Hiatus!

The MSL blog will be on hiatus until September 12th in order to celebrate the Labor Day holiday. We look forward to continuing our conversations then.

Informed Consent

A recent entry by Amy Thackeray in her family blog notes her dissatisfaction with the way she was treated during her hospital stay. She went in to have her gall bladder removed, but was made to feel ignored and angry with the way her surgeon treated her. Very important in her story was the events that transpired while she was unconscious.

The surgeon consulted a GI doctor prior to surgery and relayed the suggestion that Ms. Thackeray have an upper-GI scope while in surgery. She was hesitant and did not feel she needed such a procedure, but her surgeon begged to differ and even responded that since she'd already be unconscious it wouldn't be an issue to add in the procedure. He basically wore her down to consent. However, while performing the surgery, and discovering she also had Meckel's Diverticulum, he debated just removing the extra tissue without prior consent and despite the patient never having complained about it. He decided against performing the procedure, but the issue is that he considered it in the first place.

Physicians must fully communicate with their patients. If a patient has not been consulted about a procedure or has not decided against a procedure once consultation has taken place, excluding if it is a life-threatening situation during surgery, the medical professional should not go against their wishes and perform the procedure anyway. Amy's example was of a situation where she did not want the upper-GI scope, yet was pushed until she relented and had not complained about any negative effects of the extra tissue found during the surgeon's later exploration.

Be sure to communicate with your patients and listen to them. Do not take it upon yourself to decide what's best for the patient. Medical treatment includes a level of trust between patient and physician, so when that trust is broken, it impairs the ability for the patient to trust again, whether with the same physician or a future one.

Patient Requests For Amended Records

Physicians make notes on patient EMRs to track surrounding issues of patient diagnosis, as well as treatment choices and requests for follow-up. However, some patients request their physicians to change wording or eliminate certain notes altogether in order to change the implications of their diagnosis. A recent blog post on Mothers in Medicine covers this issue, with personal accounts from physicians.

Records can be amended, with notation of the reason, including patient request. This is not an issue. The issue comes about when a doctor must decide to follow the patient's request and change the reality of the diagnosis or if they are able to refuse based on their own moral code. The blog author brought up the topic with colleagues and got a number of answers, many admitting that they've omitted sensitive information or changed information in patients' charts when requested. Many bring up the point of records being subpoenaed. When this information is entered into evidence, it may be detrimental when it doesn't have to be.

"Sensitive information can really hurt [patients] if it ends up in court, and you’re naïve if you think it doesn't."

So, is it worth endangering the patient/doctor relationship by refusing to amend records? And at what point does the request become too much? Omission of minor issues may not negatively affect the patient's future care with another physician, but what if omitted information could aid future diagnoses? At some point, physicians must draw the line, but each have to decide for themselves what they are or are not comfortable with.

Schools Using Mobile Technology

Medical schools are moving more towards the use of mobile learning. To this end, many schools are requiring, and often providing, mobile tools which their students can use to learn the curriculum. MobiHealthNews outlined a number of medical schools in the United States and their use of mobile learning. Some schools have gone so far as to buy iTouches and iPads for their students to use. Theses are highlighted below.

iTouches Provided

UCLA School of Nursing: By providing iTouches to students, the school wants to improve the access their students have to health education materials. The devices are already loaded with relevant medical apps when the students receive them, so that they can immediately begin using and benefiting from them.

Ohio State College of Medicine: For three years, the school has provided their students with iTouches. These devices are already loaded with a number of medical apps that the college has chosen. Additionally, since the college records class lectures as podcasts, the students can download the relevant information for future review.

iPads Provided

UC Irvine School of Medicine: First year students are being provided with iPad 2s that already have their required textbooks on them. This eliminates the financial burden on students, as well as cutting down on the overall costs because students will be using digital editions rather than regular hardcover books.

Stanford School of Medicine: The school has been distributing iPads for two years now. It's becomes a welcome addition to the cadaver labs that students have to take. Students must agree not to misuse their devices, including not storing personal patient information.

