Three tech tips for new interns
The new intern class starts in less than a month. It’s easy enough to find advice on how to be well-organized, efficient, and likable. Here are some more tech-oriented tips I wish I knew back when I started.
Take photos and videos, with permission
Get an iPhone. Turn off Photo stream, or download a camera app that doesn’t automatically upload to it, like VSCOcam. When a physical exam finding is rare, stumps you, or is just cool to see, ask the patient about recording it. If you see an interesting or rare radiography image, save it. But please remove all personally identifiable information.
Useful for: appearing smart on rounds, observing disease course, creating informative slides, posters, and written case reports.
Keep track of things you are interested in
Your EMR will have a way to create custom patient lists. Use it. If you are into hematologic malignancies, eosinophilic esophagitis, MODY—or anything, really—keep track of all your patients who have it. If you don’t yet know what it is, keep a list of all the patients you found interesting and try to find a pattern.
Useful for: getting ideas for research and quality improvement projects, figuring out your career path.
Do not copy forward, copy/paste, or use templates and macros
I started my internship in 2010 so I can’t believe I’ll write this, but—back in the day before EMRs, we wrote our progress notes and H&Ps by hand. This meant reviewing the med list, vital signs, and labs each morning and writing down only the important stuff; completing and recording just those parts of the physical exam that had to be done; and writing a new assessment and plan each day. Well duh, isn’t that what interns should do?—you might naively ask, until your second or third day on the job when a helpful senior resident shows you how to shave minutes—minutes!—off your note-writing time by using some variant of copying forward, templates, or macros.
These tricks are a mental crutch, and a known cause of documentation errors. They might help your handicapped intern self the first few months on the job, but will then prevent you from thinking about what you are doing and writing. A thoughtful daily review of everyone’s medications and labs will turn into a quick glance over a two-page long list of 10-point single-spaced Courier New. Also, your typing speed will never improve if you only document by clicking.
Useful for: being a good, thoughtful doctor.
If you have a Google+ account—and you might not be aware that you do—anyone using Gmail can now email you without knowing your address. You can disable this “feature” in the settings, but having it be opt-out shows yet again how little Google cares about privacy.
Not that there’s anything wrong with that—privacy is a relatively modern invention that younger generations might not care for as much as we do. But you should understand the implications of patients and random strangers being able to leave messages in your personal inbox. Suing doctors is not a modern invention.
This is why I stopped using all Google services—search included—years ago. The company has become so large, with so many users, that it doesn’t need to cater to fringe interests. And for a business with billions of users, doctors are a fringe group—one that hates change-for-change’s-sake, having to re-learn an interface “just because”, and not being the true customer. This one in particular, as it keeps reminding me that doctors are second-class citizens in the tech world. Electronic health records are made with the billing departments in mind—we are there to provide content. Google services are created to sell adds—we are there to provide eyeballs.
Also, the number of people at Google who may access my data is huge. FastMail Yes, it’s an affiliate link., my email provider of choice, has fewer than 10 employees. Gmail alone has hundreds. Not that anyone would be interested in me in particular, but if I ever inadvertently send or receive private patient information through my personal account, I’d rather as few people as possible see it.
Email is fine, but why abandon search? First, I have googled enough ailments and substances, common and obscure, that the add network thought I was an elderly female recovering heroin addict with more than one paraphilia. The adds I would get were in that sense appropriate. Second, because of SEO the only valuable page-one results I would get were Wikipedia entries. Everything else was a hodgepodge of useless Livestrong, Huffington post and five-pages-per-500-word-article-AND-behind-a-login-wall Medscape links. Duckduckgo and, yes, Bing at least help with the first problem while not making the second one any worse.
Google calendar is the only service I would consider using. It is fast, reliable, omnipresent and easy to use. There is, however, that constant nagging fear that they will find some way to integrate it with Google+ and yet again sacrifice functionality to force people into its circle. This is why I use Apple’s iCloud calendar, its horrendous web interface and all.
