Analog Discipline

February 1, 2013

DisciplineThis story by Iltifat Hussain over at iMedicalApps is worth a peek.  Apparently he had given his medical student brother an iPad for his clinical clerkships.  He went on to receive an unfavorable evaluation by an attending for being ‘too dependent on his iPad during rounds.’

I wonder what this attending was trying to teach him.

I suspect he comes from a generation when doctors knew everything.  Literally.  There was a time when a doctor could learn the medical corpus in two years of preclinical study.  Not anymore.  Maybe someone should remind this attending that the ability to access networked intelligence will replace the laundry list memorization that defined his generation.

While my technoutopian bias has me putting all of this on the shoulders of the attending, I wonder if Iltifat’s brother has any accountability in this case.  The best clinicians are sensitive to their surroundings.  They have a kind of emotional intelligence that allows for adjustment on the fly.

How does this relate to technology?

I like to think that I’m sensitive to the patients around me.  As a pediatrician I encounter grandmothers who insist that anything short of blinkless eye-lock during conversation is a sign of disrespect.  Millennial moms, on the other hand, are more tolerant of dual tasking and the third screen.  The way I talk with a patient surrogate and engage with my EMR or iPhone is absolutely different depending upon the family in front of me.  We have to understand who’s around us and how they may respond to our tools.  I like to think of this ability to intentionally adjust as medical mindfulnessan especially critical literacy for the doctor of the information age.  There’s a time to touch and a time to type.

If you’re not in tune with your immediate surroundings you may feel the sting of smart phone attribution error.  This is when an uninformed observer makes assumptions about what you’re doing with your device.  While medical professionals such as this attending have a responsibility to understand and accept the place of tablets in the modern medical workspace, the digital physician has some responsibility to understand how he’s perceived.  When the observer is a patient, the responsibility is greater.  Every patient encounter should begin with an explanation of what we’re doing, or not doing, with our technology.

In the end the students like Iltifat’s brother are going to have to figure out how to help the world around them adjust to their new mobile tools.  There are few to help them navigate medicine’s shifting ground.


Pat Rich February 1, 2013 at 9:57 am

I recently interviewed Canadian medical residents about mobile use and they have run into similar situations of being penalized for apparently not paying attention when they were actually looking up information on a medical device.
I understand one California medical school is now giving medical students lessons on etiquette and the use of mobile devices in clinical situations.

DrV February 1, 2013 at 10:36 am

Perhaps the issue bigger than mobile health devices is the EHR. Understanding how to work with a screen is a subject that needs discussion. While I’m okay with the use of the word ‘etiquette’ I think it ignores the fact that these tools are part of our workflow rather than something more superficial. When working with students and residents I use mindfulness as I think it better encompasses the problem.

But probably an academic debate….thanks for chiming in.

Cheryl Handy February 1, 2013 at 10:36 am

The more I communicate with young doctors, the more concerned I am about the presence of technology in healthcare. I think many younger doctors use technology as a crutch.

Don’t get me wrong, I think an *established* physician can contribute to the healthcare system by sharing experiences, information on the Internet. But before a physician can share usefully on the Internet, he or she must be able to connect with patients on a one-on-one basis. The physician must be able to maintain physician-patient relationships. That skill is difficult.

My concern is this new trend that younger doctors rely on technology to the exclusion of an actual physician-patient relationship. Moving from medical school to sitting with a real, scared, confused family isn’t easy. Sharing bad information isn’t easy. Communicating bad information via email (or even telephone) or by checking an on-line medical record is easier for the physician but horrific for patient. (I learned about my cancer on voice mail. I learned about blood infection on on-line records.)

Using a smartphone or IPad when you are communicating with a patient is frankly rude. If you must do it, explain to the patient that you need to make a note on your IPad. Use the “date rule.” If you were on a date with your significant other, would you pull out the smartphone or iPad and try to “multi-task” by talking with your date and checking emails? Okay, if you said “yes,” you are a jerk.

Physicians have told me that all physicians *should* be available to their patients 24/7 and that can be done via technology. No. That is unrealistic. I want my doctor to go home, have dinner with family, feed the dog, pick up dog poop . . . be a real person.

