Medical students’ and trainees’ perspectives on smartphones

Recent studies have examined medical students’ and trainees’ ownership, usage and perspectives on smartphones. In 2012, a questionnaire-based survey was distributed among interns in the Republic of Ireland (Reference O'Connor, Byrne and ButtO’Connor 2014). This study demonstrated that smartphones were widely adopted and that they were being used daily by interns to help them perform their regular duties. The British National Formulary was the most commonly used app. Another study in the same year (Reference Payne, Wharrad and WattsPayne 2012) found a high level of smartphone ownership among the 257 UK medical students and 131 junior doctors surveyed. The majority of the participants owned between 1 and 5 medically related apps. Compared with other platforms, iPhone users were more likely to own apps. App use was similar for both the students and the trainee doctors, the majority using them for 20–30 min a day. The most frequently used apps were those for disease diagnosis and management and drug reference.

In 2013, Robinson et al carried out a questionnaire-based study looking into smartphone usage and acceptability among clinical medical students at the University of Birmingham, UK. In all, 361 students took part; 59% of them owned a smartphone and 37% of these reported using the device to help them in their learning. Importantly, the students had generally positive attitudes towards the concept of using smartphones as future educational aids, with at least 84% of them believing the devices to be useful. However, it is also important to note that about 64% of these students felt that smartphones might be too costly to introduce in clinical education.

The studies described above were largely limited to examination of smartphone and app ownership and usage rates, and the general views of medical students and trainees on smartphones and apps. There has been a paucity of research looking at apps themselves, for example, students’ evaluation and views of a particular educational app that their tutors have asked them to use. This gap in terms of research evidence has recently been addressed by Reference Payne, Weeks and DunningPayne et al (2014). This research group conducted a pilot study to investigate the effect of a hospital-specific smartphone app on the work of a cohort of British junior doctors. The investigators created an iPhone app that contained mainly disease management and antibiotic dosing guidelines specific to the hospital and tested it with 39 foundation year doctors for 4 months. Their results showed that participants felt generally positive towards the availability of such an app, with 68% reporting that it helped them save time when performing clinical activities.

In a study among orthopaedic trainees, Reference Al-Hadithy, Gikas and Al-NammariAl-Hadithy et al (2012) noted that smartphones allowed them to complete their work-based assessments without the need for computer access, which might increase completion rates and reliability. More journals now provide podcasts and video tutorials that can be accessed on smartphones, which is particularly useful for higher examinations.

Smartphone use for education in medical specialties

Reference Franko and TirrellFranko & Tirrell (2012) conducted an email survey of smartphone and smartphone app use by medical providers in the US Accreditation Council for Graduate Medical Education (ACGME) training programmes. Of the 3306 respondents, 1397 were residents, 524 fellows and 1385 attending physicians. More than 85% of the respondents used a smartphone. Importantly, the study highlighted that the app types most frequently requested by the respondents were associated with textbook/reference materials, classifications, treatment algorithms and general medical knowledge. Out of the 134 psychiatry respondents, 84% used a smartphone and 63% of them used apps. The study found no association between level of training and use of apps.

Given the generally positive attitudes and perspectives that trainees and medical students have towards smartphones and smartphone apps, more specialties are actively embracing the smartphone as an educational tool (Box 1).

Current use of technology in psychiatric training and education

For over a decade, journals such as Academic Psychiatry have noted that knowledge and skills in medical informatics are essential for lifelong learning and modern psychiatric practice (Reference Hilty, Hales and BriscoeHilty 2006) (Box 2). A needs-based assessment was conducted, and it was previously proposed that the existing psychiatry curriculum needs to integrate with the advancement in technologies. A 2006 pilot study of users’ perceptions of technology in medicine demonstrated that residents and medical students believed technology skills to be integral to their medical training (Reference Briscoe, Fore Arcand and LinBriscoe 2006). Participants indicated a preference for the use of personal digital assistants (PDAs) as these provide immediate access to critical information pertinent to the clinical care of patients. More recent research has looked into the use of e-learning in the teaching of psychiatry to medical students (Reference Weninger, Keller and FegertWeninger 2009). This particular feasibility trial, at the University of Ulm, Germany, showed that child and adolescent psychiatry case studies could successfully be added to an e-learning system primarily oriented towards somatic disease. In another German study, psychiatric educators at the Hamburg Medical School used ‘cinemeducation’ to help students gain a deeper understanding of psychiatric illnesses (Reference Kuhnigk, Schreiner and ReimerKuhnigk 2012).

