Usefulness of Mobile Devices in Learning Within the Clinical Setting for Residents of Surgical Specialties in a Tertiary Care Pediatric Hospital

doi:10.21203/rs.3.rs-1735503/v1

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Usefulness of Mobile Devices in Learning Within the Clinical Setting for Residents of Surgical Specialties in a Tertiary Care Pediatric Hospital

https://doi.org/10.21203/rs.3.rs-1735503/v1

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Background: Mobile learning refers to the use of mobile or wireless devices for learning purposes while on the move. It is a learning technique that can be applied in multiple contexts through social and content interactions. “Mobile” learners can use it as an educational technology in a variety of settings available at their convenience.

In medicine, new technology offers the potential to enhance learning and patient care, although it also poses potential risks, such as superficial learning, failure to understand how to discriminate reliable sources of information, distraction, inappropriate use, and privacy-related issues. The aim of this study is to assess the usefulness of mobile devices for residents in the clinical settings of a hospital.

Methods: Mixed method design on pediatric surgery residents. Quantitative data were analyzed via a simple discriminant analysis. Qualitative data were obtained using the focus group technique, with a subsequent triangulation of data.

Results: All residents use devices for learning and communication. The triangulation analysis yielded the following categories: agile communication, search for data on drugs and prognosis, consultation of medical applications, limitations of devices, and inconsistencies between the official regulations and their advantages in clinical practice.

Conclusions: We demonstrate the usefulness of mobile devices among surgical residents within the clinical care. Every hospital should regulate its policies for better use of devices.

mobile device

questionnaire

graduate education

communication

active learning

For the current generations of medical residents born between 1981 and 2000 (the period of technology boom), who are known as “Millennials,” the usage of mobile devices and technology for all activities, including learning,¹ is natural and common. These are portable electronic devices that allow wireless communication, provide constant connection to the Internet, enable exchanging emails and text messages, provide access to social networks, and enable conducting video conferences.^2,3

In this respect, mobile learning refers to the use of mobile or wireless devices for learning purposes while on the move.⁴ It is a learning technique that can be applied in multiple contexts through social and content interactions. “Mobile” learners can use it as an educational technology in a variety of settings available at their convenience.^5,6

In medicine, new technology offers the potential to enhance learning and patient care, although it also poses potential risks, such as superficial learning, failure to understand how to discriminate reliable sources of information, distraction, inappropriate use, and privacy-related issues. It is important for leaders of medical schools, hospital teaching, and healthcare organizations to consider this rapidly developing area to maximize its benefits and avoid harmful unintended consequences.^2,7

Several surgical specialization courses with university recognition are taught in our hospital. The resident acquires the necessary skills to meet the specialist profile through a competency-based learning system.⁸ One of the essential aspects required to evaluate the performance of surgical residents is clinical case presentation and number of surgical procedures performed. Both activities take place within the context of hospital care and learning.⁹

Currently, students and residents of surgical specialties use different mobile devices on a daily basis for personal use and as part of their training in the specialty.¹⁰ Access to medical information provides these devices with the potential of changing how medicine is learned and probably, how it will be learned and practiced in the near future.¹¹ As the literature on mobile learning by residents of surgical specialties is scarce in general our objective was to investigate this topic to promote the adequate use of mobile devices by teachers and students.

This study had a mixed triangulation design. Quantitative and qualitative data were generated simultaneously and involved the same population of residents to include them in the final analysis.¹²

A Likert scale online questionnaire consisting of 22 items with multiple-choice answers plus an open question was used to obtain the quantitative data. Three experts in medical education—two psychologists with expertise in medical education (TV and AA) and one specialist in pediatric surgery with > 25 years of teaching experience (EBB)—prepared this questionnaire based on two very similar questionnaires used for the same purpose that did not report psychometric values.^3,8 The measurements included in the questionnaire were as follows: demographic data (age, sex, and year of residence), patterns of mobile device use (for communication or learning and its frequency), communication (with other residents or attending physicians), information search in the context of hospital care (frequency and reason: definition, clinical presentation, diagnosis, and treatment of diseases), sources of information consulted, medical software applications (frequency and type), perception of the device as a support for medical education and limitations of the device.

