Use of the smartphone app to support newly qualified doctors
The quality improvement framework  provides a mechanism for drawing attention to the important ways that the textbook app was used in practice to support the work of newly qualified doctors. To present an overview of our data, we report findings under the framework headings, recognising that these elements overlap.
Many of the case reports referred to the use of the app for basic information seeking, for example, checking medicine dosages. The doctors described using the app to confirm dosages when they were not completely sure: ‘The iDoc app is often of most use when there is a situation where I am pretty confident I know what to do, but not 100 % certain; this helps to reassure and confirm my actions’ (F1 #5). Trainees specifically used the word ‘safe’ or ‘safety’ when describing the app’s facility to check medications and dosage: ‘[It’s] really useful as it is quick and safe’(F1#11); ‘It takes a few seconds to double check a dose for example, it is improving patient safety, especially during busy ward rounds’ (F1 #136).
Using the app to enhance patient safety extended beyond simple medication checks. Others referred to the textbook app to support more complex problems:
I had not come across a clinical case of hypothermia and was uncertain how to manage this patient. I was able to look up the over-view of hypothermia and initiate the appropriate management. I was guided by iDoc to start rewarming the patient slowly and to monitor her cardiac activity for arrhythmias. (F1 #26)
In such circumstances, use of the app can support decision-making, meaning treatments can be speedily implemented to the benefit of patient care.
Effective and appropriate care
Effective care is evidence-based and employs the best available methods. The app supported the trainee doctors’ decision-making in managing complex problems, particularly when they have little prior experience:
Whilst reviewing blood results I noted hypercalcaemia in a patient who had been admitted with shortness of breath and a tender left scapula … I was familiar with hypercalcaemia management, but … I wanted to check I hadn't missed anything. Using the application to access the Oxford Handbook of Clinical Medicine I was reminded myeloma was a cause of hypercalcaemia. As a result I requested [tests] … Once again I checked the iDoc app and was reminded to request skeletal survey. … The information meant investigations were done quicker and meant that by the time specialists were reviewing the patient they had more evidence to aid their opinion. [F1 #22]
This extract demonstrates how newly qualified doctors used the app to call for appropriate investigations and ensure their decisions were evidence-based. Many of the case reports identified the specific resources used, the extract #22 for example, refers to the Oxford Handbook of Clinical Medicine. The set of books on the app are up-to-date and provide the information needed to inform novice doctors’ diagnosis and treatment planning.
The provision of timely attention and reduction in waiting time is of course a key concern within medicine. Some extracts above have already pointed out time saving benefits (particularly #22). At a basic level, having information to hand could save doctors’ time in searching for books on the ward, waiting to access the internet or awaiting the availability of a senior colleague: ‘If I did not have the app I would have to use the internet or find a BNF. This can be difficult in a busy A&E [accident and emergency] department where it’s difficult to find BNF or get access to computers’ (F1 #123). One succinctly stated that ‘accessibility and reliability of information anywhere in the workplace saves tremendous amounts of time every day’ (F1 #77). Other case reports show how use of the app has reduced delays in patient management and treatment:
Child had been unwell with tonsillitis, on antibiotics. Initially improving then developed non blanching rash worse over groin and thighs. I thought this may be HSP [Henoch-Schonlein Purpura] but having never seen it [I] wasn’t entirely sure. Needed correct diagnosis to further manage child. Used the iDoc app to correctly diagnosis patient with HSP using information and photos from clinical specialities … If I didn’t have iDoc I would have had to use the Internet or refer to paediatrics without a definite diagnosis. It would have resulted in a delay in patient care and management. (F2 #291)
The reports reveal the hidden labour of seeking information: it takes time and effort. The doctors described how using a mobile resource saved time, allowing the doctor to ‘manage the patient’s condition quickly and efficiently’ (F2 #281). Likewise, wasting time was also prominent, as this means time away from addressing the needs of patients. Going off the ward to search for text books, or waiting for colleagues to return from theatre before asking for advice, all have implications for the speed with which patients are managed.
