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Perceptions of doctors, medical students, and patients on the use of smartphones and digital devices in patient care
Correspondence to AMITABH SAGAR; amitthephysician@gmail.com
[To cite: Sagar A, Sharma A, Sagar A, Pathak A. Perceptions of doctors, medical students and patients on the use of smartphones and digital devices in patient care. Natl Med J India 2025;38:339-43. DOI: 10.25259/NMJI_364_2023]
Abstract
Background
Integration of smart mobile devices (SMD) like smartphones and digital tablets into medical practice continues to be hindered despite the benefits of access to guidelines at the point of care and patient safety. The barriers include administrator attitudes, perceptions about how patients would receive it, shyness about accessing it in the presence of coworkers, and perceived attrition in medical education. We aimed to understand the perceptions of doctors, medical students, and patients about the use of SMDs in patient care areas.
Methods
A cross-sectional survey of doctors, medical students, and patients across multiple states in India was conducted. Data were collected using a validated questionnaire after ethical clearance and participant consent. A sample size of 385 was estimated for each group (95% confidence interval, alpha error 0.5, power 80%).
Results
406 doctors, 425 medical students, and 418 patients responded to the survey. 92% doctors, 96% medical students, and 57% patients owned an SMD. 81% doctors had used an SMD for patient care, with a little over 50% having used it in front of their juniors, and only 34% approved the use in patient contact areas. 99% medical students used SMD for studying; 93% advocated it to their juniors for learning, but only 68% used it in front of their juniors, and 29% in front of their patients. About 90% patients were ready for doctors to use SMDs in front of them, with over 75% agreeing that SMD use will lead to better and safer care.
Conclusions
SMDs are widely used in the patient care area and for medical education. Some perceived barriers such as patient perceptions about doctors require behavioural change and acceptance of changing times.
INTRODUCTION
Smart mobile devices (SMD) like smartphones and digital tablets are commonly used by medical professionals for access to medical guidelines, research at the point of care (POC), and for global consultation with colleagues at short notice.1 The uses of SMD in medicine by both patients and doctors include patient education materials, health monitoring applications, and linking patients to the central monitoring stations for monitoring via smartphones. Uses only among doctors include routine calls, texting, storing/sharing files, camera, social networking and checking drug dosages/interactions, and POC clinical decision-making tools. Among these, non-clinical use may evoke concerns (Table 1). Despite the benefits of SMD in medicine, some reluctance to their use still exists.
| 1. Distraction in patient area: Use of e-mails, social networking. |
| 2. Do patients approve of doctors using technology for better patient care? |
| 3. Are doctors who use SMDs in front of patients perceived as underconfident, and do patients approve of it? |
| 4. Does the administration approve the use of SMDs for patient care? |
| 5. Should SMDs be carried to patient contact areas? |
| 6. SMDs as a potential threat leading to ‘superficial learning’: Easy access inhibiting internalization of knowledge (traditional medical education) |
| 7. Concern about the validity of the information provided |
| 8. SMD use: Does it save time in patient care? |
| 9. Eminence of the senior doctor melting away in front of juniors if seen using SMD for patient care. |
We did this study to understand the perceptions of stakeholders (doctors, medical students, and patients) regarding the use of SMDs in the domains of patient care, perceived approval, patient safety, use in patient contact areas, validity of available information, and their application in medical education. We also aimed to validate or dismiss common concerns on the use of SMDs for patient care.
METHODS
We conducted a cross-sectional survey among currently practicing doctors (any specialty), medical students currently enrolled in undergraduate training (MBBS), and outpatients and inpatients not receiving psychiatric treatment at various hospitals/medical colleges in the states of Maharashtra, Haryana, Chandigarh, and Uttarakhand. The Institutional Ethical Committee clearance was obtained prior to starting the study.
Sample size and sampling technique
There are about 1.16 million allopathic doctors registered in India.2 With a population of 1.3 billion, India has more than 479 medical schools with about 336 090 MBBS students studying at any time.3 A sample size of 385 each of doctors, medical students, and patients was arrived at with a 95% confidence level, a margin of error of 5% and a power of 80% for the study. Assuming a 30% dropout rate of incomplete or no responses, a higher number of questionnaires were sent out.
We used a convenience sampling technique. This was a non-probability sampling approach that voluntarily involved participants who were available to give an opinion. Attention was given to ensure adequate representation of various disciplines (medicine, surgery, etc.) to participate in analogous sample sizes.
Data collection
The survey was composed of the following components:
Demographic characteristics: Limited non-identifiable data relating to experience, qualification level, and specialty were collected.
Ownership and pattern of usage of SMDs: Ownership of an SMD, types of health-related applications used, frequency, and area of usage (patient contact area, classrooms, or otherwise), etc.