This anonymous questionnaire was applied to the total population of pediatric surgery residents and those taking high-specialty pediatric surgery courses (neonatal, anorectal, oncological, minimally invasive surgery and urology).

The quantitative data were analyzed via a simple discriminant analysis as the number of residents was small. The focus group technique was used to obtain qualitative data, allowing us to determine the experiences of residents regarding the use of mobile devices for learning, medical care, and communication within the clinical context. The interview guide was prepared with the same measurements as the questionnaire. A sequential analysis of the texts was performed using open coding intended to translate data into concepts, followed by axial analysis that synthesized and integrated the concepts into categories.¹³ Subsequently, the data from the two sources of information were triangulated to obtain the interpretations.

Ethical aspects:

The questionnaires were answered anonymously by the residents and subsequently analyzed by one of the authors. Participation in the focus group was voluntary, and the residents were explained the reason for the group interview. The anonymity of the testimonies was guaranteed by the means of identifiers in which the year of residence and sex were noted. The participants were also reassured that their answers would have no working or academic repercussion, and they were then asked to sign an authorization to allow audio recording of the interview and their participation in the study.

The instrument was introduced to the 20 residents attending the academic year 2018–19 during October 2018. The questionnaire was answered by 15 (75%) residents. The interviews for the focus groups were performed in January 2019 and all the 17 residents in the hospital at that time were invited to the interview, of which 15 agreed to participate (88.2%, 11 men and 4 women). They were distributed into two groups.

Regarding demographic characteristics, most of the residents were aged 30–34 years (66.7%) and most of them were men (86.7%). In our hospital, the pediatric surgery specialty is completed in 4 years and the subspecialties are introduced in the 5th and 6th years. The distribution of the residents based on their year of specialty was as follows: 1st year (20%), 2nd year (26.6%), 3rd year (20%), 5th year (20%), and 6th year (13.3%).

All the surveyed residents used a smartphone as a mobile device in hospital care. The main usability features included portability (53.3%), accessibility (20%), and practicality (20%).

Through the simple discriminant analysis with percentage of original grouped cases classified correctly, the main functions used for communication were communicating with other residents and taking clinical photos, whereas the main functions used for learning were speaking with attending, consulting patient information, and searching for unfamiliar terms. Almost all participants used it more than once a day within the context of hospital care. Table 1

Table 1. Results of the simple discriminant analysis regarding the functions and frequency of use of mobile devices in hospital care

	Use of the Mobile Device for Communication Purposes	Use of the Mobile Device for Learning Purposes
Function	Communication with other residents and taking clinical photos (86.7). The use of mobile devices aids communication in the context of hospital care in terms of sharing and accessing information on surgery and searching for medication data (80). It improves residents' skills by facilitating the communication of ancillary test and surgery data (80). In the future, the device will become essential to communicate clinical presentation and laboratory tests of patients (80)	Talking to attending physicians, viewing medical or surgery videos, examining patient information, and searching for unfamiliar terms or concepts. Taking notes and making to-do-lists (86.7). Maximum advantage can be taken from the device, especially for learning the details of a surgery (80)
Daily Use	Treatment: data on surgery, clinical features of patients, and laboratory test/imaging analysis are shared with residents or attending physicians (100). Prognosis*: patient information is communicated.	Drugs: reading medical journals, searching for unfamiliar terms, and taking notes (93.3). Treatment:* unfamiliar terms are searched, and annotations are made (100). Applications:* information from applications is used for patients, photos are taken, and annotations are made. Medical articles are also read (93.3*).
Weekly or Monthly Use		Patient progress: reading medical journals about the prognosis of patients (100). Applications: they use UpToDate to perform more elaborate tasks, such as reviewing case presentations and lessons (100).
Device Limitations	They are less useful than a tablet or a laptop to communicate ancillary diagnostic tests (73.3). They consider that using the device in hospital care can pose a hygiene risk (73.3).	When used in the classroom setting, it can be a distraction to learning for residents (80). Regarding consultation of surgery data, the size of the mobile device display discourages them from using it more frequently to search for information on surgeries (73.3). They are concerned that using the mobile device in the presence of the patient has a negative impact on the image of the doctor (73.3*).

