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We are excited to present the first installation of a new column on in-House exploring #ClimateChange.

“Morning coolness, afternoon heat, evening rain — three seasons have intertwined into one large, unpredictable state. The consequence? An unsettling combination of large areas of pooled water and infrastructure damage leads to flourishing of waterborne and vector borne diseases. Hundreds of cases of dengue, malaria, typhoid fever erupt across the town.” – Pediatric resident, Shalini Shah, MD

      Kevin Campbell, MD, FACC   Cardiologist at Wake Heart & Vascular   Healthcare Consultant  @DrKevinCampbell | DrKevinCampbellMD.com

This originally appeared in Dr. Campbell's personal blog on May 24, 2014

Medicine is becoming mobile.  Physicians, nurses and other healthcare providers must be able to quickly assimilate and react to an overwhelming stream of data.  Tablet technologies, such as the Apple iPad, have been incorporated into the workflows of many clinics, emergency rooms and hospitals.  Medical Schools and Residency programs are quickly adapting the technology for teaching.  While tablets do present some security challenges, most clinicians who are currently using them tout them as revolutionary and efficient. Moreover, there appear to be many new medical uses for tablet technologies in the pipeline that may forever change the way medicine is practiced.

Tablet Utilization:  Pros and Cons

Many hospitals are now using tablet technology to help physicians and other treatment team members prepare and interact with patients while on the move.  With healthcare reform and cost containment strategies, many hospital systems are looking for ways to streamline care and cut costs.  Potential advantages of tablet use include the ability to improve workflow on rounds, reduce staffing requirements, and increase productivity and efficiency without compromising patient outcomes.  In many centers, physicians are able to “sync” their devices wirelessly or via sync stations located throughout the hospital.  Rather than moving to a computer terminal to sit down and review labs, consult notes, test results, etc, a team can move through the hallways and discuss these findings via an interaction on the iPad.  There is virtually no downtime and less staff is required to see patients in an efficient way.  When interacting with patients in their room, caregivers can actually show them images and results and discuss findings with them.  In fact, a recent study from the University of Sydney showed that secondary review of radiology study images on an iPad was just as good as a standard LCD computer screen.  For patients, it improves education and engagement in the care plan when they are able to see an image or test result as they discuss the finding with their providers.  When patients have a better understanding of their medical problem and are able to participate in their treatment plans, outcomes improve.  Tablet technology helps facilitate this type of engagement.

Some centers are incorporating their EMR (electronic medical record) into the tablet via a mobile application and this allows for quicker documentation and immediate record of the day’s plan for the patient–available for all team members to access “real time”.  The EMR mandates put in place by the federal government have become a burden to many facilities and providers–by interfacing with these technologies via tablet technology, adoption of EMR and efficiency of documentation may improve.

As with any computerized medical record or medical application, security and HIPPA regulatory compliance are always a concern.  In addition, the small size and mobility of the iPad device makes keeping the devices in the hospital a challenge.  Although several major academic medical centers, including Massachusetts General Hospital have begun to incorporate tablet technologies into their practice, many others have not due to the cost of stocking the institution with the relatively expensive devices.  Now, many EMR companies, including EPIC (a major EMR player in academic centers) have created secure applications for tablets and other mobile devices that protect privacy and are HIPPA compliant.

Tablet Technology:  Future Applications in Medicine?

At this point, we are only seeing the tip of the iceberg when it comes to mobile technology in medicine.  Tablets are very powerful, portable, and user friendly.  I believe that these devices will become standard issue in medical schools across the country.  Rather than spending 1000 dollars per student on printed materials for a year of medical education, schools such as the Yale University School of Medicine are now issuing iPads to all students and utilizing the iPad for nearly all curriculum related materials.  According to the AAMC, tablet technology is being adopted all over the country and is being used to replace reams of learning materials on paper.  In a recent survey of medical students published in the Journal of the American Medical Library Association, most students go utilize electronic based medical resources at least once a day and over 35% use a variety of mobile devices to access information.