Perceptions about use of SMD: For patient care, approval, patient safety, use in patient contact areas/in front of patients, validity of information available, and use in medical education.
The survey used 3 different physical questionnaires, as well as web-based questionnaires for doctors, medical students, and patients, respectively. The physical forms were distributed in person, and the electronic ones were sent via social media platforms (WhatsApp and email). The survey moved to additional respondents via the technique of snowballing. The physical forms were requested to be folded and dropped into an opaque bag, which the investigator carried with him.
Consent to participate was obtained from the respondents (physically on the form or electronically, as applicable, on the first page of the survey). The survey was in English. The survey contained closed-ended questions (with multiple choices, single response), Likert scale-based responses, and some free text options.
The questionnaire was pre-validated through a pilot study (on 10 doctors, 10 patients, and 10 medical students) for ease of readability, understandability, and any discrepancies.
Data analysis
Incomplete responses were excluded from analysis. The study was anonymized as we did not collect any identifiable data. Subsequently, the data were subjected to descriptive analysis using Microsoft Excel. Simple proportions and percentages were used for the analysis.
RESULTS
406 doctors, 425 medical students, and 418 patients were included in the study. The survey had a response rate of over 92%. 92% doctors, 96% medical students, and 57% patients surveyed owned an SMD.
14% doctors were involved in only administrative tasks. 81% (302/406) doctors who owned an SMD had ever used it for patient care (Table 2). Only 34% doctors approved the use of these devices in patient contact areas, and a little over half of them had used them for patient care in front of their juniors. In comparison, 99% of medical students used SMD for studying and 98% carried them to clinical wards (Table 3). On the other hand, 93% patients agreed that doctors should use SMDs for patient care, and 88% felt that it was appropriate if SMDs were used in front of them (Table 4). 79% patients agreed that the use of an SMD for clinical purposes had a positive effect on patient care and minimised adverse outcomes or errors. 74% of the medical students believed that SMD usage improved patient care with better treatment outcomes.
Some barriers to the usage of SMD are summarized in Table 5.
| Question | Per cent |
|---|---|
| Graduation year before 2000 | 61 |
| Smartphone ownership | 92 |
| Approved use of SMD in patient contact areas | 34 |
| Doctors who owned smartphones (n=373) | |
| Used SMD for patient care | 8 1 |
| Used SMD in front of juniors for patient care | 5 6 |
| Carried SMD to patient contact areas | 87 |
| Used only free medical apps | 78 |
| SMD smart mobile device |
| Question | Yes (%) | No (%) | Cannot say (%) |
|---|---|---|---|
| Smartphone ownership | 96 | 4 | 0 |
| Use of technology for studying | 99 | 1 | 0 |
| Carriage of smart devices to patient contact areas | 98 | 2 | 0 |
| Used SMD in front of patients to check medical knowledge. | 29 | 71 | 0 |
| Advocated use of SMD for medical learning to juniors. | 93 | 7 | 0 |
| Checked medical facts using SMD in front of juniors. | 68 | 32 | 0 |
| Concerned about validity of content on medical apps | 58 | 42 | 0 |
| Does your faculty approve of usage of SMD for patient care in front of patients? | 21 | 9 | 7 |
| Do SMD improve patient care? | 74 | 11 | 15 |
| Question | Responses (%) | ||
|---|---|---|---|
| 1. Education level | No formal | Less than | Graduate and |
| education (9) | Class 12 (46) | above (45) | |
| 2. Ownership of SMD | Yes (57) | No (43) | |
| 3. Should doctors use smart devices for better patient care? | Yes (93) | No (7) | |
| 4. Is it alright if your doctor uses a smart device in front of you for your medical care? | Yes (88) | No (12) | |
| 5. Can smart devices improve doctor’s performance towards better patient care | Yes (79) | No (10) | Cannot say (11) |
| 6. Doctors who use smart devices in front of patients are: | Under confident (16) | Confident with less chance of error (49) | Cannot say (35) |
| 7. How often have you seen doctors use smart devices in front of you (for your care)? | Once (51) | Seldom (35) | Often (14) |
| Group | Barriers |
|---|---|
| Doctors | • Administrator attitudes |
| • Perception that patients are not ready to accept this • Junior’s negative perception • Cost |
|
| • Lack of internet at key hospital areas • Medical education and learning will become weak in the long run |
|
| Medical students | • Lack of internet in patient areas • Administrator attitudes |
| • Patients not ready for this paradigm shift • Juniors may think that senior does not possess sufficient knowledge • Cost |
DISCUSSION
The salient finding of our survey is the sharp divide in perceptions of SMD use among the three groups surveyed. Over three-fourths of the doctors (81%) used SMDs for patient care, but only a little over half (56%) ever used them in front of their juniors or patients (although 87% of them carried the devices to patient areas). Almost all medical students (98%) carried SMD to patient areas and 93% advocated the use for patient care, but only a little over one-fourth (29%) used them in front of their patients (even while they felt more comfortable using them in front of their juniors to check medical facts (68%). Interestingly, 88% of the patients surveyed would not mind if the SMD was used in front of them. Four-fifths of the patients (79%) felt that SMD use led to better patient care delivery, with an overwhelming 93% feeling that doctors should use SMDs for better care.