(*) = % of original grouped cases classified correctly

The triangulation of the quantitative and qualitative data yielded five general categories: agile communication during medical care, drug information and disease progression, consultation of medical applications, limitations of mobile devices, and inconsistencies between the official regulations on the use of mobile devices and their advantages in the medical practice.

Agile communication during medical care

Most residents agreed that mobile devices aided communication, supported clinical practice and hospital care by enabling the search for data on drugs and surgeries. Likewise, they helped the residents communicate data regarding surgeries or examinations of patients, and the residents believed that mobile devices could become an essential medium to communicate data in the future. The use of mobile devices also allowed them to manage and resolve any uncertainty as they could communicate with peers and residents of higher-hierarchy and with more experience to resolve doubts or confirm decisions during their clinical activity.

In this respect, mobile devices were mainly used to capture and send clinical images (after obtaining prior authorization from the patients or parents), making it possible for lower-grade residents to get the opinion of more experienced attending physicians or residents.

Mobile devices were also useful to report the patients’ progress, notify the residents about shifts and emergencies, report laboratory or imaging results, and clarify doubts. Said communication was conducted using the WhatsApp® application, mainly through text messages (used by 93%), and allowed the residents to share multimedia content, text, voice messages, and documents. The social network was preferred for its practicality (50%) and popularity (21.4%).

The creation of groups in WhatsApp® was also relevant as the residents could disseminate the same information to several colleagues and avoid distortions in communication or unintentionally leaving out someone who would need to be informed. Likewise, it was found that the communication time was considerably reduced, which was very valuable, particularly in emergency situations.

Regarding the management of medical information for their learning, all the responders used the device to search for medical terms and read medical journals. Further, 99.3% used it to read medical books, watch medical or surgery videos, and take notes; 86.7% used it to make to-do lists and read medical news; 73.3% used it to write down tasks accomplished; and 66.6% used it to attend online lectures and listen to medical podcasts.

Drug search

All residents used the mobile device daily to search for drug data, unfamiliar terms and to take notes. They found it particularly useful to search for information on the dosage of some drugs and review drug interactions, especially in patients with very complex diseases.

Patient progress and prognosis

Residents used the mobile device daily to take notes, share patients’ information and send photos of clinical images. It was used sporadically, on a weekly or monthly basis, to read medical journals on the progress and prognosis of patients.

For any query that residents have during their traineeship, they used web searches. The most frequently used search engine was Google® (86%). Most residents (42.9%) based their decision of opening a particular page on the journal name. All residents searched one or more times per day for issues related to disease definition, medications, surgeries, and complications.

Consultation of medical applications

A very important functionality of the mobile device for the residents in this study was the consultation of applications (medical apps) considering that 80% of the residents used them. Among them, 50% of the interviewees used UpToDate®, 20% used Read by QxMD, 20% used PubMed®, 13.3% used Stay Current in Surgery®, and 13.3% used Pedz®. UpToDate® was more often used weekly or monthly than daily. For residents, this application had the advantages of being downloaded even with poor internet connectivity, regular updates, and categorization to display the specific information desired. Using medical apps, residents took notes and photos, thus helping them to perform more elaborate tasks such as academic presentations.

Regarding the limitations of the mobile device, most residents agreed that it can be a distraction if used in the classroom. Also, they expressed that it is less useful compared with tablet or a computer for disseminating radiological images or reading texts. Likewise, they believed that its use in hospital care can pose a hygiene risk. They also thought that the display size can sometimes hinder the perception of the details of a surgical procedure.

