On a rainy day in February, Ruth Wang’ondu arrives at the Winchester Chest Clinic. The clinic is packed with patients making up appointments missed due to a rash of recent snowstorms, and Wang’ondu, who’s in the M.D./Ph.D. program, is armed with the arsenal of references and notes that every medical student requires during clinical rotations. Last year, these materials would have filled her pockets, weighing down her petite frame and forcing her to rifle through a multitude of pages to check a dosage or learn more about a lab value. This year, all these materials, as well as additional texts, videos, and access to Epic, Yale’s electronic medical record system (EMR), are contained in her iPad mini, a 5x8-inch device that fits neatly in the pocket of her white coat or the back pocket of her scrubs.
In the fall of 2011, Yale made headlines by switching from paper copies of course materials to providing every medical student with an iPad. Two of the key incentives were to go green by saving paper and to ensure that students had a HIPAA-compliant mechanism for protecting patient information. The change was transformative—students now have constant access to the entire medical curriculum, electronic textbooks, instructional videos, and Web content, as well as the opportunity to develop and download applications that render their educational experience highly interactive. In the clinical years, however, students weren’t using their full-size iPads as much as expected, which led the School of Medicine last fall to offer iPad minis to third-year students at a subsidized rate. Out of 100 students, 99 accepted the offer. The mini provides unfettered access to updated course content, Internet resources, and patient records in a light, thin, and small device. The mini and its big brother enrich the medical school experience in ways that are both obvious and unexpected. They are changing the way students learn.
24/7 access to medical records
Wang’ondu’s first patient at the chest clinic is a 4-year-old girl with latent tuberculosis (TB). She has seen the girl before during her year-long elective at the TB and HIV clinics. Before she enters the exam room, Wang’ondu uses her tablet to compare today’s blood pressure reading with a previous one from November. She uses the encrypted device in other settings as well.
During the HIV clinic, a supervisor often asks her to look up patients’ lab results—a task more easily accomplished with the mini than at the clinical work station, which is in another room and in high demand. If Wang’ondu wants to prepare for the cases she’ll be seeing in the clinic, she can log in to Epic the night before.
She uses a wide variety of apps to help her learn, including Lab Values Pro, which explains lab values; Heart Sounds to hear what cardiac conditions sound like; and a video atlas as an ultrasound reference and to view laparoscopic images. In the HIV clinic, for example, she frequently uses Epocrates, a mobile and online clinical and drug reference resource, to show patients photos of pills when they’re not sure which ones they’ve discontinued or may be causing side effects.
Inventing new apps
Students have embraced the iPads in their curriculum so much that some are devising new applications for them. Last year, Paul Guillod, a second-year student, created Quizzler to help study for boards. Amy Yuan, a first-year student, turned a neurobiology lab manual into a digital book that Michael Schwartz, Ph.D., associate professor of neurobiology and associate dean for curriculum, now distributes to all of his students. A self-proclaimed “closet geek” who spearheaded the iPad initiative, Schwartz praised the tablet’s versatility, interactive capability, and multimedia features. “It’s not the iPad per se; it’s the technology that the iPad allows in our pedagogy that’s important,” said Schwartz.
Unlike many medical schools, where students download one file at a time from their learning management system (LMS), Yale enables students to sync electronically to the latest version of curriculum material. “Students tell us that if we expect them to use these materials and take notes on them, they have to be able to access what they’re actually seeing during the lecture. If a faculty member changes a slide the night before, the outdated version isn’t good enough,” said Schwartz. “When faculty come into the lecture hall with modified presentations that have not been uploaded to the LMS, within two or three minutes that lecture material is converted at the podium, uploaded to the server, and students are notified, so they have immediate access to the most up-to-date material.”
In some instances, the iPad is changing the medical school’s approach to teaching. Some instructors use Quizzler and other Web-based applications for interactive small-group discussions and quizzes. The instructor can control what students see on their iPads and ask them questions. The responses are delivered to the instructor as well as to other students. This process enables everyone to see the correct answer and encourages discussion. The app tracks the students’ correct and incorrect answers on their iPads, so that group members know where to concentrate their efforts. “In many of our small-group settings, it has dramatically changed the interactive nature of the discussions,” said Schwartz.
The iPads, Schwartz has found, are also a terrific delivery mechanism for instructional videos that he encourages faculty to produce. In contrast to podcasts of full lectures, these short videos help students prepare for class more efficiently. Schwartz has set up a studio in the library for making and annotating the videos. “It expands a little bit what we’re capable of delivering to students in terms of curricular materials,” he said.
The iPad in the clinic
Back in the clinic, Wang’ondu checks the 4-year-old’s record and confirms that she’s taking the prescribed medication. When she learns that the girl’s surgeon has postponed a tonsillectomy due to the TB diagnosis, she enters the surgeon’s name in her tablet, so that she can follow up later. After examining the girl, she excuses herself to present her findings to Robert Baltimore, M.D., professor of pediatrics (infectious disease) and of epidemiology (microbial diseases). She answers his questions, sometimes consulting her tablet. “She finds things out in a quarter of the time it takes me,” said Baltimore.
Wang’ondu and Baltimore move on to their next patient, a 5-year-old girl. Before entering the exam room, Wang’ondu orders a chest X-ray for Baltimore to sign, then looks up the girl’s chart on her device. It shows that the girl had a positive PPD skin test for latent TB, but a blood test gave a contradictory result—negative. Wang’ondu also discovers that the girl had received Bacillus Calmette-Guérin (BCG) immunization, which is given in some countries to prevent TB. The BCG may explain the positive PPD.
After she and Baltimore finish with the 5-year-old, Wang’ondu returns to the clinical work stations. The room is normally crowded with attendings, fellows, residents, and nurses who need access to the computers. Before she had her mini, Wang’ondu would wait her turn, but now she can consult and update patient records before, during, and after patient visits. During a lull in activity, she sits down at a work station to write her notes in the charts of both patients, referring to notes she had taken on her mini.
She finishes typing in her notes on Epic and then heads back to her surgery rotation. She is out the door quickly; using her mini, she accesses the surgery schedule and locates the case she is following. She didn’t have to decide before leaving home that morning which notes and texts she might need or want to review during the day. “You have all the information you could possibly need in that tiny electronic device,” she said. “I think it’s the best thing that’s ever happened.”