conferences or teaching rounds whilst simultaneously performing a necessary invasive procedure for patient care or discharging several patients timed to deadlines set by the case manager. Pagers are constantly invading the conversational flow of patient interviews, sometimes with messages urgent and other times mundane, sometimes informative and other times meaningless (the classic number page). New parties now have a greater foothold in the domain of attention of the training physician through electronic connections: loves ones, friends, and family. Physicians, previously unanimously choosing “dedication” and “commitment” to their patients in the form of long, isolating hours at the hospital over the cultivation of family and non-professional friendships, now have new methods that help maintain connections to the outside world during the breaking down and remolding process of medical school and residency training, a process that often involved the shedding of relationships. The current task at hand for the young physician is to develop the most appropriate methods of triaging the demands for their attention: focusing first on immediate patient care needs, attending to urgent personal matters when time allows, and delaying less time sensitive matters to off-work hours.

Underlying the criticism, however, is an unsustainable proposition: that technology is the enemy of the patient-doctor relationship. Over time, the impression has developed that computers and information technology draw training physicians away from the bedsides of their patients. In reality, the major factors that remove physicians from the patient’s room are the exponential paperwork demands (produced at the computer) and the processing of greater amounts of clinical data (read on the computer, in the form of laboratory values, imaging scans, or consultant reports and physician notes). In other words, the technology itself isn’t the problem: technology merely facilitates the information and documentation overload demanded by a litigious and defensive culture of practice. Technology can, in fact, bring physicians back to the bedside: doctors can update patients on their most recent lab values, check and update medication lists, explain their medical conditions in the context of an MRI or CT scan displayed on a tablet, use three dimensional models to explain basic principles of the function and dysfunction of individual organs (such as the brain or heart), and show them where to find trusted medical information sources on the Internet. Eventually, more digital documentation such as progress notes and discharge instructions will be easily generated by physicians at the bedside, minimizing the time spent at computer bays. In due time, both senior and training physicians will need to face the true problems within the practice of medicine and the delivery of health care that are underscored by the adoption of new technology.

The date wheel rolls over to “thirty-one,” but I know this is wrong. Twisting the stem of my watch ahead one stop, it lands on “one.” A year has passed, it is again July the first, and I am no longer an apprentice at this trade of medicine, but perhaps, a journeyman with still a long sail ahead. When I left my first training waters, I wasn’t sure what to expect of the sea: the great, vast body of bodies filled with pain and suffering and fractured dreams of a better life. My intern year was less a safe, quiet harbor for learning balanced with occasional challenges and more a constant, recurring blockade run of defiance against the forces superior in number that conspire to prevent me from providing what I believe to be the best care I can provide for my patient. The nurse who refused to give pain medication to a person with a history of drug abuse or who concocted a new “policy” that obstructed a doctor’s request. The phlebotomist who ignored requests for stat lab draws off the normal lab draw schedule, be they blood cultures in a patient progressing to sepsis or cardiac enzymes in another showing the first signs of a non-ST elevation myocardial infarction. The consultant who answered each consult request with a barrage of demeaning questions. The resident or nurse practitioner or physician assistant who constantly punted patients to other services to avoid having to address the dreaded task of “disposition,” transitioning patients out of the hospital and toward home. And those who delivered the scores of number pages each day that interrupt important conversations with patients and providers and the flow of patient care, with intentions skewed toward the ability to document “MD Notified.” I left the year worn and battle hardened, trusting few but myself and the men and women who fought beside me every day in these unforgiving waters.

A year has passed, and I have been promoted. I earn better pay, my name is emblazoned across my jacket, and I have a new stripe to indicate my rank. I am now a second year officer of the House, and I have started this new assignment with one young officer to supervise: a first year, an intern. Admittedly, this is a cushier assignment than those assumed by many of my comrades in officer training: the hours are still long, but these western waters are calmer, these crews more experienced and seaworthy. I have new responsibilities: whereas last year I theoretically was always supervised in person, I now command respect as an officer and representative of Her Majesty’s fleet (Her Majesty, of course, being the Queen of medical disciplines, Neurology), and I often stand alone. I received the first call from the port master, the Emergency Room, as word of a distressed vessel traveled with the frantic hum of the helicopter blades. Upon arrival, I was immediately notified and was at the bedside in minutes with the attending physician speaking directly to me and asking for my recommendations as I stepped into the crowded room with eyes turning to me: “Where would you (Neurosurgery) like the blood pressure? We were planning to go to the CT scanner immediately; do you want a plain CT or a CT angiogram?” A member of the Emergency team recognized me and called me amiably by name. It has only been a few weeks, but I have a name, a reputation. Immediately a voice from within relayed, “Keep the systolic blood pressure under 130. We usually use Nicardipine. I would like a CT angiogram of the Head.” A handful of times in the past I have been involved in time-sensitive critical care, including in cardiac arrest codes, but often as the ensign delivering chest compressions or running to the phone to call for more specialized help. But now, the bridge is yours. Although ultimately my attending, my captain, was the primary force steering this ship through the storm of blood and steel and electricity, I was everywhere: by the bedside monitoring the patient’s condition and teaching apprentices, in the scanner control room identifying the aneurysm, coordinating the collection of supplies for a ventriculostomy, sending in my crewman to place the drain (knowing this was his chance to learn and shine), speaking with family about the upcoming procedures and the hard road ahead, and signing out to nurses and doctors in the ICU as we pulled into dry dock and out of the fire and rain. At each step, each individual performed admirably, and I was there to see it all, there to direct and guide and encourage and compliment.

I have a name. I have a command, however modest, and a role to fill in service of the Queen, of Neurology, and of the men and women of her domain whose suffering I can alleviate. I have a responsibility to not be that consultant belittling those without specialized knowledge or that physician recklessly dispersing patients rather than seeing assignments through to the end. I have a junior officer who is eager to break the rules to continue to serve and be at the front lines, and I have an obligation as his commanding officer to protect and guide him, to use him where he can be most effective and gain the most experience and not waste his skill and energy on tasks another officer might feel himself too senior or superior to perform. I accept this new assignment. I am a resident.

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.

Teaching

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.

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