Making Decisions, Not Memorizing Facts
Observers at Georgetown’s School of Medicine might be forgiven if they wonder how its students have so much free time to listen to music, and do so much texting, on their “i" devices. The students seem obsessed with their iPods(R), iPhones™, or iPod Touches(R) – they are always at hand, at ear, even during patient rounds.
Blame it on me, says Steve Schwartz, MD, with a laugh. He started requiring medical students to use handheld devices, such as Palm Pilots(R), six years ago as director of the family medicine clerkship at Georgetown University Hospital. These miniature computers provided access to the Internet and storage for a large quantity of data files, allowed students to research an answer to a clinical question on the spot.
Now, as associate dean for informatics at the School of Medicine, Schwartz has made sure that second-, third-, and fourth-year medical students have the devices, which are being switched over to Apple’s products.
The students aren’t just using them for recreation. If buds are in their ears, they are probably listening to lectures being digitally streamed from GUMC computer servers. If they look like they’re texting, it is likely because they are accessing the Internet to find information from a cornucopia of databases available through these tools-- everything from the National Library of Medicine to patient practice guidelines and drug reference guides.
“There is no way you can learn everything you need to know in medical school, and it is foolish to think that you can just memorize what you do learn,” says Schwartz, who was trained in family medicine, a specialty that traditionally draws on a number of data sources for a wide range of diseases, and which has championed the principles of evidence-based medicine (EBM), the cornerstone of medical informatics.
“Physicians have to make decisions by applying the best medical knowledge available, not solely by pulling up facts from memory or thumbing through a few limited resources,” Schwartz says. Using today’s digital tools enhances students' ability to treat patients using the latest information and facts.
“The amount of biomedical information has been and continues to grow at an explosive pace. With thousands of journals publishing tens of thousands of articles every month, much of what our current students will use in clinical practice is yet to be discovered,” he says. “Current paradigms will change. And what medical students learned was ‘fact’ will become disproven.”
What medical school should do, he says, is both teach students the fundamentals – “gross anatomy or pharmacology principles, for example” – and also focus on how to apply the latest clinical knowledge to support a decision. “That is the essence of learning – how do you weigh options and apply facts; how do you choose to make decisions?” Schwartz says.
There are many on the medical school faculty who agree with him. Schwartz talks about how some surgeons several years ago recommended that medical students leave their so-called “handhelds” at home, but now encourage students to carry the devices with them.
“The idea is that the students will tend to learn in smaller bites, retrieving information when they need it and where they need it,” he says. “Think about how a medical student, about to scrub in for surgery, can have audio-animated text or video describing the procedure so they will be even more prepared when they go in.”
This can only help the practice of medicine in the long run, Schwartz says. “Medical mistakes are made by every physician, and they are made every single day, but most don’t cause harm,” he says. “I remember as a resident making a classic error, putting the decimal in the wrong place while prescribing a dose of medicine.”
“The error was found in time, but it didn’t need to be made at all if I had a drug dose calculator on my iPhone™,” he says, referring to an application available for download by iPhone™ users.
He could also have used his handheld to look at the most common reference guide in use today, the drug database ePocrates(R) “If I have a patient on 8-10 medications, I could look for drug-drug interactions, make a decision about whether or not to change those medications and draw from a broader scope of medicines which includes newer agents,” Schwartz says.
Other databases and tools are also available, such as the Framingham Risk Calculator, which looks at risk of having or developing heart disease. That can be used to, say, decide whether an individual patient needs to go on a statin drug to lower cholesterol, but at the same time, treatment guidelines can be accessed which help define which statin drug is best given the latest research. These treatment, or practice, guidelines are developed by the government as well as by physician professional organizations, to promote best practices based on available evidence.
Handhelds can help physicians pull up clinical information on the spot, at the point of care.
“It happens all the time now that a patient will come into a meeting with a physician, and ask about this new procedure or that new drug. Patients have significant access to information these days, but need help interpreting and applying this information,” he says. “Doctors can now call up original studies and other relevant information to answer their patients’ questions.”
Schwartz says that GUMC is planning to use electronic information systems on an even broader scale. Curricula projects underway for next year are student training in “e-prescribing” and use of electronic health records. The bioinformatics group is currently exploring adapting WorldVistA, an open-source, electronic health record and health information system designed for use by the U.S. Department of Veterans Affairs, for educational use at GUMC. It will be used in a patient simulation center with “patient” actors. Their task will be to use these tools to help support the treatment decisions they make, and to also help answer patient’s questions.
Schwartz is also using informatics to help track student procedures and performance and to continue to build up GUMC’s web-based presence, such as the archiving of streaming lectures, podcasts, and videocasts that students can download at any time.
“Medicine can be so complex, but it is easy to miss even the simplest things,” Schwartz says. “If you ask any medical student if you should use aspirin on a patient who is having a heart attack, everyone says yes, but the actual use, compared to what it should be, is extremely low,” he says. “So make the use of aspirin part of the set of evidence-based decisions that a student should follow and learn from. Medicine isn’t being delivered by an iTouch, but by a student who is much more in touch with best medical practices.”
By Renee Twombly, GUMC Communications
Interested in learning more? One blog listed its top-ten medical iPhone apps here: http://mobihealthnews.com/850/the-real-top-ten-iphone-medical-apps/