American College of Physicians: Internal Medicine — Doctors for Adults ®


Residency programs gear up for the computer age

From the June 1996 ACP Observer, copyright 1996 by the American College of Physicians.

By Christine Wiebe

Bryant Karras, MD, noticed something different when he went across town to do an elective rotation at Providence Medical Center in Portland, Ore. Residents there regularly used computers to consult authoritative diagnostic sources and to do literature searches. They were practicing what computer enthusiasts call "evidence-based medicine."

Dr. Karras' observations were no coincidence to his rotation--he went to Providence for training in clinical computing, with the intention of taking his newfound knowledge back to Good Samaritan Hospital and Medical Center.

He was most impressed with how accessible computer programs were at Providence, and he set up the workstations at his own hospital with that in mind. He created a computer "menu" to display the files residents used most often, so they could be located quickly. He has also given lectures to help other residents improve their computer skills.

Dr. Karras said he believes that moving into the computer age is essential for young doctors. Those who resist probably will survive, he said. "But our goal is not to just get by, but to do the best we can."

A running start

The Internal Medicine Residency Review Committee, which oversees accreditation of training programs, has said that "each resident must be given the opportunity to learn basic computer skills." It identifies four areas that should be covered: introduction to computer capabilities and medical applications; basic techniques for electronic retrieval of medical literature; computer-assisted medical instruction; and electronic information networks.

However, training in medical informatics still varies widely, said Paul Gorman, FACP, assistant professor of medicine and health informatics at Oregon Health Sciences University in Portland, and assistant director of medical education at Providence Medical Center.

He recently conducted a survey of residency programs and found that 4% provide no training at all. On the other end of the spectrum, only 10% offer block rotations in informatics. Most programs fall somewhere in between, providing informal training during other rotations.

That means most residents are probably getting a running start for a future in which computer skills will be a necessity for practicing physicians, Dr. Gorman said. However, some residents may need to supplement their program training by taking electives outside their institution or by inviting experts to give guest lectures.

Beware cocktail talk

Even the most ardent computer advocates warn that residents who do find opportunities for training ultimately can waste precious time on computer applications with little value. For instance, medical information available on the Web ranges from peer-reviewed literature to cocktail conversation, said David Trace, FACP, dean of clinical affairs at Chicago Medical School. "Sometimes it's hard to tell them apart," he said, "especially under time constraints."

Computer searches also can take extra time for residents who like to consult CD-ROM texts or Medline when confronted by a difficult diagnosis or complex treatment protocol. "The problem is it involves stepping out of whatever you're doing and adding time to the decision-making process," said Robert Elson, MD, a PhD candidate and National Library of Medicine fellow in medical informatics.

One way to avoid that pitfall is to conduct limited, focused searches, suggested Matthew Ringel, ACP Associate, an endocrinology fellow at Johns Hopkins University. "I try to be very goal-directed so I don't waste time," he said. However, becoming good at literature searches takes practice. Dr. Ringel said residents may have more time during subspecialty rotations to refine that skill.

Though many experts agree that the Internet's more popular areas like the Web currently offer little to enhance the day-to-day practice of medicine, they also agree that learning to navigate the Web is itself an important skill. "We're still at the front wave of what will be available there," Dr. Elson said. Becoming comfortable with the Web now will pay off in the future, he predicted. In fact, many companies already are cloning the Web's format for commercial computer applications, he said.

Dr. Trace agreed. "The more facile house officers can become [on the computer], the easier their lives will be," he said.

Under ideal circumstances, computers can become an integral part of medical training. But accomplishing that requires certain components: the right computer tools, including both hardware and software; faculty to encourage and role model computer utilization; and the time to do it. Only a few residency programs have achieved success at all three levels, said Dr. Gorman.

Making the commitment

One of those few is McMaster University Hospital in Hamilton, Ontario. Residents there regularly conduct Medline searches, using one of eight computer workstations on a given ward, said Patrick Brill-Edwards, FACP, program director in internal medicine. During morning report, when the discussion inevitably reaches the point of "group ignorance," he said, someone immediately goes to a computer for more information. "It becomes part of our daily routine."

Dr. Brill-Edwards credits the informatics faculty for supplying the program with appropriate, accessible computer tools, and other faculty who share the commitment to making computer utilization an integral part of residency training. "If you have a faculty that's interested in evidence-based medicine, you don't get this start-stop phenomenon," he said.

Residents who see somewhat less commitment to informatics in their own program can initiate changes, said Good Samaritan Hospital's Dr. Karras. They can start by encouraging their program director to budget for more and better workstations, he said. He recommends some minimum capabilities: a CD-ROM drive, a modem, access to the Internet and e-mail accounts for all residents.

Additionally, residents can work with their hospital's information resources department to improve computer utilization in their institution, such as easing physicians' retrieval of information from the hospital laboratory. Often, just letting the information resources department know what would be helpful from the residents' perspective can lead to improvements, he said.

Most important, residents should not passively accept inferior computer capabilities, Dr. Karras insisted. "As our profession advances, more and more it's going to be important to incorporate informatics into our practices."

Christine Wiebe, of Providence, Utah, writes frequently on issues related to medical residency.

Informatics: what every resident should know

"There really isn't a consensus curriculum that's been drawn up," said Paul Gorman, FACP, assistant professor of medicine and health informatics at Oregon Health Sciences University in Portland, and assistant director of medical education at Providence Medical Center. However, through his survey of residency programs and discussions with program directors, he has found agreement on several priorities:

  • Patient data. Residents must know how to access patient data, particularly within their own hospital system, such as retrieving lab data. Most residents learn this skill on the job--often from other residents, Dr. Gorman said.
  • E-mail and other information management. Residents should become proficient in on-the-job information management, including word processing, electronic mail, presentation graphics and statistical reports.
  • Literature searches. Perhaps most important, residents should become adept at literature searches, Dr. Gorman said. Medline, an electronic index of medical literature created by the National Library of Medicine (NLM), is the most commonly used source, and most libraries will provide basic instruction on how to navigate it. Residents with home computers can access Medline free on a site on the World Wide Web (the address is The site, which is sponsored by a commercial organization and not part of the NLM, also allows users to seach other medical databases for a fee.
  • Other resources. Residents should be able to access other important resource materials available on CD-ROMs, including texts such as "Harrison's Principles of Internal Medicine" or "Scientific American Medicine." Beyond such standard fare lies a vast array of unproven software, and even the experts say they are overwhelmed by the choices. As a result, program directors agree that residents must be comfortable testing new software, so they can decide which are the most helpful, said Dr. Gorman.

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