Also: Reader. I use FeedWrangler now, but man.
Doctors' concerns aside, Google is all set to become the network TV Or Microsoft. of the internet—large, bland, and largely not relevant to the people who are. It is already two-thirds of the way there.
Two podcasts, three doctors, one good show
In the last two months, two of my must-listen podcasts, Systematic and Mac Power User, have had medical professionals on as guests. I don’t usually listen to medical podcasts—Twitter and saved PubMed searches are big enough firehoses—so I thought it would be interesting to hear how my more experienced colleagues use technology. Two of the three episodes were underwhelming, one was stellar.
It started with Brett Terprstra and Dr. Pamela Peeke on Systematic. She has several books targeted towards lay public, and the episode went in the same vein—broad advice on nutrition, well-being, etc. I cringed more than once, but that was to be expected—public health information relies on overplaying the risks and simplifying facts to the point of absurdity. Much like weather forecasts. The one thing I could agree with was how important meditation can be, as mindful meditation might decrease physician burnout. Negative points for not mentioning Mindfulness in Plain English as essential reading, though I haven’t read Dr. Peeke’s own recommendation, The Miracle of Mindfulness.
I had higher hopes for Episode 169 of MPU, since Katie Floyd’s and David Sparks’s guest, Dr. Jeffrey Taekman, has an excellent productivity blog. Alas, McSparky spent more than half of the show being fascinated by the minutiae of what doctors do. Which is better than what followed—long periods of uncomfortable silence while the unprepared guest clicked through every app in his menu bar to see if there is anything worth mentioning. OK, it was not total silence. You could hear Katie fuming in the background. There wasn’t.
Then another episode of Systematic came on, with Dr. Don Schaffner, a microbiologist. PhD, not MD. Wonder if that explains why the show was better. It was outstanding. Brett was a better interviewer than David, and avoided getting too side-tracked by his guest’s interesting work. But ultimately, the show was good because Dr. Schaffner had useful tips and app recommendations that did not simply regurgitate the latest round of MPU/Mactories/Macdrifter/etc. sponsors. His paper review workflow gave me several ideas I will work on during the holiday downtime. He also suggested a promising contender in my quest to find headphones that will survive more than 8-12 months of intensive use.
One more thing for me to do during the downtime: promote Zotero. Between the developers fumbling Papers 3 and Mendeley being taken over by an evil corporation, Zotero coupled with a few extensions is the best reference manager on any platform. Coming in 2014.
30 iPad apps I use almost every day
After 18 months of intensive use, here are some of the apps left standing on my iPad 3, sorted by category. I like to think I’m a semi-advanced user, so for some of them I have also listed simpler alternatives. It goes without saying that you should download all the free iWork and iLife apps.
Medicine
MKSAP 16
- For: all medicine residents
- Recommendation: strong
- Price: free (if you bought online MKSAP access)
MKSAP question bank. No-brainer if you are studying for your internal medicine board or MOC exam. Less page-flipping and instant gratification. Unfortunately, it doesn’t allow you to highlighting or annotate the explanations. Also, it can’t make custom quizzes, can’t review unanswered/wrong questions, and doesn’t allow you to copy any of the text to your notes. Lot’s of cants, but it’s the only MKSAP app available. Free if you purchase the electronic version of MKSAP 16.
Download MKSAP 16 from the app store here.
ACP Guidelines
- For: all interns
- Recommendation: ok, sort of
- Price: free
It seems like a good idea, and the content is great, but it is more of a branded PDF reader than anything else. Doesn’t have search or favorites, and you have to download each recommendation one by one. The download is fast, but good luck getting what you need without internet access. So, good for night-time reading, particularly if you’re an intern, but not a good POC tool.
Download ACP Guidelines from the app store here.
Stanford 25
- For: everyone
- Recommendation: just OK
- Price: free
If you haven’t heard of Stanford 25 before, see this TED talk and see the blog. It’s another good, if ugly, night table app.