Efficiency involves seeking to reduce waste of supplies, equipment, space, capital, ideas, time and energy within the healthcare system. A principal way in which the textbook app supports efficient care is how trainee doctors use it to determine appropriate and relevant investigations, rather than calling for an unnecessary array of tests.
A patient with a known pituitary lesion was admitted under our care. She had presented generally unwell due to a likely urinary tract infection [UTI], and had gradually become less responsive over days … I was asked by my consultant to refer to resources on my iPhone to determine which tests would be needed … We discussed the case as a team with the aid of the OHCM [Oxford Handbook of Clinical Medicine] and set about requesting relevant lab tests. [Without the app] it would have taken much longer to ensure the relevant tests were performed … We also felt that we were not requesting irrelevant tests or receiving too many confusing or conflicting test results all at the same time. … (F1 #76)
Patient-centred care, which is respectful of and responsive to individual patient preferences, cultural values, social context, and specific needs, is reflected in many current healthcare policies (see for example Department of Health (UK)) . The following extract from the case reports describes the new doctor using the app in front of patients and sharing the results:
Many of the usual treatments for endometriosis were inappropriate as [patient] was keen to conceive. With the agreement of the consultant we agreed to continue managing her symptoms conservatively, but the patient was concerned as I could not tell her from memory how safe these drugs were in pregnancy … I used iDoc to look up the information I needed and physically show it to the patient which I felt reassured her. (F2 #241)
Although involving the patient in this way may only serve to ‘reassure’, this instance highlights the possibility of actively involving the patient in shared decision-making. Showing the patients what the doctor was looking at might not seem ground breaking, however, this practice was uncommon. Significantly, phone use in front of patients and colleagues was sometimes viewed as problematic. In a later section we explore how the use of mobile phones within a healthcare environment can present boundary challenges.
Supporting the novice learner in a challenging environment
The quality improvement framework is useful to indicate the various factors that make up good quality medical care. But what many of the case reports also revealed was how the textbook app was particularly useful because the doctors were novices. Many of the case reports referred to the new doctors being in new and potentially stressful situations, where they needed to make the right decisions for both the patients and their senior supervisors. Several, for example, referred to being on night shift or on call for the first time, or working on their own. These were situations with high cognitive load and as novices they had limited automated knowledge . Having ready access to up-to-date information allowed the doctors to feel confident in their work and provided the knowledge to confirm that they were working correctly. This was the case for one trainee who stated:
[I had] limited surgical experience at the time (first on-call shift). [I] wished to consider all options prior to presenting to seniors … The app enabled me to feel more confident with my provisional diagnosis (F1 #89)
In the following extract the new doctor describes how he/she used the app ‘on the way to the ward’ to prepare for an examination of the patient and importantly, before discussion with a senior colleague:
I was called to the ward to see a patient who was scoring highly on his MEWS [Modified Early Warning Score] chart during one of my first medical twilight shifts. I wanted to refresh myself on what to do in this situation and make sure I covered everything I needed to. I was able to look on iDoc on my way to the ward so I didn’t waste any time in getting to the unwell patient. When I arrived I knew exactly what to do and was able to start examining and requesting appropriate investigations before … I phoned my senior for help. (F1 #80)
Many of the case reports specifically noted that the app was a useful tool that supported both personal and collective learning. One trainee doctor (F1 #63) spoke of actively using the app ‘with other colleagues and it helps to stimulate ideas and discussion, that ultimately lead to improved care’. In another case report (F2 #279) the trainee described how he/she used the app with colleagues ‘to see if we could generate any more ideas and to gain further understanding of the ideas we had already come up with’.