University of Minnesota: With a grant dedicated to increased electronic learning, the school has purchased iPads for both students and faculty. Users are able to take advantage of the multiple medical apps and other digital content available.

University of Central Florida College of Medicine: Through a donation made to the school, students were provided with iPads which they can use for their classes. The device allows students to take advantage of a number of apps, as well as digital access to relevant published materials.

Time Management For Physicians

Patients often complain about the wait times they encounter at their doctor's office. They are often told that the physician is running behind schedule, which means patients are often forced to wait ten, thirty, or forty-five minutes past their appointment times.

One reason has been laid to the fact that physicians overbook, preparing for patients who will cancel and cause a gap in their schedules. Physicians have to balance their time with the decreasing amount of reimbursement they'll receive for patients, thus pushing them to try and see as many patients as possible. This can cause issues with time management and cause the physician to run behind on later appointments.

However, another reason has been put forth in an article by Dr. Middleton. Instead of trying to rush through as many patients as possible, she indicates that the delayed schedules may come from the fact that physicians want to spend appropriate time with each of their patients. When delivering difficult diagnoses, doctors want to make sure that their patients understand what treatment will entail, as well as lending any support patients may need to understand what they've been told. This causes doctors to run behind on the next appointment, which continues on through the rest of the day and makes wait times increase.

So, while the doctor's office may be an investment in more time than patients were originally planning to spend, the reason is not necessarily a bad one. When doctors care enough to spend the time, patients benefit.

Media Perceptions of Medicine

The current media market has a number of medical-related television shows. House, Grey's Anatomy, and the former Scrubs have all highlighted what it's like to be a doctor in a hospital environment. However, they're all played for an audience and not for reality. The problem is that public perception may be shaped by these media representations, as a recent article highlighted.

Being inspired by media to follow a specific career field is not a new concept. Science fiction programming has turned out a number of engineers, police procedurals have set young minds on the path of criminal justice, and medical programs have inspired people to become doctors and nurses. But these inspired, potential students must remember that reality will not match fantasy and the issue of ethics that has been highlighted in recent programs has made it even more difficult.

"There are a lot of inappropriate relationships on these shows and I think that's something that's not so good for students to see." ~ Dr Roslyn Weaver

Medical students must go into medical school with an open mind and learn the proper procedures of treatment and ethics. They must know when it is inappropriate to take an action and how to deal with coworkers who cross over into questionable ethics. It's great that medical dramas can inspire careers, but these characters should never be seen as role models in their field. The reality of medicine is not played for an audience, but for the well-being of patients.

Mobile Tools for Medical Professionals

Mobile technology is ever-expanding in the medical industry. However, there is not a single tool that all members of the industry uses or prefers. This is why the IT departments of hospitals and other medical settings must be aware of what is available and how they can be best supported. Recently, eWeek.com highlighted a number of these tools and how they are being used by medical professionals. Two of these, most relevant to medical students just starting their careers, are highlighted below.

Smartphones: Medical apps are increasing dramatically for use on Android and Apple technology. Many physicians have smartphones, which they can use to take calls, as well as do online research and receive information on-the-go. This use will continue to increase, so medical IT professionals must be able to support these devices and provide help as needed.

Tablets: Just as the use of smartphones is increasing, so too is the use of tablets. These devices have been around a long time, but they are becoming more streamlined so that they're lighter and easier to carry. Apps for tablets are also becoming more common, as the integration of EMRs and patient data is becoming mobile.

Additionally, the use of Machine to Machine (M2M) is increasing as well. Medical providers can monitor patient stats through wireless or other mobile technology. This allows for patients not to have to travel to the office for certain data and the medical professional can get more up-to-date monitoring and see a problem much sooner than in traditional settings.

Mobile technology is becoming a vital and integrated tool within the medical industry. Support for these advancements must be in place for medical professionals to get the most out of these devices. By pairing a strong support system with the cutting edge of technology, patients and providers alike can participate in the best care available.

