With computers, residents need to go beyond basics
Surfing the Web is a good start, but housestaff should master a wide range of applications
From the October 2000 ACP-ASIM Observer, copyright © 2000 by the American College of Physicians-American Society of Internal Medicine.
By Edward Martin
When Daniel L. Boss, ACP-ASIM Associate, was recently called to the emergency room at Saint Vincents Hospital and Medical Center in New York to examine a rash on a young woman's leg, he felt a twinge of uncertainty. "Dermatology is a weak point for me," he said, "and the diagnosis wasn't obvious."
So the chief internal medicine resident went to the Internet to consult two clinical sites, Harrison's Online and MD Consult. To his relief, the sites verified his diagnosis: erythema nodosum, a potential streptococcal infection.
Across the country, residents like Dr. Boss are learning how computers can help them do a better job of caring for patients. Training programs everywhere are putting new emphasis on high-tech tools, and some are even giving residents handheld computers to keep up to date on clinical information.
But residents and educators say that while surfing the Web for clinical information is a good start, housestaff need to learn to use computers to do much more. Before you finish training, they say, you should gain expertise with a wide range of computer applications, like spreadsheet and database software that is widely used in research, medical calculations and training.
Managing patients and time
Gauhar R. Khan, ACP-ASIM Associate, chief internal medicine resident at Michigan State University College of Human Medicine in East Lansing, has created a database to track certain diseases and conditions. When he recently saw a patient with cardiac arrhythmia, he suspected hyperkalemia, or potassium overload.
To check his diagnosis, he pulled out a palmtop computer that Michigan State gives all its residents and opened the file of metabolic and other hyperkalemia data he had created using Microsoft Access, software to create and manage files with tables, forms and reports. Using the file, Dr. Khan was able to confirm his diagnosis of hyperkalemia and begin analyzing whether it was linked to dietary or systemic causes.
Dr. Khan, who expects to enter a cardiac fellowship next year, is not alone at his program. He regularly exchanges his files with other residents through infrared connections on their palmtops. When the next shift of residents arrives, everyone shares information on patients.
Using computer technology to save and manage time is also popular among residents. At Evanston Hospital in Evanston, Ill., Northwestern University residents use computers to speed the process of creating patient records that incorporate evidence-based literature. With the help of the Internet, they can incorporate the expertise of top researchers to explain their recommended treatment, something that they would not have time to do without computers.
"When you're justifying what you're doing to another human being, you want to be able to document all that goes into your decision," said Kim C. Meyers, FACP, chair of medical informatics at Evanston Hospital. "Residents often truncate that process because of time."
Dr. Khan also uses his palmtop computer to help him manage his time. "I have quite a few meetings with residents every day," he said. "My handheld computer has an alarm that alerts me when meetings are coming up."
One factor driving the growing emphasis on medical computing in residency programs is pressure from accrediting organizations.
The Accreditation Council for Graduate Medical Education, for example, now requires training programs to give residents a basic introduction to computers and their application in clinical epidemiology, biostatistics and decision-making. The standards also require programs to teach residents to become proficient in electronic literature retrieval, computer-assisted instruction and electronic information networks.
Saint Vincents in New York, for example, introduces its residents to medical computing with eight formal sessions, covering everything from computer basics and online searching to biostatistics and presentation software. Program director Steven L. Sivak, FACP, said that the program tries to integrate those skills into residents' daily tasks.
"We challenge residents to use medical computing in real time," he said. "In clinic, if they need guidelines for colorectal screening, we have them look that up." Each ward at Saint Vincents has computer stations where, time permitting, residents can look up the information while their attendings watch.
Training programs also try to teach residents how to use computers by incorporating technology into day-to-day educational activities. At Oregon Health Sciences University in Portland, residents routinely prepare for housestaff conferences or morning report using computer tools. "Residents should learn to a large degree by teaching," explained Paul N. Gorman, FACP, professor of medicine and health informatics.
At Saint Vincents, residents preparing for morning report gather information from the Internet. Using Microsoft PowerPoint presentation software, they merge that information with pictures of slides, blood smears and other materials. The group then gathers around a conference table facing a large screen, and each resident, with a wireless keyboard, shows a PowerPoint slide presentation to the group. The chief resident often asks residents to answer a question using the Internet, a CD-ROM or other resources on the big screen while the group watches.
At Michigan College of Human Medicine, Michael H. Zaroukian, FACP, internal medicine program director and a veteran teacher of medical computing, said that many programs now use computers to supplement or replace large group lectures. Some programs ask housestaff to find and use information in real-time settings such as the lab or even during patient encounters.
And at the conclusion of Saint Vincents study course, Dr. Sivak said, residents must incorporate computers in a scholarly activity, such as hypothetical research. "We teach them to use spreadsheets and databases to interpret data, then presentation software to present it," he explained.
Honing your skills
Once you get comfortable with the basics of computing, educators say, you should fine-tune your skills. After you leave training, you won't have much time to look for information, so you need to learn how to quickly and critically evaluate online, evidence-based resources.
"We teach residents to become educated consumers of information and to know the limitations," said Dr. Gorman, who also heads a section on residency computers in the College's Oregon Chapter. "There remain situations where the textbook is still the best resource."
Targeting your searches is critical, added Dr. Sivak. "Not all residents really know how to use electronic resources," he said. "Some still go to Yahoo! because they haven't heard of resources like ACP Journal Club," a College publication that offers authoritative articles from about 100 journals.
To avoid becoming overwhelmed with literature that may not be authoritative, Dr. Boss said he has learned to rely on a few, select sites such as Medline, which searches 40 online databases, rather than wading through dozens of other sites.
Some residents are refining their computer skills in other ways. They figure that in the not-so-distant future, they will need to integrate computers into the exam room, using wireless keyboards, voice recognition and other technology to merge progress notes, imaging reports, vital signs and medication data seamlessly into examinations.
David Gelman, MD, a third-year resident at Saint Vincents, for example, already uses his handheld computer to keep track of the telephone numbers, addresses, medications and other information for his 72 outpatients. "That's a tremendous help to me if I get a call in the middle of the day for a medication renewal or to answer a question about care," he said.
Dr. Khan at Michigan State feels his experience working with computers in training has prepared him for the future. When a 52-year-old man with a family history of coronary disease recently balked at his suggestion of an aspirin prophylactic regimen, citing reports of potential stomach damage, the resident showed him reassuring studies with his handheld computer. "It made my decision-making easier, but it also helped improve my rapport with the patient," he said.
Perhaps most importantly, though, educators say residents need to learn as much about using computers as possible to keep from falling hopelessly behind their peers. "Considering the enormous resources and technology available," said Dr. Sivak of Saint Vincents, "a resident without access to medical computing will never be able to maintain the standard of care."
Edward Martin is a freelance writer in Charlotte, N.C.
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