The latest advancement in technology is the application of unique tele technologies to help augment resident training in psychodynamic psychotherapy (Reference Katzman, Abbass and CoughlinKatzman 2015).

A framework for psychiatry to adopt

Although our literature search for this article revealed no recent reviews of apps specific to psychiatric training, there are many apps for academic purposes in the commercial app stores. A quick search using the key words ‘psychiatry education’ reveals 266 apps in the Apple App Store and 240 in the Android Play Store.

A scoping review was recently conducted by Reference Boydell, Hodgins and PignatielloBoydell et al (2014) to assess the use of technology (such as videoconferencing, mobile phone apps and websites) in delivering mental health services to children in Canada. They carried out a descriptive numeric summary and thematic analysis of the reviewed literature. They concluded that technology did indeed play a major role in the service and support provided to children; it also played a role in the prevention, assessment, diagnosis and treatment of psychiatric disorders.

It might be worth carrying out more scoping reviews in psychiatry. One might analyse peer-reviewed studies on education in psychiatry, to summarise the key findings of current research and to identify knowledge gaps. Another might assess the application of technology in the specialty, which would be essential for understanding the breadth and impact of current research. A scoping review could also consider commercial psychiatry-related educational apps that are currently available in app stores and highlight their common themes.

Reference Haffey, Brady and MaxwellHaffey et al (2014) have suggested two ways of overcoming the lack of evidence-based educational apps in pharmacology that would serve well in psychiatry (Box 3). The first involves encouraging universities and healthcare organisations to create their own ‘in-house’ apps. They suggest that in-house apps have inherent advantages, including the fact that they could focus on current shortfalls in clinical education or deficiencies in the competencies of medical students or junior doctors. The second is for universities and healthcare organisations to compile lists of apps that have been peer-reviewed and deemed suitable for use by medical students or junior doctors.

Developing in-house educational apps

As regards Haffey et al’s first suggestion, clinicians in universities could play a greater role by using existing easy-to-follow software to develop simple web-based apps. This strategy has been described by Reference Subhi, Todsen and RingstedSubhi et al (2014), who show how to create a simple web-based mobile app using just an internet browser and a text editor. The jQuery Mobile builder (jquerymobile.com) leads the clinician through a step-by-step process of creating a custom app. The builder automatically generates codes based on the content that the clinician has included and the clinician pastes these into a text-editor file, thereby creating a simple smartphone-based web app. They can thus create their own apps for the dissemination of information they feel is pertinent for the educational needs of medical students and junior doctors. Elsewhere (Reference Zhang, Cheow and HoZhang 2014a, Reference Zhang, Tsang and Cheowb) we describe in greater detail how psychiatrists could be app developers and introduce two other cost-effective methods for app development. Here, we outline two educational portals and apps for undergraduate and postgraduate education with which we have been involved.

The Mastering Psychiatry portal

In collaboration with colleagues around the world, we used the method described above to develop the Mastering Psychiatry online portal and smart phone app (masteringpsychiatry.wordpress.com). The portal, which went online in 2013, was originally conceived to help Singapore’s medical undergraduates, giving them access to a free online textbook and simulated patient videos (Fig. 1). By August 2014 there had been 15 803 views and 2109 downloads of the online textbook (Reference Zhang, Ho and ShankarZhang 2014c).

FIG 1 The Mastering Psychiatry textbook and online portal (www.masteringpsychiatry.com).

