Considering Point-of-Care Electronic Medical Resources in Lieu of ...

TECHNOLOGY AND EDUCATION

Considering Point-of-Care Electronic Medical Resources in Lieu of Traditional Textbooks for Medical Education LaDonna S. Hale, PharmD; Michelle M. Wallace, MPAS, PA-C; Courtney R. Adams, BS; Michelle L. Kaufman, BS; Courtney L. Snyder, BS

Feature Editor’s Note: The rigors and condensed nature of the physician assistant (PA) curriculum require course resources that balance brevity with comprehensiveness. Students must build a strong foundation of medical knowledge and effective and efficient information literacy skills. The ability to recognize a gap in one’s knowledge and to identify, locate, evaluate, and apply evidence-based information to patient care requires instruction, practice, and feedback. Early integration of clinically relevant electronic point-of-care (POC) resources offers more time for students to develop this proficiency while being mentored by faculty and it may help to bridge the gap between the classroom and clinical setting. This article explores the use of POC, evidencebased resources in lieu of traditional medical textbooks during didactic training. LaDonna S. Hale, PharmD

With an average of 26.4 months of training,3 half in the didactic setting and half in the clinical setting, physician assistant (PA) students are transformed into licensed health care providers with a high level of responsibility and autonomy in a short period. This means that students must develop background knowledge and information literacy skills simultaneously. One way to blend these skills is to use POC resources in lieu of traditional medical textbooks during didactic training. The transformation from student to clinician requires resources that are current and evidence-based, contain appropriate scope and breadth of information, and include multiple perspectives. Ideal resources present material in a variety of ways, using text, pictures, tables, and summaries, and they should contain a balance of background knowledge and clinical application to meet the student’s stage of training.4 Most importantly, the rigors of PA curriculum also require resources that balance brevity with completeness. Information Literacy Skills Take Time to Develop

Introduction Textbooks and resources and how they are used set the tone for a course; they fill the gaps in students’ background knowledge and are a main source of clarification and deeper conceptual understanding. Students often believe that they can perform relatively well in most courses without reading the textbook.1 However, as clinicians and educators, we realize that students need more than a skeleton of information and the PowerPoint bullets provided during lectures. Selecting course resources is a critical decision when planning or changing a course—in many ways, it is like selecting a coinstructor for the course. Textbooks are traditionally used for didactic education to build background knowledge, whereas point-of-care (POC) electronic resources (eg, UpToDate, DynaMed), drug information resources (eg, Clinical Pharmacology, Epocrates), and clinical apps (eg, AHRQ ePSS, QxMD Calculate) are traditionally used in the clinical setting. It is expected that during clinical rotations, students will demonstrate strong information literacy skills and proficiency with the same evidencebased POC resources and medical apps used by clinicians.2 The authors declare no conflict of interest. J Physician Assist Educ 2015;26(3):161–166 Copyright ª 2015 Physician Assistant Education Association DOI 10.1097/JPA.0000000000000035

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Information literacy is “the ability to recognize when information is needed and to identify, locate, evaluate, and use effectively the needed information for the issue or problem at hand.”5 Information literacy forms the basis of lifelong learning and is essential in today’s rapidly changing medical environment.6 Yet, the idealized academic research model of comprehensively searching for relevant information is very different than the search strategies used in the clinical setting.7 When practicing clinicians need to learn a new topic or verify a clinical decision, they are more likely to use a POC electronic resource than a traditional textbook.8–10 Also, using POC resources in lieu of traditional textbooks during didactic training would require students to start developing information literacy skills earlier, while still under the guidance of faculty. Robust information literacy skills allow students to become self-directed, independent learners.6 Thus, students with the ability to quickly locate or confirm answers to clinical questions will be more likely to do so when needed, will feel more self-confident and independent, and will be more useful to the medical team. Students without information literacy skills struggle to find answers. Not knowing where to look first, they often use inappropriate resources and search strategies, such as googling general Web sites or performing a literature search to answer a question that could easily be located in a drug information resource. This inefficiency can cause students to miss out on important learning opportunities. 161

Copyright Ó 2015 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited.