Inconsistencies between the official regulations on the use of mobile devices and their advantages in the medical practice

Residents remarked that there were inconsistencies regarding the use of mobile devices in hospital settings. On the one hand, attendings demand the use of mobile devices as they speed up and improve communication among peers. On the other hand, the use of mobile devices is prohibited in the hospital (like tablets) to send patients’ clinical information.

Internet connectivity is restricted, and residents must request full access as a special favor to those in charge of the telecommunications service. Further, 93.3% of those surveyed reported that it would be beneficial to legislate and regulate the use of devices in the hospital setting as they will be increasingly used in hospital care.

As a suggestion to resolve this inconsistency, residents remarked that the institution’s regulations on the use of mobile devices should be established, not only from the administrative point of view but also considering the medical insight. They expressed the relevance of educating healthcare personnel on its ethical use, providing greater knowledge of the technological potential and usefulness in patient care while avoiding hygiene risks, as well as the authorities regulating the use of media within the hospital so that they can learn about the benefits that mobile devices offer throughout the patient care process.

Examples of residents’ testimonies about the use of mobile devices during medical residency are presented in Table 2.

Table 2. Examples of testimonies of the interviewees about the use of mobile devices during medical residency

Agile communication during medical care	…we receive instructions from our higher-hierarchy residents. We can also instruct our lower-hierarchy residents on the follow up of patient plans. (R6-MALE)* …we ask permission to take photos. Sometimes we want to show other clinicians or one of our colleagues the characteristics of a drainage. We take photos, not of the patient’s face, but of the drainages, the catheter, or the surgical wound. We explain them (the patients) that the photo is to be sent to other clinicians. (R5-MALE)* WhatsApp® is a tool to send information to the whole group at the same time. You do not need to send the information individually. It reaches all members in the same way, such as different images, indications, laboratory results, etc. (R5-FEM). We even have groups with our attending physicians where we discuss the patients’ progress over the weekend (R5-MALE).* I took my cell phone and sent the message, and it took me less than 1 minute to do so. Otherwise, I would have had to go to the landline telephone, ring, call out, explain, and wait. In our area, where we have emergency cases, we can solve those issues rapidly. (R4-MALE)*
Data search for medical products	…when I get to use it (the mobile device), it is to consult the dosage of some drugs. Mainly because the patients that we encounter have very complex diseases. There are very special drugs. Most of all, in terms of dosage or some drug interactions. Or in cases when we cannot use a certain drug due to some other pathology they have. (R4-MALE)*
Patient progress	…when all of us (attending physicians and residents) are no longer physically present due to being on-duty, weekends, and holidays, we monitor the patients’ progress using the mobile device. (R4-MALE) * The use of mobile phones allows us to share information and be aware of the patients’ progress. (R4-FEM)*
Consultation of medical applications	The advantage of UpToDate® is that it is a platform that is continuously updated. It has the update date; it almost always is the current year. (R5 -FEM)* It is easier to read on a slightly larger display than on a mobile screen, such as that of an iPad or a tablet. (R5-MALE)*
Inconsistencies between the official regulations on the use of mobile devices and their advantages in the medical practice	There is a lot of discrepancy on the use of cell phones. About 6 months ago, there was a poster explaining that it was illegal to disseminate clinical information about patients via cell phones or to take photos. (R4-MALE)* …it is prohibited, but our attending physicians and other clinicians demand their use to make certain decisions. (R5-MALE)* It is ambiguous; is it prohibited or not? There is the Internet, but it is not for free use. (R4-FEM)* Sometimes if you get on well with the IT expert, he/she lets you access some networks. But they change passwords every 2 weeks. Then you must socialize with them again. (R4-FEM)* There is a need to regulate its use. Since it is not regulated, if we make a clinical decision based on a message or an image sent by WhatsApp®, we might very easily believe that we did something improper because it is not regulated. (R5-MALE)*