Download Stanford 25 from the app store here.
Productivity
Things for iPad (or Omnifocus)
- For: everyone
- Recommendation: strong
- Price: $19.99 for Things, $39.99 for OmniFocus
Whether you’re a GTD fan or not, this or it’s more powerful and more expensive sibling OmniFocus are a must-have for anyone shuffling between more than two areas of responsibility. It still hasn’t been updated for iOS 7, but is very functional. Only two missing features for me, really: there are no nested tasks/dependencies, and you can’t filter by more than one tag.
I’ve been thinking about switching to OmniFocus, but this works well enough for me that the hassle of complete overhauling my system wouldn’t be worth it. Not to mention the >100$ price tag.
Download Things for iPad from the app store here. You can find OmniFocus for iPad here.
Boxer
- For: everyone who gets more than 5 emails/day
- Recommendation: strong
- Price: $0.99
The best mail client on the iPad. Apple’s Mail.app was OK until I realized I spent way too much time scrolling through my list of 20 IMAP folders whenever I wanted to move an email. Boxer works with Gmail, IMAP and Exchange accounts, has smart email sorting, and integrates with Sanebox.
Dropbox
- For: everyone
- Recommendation: strong
- Price: free
If you use Dropbox on your PC—and you must—then this is a no-brainer.
Download Dropbox for iOS from the app store here
iThoughts HD
- For: nerds
- Recommendation: OK
- Price: $9.99 for either
I found Tony Buzan’s book on mind mapping as a first-year medical student and used the hell out of it for my biophysics, chemistry and genetics coursers. As the material got more complicated, shuffling huge stacks of A3 paper became unwieldy, so I went back to plain old Cornell notes for biochemistry et al. This app is what got me back to making maps, this time when writing review articles and planning out other research. Also good when contemplating the GTD 50,000 ft view.
Download iThoughts HD for iPad from the app store here. It’s prettier new cousin Mindnode 3 is available here
Calendars 5
- For: all busy overachievers
- Recommendation: ok
- Price: $6.99
The default calendar used to be ugly and impractical. With iOS 7 it’s just the latter. This is a good replacement. Fantastical for iPad would be nice, though.
Download Calendars 5 from the app store here.
Drafts
- For: advanced users
- Recommendation: strong
- Price: $3.99
Quick note-taking and automation rolled into one. I use it as the default inbox for anything and everything, mainly by appending a dump.txt file in my Dropbox. There is a separate iPhone version that is just as useful.
Download Drafts for iPad from the app store here.
Pinner
- For: pack-rats
- Recommendation: ok
- Price: $1.99
Pinboard is an excellent almost-free bookmarking and discovery service. There are plenty of iPad clients available, but Pinner seemed to be the most cost-effective. I haven’t regretted the purchase.
Download Pinner from the app store here.
GW Mail
- For: anyone who is forced to use GroupWise
- Recommendation: meh
- Price: $9.99
I have to use GroupWise email for work. This is the only decent client I found for iOS. Stopped looking for a replacement since my last day of residency is less than six months away.
Reading
Reeder 2###
- For: serious feed readers
- Recommendation: strong
- Price: $4.99
I’ve been using RSS feeds since the days of Bloglines (circa 2001) and switched to Google reader after the first big redesign. It’s sad that Google decided to murder it instead developing its potential as a social service. Feed wrangler is a good replacement, Feedly is a free one. Reeder 2 is the best iPad feed reader there is, and works well with both.
Download Reeder for iPad from the app store here.
Instapaper
- For: everyone who reads
- Recommendation: strong
- Price: $3.99
If you read any text that’s longer than 500 words with any regularity, you need a service that will keep track of the articles and remove all the annoying cruft surrounding the text. Instapaper is the first one of its kind, and the best way to read articles on it is on an iPad.
Download Instapaper for iOS from the app store here.
NextDraft
- For: everyone
- Recommendation: strong
- Price: free
Ten good articles hand-picked by an expert hand-picker and delivered (almost) every weekday. My only source of news for the past six months.