The app, which was developed between August and December 2013, was supported by an educational grant and subjected to a user survey to evaluate students’ perceptions of it. A total of 185 students participated in the survey. Results showed that a high proportion of the students would like an educational psychiatry smartphone app to have the following features: textbook-based content, clinical videos of objective structured clinical examinations (OSCEs) and an event notification service. A high proportion of the students concurred with the perception that a smartphone app would be helpful in psychiatry education and that smartphones can be a viable and good alternative to a book.

The CASC Feedback portal and the Deja Vu CASC app

Another international collaboration, this between the Singapore MRCPsych CASC Consortium and the Cornwall Partnership NHS Foundation Trust in the UK, resulted in the CASC Feedback portal (cascfeedback.org) and the Deja Vu CASC smartphone app (dejavucascsg.com/deja-vu-casc-app) (Fig. 2). The latter is now available from the Google Play app store. These were developed between January and April 2014 using methods similar to that outlined above for the creation of web-based apps. Their purpose is to help trainees master the MRCPsych Clinical Assessment of Skills and Competencies (CASC), which is the final examination towards obtaining Membership of the Royal College of Psychiatrists.

FIG 2 The Deja Vu CASC smartphone app (dejavucascsg.com/deja-vu-casc-app).

By August 2014 there had been 57 downloads of the app from the web-link made available to trainees via the PsychClub website (www.psychclub.com). In addition, there have been 225 views of the videos deployed within the app. Since the launch of the CASC Feedback portal, there have been 65 visitors to the site, the majority of whom are from the UK (n = 36) and Singapore (n =18). These early data, in particular the number of downloads of the app, show that trainees are willing to consider using such a system.

Identifying suitable educational apps through systematic peer review

The second suggestion made by Haffey et al is for universities and healthcare organisations to compile lists of peer-reviewed apps that educators and clinicians deemed to be suitable for use. Reference LewisLewis (2013) has suggested criteria for conducting such peer review of smartphone medical apps using a self-certification model. The model (Table 1) builds on what has been developed by the Health on the Net Foundation (HON) to assess the reliability and credibility of the information presented on medical and health websites. Note that the self-certification model provides criteria for evaluating the reliability of the information contained in an app – more work is needed to further a set of criteria to determine the educational value of the app.

TABLE 1 A self-certification model for the review of smartphone apps

Before developing new apps, psychiatrists need to assess the increasing numbers of psychiatry-related apps in the app stores to identify those (whether educational or clinical) that are safe and might be of value in their specialty and to reveal current needs and knowledge gaps. The self-certification model can help in such assessments. The literature review on apps that we conducted for this article showed that most papers are limited merely to the identification of apps and have not begun to use models for their peer review and evaluation. If more psychiatrists become involved in the review of psychiatry-related apps and more related publications appear in informatics journals psychiatry as a specialty will further advance.

Advantages and disadvantages of the proposed framework

MCQs

Select the single best option for each question stem

1. 1 Which one of the following technologies have been used in psychiatry education?

   1. a portable digital assistants to check for evidence-based information

   2. b an online e-learning portal on child psychiatry

   3. c video technologies to share more insights into psychiatric disorders

   4. d video technologies in the supervision of residents for psychodynamic psychotherapy

   5. e all of the above.

2. 2 To identify the current gaps in education, which one of the following would be a recommended approach?

   1. a scoping review

   2. b focus groups

   3. c randomised controlled trials

   4. d observational study

   5. e naturalistic study.

3. 3 Which one of the following is not included in the proposed self-certification model for the evaluation of psychiatry-based apps?

   1. a disclosures

   2. b information

   3. c privacy and confidentiality

   4. d justification of claims

   5. e app ratings.

4. 4 Which of the following has not been used in undergraduate and postgraduate psychiatric education?

   1. a video technologies

   2. b smartphone technologies

   3. c online portals for web-based learning

   4. d augmented reality

   5. e tele-technologies.

5. 5 Research has shown that most junior doctors in the UK own on average how many medically related smartphone apps?

   1. a 1–5

   2. b 6–10

   3. c 11–15

   4. d 20–25

   5. e more than 30.

MCQ answers

1

e

2

a

3

e

4

d

5

a