These days, physicians-in-training are carrying more than just stethoscopes and pocket guides around with them on the wards. They’re toting high-tech tools in the palm of their hands to keep pace with the speed of modern medicine.

By Katrina Woznicki

Like anyone on the go, Jon Rittenberger, a third-year medical student in Pittsburgh, keeps everything he will need for that day on hand, literally attached to his body in some fashion or another. The 24-year-old frequently races the hospital halls carrying: his Palm, a handheld device that never escapes the reach of his fingertips; an inch-thick paperback guide on patient care in his lab coat pocket; another paperback medical reference guide in his other pocket; several pens; a penlight; alcohol pads; 3-by-5 note cards; two 14-gauge needles; a stethoscope; a pager on his belt; and every now and then, a cell phone is hooked on wherever there may be room.

It all adds up to about 5 pounds of equipment, Rittenberger says, but it used to be a much more cumbersome load to lug. “A lot of the books [other medical students] carry, I already have on my Palm,” he says. “It just makes my job easier and faster.” Trying to get through a day of medical training without his Palm, Rittenberger says, gives him “really just a sinking feeling. For me, it’s like forgetting your stethoscope or forgetting your white coat…. [Without it] I feel kind of naked.”

Digital boost

Handheld technologies seem to be making every health-care professional’s job easier and faster, and the medical student is no exception. The use of these devices and the information that can now be obtained on them has exploded in the past two to three years. Medical institutions and universities are now recognizing that students and residents who aren’t using this new technology could fall behind.

Although handhelds are getting the most buzz in the white-coat world, other digital training techniques such as virtual surgery, computerized pathology images and patient simulation interaction are becoming medical education’s staples—providing students with speedy, cutting-edge information. What makes this technological revolution so much more different in the medical community than the burst of personal computers in the 1980s or the Internet in the 1990s is that these advances offer something physicians and medical students constantly need: mobile, instant, current data.

“One of the problems we’ve had traditionally in medicine is that you’re relying on information that is old,” says Dr. Jody Pettit, a clinical consultant for Medscape, a Hillsboro, Oregon-based company that provides digital medical data and mobile computing devices to health-care professionals. “It’s in a textbook or something [stationary], and it’s not always accessible at the point [when] you’re caring for a patient.” Textbooks are clunky and tedious. Handheld devices are light and fast. The gap be-tween the time medical research was conducted and the time it reached the medical student in print was glacial, making it difficult for even teachers of medicine to stay current, she says. The time it took to look something up in a medical journal was also painstaking. Handheld technologies, Pettit says, can leapfrog both the arduous task of getting research printed and the menial job of combing through the Dewey Decimal System to bring the latest medical information to the fingertips of eager-to-learn physicians-in-training.

The plethora of information readily available on hardware—not seen on medical school campuses a few years ago—feeds that youthful eagerness in a generation of medical students who have grown up with video games, personal computers and the Internet. “They’re just absorbing it like a sponge,” says Dr. Barry Issenberg, assist-ant professor of clinical medicine and director of educational research and technology at the University of Miami School of Medicine. More than 90 percent of Miami’s medical students, he says, are arriving with their own laptops in tow, and handheld devices are becoming the norm on campus.

The advantages of having this equipment can help propel a medical student ahead. At the University of Miami, for example, lectures can be accessed on a digital file prepared by the professor and available either on the Internet or a compact disc, Issenberg explains. He says this makes learning more interactive. A medical student can download a program on his laptop and listen to and view a two- to three-minute talk on a given subject. Every so often the talk is paused, and the student is asked a few questions based on what was just discussed. Before going on to the next segment, the student must answer the questions correctly.

Another technique being used at Miami and elsewhere across the country is virtual reality. Skills medical students could once only learn on cadavers or living patients are now being taught on computer programs and computerized mannequins that can simulate disease, Issenberg says. These techniques allow students to repeatedly practice a procedure so they can improve their coordination skills, something not easily done on patients or even corpses.

Where to get connected

The latest information on the latest treatments can be accessed from a booming array of sources. Some of the most popular sources used by medical students and doctors include: ePocrates, ePhysician, Medscape and Handheld-med. Many of these companies, which all have their own Web sites, cropped up around 1998 during the peak of the technology boom, and all are reporting an ever-increasing use of their products and services in the past two years, both online and off.

ePocrates, based in San Carlos, California, provides software applications that can be downloaded onto a Palm and at medical students’ fingertips should they need an answer in a nano-second. One application is ePocrates’ qRx 4.0, a drug reference guide that provides everything and anything a medical student needs to know about a particular drug, from its side effects to adult and pediatric dosages to interactions. So, for example, a student or resident could find out with just a few touches of the stylus to the handheld keypad whether it’s unsafe for an arthritis patient taking a prescription pain reliever to also continue taking aspirin or ibuprofen.