Uncertainty of use
Despite the evident beneficial role that mobile resources play in supporting newly qualified doctors, it is possibly not surprising that new technology can also present challenges. Specifically, some participants expressed concern about how or whether to use their phone in front of patients and ward staff. Mobile phone use presents a visible challenge to tacit rules of ward behaviour. The case reports reveal that many of the doctors were aware that using their mobile phone contests workplace boundaries, with the potential to attract unwelcome attention and criticism. Uncertainty of use was related to concerns about how others might misconstrue their use of a mobile phone and judgements were made about the extent to which colleagues or patients might be open to the use of new technology. This was the case when referring to older patients for example, who were characterised as lacking awareness of smartphones and therefore potentially reluctant to accept their use to support mobile learning:
I did not want to use the application in front of an elderly patient as I think it would have looked unprofessional, certainly with the older population who may be less aware of the clinical use of such technology. (F1 #47)
I still feel awkward if people (staff or patients) see me using my phone at work so I only ever use it when there is no--one else around or if I can go somewhere more private to look things up. (F2 #263)
One of the main reasons why there is uncertainty over using a mobile phone and concern about the image it might project is because of the blurring between work and leisure activities. In particular, mobile phones can be used for personal leisure activities such as social networking or playing games, and this was suggested as the reason why their use may be frowned upon by colleagues:
Sisters/nurses on the ward have asked me to put my phone away in a clinical area. Even when [I] explained that I am not using it for personal reasons, it can be difficult to use it in this situation. (F2 #236)
Nurses thought that I was checking my text messages (F1 #179)
Newly qualified doctors were acutely aware that using a mobile phone might threaten their professional image. Indeed, many of the case reports highlight how use of a phone can attract attention from other members of staff:
On several occasions I have found that when using the app on my phone, nursing staff approach me with various jobs as they think that I am not busy with work (despite informing them that I am using the app). I find it difficult to use the app whilst on the ward as it looks as though I’m texting and not doing work related jobs. (F2 #219)
The case reports revealed that the doctors developed personal strategies to address uncertainty over mobile use. For example, as with the previous example (#47) judgements were made about when it might be appropriate to use a mobile phone, and when not. Some new doctors chose not to use their phone in front of others, attempting to find somewhere ‘more private’ (F2 #263) or ‘away from the clinical case’ (F2 #242) for example. Using their phone away from other people in order to avoid criticism of unprofessional behaviour suggests barriers to the point-of-care potential for mobile resources being realised in practice.
Some doctors found that they could combat potential criticism by being overt about the resources they were accessing, although as F2 #219 suggested, this was not always successful. The strategy employed was to offer a clear explanation as to why they were using their mobile phone:
Some of the members of staff see you using your phone and look disapprovingly at you but once you explain what you are doing they were happy with me using my phone. (F1 #105)
As the patient was an elderly gentleman I was slightly apprehensive that he wouldn’t appreciate me using a phone during the consultation however with explanation of my actions he was perfectly content with my use of iDoc. (F2 #240)
The newly qualified doctors recognised that the way they were using their phone was important. By sharing the resources with patients, their mobile phone facilitates patient centred care but it also avoided the potential for criticism and uncertainty. Providing explanation, to patients or ward staff, as to why a mobile phone was being used within a work space usually enabled the doctors to proceed with confidence. Rather than being secretive about their mobile use by moving away from the patient or nurses station, the strategy was to become more visible. A previous extract (F2#241) has highlighted how the screen can be shown to patients so that they are aware of what information the doctor is using. For one trainee doctor, resting the phone on a table ensured that anyone watching would be able to see the screen, recognise how the user was interacting with the device and would therefore not question its use:
I tend to use it whilst it’s resting on the table so that anyone glancing at the phone can immediately see that it is text and not a game! (F2 #226)
Through openness, including education and increased visibility, the doctors were able to re-position their mobile phone as a work tool, and its use as legitimate. Part of the perceived problem was a lack of awareness of how a mobile phone has become an essential tool in the ‘doctors’ kit’:
Patients and staff probably have yet to come to terms with the fact that the smartphone is now as much a part of the junior doctors’ kit as a stethoscope. (F1 #179)
A significant barrier to greater use of the resource is that a range of actors, including patients, ward staff, senior medical colleagues, as well as hospital managers, policy makers and medical educators, have yet to demonstrate their trust in newly qualified doctors using mobile technology appropriately.