Download NextDraft from the app store here
ReadQuick
- For: dabblers
- Recommendation: ok
- Price: $4.99
The second book from Tony Buzan that I read was on speed reading. This app will flash words from any article you find online or in your Instapaper/Pocket queue one-by-one at a set rate. Good for those who are too lazy to swipe.
Download ReadQuick from the app store here
Writing
Day One
- For: everyone
- Recommendation: strong
- Price: $4.99
A journaling app. I don’t use it for the Dear-Diary types of texts—though I have no doubt it would be perfect for that. Instead, I use it to keep an archive of meeting and lecture notes (usually started in Drafts and sent to Day One), with an occasional milestone in between. Feature request: multiple journals.
Download Day One for iOS from the app store here
Byword
- For: beginner iPad writers
- Recommendation: ok
- Price: $4.99
If you want to write a long text on an iPad and don’t need automation, text expansion et al. then this is the app for you.
Download Byword for iOS from the app store here
Editorial
- For: advanced users
- Recommendation: strong
- Price: $4.99
If you want to write a long text on an iPad and like mucking about with workflows, text snippets and Python scripts—which I most certainly do—this is your only choice on any platform. This will become essential next July when I start my long commute.
Download Editorial from the app store here
Social
Twitterific 5 or Tweetbot
- For: everyone
- Recommendation: meh… you might want to wait for the newest version of Tweetbot to come out
- Price: $2.99 for Twitterrific, $2.99 for Tweetbot
If you are on Twitter—and if you are a physician you really should be—please get a decent iOS client. The official one is definitely not it. Tweetbot used to be until iOS 7 came and made it look and feel ancient. Twitterrific is a good—if slightly annoying—substitute, with the added benefit of being universal (i.e. iPhone and iPad with the same purchase). I’m using the old version of Tweetbot and waiting for the new one, since Twitterific tended to make a mess of my position in the stream.
Download Twitterrific 5 here and Tweetbot for iPad here
- For: everyone who uses Facebook (why?)
- Recommendation: my wife likes it
- Price: free
OK, I guess, if you’re into that sort of thing.
Download Facebook for iOS here
Skype
- For: everyone away from family
- Recommendation: OK
- Price: free
This is the international default for long-distance communication, I guess. It gets choppy and drains the battery, but it’s the only thing my mom knows how to use so I’m stuck with it.
Games
Letterpress
- For: everyone who can spell
- Recommendation: strong
- Price: free (with in-app purchase)
An excellent turn-based word game. The only multiplayer game I play with any regularity. You need an in-app purchase if you want to play more than two games at the same time, but it’s well worth it. I have five going on right now.
10000000
- For: nerds
- Recommendation: strong
- Price: $1.99
Bejeweled meets a 2D RPG. Hours of fun, even when you get to 100000000000 or however many points.
Aquaria
- For: adventure gamers
- Recommendation: strong
- Price: $4.99
A 2D side-scrolling action-adventure game set under the sea. At my pace I will finish it in about two years, but it’s great even in 15-minute increments.
Shopping
Deliveries
- For: serious shoppers
- Recommendation: strong
- Price: $4.99
Forward an email containing a tracking number to a special email address. Boom, you can now track your package through this app, with push notifications if you’re into being interrupted whenever a case of -diapers- Wild Turkey is delivered to your front door.
Download Deliveries for iOS here
Eat24
- For: serious eaters
- Recommendation: OK
- Price: free
Good app for ordering food in the Baltimore area. Don’t know about rest of the country.
Hipmunk
- For: world travelers
- Recommendation: strong
- Price: free (you pay for the plane ticket, though)
The best flight comparison engine there is. Find the most affordable and least annoying plane route. Also does hotel rooms, which I haven’t tried.
Entertainment
Netflix
- For: everyone with a Netflix subscription
- Recommendation: OK
- Price: free
I have used this app exactly once, to watch a couple of episodes of Buffy the Vampire Slayer while waiting for an Amtrak train. Well worth it, though.