Applications continue to be developed that have important educational roles in medicine–apps for learning EKGs, reviewing histology, learning pharmacology and others are becoming mainstream and will likely be an integral part of medical education going forward.  A recently published study in JAMA: Internal Medicine evaluated the changes in resident efficiency when using iPad devices for clinical work.  In the study, the authors found that the utilization of mobile devices improved workflow and both perceived and actual resident physician efficiency.  In fact, orders on post call patients were placed earlier–before 7am rounds–likely resulting in improved care and more timely delivery of medications, treatment plans and orders for diagnostic studies.

For patients, tablet technologies may improve their visit experience and may help reduce medical errors.  I can foresee a clinic where patients check in for their appointment and are given an iPad to fill out forms and answer a wellness screening questionnaire prior to their visit with their primary care doctor.  With more “meaningful use” requirements imposed by government bureaucrats, these electronic screening opportunities will allow clinicians to not only meet regulatory requirements but also continue to spend meaningful time with their patients during a visit.  In addition, patients can have the opportunity to review imaging with their clinician at their side and actually “see” what the doctor is able to see.

        Alexa Miller   Owner and Consultant in Arts and Clinical Learning   ArtsPractica

What does it mean to really see a patient?

This question drives the work of ArtsPractica, a medical education consultancy dedicated to improving the skills of diagnosis with arts learning. I have explored this question in collaboration with expert diagnosticians and in the arts.

Seeing is about longitudinal skill development, multiple perspectives, suspending judgement, and metacognition. It is more than just “visual skills,” and has little to do with perfect vision.  In my opinion, many medical errors are a question of seeing or not seeing.

“Seeing patients” is a central to medical practice, but it’s an out secret that medical training lacks a consistent model for learning to look. In fact, systemic pressures often justify skipping adequate patient inspection. Too often, treatments and tests take precedent overseeing the problem in the first place—and this is where medicine risks failing on its first promise, to “do no harm.”

Seeing to learn about art, patients, and cognition

ArtsPractica is based on the concept that careful study of art can support the development of skills in diagnostic acumen and in communication. This work stems from a decade of collaboration with Harvard physician-educators on the “Training the Eye” program, an arts-based course that produced published outcomes.

Our research found that learning to view detail in art translates to better skills in observation. Students who participated in seven or more arts-based sessions, for example, made 38% more observations in response to both clinical and art imagery than their peers. They further provided evidence for their interpretations significantly more frequently.

Our qualitative study further showed changes in language. Arts concepts like “contour” or “shading” appeared in students’ clinical descriptions after taking ”Training the Eye,” producing more robust and precise clinical communication. Other studies in medical humanities and arts learning indicate arts interventions link with increases in clinically-relevant abilities, such as critical thinking and tolerance of ambiguity.      

Learning to look in art helps practitioners notice their biases, see what others see, discover that what we see is sometimes different from what we want or hope to see, and experience how discussing the vast differences in individual processing are an asset to seeing the whole picture.

Cultivating an environment where it’s “safe to ask”

Let’s face it: medicine is vulnerable to certain pressures—an ethos of certainty, hierarchical inhibitors to communication—which present safety issues. Students and practitioners alike often feel pressure to know everything. Arts experiences are one place where authentic uncertainty is a positive thing, and where effective habits for contending with it can be cultivated.

In art-viewing, colleagues work together to get at truth in ambiguity, as they might in teams on the wards, although the conditions are quite different from those of the clinic. Stakes are low. No one is the expert. Everyone’s perspective is uniquely helpful. It is far easier in this context to cross the boundaries to seeking second opinions. It’s easier to cultivate curiosity about what others have to say, easier to stay a place of not-knowing, easier to inquire, and easier to turn inquiry into action. It is in this way that ArtsPractica aims to help contribute to larger discussions about seeking second opinions.