The more physicians trend to technology, the more jobs open up for non-medical professionals to keep docs on line 24/7. Consultants, technology experts, social media experts. It would be easy for physicians or hospitals to delegate the responsibility of giving information to the tech experts. A hospital or physician web-site is one thing. But, dealing with patients directly cannot be delegated in any shape, manner or form. technology cannot replace direct human contact.

Put the smartphone in your lab coat. Sit down. Look at the patient in the eyes. Remember, that the patient wants a connection with the physician. If for no other reason, a patient is less likely to sue a doctor that they like. :-D

DrV February 1, 2013 at 12:35 pm

While I generally agree, Cheryl, I think that the issue isn’t so simple. Medical mindfulness must involve more than simply putting everything away and staring at the patient. Independent of mobile devices, for example, our EHR is an unavoidable presence in the exam room. Turning it off is not an option. But developing strategies that optimize all aspects of the encounter is key.

Rather than denying that technology is part of how we care for patients, we must find a way to maintain the connection that you describe while leveraging mobile devices.

Cheryl Handy February 1, 2013 at 5:00 pm

Okay, for clarification, I have no problem with doctors on IPads or smartphones. Technology enhances the medical health care system (without tech, we wouldn’t have 33 Charts!)

But the same way you would explain to your date that you have to check your mobile phone, just tell the patient that you need to make notes or pull up radiology films. If you pick up the mobile on a date, you might go home alone. You don’t want to lose a patient – even for a nanosecond.

We are just talking about being rude. Of course, no doc wants the patient to feel ignored. Communicate. Remember, patients typically use smartphones and IPads to check email and Facebook. Think about the perception of the patient. It’s a great opportunity to explain function of tech in healthcare and educate the patient what you as the doc are doing. It’s just all about the new tech etiquette.

Generally, physicians I’ve worked either use a desktop style picture (so the patient can see what is on the screen) or they place the laptop on table.

Craig Canapari MD February 1, 2013 at 11:10 am

I agree with Cheryl’s point above about explaining what you are doing. I occasionally need to look up phone numbers or my DEA number (I don’t use it that often.) I always tell the family exactly what I’m doing when I do it.

I struggle with what to do when a patient’s parent (I’m a pediatrician) is on the phone during a conversation. I will say something if they make a phone call but it is less clear when they are looking up something on the screen.

DrV February 1, 2013 at 12:43 pm

I might add that I frequently use Epocrates’ pill identifier to establish what medicines a child is taking (when the parents forget the name). Knowing what medicines a child is taking is pretty important information. Before mobile technology this was close to impossible. I’d consider this a pretty important part of an encounter. The parents who see the pill image and have the satisfaction of knowing the record is right are typically really relieved. They love seeing this technology in action. Further, this isn’t something that we feel we should have to defend. It’s how good medicine is practiced here in the early 21st century.

Rather than vilify and excuse technology, we have to work to see how it fits in a healthy doctor/patient relationship.

Regarding the phone issue, this gets lots of dialog but as someone who sees lots of parents, it is extremely rare that patient will not put down their phone when I come in a room. While it happens, my experience has been that parents are generally more considerate than these isolated stories may make them appear.

Cheryl Handy February 1, 2013 at 5:26 pm

V: Are there written standards on how to engage patients with technology both in clinic and outside clinic? Or is it left to the judgment of individual practitioners? I deal primarily with the elderly. Granted, they have families with them but misunderstandings can still happen.

Off topic & reason for my new found concern about technology/healthcare: If the elderly patient never checks his email or a patient portal then the medical office providing him access effectively means that family members, caregivers will hijack access. I know some elderly men who don’t need POA and they sure don’t want the whole family reading medical information. Raises tremendous ethical issues.

DrV February 1, 2013 at 8:33 pm

Not the kind of standards that you suggest. Balance of our encounters with technology is an area of evolving interest and discussion.

Brenda Dintiman February 2, 2013 at 7:05 am

I think technology is a wonderful tool to cross reference medications and drug reactions when creating you treatment plan. I use it to look up the specifics about diseases that are not in my specialty and also interactively use technology to look up information and resources for them. Yet, when I see a brilliant surgeon talking to a patient that is seeing postoperatively, it bothers me when the students are searching one reading their phone rather than learning from an experienced physician about the critical art of communication and physical examination. This is not the time to search for an answer.
So maybe it is about technology etiquette .

Gustavo February 2, 2013 at 6:25 pm, apparently other people are experimenting the same.

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