Before handheld devices such as the Palm, Handspring or Microsoft’s Pocket PC, “You had to keep [all that information] in your head, and that was the challenge,” says Dr. Richard Fiedotin, vice president of business and product development and co-founder of ePocrates. Or you dragged out a heavy textbook and took a few extra minutes to look it up. ePocrates’ drug database, which Fiedotin says is uninfluenced by the pharmaceutical industry, is attracting 25,000 users a month. “It’s a very intuitive application,” he says.

It’s so intuitive that apparently it saves time, about 35 minutes a day in not having to answer calls from pharmacies or chase down information in different rooms, according to Fiedotin. He says it also cuts down on medical errors, an issue on the public radar after a 1999 Institute of Medicine report showed medical errors accounted for 44,000 to 98,000 deaths a year. Ac-cording to a seven-day survey by Brigham and Women’s Hospital in Boston, half of the 870 physicians questioned reported the drug reference guide helped them avoid one or more serious adverse drug events per week. If every physician prevented one drug mistake a week, the cost savings could be huge, doctors suggest.

ePhysician, based in Mountainview, California, offers several products, in-cluding ePad, Superbill, A to Z Drug Facts, eTalk, and coming soon, eLab, where physicians can order and view lab results downloadable to a handheld device. ePad, says Dr. Stuart Weisman, chairman and chief executive officer of the company, “is really our flagship product. You can literally be on the soccer field, and you can make three taps on this handheld device, and you can [send a prescription] to the pharmacy.”

But despite the praise students and physicians shower on the creation of the handheld computer, it is not a medical panacea. Its drawback—and it’s a big one—is that it cannot readily download data wirelessly. Programs provided by ePocrates, ePhysician, Medscape and Handheldmed must be downloaded from another source, usually a desktop or laptop computer, and transmitted on to the handheld. Or, these programs can be accessed through costly wireless modems connected to wireless networks installed in hospitals and universities willing to foot the expense of a wireless system.

So, while the handheld serves as an excellent mobile reference source, a medical student who comes into a situation or has a question about a subject that hasn’t been previously downloaded onto the handheld, and who does not have this kind of wireless access on site, may need to make that trip to the library or the computer lab after all.

Experience the difference

Mobile reference guides are exactly what physicians-in-training need and want. And as institutions gradually ease their way into going wireless, students who familiarize themselves with these programs now are going to experience a difference in their education and ultimately, their practice. Much of practicing medicine is about gathering the best information available. Having a handheld device that churns out instantaneous, current data can allow doctors to have more flexible time that they could devote to patients.

Most physicians say their patients have been receptive to seeing their doctors carrying a handheld device. Will it give an aloof physician a warmer bedside manner? Not necessarily. But the time once spent on unraveling paperwork or hunting down information that might be five floors up can be eradicated by information provided on these handheld technologies, allowing a doctor to have less harried conversations with his patients. The average American physician currently spends approximately seven to eight minutes seeing a patient. In the next few years, as handheld technologies become more widely accepted across the board of various practices, that amount of time could increase.

Fiedotin says the handheld won’t turn off patients whose doctor might need to quickly check something on the Palm at the bedside or in the exam room. “It comforts the patient who knows the physician is pressed for time and is taking the couple extra seconds to be sure he’s not making a mistake,” he says.

It is also a comfort to students like Rittenberger, who sometimes feel overwhelmed by the amount of information thrown their way. Having such programs on a handheld device that is always with you, he explains, can be a lifesaver, literally, when a student is “under a pressure situation, [and] you need data, and you need it now.”

A student savvy with handheld technologies is going to likely turn out to be a very time-efficient physician. Another aspect of using programs available on handheld technologies is that it takes the pressure off medical students and residents to cram as much data as possible into their memory—a task that could produce risks simply because humans, unlike computers, can suffer information overload.

“I don’t think any of us can claim we are so smart that we can remember how to accurately prescribe thousands of medications, many of which were just introduced in the last few years,” says Dr. Michael Beheshti, chief executive officer of Handheldmed Inc., a Springboro, Ohio-based company that also provides digital medical data applications for handheld devices. “[The next] generation of medical students who are going to rely on this technology [are] going to be better practitioners for it.”

Doling out the handhelds

Some universities want to ensure their medical students take advantage of this medical digital revolution. At Wake Forest University School of Medicine in Winston-Salem, North Carolina, the more than 100 students entering medical school every year get a $2,500 laptop to take to class with them, says Johannes Boehme, Ph.D., associate dean of academic computing. “The ability to study anytime, anywhere, is a powerful statement,” he says.

On these laptops, students can use one of the school’s patient simulation programs, in which a student is given a specific patient case and is required to decide which tests are necessary and how the patient should be treated. The program, which involves digital audio, pathology images and slides, also offers varying scenarios of a patient case, allowing the student to test his or her hypothesis. When the student reaches his third year, Boehme says, he is provided with a Palm—subsidized by the school at roughly $350 apiece—to be used on clinical rotations. “The personal digital assistant [PDA] has turned out to be a very nice unit of choice,” Boehme says. “Quick reference data is superb for the Palm. It can always be updated and refreshed.” And, he adds, “It’s not that the PC goes away; it’s just that it’s hard to take a 7-pound laptop to the [clinic] floor.” Students get to keep both devices after graduation.