Table 1: Electronic Evidence-Based Point-of-Care Resources

Product 5-Minute Consult http:\\5minuteconsult.com

Cost

Mobile App Available

$99 annually

Y

Key Features USPSTF guidelines Diagnosis and treatment algorithms Procedure skills videos Laboratory test information Medical calculators

ACP Smart Medicine (formerly ACP PIER) http:\\smartmedicine.acponline.org

$109 annually for PAs (free to American College of Physicians members)

N

Targeted, concise content

Bulleted summaries of evidence-based recommendations Clinical Key (formerly MDConsult) http:\\www.clinicalkey.com

$449–$1248 depending on package purchased

Y

Information portal to medical books, journals, and guidelines published by Elsevier Graphics, pictures Procedure videos Patient education

DynaMed Plus http:\\www.dynamed.com

$200 annually Student pricing: $100 annually

Y

Targeted, concise overviews, and recommendations Graphics, pictures, charts Drug content partnered with Micromedex

Epocrates Essentials http:\\www.epocrates.com

$175 annually

Y

Targeted, concise summaries of practice guidelines ICD and CPT codes Alternative medications Drug content and pill ID Diagnostic/lab tests

Essential Evidence Plus http:\\www.essentialevidenceplus.com

$85 annually

N

Targeted, concise summaries of practice guidelines Cochrane Systematic Reviews Graphics, pictures Diagnostic/lab tests Medical calculators ICD and CPT codes

Family Practice Notebook http:\\www.fpnotebook.com

Free

Y

Rapid POC resource for primary care and emergency clinicians

Medscape http:\\www.medscape.com

Free

Y

Medical news

Divided into 31 specialties

Searchable medical and guideline information Free CME Does not require the Internet Pill ID and drug interaction checker Medical calculators Procedural articles (Continued)

162

Journal of Physician Assistant Education



Table 1: Electronic Evidence-Based Point-of-Care Resources

Product Sanford Guide to Antimicrobial Therapy http:\\www.sanfordguide.com

(continued )

Cost

Mobile App Available

$30 annually

Y

Key Features Exclusively Infectious disease-related information Dosing calculators and algorithms Separate versions specific for HIV/AIDS and hepatitis

UpToDate http:\\www.uptodate.com

$495 annually AAPA pricing: $399 annually (regular $499) Student pricing: $199 annually

Y

Targeted, concise overviews and recommendations

Patient education Medical calculators Graphics, pictures, charts Drug content partnered with Lexicomp Links to full-text articles AAPA, American Academy of Physician Assistants; CME, continuing medical education; CPT codes, current procedural terminology codes; ICD, International Classification of Diseases; PA, physician assistant; POC, point-of-care; USPSTF, Unites States Preventive Services Task Force.

Information literacy is often taught as a one-time event in workshops, lectures, or online tutorials; these are insufficient.6,11 Information literacy must be integrated throughout the curriculum, and faculty must construct a purposeful framework for students to learn how to become independent learners by providing direction regarding optimal use of these tools, monitoring student progress, and providing feedback.6 Regular, frequent use of electronic POC resources has been associated with modestly enhanced performance on Maintenance of Certification Examinations,12 and hospitals with access to UpToDate have been reported to have better quality of care and shorter length of stays.13 Although preceptors are encouraged to prompt students to locate their own answers through evidence-based resources, this often does not happen.10,11 Strong information literacy skills can only develop over time6 through application, repetition, and feedback. Requiring students to heavily rely on POC resources during didactic training should sharpen these skills by increasing exposure to and familiarity with these resources. Advantages and Disadvantages of Traditional Textbooks Traditional textbooks are specifically designed for students of various levels and with various foci. They often have learning objectives, summaries of key points, and they may be bundled with or include case studies, lecture materials, and other online resources. Assigning readings is relatively easy using chapters or page numbers. Print books allow students to navigate through pages, to cross reference more than one book at a time, and to easily highlight and annotate in the margins, thus blending reading and writing into an active process.14 However, print books can become quickly outdated and are not as useful for POC decisions during clinical experiences because of the cumbersome nature of trying to locate specific information quickly. There also may be a psychological September 2015 Volume 26 Number 3

disadvantage to traditional medical textbooks. Unfortunately, an adage in medicine promoted by some students and clinicians alike is, “The book says it should be done that way, but in the real world we do it this way.” So textbooks can be seen as counter to the “real world,” which PA students desperately want to become a part of as quickly as possible. Some students may view textbooks as a source of “that way” information that must be memorized for examinations but that may not be clinically relevant. Students often report being successful in undergraduate coursework without relying on the course textbook,1 and therefore may assume that textbooks are not needed in PA education either. These may represent possible reasons why some students do not read or value textbooks. The high value students place on “real world” learning from the same resources as practicing clinicians may change students’ perceptions of required reading assignments. Advantages and Disadvantages of Point-ofCare Resources No research could be found comparing student perceptions or learning outcomes for didactic medical education using traditional textbooks versus POC resources; however, most research indicates that medical residents in clinical practice do prefer electronic resources over traditional textbooks.9,10 Research comparing paper versus electronic textbooks shows mixed results. When college students were asked to compare traditional textbooks to e-textbooks, 97% liked the price, 88% believed the information was clear, and 79% appreciated the portability; however, 18% found the technology frustrating.15 In a qualitative study of 91 undergraduate general psychology college students, Woody et al16 reported a higher level of satisfaction with print books and more frequent reading of section summaries but lower use of online activities or related online resources. Despite the differences in how these 163


