Views on when a mobile device containing texts would be most useful
Both the iDoc baseline and the F2 survey included questions about the stage in their medical career when a mobile device containing reliable information would be most
useful. F1 (newly qualified) was judged to be the most useful time to have such devices (54% iDoc baseline; 43% F2 survey). These data are reported in full in Table
. We note that although respondents were advised to tick one box, some respondents ticked more than one. Most common ‘other’ responses related to ‘training being lifelong’ and ‘all grades’ of training.
Training grade when a mobile device was thought to be most useful
Respondents were asked to provide the main reasons for their selection of training grade. Responses were provided by 86% (iDoc baseline) and 67% (F2 survey) of participants. Across both datasets the main reasons given related to: increased responsibility, lack of knowledge, lack of experience, needing quick answers, needing most help, still learning, having time to read and early adoption of the technology. These responses were explored in relation to the level of training grade selected and are reported in Table
Main reasons why a mobile device would be useful at selected stage of training
The responses show that most reasons given for identifying the F1 as a time when a library of texts on a Smartphone would be most useful related to increased responsibility, lack of knowledge and experience, and a time of needing quick answers and most help. Example comments include:
It [F1] is the first point at which we are expected to know answers, often on our own, with senior support not always available…
Very important that F1s have access to resources to confirm and double check their knowledge as they are only newly qualified and still learning a great deal on the job.
iDoc case reports
Case reports on experiences of using iDoc were received from 57 participants between May 2011 and July 2012. Most submitted more than one, providing a total of 117 reports. These reports were submitted mainly by foundation doctors (n
47). The others ranged from 4th year medical students to specialist training year 3 (ST3) grade doctors.
The case reports were first classified by scenario-type. The majority related to either an information-based problem (n
48) or were classified as problem-based (n
52); seven were skills-based; and the remainder addressed wider questions. To illustrate, one information-based problem related to safe prescribing and dose adjustments in renal failure. In this example, the F1 trainee reflected:
The iDoc enabled me to quickly prescribe the necessary analgesia safely. The A&E department is extremely busy, so to wait for advice from a senior would have kept the patient waiting in pain for longer than was necessary with the use of the iDoc.
In a skills-based example, an F1 trainee reported the use of the iDoc device (Smartphone library) in obtaining guidance for setting up a urinary catheter. This trainee found “a step-by-step guide of the preparation and considerations for the procedure” which enabled him to “quickly and easily refresh my knowledge and prepare for the procedure thereby saving valuable time and improving patient care”.
One problem-based example described using the Smartphone library to assist in the diagnosis of the cause of an extensive blistering rash. This F1 trainee reported that:
With the rest of the senior members busy, the iDoc was invaluable in giving me a working diagnosis of Stevens–Johnson syndrome and suggesting a management plan and possible complications that I should be aware of…. [N]ot only did it help me initiate management to stabilise the patient but also directed me in organising further care by requesting a dermatology review.
Beyond the classification of case report by scenario-type, sub-themes were identified. The principal sub-themes were use of the Smartphone library in supporting: teaching and learning from observation; transition (from medical student to F1); trainee discourse with senior colleagues; and independent practice (supporting trainees when seniors were unavailable). The use of the device as a resource for fast access to reliable information in the workplace and the implication this had for confidence and efficient patient care was a further theme. We provide evidence for these themes. The first illustration relates to the teaching and learning from observation. In this example, the medical student used the Smartphone library to prepare for and consolidate learning:
Often within the surgical setting a student is not scrubbed in and simply observes the procedures of the day… Yet with prior knowledge of the cases it is possible to use the time between patients being in the theatre to gain further insight into the anatomy the surgeon will be encountering, the condition the patient suffers from and the surgical techniques used. Being able to find all the relevant information on my iDoc phone gave me immediate insight into each procedure and provided an improved knowledge base.
In another, complementary example, a more senior trainee (core training year 2) reported how he, as a teacher, used the iDoc device with students in the operating theatre:
Between cases, I taught two final year medical students anatomy relevant to the cases in theatre. Images from Atlas of Human Anatomy (Netter, 2003), on the Smartphone, provided visual reference.
Interestingly, this doctor reflected on how the device supported ‘situating learning’, making specific reference to Lave and Wenger [10
When teaching is impromptu, conventional multimedia equipment may be either unavailable or inappropriate. Describing the concept of ‘situated learning’, Lave and Wenger (1991), suggest learning is more effective when performed in an appropriate context. The portability of the Smartphone facilitated teaching anatomy in the context of its clinical application within general surgery. It provided visual stimuli to enrich several ad hoc teaching experiences in a single day.
The sub-theme of transitions is illustrated by an F1 doctor who described how the iDoc had helped him “enormously with the transitional process from medical student to F1”. In alluding to the hidden curriculum of the workplace, he explained how:
The iDoc books and information are incredibly helpful not only for answering medical questions but with the many wider jobs that an F1 doctor must be competent at. This is often pieces of information that are never actually taught or tested whilst at medical school and are relied upon to be picked up within the hospital setting.
Data related to the preparation for discourse sub-theme demonstrated how the Smartphone library was used to prime the trainees for discussion with senior colleagues. For example, an F2 trainee reported how:
The iDoc provided me with relevant information, so that I was able to articulate the urgency of the situation to the medical registrar so that this patient's management may be reviewed for escalation to ITU.
Another doctor (core training year 1, CT1) explained how she used the device to get “the answer to a question” instead of bothering “senior colleagues”. However she elaborated:
If I cannot find the answer or feel that my patient is a little more complex and needs discussion with my registrar or consultant, I can then enter into this discussion.”
How the Smartphone library complemented rather than displaced trainees’ discussion with their senior colleagues was emphasised by others:
The iDoc device does not replace the need for senior opinion in complex cases (Male, Specialist training year 1, ST1)
Seniors were not always available. They may be, for example, scrubbed in theatre, attending an emergency or remotely supervising trainees on nightshift. The case report data also provided evidence of the Smartphone library supporting trainees in circumstances when seniors were unavailable. One F2 described how the device “contributed to addressing the problem as senior advice was unavailable”. She added that:
It benefited the patient who then had correct initial treatment and investigations prior to senior review.
The final theme from the case reports that we consider here related to the value of speedy access to reliable information and how this could enhance efficiency. One F2 thought that consulting the texts (the BNF) on the Smartphone was:
Much, much quicker than flicking through the paper version… Looking things up in the paper BNF for the n-th time on ward rounds puts time pressure on the junior doctor causing stress and increasing risk of errors.
Another F2 commented:
Because I had found out information relatively quickly the patient got faster treatment and I was able to carry on with the rest of my jobs.
Analysis of the case reports showed that the Smartphone library was used for seeking information for simple (information-based) and complex (problem-based) clinical questions as well as clinical procedures (skills-based scenarios). On further analysis additional themes were identified relating to how use of the Smartphone library assisted teaching and learning from observation, transition from medical student to F1, preparing trainee doctors for discussions with their senior colleagues and as a support when seniors were unavailable. The use of the device as a resource providing ‘just-in-time’ access to reliable information which enhanced the efficiency of patient care was a further theme.