AppleTV Remote
- For: everyone with an Apple TV
- Recommendation: strong
- Price: free
I don’t have my original remote any more. We assume Dora ate it. This app is even better, since you don’t have to muck around with the tiny remote buttons when entering your wifi password or searching Netflix.
comiXology
- For: everyone who reads comics
- Recommendation: strong
- Price: free (the app, not the comics)
The only way to read comics on an iPad.
On patient notes and busy interns
Electronic patient notes, the way they stand now, are dangerous. As physicians wiser and more experienced than myself have noted, they are made for billing, not story-telling and communication between healthcare professionals; and as anyone with even basic literacy in the English language will notice as soon as they read one, they are a barely comprehensible, intelligible, muddled word salad that looks computer generated because, well, in most cases it is.
Why?
For one, they are ridiculously easy to create. Click on a checkbox and every admission note you start will come pre-populated with what the EMR thinks are the patient’s current home medications, prior surgical procedures and such. Have trouble accurately documenting the dozen medications your 72-year-old with systolic heart failure, diabetes, CKD and vascular dementia has? No big deal—the e-patient has at least something listed from an ER visit 9 months ago. You’ll make sure to go back to the admission note later and append it with the correct list when you get it from the family member tomorrow, right? Right.
They also save you from having to type. Click click click, and the review of systems is done. Too much clicking? There is a solution: spend 5 minutes to create a macro, and you will have all your common questions pre-answered as No on all the notes, shaving of seconds of additional clicking. Because asking all your patients the same questions and expecting identical answers is just plain common sense, amiright? Oh, and of course tachycardia is a symptom. It’s right there on the ROS list, waiting to be clicked.
Most of all, electronic notes are the one cure for writer’s block. While in the distant past1 you had to spend agonizing minutes staring at a blank admission note trying to form a coherent story on why the patient came to be seen, and then try putting it down on paper down without feeling ashamed, you learn from EMR that it is OK to sign a medico-legal document that contains this brilliant turn of phrase:
The reason for visit is: pt missed hd, high bp, n/v. The course was: constant. The exacerbating factor was: none. The alleviating factor was: none.
But why? Medicine residents are, in general, all moderately-to-ridiculosuly smart and ambitious people who should know better.
Well, for starters, some of them don’t. Even in the olden days1 you had a couple of interns who weren’t the best ever history-takers They would be the ones calling the patient “a poor historian”, and were usually correct, although not in the way they intended. Patients are the ones giving a (hi)story, the physician is the historian. and wrote poor-quality notes. Electronic notes, unfortunately, help them obfuscate their deficiencies. It is very easy to see in a one-page note how much useful information the resident has actually obtained. Not so much with computer-generated six-pagers.
Then there is your typical smart intern just finishing putting in orders for her fourth admission admission that day after discussing each one with the supervising resident, all while answering a barrage of pages about the 30 patients she is cross-covering. The first two admission notes are almost done—she has to updated the plan after talking with the resident—but the other two will have to wait until she updates the sign-out and hands off all the patients to the night float. This is arguably much more important than notes as it directly affects the care those newly admitted patients will get overnight, while the admission note is not really needed until the following day during morning rounds. She’s smart enough to prioritize.
She’s also smart enough to know what is expected of her. What she know about writing admission notes during residency she learned from her peers, particularly seniors—who concentrated on efficiency —and that lady at the billing department who gave a noon conference talk on the importance of complete documentation for coding. So The Man wants me to be efficient-yet-thorough, and then he gives me this electronic tool with auto-population, templates, macros and such. Hmmmmm…
Yes, she might get in trouble if her notes are so horrendously bad to significantly impede patient care. From my very limited experience this just does not happen. Or rather, if it does, appropriate documentation is a single bullet in the long list of areas of improvement during an M&M.
What to do?
-
Or in my program, six months ago. ↩︎