TECHNOLOGY AND EDUCATION resources were used, there were no detectable differences in learning outcomes. Point-of-care resources are not specifically designed for didactic education, which can make reading assignments initially more difficult, especially early on when students are still orienting themselves to the resource. When assigning readings, students will initially require guidance regarding exactly which topics to read and how to locate the readings and how much to read (eg, the entire section, just the summary/key points, focus on diagnosis). As their skills progress, students should be able to identify and locate relevant readings on their own. Electronic resources typically provide embedded links to additional explanation, both remedial (eg, defining a term/ condition) and advanced (eg, more detailed information or explanation), which can prove to be advantageous by both filling knowledge gaps and supporting inquisitiveness.

However, students may also become “lost” through overuse of these embedded links, “rabbit chasing” into areas irrelevant to the material being studied. Some students may also have eye strain because of reading from a computer screen and will print sections to annotate and highlight.17 There may be a learning curve as students adjust to the online delivery method, navigation issues, and different nature of the resource.17 The average cost of new textbooks has increased nearly 30% from 2009 to 2013.18 Carefully selected electronic resources can be cost-effective, especially if replacing multiple textbooks across several courses. Point-of-care resources may be available through the university library or at discounted student rates (Table 1). Sophisticated drug information resources (Table 2) and commonly used medical apps (Table 3) are also available at low cost. The number of free online open access textbooks is growing; however, at this time, most of these textbooks target general content undergraduate courses. Physician assistant

Table 2: Electronic Drug Information Resources

Product

Cost

Drug Interaction Checker

Epocrates Rx* http:\\www.epocrates.com

Free

Y

Pill ID

Drug Cost Information

Compatibility

Y

Y

Apple Android Web

DynaMed Mobile http:\\www.dynamed.com

Student pricing: $100 annually

Y

N

N

Apple Android Web

Lexicomp http://www.wolterskluwercdi.com

$175–595 annually depending on package purchased

Y

Y

Y

Apple Android Windows Web

Medscape Mobile http:\\www.medscape.com

Free

Y

Y

Y

Apple Android

Micromedex http:\\www.micromedex.com

Free

Y

N

N

Micromedex (extended version) http:\\www.micromedex.com

$2.99 annually

Y

N

N

Apple Android Apple Android

Monthly Prescribing Reference (MPR) http:\\www.empr.com

Free

Y

N

N

Apple Android Windows Web

Tarascone Pharmacopoeia http:\\www.tarascon.com

$40 annually (Apple/Android) $45 annually (Web edition)

Y

Y

Y

Apple Android Web

*Additional features available with Epocrates Essentials (full version); see Table 1.

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Table 3: Other Electronic Medical Resources and Apps Product

Cost

Purpose and Key Features

Compatibility

AHRQ ePSS http:\\www.epss.ahrq.gov/PDA/index.jsp

Free

Decision support regarding USPSTF guidelines

Apple

Does not require Internet

Android Blackberry Windows

LabGear, no Web site; available in App Store only

$2.99

Medical laboratory tests with differential diagnosis, related symptoms

Apple

Customizable reference ranges Customizable with bookmarks Medpage Today http:\\www.medpagetoday.com

The Merck Manual Professional Version http:\\www.merkmanuals.com

Free

$35

Medical news

Apple

Free CME

Android

Customizable with bookmarks

Web

Medical news

Apple

Searchable medical and guideline information

Android

Does not require Internet

Kindle

Pill ID and drug interaction checker Procedure videos No subscription or registration Pocket Lab Values, no Web site; available in App Store only

$2.99

Medical laboratory tests with differential diagnosis

Apple

Customizable reference ranges

Android Windows

QxMD Calculate http:\\www.qxmd.com

Free

Risk calculator decision support

Apple

Detailed references with PubMed integration

Android Blackberry Windows compatible

Visual DX http:\\www.visualdx.com

$200

Diagnostic tool searchable by symptoms and visual cues

Apple

Extensive database of images

Android

ICD and CPT codes AAPA, American Academy of Physician Assistants; CME, continuing medical education; CPT codes, current procedural terminology codes; ICD, International Classification of Diseases; USPSTF, Unites States Preventive Services Task Force.

educators may find some of these useful in courses such as statistics, anatomy, or pathophysiology. Summary Selecting resources to support didactic courses is a critical decision, and the advantages and disadvantages must be carefully considered. During clinical rotations, students not only need to possess strong background knowledge but also are expected to be proficient with the same evidence-based POC resources used by clinicians. Students place high value on “real world” learning and therefore may place more value on POC resources that they know practicing clinicians use as compared with medical textbooks. The condensed nature of September 2015 Volume 26 Number 3