70% medical students were unaware of faculty approval of SMDs, or they felt that at least the faculty had not objected to the POC use of SMD. Only 34% of the total number of doctors approved the use of SMD at POC, and only about half used them in front of their juniors.
A UK study estimated that 80% of physicians, trainees and medical students use SMD in medical practice and the use was expected to increase in the coming years.4 39% of 1501 physician users of SMD in the USA reported using clinical reference software at the POC (pharmacopeia, infectious disease reference, medical diagnostic or therapeutic reference).5 In another UK study on 213 participants (76 medical students, 65 trainee doctors, and 41 faculty members), to evaluate SMD use in medical education and practice, more than 85% of participants reported using SMD at the POC.6 Our findings were, however, different at 81% of doctors otherwise using SMD, but only 34% approved the use at POC, suggesting that use of memory was preferred in patient contact areas (even though 87% carried SMD with them). Over 75% of the medical students in our study believed that SMD use improves patient care, but less than 30% used the devices in front of patients. At the same time, 93% medical students advocated the use of SMD for medical learning, but only 68% used them in front of their juniors, suggesting some barriers between belief, advocacy, and practice. With medicine being a scientific art, it is the ethical front that often challenges the open usage of SMD in patient care settings.
A few questions arise on the usage of SMDs: does the use enhance patient safety, and is the use already an established practice? SMD has been in use in the West for clinical decision-making. National Institute for Clinical Excellence (NICE) UK and British National Formulary (BNF) have their own apps to provide POC access to prescribing information within the National Health Service (NHS).7 Patient safety is the cornerstone of modern medicine as well as for medicolegal disputes. Drug interaction checkers improve patient safety outcomes.8 A study compared the use of an SMD drug calculator versus a physical copy of the British National Formulary for Children (BNFC) for accuracy, speed, and confidence of prescribing in a simulated paediatric emergency. The study concluded that the SMD arm was significantly more accurate and faster, with prescribers being more confident in their calculations.9 A randomized control trial (RCT) was conducted in the UK to evaluate the effectiveness of an SMD-based clinical decision support system (CDSS) on nonsteroidal anti-inflammatory drug (NSAID) prescribing safety in the outpatient setting versus conventional prescribing (in front of patients). Prescriptions were judged as safe or unsafe. It was concluded that participants using the SMD-based CDSS for NSAID prescribing made fewer unsafe treatment decisions than participants without the CDSS.10 The RCT also established that the practice of using SMD in front of patients is acceptable in the UK. NICE encourages medical professionals to use the apps at the POC to reduce medical errors.11
Patient perception of the use of SMD (in front of them) is positive and improves further (as a good communication and rapport gets established) once the patient is reassured of their safety.12–15
We also explored the use of SMDs in medical education. We know that medical students use SMD for studying, as well as at the POC, to check random facts. But the larger question is whether it is relevant and if seamless integration with medical education is possible. Till recently, medical education has traditionally focused on the internalization, organization, and application of a huge quantum of knowledge in the mind of the doctor. The National Medical Commission of India (NMC) brought out a new undergraduate medical curriculum in 2019, which now envisions the Indian Medical Graduate (IMG) to assume the responsibilities of a primary care doctor with the ability to provide compassionate, holistic care of health promotion and prevention, as well as provide curative and palliative treatment. The ‘5-star’ IMG should have competencies in 5 areas of clinical proficiency, leadership, communication, professionalism, and lifelong learning.16 Stage-wise learning outcomes for the curriculum are now clearly specified. Self-directed and problem-based learning, combined with early clinical exposure, has been introduced.17 This means that the medical student and the teachers know exactly what needs to be learnt. SMDs can thus be in a complementary role in medical learning.
58% of medical students surveyed expressed concern about the validity of the content of the medical applications they accessed. This leads to the question that are there any reliable sources, or do we need to develop new ones, and is there a need for ‘officially certified’ applications/websites? POC use of SMDs requires the applications to be reliable, safe, and have an evidence base. They need to have a seamless ability to be used by all. This will require a body of experts to evaluate existing applications and the need to develop more. The BNF is already in use across the UK and is the only one that is accepted in that country. A similar application for India needs to be developed. The American College of Physicians is the only professional body that supports, advocates, and provides DynaMed (a POC treatment guide software) as part of its subscription. DynaMed is automatically updated to provide appraised evidence, along with standard treatment guidelines, as recommended by various subspecialties worldwide.