*In parentheses year of residence and gender of commentator

To identify the usefulness of mobile devices in communication, learning, and clinical practice among residents of surgical specialties of a third-level pediatric hospital, mixed methods have been introduced to address health challenges and problems with a broad perspective and with as little uncertainty as possible.¹⁴

Those with surgical specialties frequently encounter seriously ill patients and are required to make urgent decisions assertively.¹⁵

This study shows how the use of mobile devices helps to aid communication between residents and the attending physicians and clinicians of different academic degrees, improve learning processes and clinical practice, and support hospital care as they allow them to search for drugs and surgery data. As reported in the literature, WhatsApp® was the application preferred by medical students to establish communication and academic relationships among peers as it has the added advantages of being free of charge and easily accessible, with the only requirements of having a smartphone and internet connection.¹⁶

Likewise, it has evidenced the tension existing between the need for communication through these devices and the hospital regulations regarding their use.

Mobile devices also promote teamwork as it allows them to manage and resolve uncertainty by communicating with peers and higher hierarchy, solving doubts, or confirming decisions during their clinical activity, becoming a multi-channel learning.^4–6

When medication prescriptions, mobile devices become an effective tool as there is no pharmacist in charge of monitoring said interactions in our hospital..¹⁷

The testimonies of the residents show the inconsistencies in the official regulations on the use of mobile devices and their advantages in medical practice, revealing the need to review the administrative rules about the use of mobile devices. This issue could interfere with the learning process of the residents as well as patient care, instead of promoting learning and teamwork.¹⁸

Other similar studies found that mobile devices with internet access can be a valuable tool for residents to search for information from different sources (videos, images, books, and specialized journals) in a simple and fast manner and at the right time.^19–21 The development of mobile devices with greater capacity and larger displays, coupled with high-speed internet connection, also facilitates distance learning (e-learning) through a wide range of uses, thereby improving communication and diagnosis with the aid of several applications,²² which surgical residents frequently use.²³

One strength of this study is that the mixed design helped reveal the experiences of the residents regarding the use and utility of mobile devices in the hospital setting. The small number of included residents is a limitation. However, to address this limitation, we used a discriminant analysis and qualitative data analysis. The data were collected before the Sars-Cov-2 pandemic, and perhaps the study would have yielded different results if it was conducted at present. The surveyed and interviewed population included only residents of pediatric surgical specialties. Therefore, the generalizability of these findings to residents of pediatrics or other surgical specialties remains unknown.

The present study provides evidence that mobile devices are a necessary learning tool used daily by surgery residents to help communicate within the clinical care context, ensure teamwork and speed in delivering medical attention, and facilitate theoretical learning.

The professors and administrators of surgical specialty courses must understand the role of mobile devices in a hospital setting and thus establish local policies to optimize their use.

4-year residence

5- year residence

6-year residence

Ethical approval and consent to participate

The ethics approval for this study was granted by the Research Ethics Committee of the Hospital Infantil de México Federico Gómez, with register number under authorization HIM-SR-2021-004.

All methods were performed in accordance with the relevant guidelines and regulations.

Consent to participate

Participants read and signed Informed consent forms prior to participating in the study.

Consent for publication

Not applicable

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to the nature of the data but are available from the corresponding author on reasonable request.

Corresponding author

Dr. Eduardo Bracho-Blanchet

Department of General Surgery Hospital Infantil de México Federico Gómez

Dr. Márquez 162, Col. Doctores, Mexico City, Cuauhtémoc, 06720, México.

e mail.- [email protected]

Competing interests

The authors declare that they have no competing interests.

Funding

No funds were required.

Authors' contributions

TVV: Conceptualized, drafted the paper and conducted fieldwork

AAH: Conceptualized, drafted the paper and conducted fieldwork

DAM: Literature review and drafted the paper

EBB: Conceptualized, analysis and drafted the paper

All authors read and approved the final version of the manuscript.

Acknowledgments

None

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No competing interests reported.

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Usefulness of Mobile Devices in Learning Within the Clinical Setting for Residents of Surgical Specialties in a Tertiary Care Pediatric Hospital

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