Violence Towards Medical Students

Medical students have much to look forward to when they put their knowledge into practice. However, one area that they might not be aware of is the potential for violence performed against them while they are treating patients. In a recent study by JAMA, which surveyed third year medical students, 16% reported being subjected to physical attacks from patients.

What spurs these assaults? There are a number of reasons, but none can be pinpointed as always leading to attacks. Among them is the fact that patients may feel frustration over having to wait for care, they may be already prone to violence, patients may feel less inhibited by societal protocol while in a hospital setting, or it may be a side effect of the disorder they're experiencing. Whatever the reason, it's important that providers are aware that it's a potential event in their practice.

However, just because it's likely doesn't mean it should be ignored. When medical students are a target for attack, they should always report it to their superiors. The problem cannot be corrected if no one knows about it. Additionally, healthcare settings must look into ways to curb and cease the potential for attacks on their staff. One area is increased security to deal with attacks, as well as education on how to increase awareness of troublesome situations and how to deal with them when they occur. By working together, the potential for assault can be decreased and medical professionals can no longer be hesitant to treat all patients, regardless of surrounding circumstances.

Rise of Standardized Patients

The use of Standardized Patients in medical school has become more widespread over the years, originating in the UK's College of Medicine and becoming integrated into many schools across the world. Medical schools have seen the value in teaching hands-on patient interaction in these types of settings, allowing students to receive suggestions and feedback on how they can improve their skills.

"Before this program started, you sat in the classroom and took notes and then they threw you in, sink or swim, with patients. Now there is an established method of measuring their competency — both communication and technical skills." ~ Joe Gatton, SP Program Coordinator (University of Kentucky)

In typical SP programs, though they vary by institution, actors are assigned from a pool of pre-evaluated potentials. They are given patient information that they must act out, pretending to have a particular disorder so that students can be evaluated on multiple areas such as proper diagnosis, communication, and professionalism.

Medical students must know how to successfully interact with their patients in order to gain the information they need to successfully diagnose. These skills are tested in the USMLE, so the integration of SP programs into curriculum has the two-fold effect of preparing students for their exams and their future practices. By emphasizing the personal component of patient care, doctors will be better equipped to deal with varying treatment circumstances and that will translate into better care for all involved.

Promoting Rural Care

Rural care is an increased concern in the United States and will become moreso as healthcare reform brings new patients into care. It is important that medical schools highlight and promote the opportunities that rural care can provide for a physician. The experience and one-on-one nature of care has become a much appreciated and sought after aspect of medicine for many. American Medical News recently did an article about these issues.

The statistics that compare urban versus rural physicians shows that rural areas are often stretched in the doctor to patient ratio. Physicians in more populated areas number 104.5 PCPs per 100,000 residents, while that number drops to 65 PCPs per 100,000 residents in rural communities. While rural doctors are on-call and work longer hours than their counterparts in more populated areas, they are also allowed a more personal relationship with their patients. This translates into getting to know the entire person, not merely their listed symptoms, and can be more beneficial in diagnosis and treatment. The physician is also looked upon as a well-respected part of the rural community who is making the lives of its members better.

"There are incredible rewards. You can be a leader in your community. One person can make a difference in thousands of people's lives. You can't put a price on that and the way that makes you feel." ~ Jim Nemitz, PhD, Vice President for Administration and External Relations(West Virginia School of Osteopathic Medicine)

Some medical schools have created rural education in their curriculum in order to highlight and steer students towards a potential career in rural areas. However, there is always room for expansion. Students may be drawn to more populated areas because of larger paychecks or lower on-call hours, but the experience they can gain by treating rural patients cannot be replicated. It's an enriching experience all-around.

Twitter As An ARS

Medical students have often taken part in audience response systems. The idea is that students can use a clicker to log their real-time answers to a proposed question and their professor can show the results to the class as a whole. But with new technology, there are ways to expand this real-time interaction outside the traditional means.