At the Good Samaritan Hospital in Baltimore, the more than 30 residents who come through each year also get a Palm purchased for them. “It’s become an essential clinical tool,” says Dr. John Hong, program director of the hospital’s internal medicine residency. “[The handheld] makes [residents] much more effective on the floor,” he says, and adds that these devices’ growing popularity among residents and physicians is “just a harbinger of the information revolution [in medicine.]” Good Samaritan Hos-pital is already moving to the next stage of its own information metamorphosis by installing wireless access throughout the institution that should be fully integrated within one year.

At the University of Minnesota Medical School in Minneapolis, second-year medical student Adam Kim relies heavily on his laptop, purchased for him by his employer, the university’s surgery department laboratory. Without the laptop, he would miss out on lessons, such as downloading CD-ROMs provided by his professors so he may view pathology slides. He can do this in the classroom, the library, even the cafeteria, thanks to the school’s wireless network nodes, which offer wireless Internet access. Range is limited; a student must be sitting within only a few hundred feet of a node. Schedule changes and class notifications are sent to the students by e-mail only, he explains, so it’s imperative to regularly check e-mail. Some courses have no paper syllabus, and students are simply referred to an e-mail address to find out what the course will entail. Having a Palm on hand, Kim says, would make accessing these class e-mail updates easier.

Kim could wait another two years when the school loans Palms for six-week rotations to its fourth-year medical students, but he is eyeballing buying one this summer to get a jump on using the device. Carrying Palms during his rotations could make an impression on patients, Kim says. “If a patient sees you pulling out a big textbook and looking up something, that patient is going to think, ‘This guy doesn’t know what he’s doing,’” he says. “But if [you] pull out a handheld device and look up some information, [patients] think, ‘Oh this doctor has the latest information, and he’s on the cutting edge of technology and knows the latest treatments.’”

Cyberdocs young and old

Going wireless may thrill tech-savvy, 20-something-year-old residents, but what about older doctors who learned diseases and drug references by using stacks of paper and their own memory skills? While some physicians say the occasional colleague hesitates before dipping his toe into the digital medicine pool, most report that their peers are just as excited as the young residents over what these devices can do for their practice. “There’s been across-the-board acceptance,” says Dr. Scott M. Strayer, an assistant professor at Saint Louis Uni-versity School of Medicine and faculty director of its family practice residency program. “There really isn’t much of a generational difference, to be honest with you.”

“The affinity for technology is apparently independent of age,” Pettit concurs. Older physicians aren’t waving their pencils and papers at whippersnappers toting handhelds. It’s just that earlier generations of physicians didn’t incorporate the technology they used personally into their professional lives—until now.

“[They] did embrace the computer revolution,” Weisman says. “They just didn’t do it at work. They did it at home.”

In fact, the wave of technological advances that has washed over Western medicine during the last few years has placed young residents and gray-haired physicians in the same boat: Both are learning how to incorporate handheld computing devices that offer instantaneous data during the infancy of the PDA and wireless technology.

This dawn in medical digital data has spawned a new class of physicians, colloquially known as “cyberdocs.” Dr. Kevin Frickenscher is a perfect example. In February 2000, he joined WebMD Corporation, based in Elm-wood Park, New Jersey, to become the senior vice president of the company behind WebMD.com, a Web site geared to providing both physicians and consumers with medical information. He is also a family physician and chief medical officer at Catholic Healthcare West near San Francisco, where he lives. More physicians, he says, are going to carve out careers where one foot is in a traditional medical practice and the other is in some sort of technology delivery service. The reason is because doctors are increasingly recognizing the need for up-to-date, sound clinical data to be readily available at the point of patient care. Who better to design and direct such technological efforts than doctors themselves? “If we’re going to change medicine,” Frickenscher says, “if we’re going to make it better for people, it’s really about getting the right information into the hands of physicians.”

Some doctors do go to the other side and don’t return to mainstream practice. “I left the practice of medicine,” Fiedotin says, “to go into the health information industry.” An unusual step, given that he made this choice in 1994, when it was still “difficult for a physician to get a job in the corporate world.” Now it’s more the norm, he says, and it allows doctors to improve the quality of health care in this country without going into a traditional practice.

By the time students like Ritten-berger and Kim are farther along in their careers where they might consider becoming a cyberdoc, the technology will have already dramatically evolved.

Handheld computers, pagers and cell phones, Hong suggests, will all mesh into a single wireless device. Some companies have already developed such tools. With them, physicians will be able to order and view lab tests and electronically send the results to a colleague, for example. Patient records, billing and insurance documents will be a point-and-click away from the physician’s fingertips. The technology will get smaller and lighter down the road, making the 5 pounds of equipment students like Rittenberger now tote around seem archaic. Showing up for work without such an all-purpose data powerhouse could leave the physician of the future fumbling for answers.

© Copyright 2001 The New Physician.