A Case for Larger Pockets

J Richard Pittman

ipadOutside Ms. Smith’s room, my internal medicine ward team crowds around to discuss her admission to the hospital for abdominal swelling and evidence of worsening kidney function. This is my usual classroom: a space in the hall of Grady Memorial Hospital. Most of my inpatient teaching of medical students and residents takes place here, in brief conversations during rounds. An early adopter of technology, I have been carrying an iPad for more than a year and have found it exceedingly useful. My iPad enables me to demonstrate concepts and present current data on the spot, instead of having to track down a computer or photocopy articles later. 

In the hallway, a medical student concludes her case summary: “Ms. Smith is a fifty-year-old woman presenting with advanced cirrhosis and acute kidney injury, most consistent with hepatorenal syndrome.” I think through questions to begin our discussion on cirrhosis and kidney injury as I reach for my iPad. I know the facts about hepatorenal syndrome, but I also know that monologues can lead to glazed eyes and interns with suddenly urgent pages.

“Tell me what you know about kidney problems in patients with cirrhosis,” I say. The student makes a rudimentary but correct answer, as I open an application called Papers containing a repository of articles I’ve found useful—a veritable trunk-load of journals.

“What happens to make the liver and kidneys stop playing nicely?“ I ask, flipping through an article on the screen to a figure depicting the pathophysiological cascade of liver dysfunction leading to inadequate blood flow to the kidneys. We discuss the student’s answer using the diagram for illustration.

“How do you know this is not another kind of kidney injury or a separate kidney problem altogether?” I ask, flipping to another article with the diagnostic criteria for hepatorenal syndrome. The student pulls out her pocket manual, and we compare information. “Good,” I say. “I think you’re right.”

The session is almost over, and I come back to our patient, whose liver problems are quite advanced. “Given that Ms. Smith may actually have hepatorenal syndrome, what would you say if she asked how much time she had?” The group mumbles inaudibly, and I point to an enlarged graph on the screen from a third article that depicts the decline in months for patients with hepatorenal syndrome.

Realizing I have covered a lot of information in just a few minutes, I assign homework with the tap of my finger, emailing articles from my iPad. “You all take a look at the articles I just emailed you tonight. Let’s go talk with Ms. Smith,” I say as we knock on her door and enter.

Tablet technology has become an essential tool in medical pedagogy. By engaging more of the learners’ senses, the concepts I teach stick more consistently. My simple, quick access to primary literature increases the caliber and efficiency of these hallway discussions. In addition, I’m using a medium increasingly familiar to my learners. My only complaint: lab coat pockets are too small to hold an iPad.