Institutes of national repute like the AIIMS New Delhi, PGIMER Chandigarh, JIPMER Puducherry, and the Indian Council for Medical Research, New Delhi, already have management guidelines for many conditions. For use at the national level, these may have to be run through a body of experts, to suit the requirements for all (urban and rural), and then suitably made available in an application format for offline usage on the SMD (with the ability for automatic update when connected online). We feel that officially certified applications are the way forward for the use of SMDs at POC to deliver learning with patient safety, using technology. We also feel that SMD is an electronic version of updated books (just like ultrasound and echocardiography are today, as an extended clinical examination). The use should be self-regulated in patient care areas. Most institutions have mobile device usage policies that may be suitably tweaked to allow healthcare personnel to use the SMD at POC. Posters may be displayed at prominent hospital locations stating that healthcare personnel may be using an SMD, but it is for work purposes only (as is currently being done at the National Health Service, UK). This is an easily replicable model without any need for legislation.
SMD offers portability, speed, and ready access, as well as improving guideline adherence and ambulatory prescribing with improved clinical outcomes linked with critical care antibiotic prescribing.18 However, before recommending SMD use in patient care and medical education, we also need to check if we have internet connectivity. India has a large urban–rural divide in the distribution of medical colleges, as well as internet connectivity. India has the second-largest telecommunication network globally by number of telephone users (including fixed and mobile phones).19 Tele-density is defined as the number of telephone connections (traditionally for fixed lines) per 100 people in a specified geographic area. The national tele-density, total subscribers, and the break up for wireless and wired connections, as well as urban–rural distribution, are shown in Table 6.19,20
| Particulars | Wireless | Wireline | Total |
|---|---|---|---|
| Total telephone subscribers (million) | 1149.11 | 25.97 | 1175.08 |
| Monthly growth rate (%) | 0.09 | 1.34 | 0.12 |
| Urban telephone subscribers (million) | 627.09 | 23.98 | 651.07 |
| Monthly growth rate (%) | 0.06 | 1.38 | 0.10 |
| Rural telephone subscribers (million) | 522.02 | 1.99 | 524.01 |
| Monthly growth rate (%) | 0.14 | 0.83 | 0.14 |
| Overall tele-density (%) | 83.27 | 1.88 | 85.15 |
| Urban tele-density (%) | 129.75 | 4.96 | 134.71 |
| Rural tele-density (%) | 58.22 | 0.22 | 58.44 |
| Share of urban subscribers (%) | 54.57 | 92.35 | 55.41 |
| Share of rural subscribers (%) | 45.43 | 7.65 | 44.59 |
| Broadband subscribers (million) | 783.57 | 30.37 | 813.94 |
PM GatiShakti National Master Plan Platform for the 5G rollout services (launched in October 2022) foresees service delivery in villages through BharatNet, which aims to deliver broadband (and mobile connectivity) in border and hill states of India. Where terrestrial connectivity is unavailable or difficult, satellite connectivity for the internet is being started to connect the most remote communities.19 The connectivity issue should cease to be a major hurdle in the near future.
Globally, India has the maximum number of medical colleges (followed by Brazil and China). As of 2018, India had 640 districts (480 rural categories), but only 132 rural districts (27.5%) had a medical college (467 medical colleges nationally).21 Uttarakhand, Haryana, Madhya Pradesh, Uttar Pradesh, Rajasthan, Bihar, Punjab, and Assam had less than 30% of their rural districts with a medical college, with Jharkhand, Arunachal Pradesh, and Jammu and Kashmir having none in rural areas.21 Another study, published in 2020, examined 494 medical schools for urban–rural disparity in India. Two hundred and seven new medical schools (41.98%) opened between 2009 and 2019. Medical schools were situated in clusters in and around major cities and provincial capitals, with the median distance between a new medical school and an older medical school being just over 20 km.22 Thus, there are fewer medical colleges in rural areas, with clustering around provincial capitals. Whilst this is not good for healthcare delivery, it seems to suggest that internet connectivity should not be a challenge in most medical colleges.
There is a further scope of use of SMDs in medical education with the potential for artificial intelligence (AI). The AI adapts to the content presented and fine-tunes the questions to support the learner in grasping the specific concept.23 The authors feel that AI is likely to establish a role in medical learning in not so distant a future from now, integrating learning at the POC with SMDs.
In conclusion, the use of SMD is safe for patient care at the POC and is accepted in many parts of the world (including in front of patients), unlike in India, where barriers remain. However, we need to identify reliable sources of information, preferably certified applications for medical education or POC treatment. With an aggressive telecom push to the farthest corners of the country, the primary barrier to internet connectivity is also likely to fall. However, offline applications can step in where connectivity is still a challenge.
Conflicts of interest
None declared
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