Dr Alvin Rajkomar was doing rounds with his team at the University of California, San Francisco (UCSF) Medical Center when he came upon a puzzling case: a frail, elderly patient with a dangerously low sodium level.
As a third-year resident in internal medicine, Dr Rajkomar was the senior member of the team, and the others looked to him for guidance. An infusion of saline was the answer, but the tricky part lay in the details. Concentration? Volume? Improper treatment could lead to brain swelling, seizures or even death.
Dr Rajkomar had been on call for 24 hours and was exhausted, but the clinical uncertainty was “like a shot of adrenaline,” he said. He reached into a deep pocket of his white coat and produced not a well-thumbed handbook but his iPhone.
With a tap on an app called MedCalc, he had enough answers within a minute to start the saline at the precise rate.
The history of medicine is defined by advances born of bioscience. But never before has it been driven to this degree by digital technology.
The proliferation of gadgets, apps and Web-based information has given clinicians — especially young ones like Dr Rajkomar, who is 28 — a black bag of new tools: new ways to diagnose symptoms and treat patients, to obtain and share information, to think about what it means to be both a doctor and a patient.
And it has created something of a generational divide. Older doctors admire, even envy, their young colleagues’ ease with new technology. But they worry that the human connections that lie at the core of practice are at risk of being lost.
“Just adding an app won’t necessarily make people better doctors or more caring clinicians,” said Dr Paul C Tang, chief innovation and technology officer at Palo Alto Medical Foundation in Palo Alto, California. “What we need to learn is how to use technology to be better, more humane professionals.”
Dr Paul A Heineken, 66, a primary care physician, is a revered figure at the San Francisco VA Medical Center. He is part of a generation that shared longstanding assumptions about the way medicine is practiced: Physicians are the unambiguous source of medical knowledge; notes and orders are written in paper while standing at the nurses’ station; and X-rays are film placed on light boxes and viewed over a radiologist’s shoulder.
One recent morning, while leading trainees through the hospital’s wards, Dr Heineken faced the delicate task of every teacher of medicine — using the gravely ill to impart knowledge.
The team arrived at the room of a 90-year-old World War II veteran who was dying — a ghost of a man, his face etched with pain, the veins in his neck protruding from the pressure of his failing heart.
Dr Heineken apologised for the intrusion, and the patient forced a smile. The doctor knelt at the bedside to perform the time-honoured tradition of percussing the heart. “Do it like this,” he said, placing his left hand over the man’s heart, and tapping its middle finger with the middle finger of his right.
One by one, each trainee took a turn. An X-ray or echocardiogram would do the job more accurately. But Dr Heineken wanted the students to experience discovering an enlarged heart in a physical exam.
Dr Heineken fills his teaching days with similar lessons, which can mean struggling upstream against a current of technology. Through his career, he has seen the advent of CT scans, ultrasounds, MRI’s and countless new lab tests. He has watched peers turn their backs on patients while struggling with a new computer system, or rush patients through their appointments while forgetting the most fundamental tools — their eyes and ears.
For these reasons, he makes a point of requiring something old-fashioned of his trainees. “I tell them that their first reflex should be to look at the patient, not the computer,” Dr Heineken said. And he tells the team to return to each patient’s bedside at day’s end. “I say, ‘Don’t go to a computer; go back to the room, sit down and listen to them. And don’t look like you’re in a hurry.’ ”
Thirty-eight years and a technological revolution separate Dr Heineken from Dr Rajkomar. In 2009, in his third year of medical school at Columbia, he was among the first in the hospital to use an iPhone as a clinical tool. Among the new crop of device-happy physicians, Dr Rajkomar is now an elder statesman of sorts, showing trainees his favourite apps.
He stores every clinical nugget he finds on an application called Evernote, an electronic filing cabinet. “I use Evernote as a second brain,” he said. “I now have a small textbook of personalised, auto-indexed clinical pearls that I carry with me at all times on my iPhone.”
Along with MedCalc, the clinical calculator, Dr Rajkomar’s phone has ePocrates, an app for looking up drug dosages and interactions; and Qx Calculate, which he uses to create risk profiles for his patients. His favourite technology is his electronic stethoscope, which amplifies heart sounds while cancelling out ambient noise.
Tablet computers that are linked to electronic health records are making their way into the hands of medical trainees around the country. All internal-medicine residents at the University of Chicago and Johns Hopkins are given iPads; entering medical students at Stanford are given vouchers they can use to buy one.
A University of Chicago study this year in Archives of Internal Medicine found that residents with iPads were able to enter orders in a more timely manner, and a majority of residents perceived that the iPads improved their work efficiency. At the UCSF Medical Center, some physicians use iPads, and many use one of the hospital’s computers on wheels.
Dr Rajkomar’s outpatient clinic is four miles west of the UCSF hospital, where he works down the hall from Dr Heineken. As the conversation with the patient goes, so goes Dr Rajkomar’s interaction with the computer. Lab results? On the screen in a flash. A list of past and current medications and dosages? Voilà!
Yet he knows he has a great deal to learn about being a physician, especially patients’ social and psychological complexities. “One patient fired me,” he said, smiling as he added, “Dr Heineken gets those patients.”