PA education requires students to develop background knowledge and information literacy skills over a short period. One way to build that knowledge and those skills simultaneously is to use POC resources in lieu of traditional medical textbooks during didactic training. Electronic POC resources offer several advantages over traditional textbooks and should be considered as viable options in PA education. LaDonna S. Hale, PharmD, is a professor in the Department of Physician Assistant Studies, Wichita State University, Wichita, Kansas. Michelle M. Wallace, MPAS, PA-C, is a clinical educator in the Department of Physician Assistant Studies, Wichita State University, Wichita, Kansas. Courtney R. Adams, BS, is a Master of Physician Assistant Studies student at Wichita State University, Wichita, Kansas.

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TECHNOLOGY AND EDUCATION Michelle L. Kaufman, BS, is a Master of Physician Assistant Studies student at Wichita State University, Wichita, Kansas. Courtney L. Snyder, BS, is a Master of Physician Assistant Studies student at Wichita State University, Wichita, Kansas. Correspondence should be addressed to: LaDonna S. Hale, PharmD, Department of Physician Assistant Studies, Wichita State University, 1845 Fairmount, Wichita, KS 67260-0043; Email: [email protected]

REFERENCES 1. Richard B, Cleavenger D, Storey VA. The buy-in: a qualitative investigation of the textbook purchase decision. J Higher Education Theor Pract. 2014;14:20–31. 2. Kronenfeld MR, Bay RC, Coombs W. Survey of user preferences from a comparative trial of UpToDate and ClinicalKey. J Med Libr Assoc. 2013;101:151–154. 3. Physician Assistant Education Association. The Twenty-Ninth Annual Report on Physician Assistant Educational Programs in the United States, 2012-2013. Published 2014. Available at: http://www. paeaonline.org. Accessed April 25, 2015. 4. Keahey D, Goldgar C. Evidence-based medicine databases: changing needs along the path from physician assistant student to clinician. J Physician Assist Educ. 2011;22:48–52. 5. American Library Association. Presidential Committee on Information Literacy. Final Report. Chicago, IL: American Library Association; 1989. Available at: http://www.ala.org/acrl/publications/ whitepapers/presidential. Accessed April 10, 2015. 6. American Library Association. Information Literacy Competency Standards for Higher Education. Chicago, IL: American Library Association; 2000. Available at: http://www.ala.org/acrl/sites/ala.org. acrl/files/content/standards/standards.pdf. Accessed April 10, 2015. 7. Younger P. Internet-based information-seeking behaviour amongst doctors and nurses: a short review of the literature. Health Info Libr J. 2010;27:2–10.

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8. Addison J, Whitcombe J, Glover SW. How doctors make use of online, point-of-care clinical decision support systems: a case study of UpToDate. Health Info Libr J. 2012;30:13–22. 9. Edson RS, Beckman TJ, West CP, et al. A multi-institutional survey of internal medicine residents’ learning habits. Med Teach. 2010;32: 773–775. 10. Lai CJ, Aagaard E, Brandenburg S, et al. Multiprogram evaluation of reading habits of primary care internal medicine residents on ambulatory rotations. J Gen Intern Med. 2006;21: 486–489. 11. Allan GM, Ma V, Aaron S, et al. Residents’ clinical questions: how are they answered and are the answers helpful? Can Fam Physician. 2012; 58:e344–351. 12. Reed DA, West CP, Holmboe ES, et al. Relationship of electronic medical knowledge resource use and practice characteristics with Internal Medicine Maintenance of Certification Examination scores. J Gen Intern Med. 2012;27:917–923. 13. Bonis PA, Pickens GT, Rind DM, et al. Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States. Int J Med Inform. 2008;77:745–753. 14. Sellen A, Harper R. The Myth of the Paperless Office. Cambridge, MA: Massachusetts Institute of Technology Press; 2002. 15. Falc EO. An assessment of college students’ attitudes towards using an online e-textbook. Interdiscip J E-learning Learn Objects. 2013;9: 1–12. 16. Woody WD, Daniel DB, Baker CA. E-books or textbooks: students prefer textbooks. Comput Education. 2010;55:945–948. 17. Everad A, St Pierre K. A case for student adoption of open textbooks. J Acad Business Education. 2014;15:66–76. 18. National Association of College Stores Web site. Higher Education Retail Market Facts & Figures. 2015. Available at: https://www.nacs. org/research/industrystatistics/higheredfactsfigures. Accessed April 10, 2015.