One such technological advancement is the use of PowerPoint Twitter Tools prototypes. These tools allow students to answer questions with their Twitter account and their professor can show real-time results through a Powerpoint presentation. On the surface, this seems like a great idea, since it would eliminate the need for clickers and students could use the smartphone they likely already have in order to take part in the presentation. Reality, however, doesn't illustrate that this particular tool may be ready for widespread use.

Dr. Mintz tested out the prototype tools and wrote about his experiences. One large problem that he found was the fact that medical students often didn't have Twitter accounts, thus eliminating them from participation. Medical students seemed to rely more on Facebook to maintain their social interactions, not seeing the advantage of Twitter, so they were less likely to create an account solely to participate in the classroom presentation. Another large problem comes from the anonymity of answers. With clickers, the votes are counted without association with a particular person. With Twitter integration, all answers are tagged with the user who submitted it. This may color the results, as students may vote a particular way in public but another way in private.

However, there are also advantages to the use of Twitter in ARS. One is the ability to expand the voting pool beyond the immediate classroom. By posing a question and using a hashtag for votes, people from around the globe can vote their opinion. Secondly, the use of Twitter allows voters to give more thorough text answers than simply a number, as the clicker imposes.

It seems that the prototype tools have to make more advancements before they can be deemed ready for a larger audience. However, the potential these tools include shows us what can be achieved with the integration of technology. Learning has gone mobile and is looking towards the future for the next big advancement.

Mobile Technology Shouldn't Replace Personal Care

With the spread of mobile technology in medicine, physicians are gaining tools that make patient care easier and more effective. However, with these tools also comes to possibility the physicians will start relying on them more than they should. It's important to strike a balance between effective use of technology and effective care. Sara Jackson touches on these issues in a recent Firece Mobile Healthcare article.

Remote Care Is Not The Answer: Apps, email, and remote testing are all helpful in reaching a diagnosis, but they should not be the only things used when treating a patient. By not assessing the patient in person and simply relying on test results, the physician runs the risk of missing a vital piece of information and misdiagnosing the problem. Personal examination is vital in finding the exact needs of a patient and how to best treat their conditions.

Prior Tests Are Not Current Tests: Results of previously administered tests are helpful in seeing a patient's history, but current test results should always be acquired to diagnose the immediate case being presented. Review all that has been presented before, for clues as to how to proceed, but don't rely on them to make a current diagnosis. And using prior test results in current case notes is also questionable should the case ever be called into court for error.

Maintain the Lines of Communication: Patients are now becoming accustomed to sending emails to their doctor and getting immediate answers. Should those answers start coming more slowly or cease to come at all, patients are likely to become disgruntled. Additionally, they rely on the belief that their answers are coming from a trained health professional, namely their doctor, so having someone else give health advice is questionable.

Mobile technology has helped the medical industry make great strides in care. Patient treatment has increased in positive outcomes because of the addition of these new technologies, but physicians cannot lose sight of the patient when using them. They are meant to be tools to help the physician, not eliminate the need for patient presence at all.

iPads in the Classroom

Recently, the University of Arizona joined many other institutions in implementing a program which brings iPads to the classrooms in their medical school. More than 100 medical students received iPads on Saturday, which are meant to supplement and maybe even replace the physical books required for their classes. This paperless instruction can also expand into assignments so that students will not have to physically print off any of their assignments.

"I don't need to buy a book, I don't need to actually carry that book with me everyday. I really do think this is the wave of the future. As a tech enthusiast I feel like this is long overdue." ~ Adity Paliwal, First Year Medical Student

This move to paperless learning has been in the works for five years, but finally technology has caught up with expectations. The use of iPads will not only translate into both lighter loads for students carrying textbooks, but also a savings for the college in terms of printing costs. Kevin Moynahan, Deputy Dean of Education at the University of Arizona College of Medicine, estimated that they currently spend $50-60,000 annually on paper printing, while many of those materials are discarded once they are no longer relevant to the classwork. By keeping these materials in a digital format, waste and costs can go down and the savings can possibly translate into increased funding in other areas.