Meadville Tribune

July 24, 2013

Could a smartphone physical be in your future?

By Ravi Parikh
The Washington Post

— As my attending physician walked in with the next patient, I quickly stuffed my iPhone into my pocket. There was a strict "no cellphone" policy in the pediatric clinic where I was working as a third-year medical student. If my attending had caught me, I would have received a stern lecture about how cellphones were not to be used while patients were in the room.

We proceeded to examine the patient, a young boy named Tim, who had an earache. As part of the routine physical exam, I used my otoscope - a device first described in 1363 - to examine Tim's eardrum. Unfortunately, it was difficult to see the characteristic cone-shaped membrane. The more I maneuvered the otoscope, the more Tim yelped in pain. I finally gave up and admitted that I couldn't find the eardrum. Tim had been subjected to enough agony, and we sent him home with a course of antibiotics for a presumed ear infection. My attending later confessed that after 10 years of practicing, she still sometimes had trouble seeing the eardrum.

I remembered Tim's eardrum when reading the 2013 program of TEDMED, an annual conference in Washington showcasing the most promising medical advances in the country. A medical technology blog that I write for had organized an exhibit called "The Smartphone Physical" to showcase smartphone apps - many of them already commercially available - that doctors could use in a physical. As part of the exhibit, the team used CellScope, a mobile phone attachment to show attendees a picture-perfect magnification of their inner ear canal - much clearer than I'd seen with my otoscope.

I recently mentioned the device to a pediatrician. "That'll be the day," she replied.

 Many doctors share her skepticism of smartphones in medicine. Less than half of attending physicians in a recent survey reported using smartphones for patient care. Many doctors worry that these technologies will hurt their relationships with patients. In a 2012 essay in the Journal of the American Medical Association, Georgetown University physician Caroline Wellbery warned that "these devices deprive us of the very essence of presence. . . . We may be surrendering our capacity to be in the moment."

But what if these technologies not only make physicians' physical exams easier but also improve our interactions with patients? Smartphones can offer doctors a more reliable exam while increasing patient involvement in their care. Within the next decade, the smartphone physical might replace the traditional physical exam. Even now, the long-standing "routine physical" may no longer be so routine.

The traditional physical exam may be overrated when it comes to picking up diseases. A chest exam done as part of a physical, for instance, has been found to pick up only half of all pneumonias. A study found that stethoscopes wielded by young doctors correctly identified only one-fifth of previously diagnosed heart conditions.

So while the traditional physical exam may be hands-on, it's probably time to find ways to improve it; to me, smartphones offer that possibility.



Smartphone EKG



How can doctors wielding smartphones make a physical exam more effective? Technologies such as CellScope are often smaller and less unwieldy than otoscopes, stethoscopes and ultrasounds. "The Smartphone Physical" included a smartphone case that doubles as an EKG machine. Participants could get readings of their heart rhythms just by placing their fingertips on sensors located on the back of the smartphone case. By contrast, a standard single-lead EKG usually requires a technician to attach sensors to a patient's body in a clinic, doctor's office or, often, ambulance.

A study of the smartphone EKG presented at the 2012 American Heart Association annual meeting showed that its results were as accurate as a single-lead EKG at detecting atrial fibrillation and other arrhythmias. (Hospitals and emergency rooms use 12-lead EKGs to detect heart attacks and other conditions.)

Furthermore, the new device allows patients to participate in their own exam: The EKG readings can be transferred directly from iPhone to the Web, enabling a doctor to remotely look for specific heart wave abnormalities in real time - as opposed to having the patient go to an ER or doctor's office to be evaluated.

One doctor has used the app on two occasions to diagnose life-threatening heart conditions on airplane passengers in distress.

These devices also can increase patients' ability to understand their own care. Smartphone technologies provide user-friendly visual and audio output that patients can have literally at their fingertips and, with help from their doctor, can be shown how to use and understand at home as well.

Imagine, for example, that you didn't have to wait days to get your blood pressure checked at the doctor's office (where blood pressure readings are often artificially high due to "white coat syndrome". but could instead measure it whenever you wished using a smartphone blood pressure cuff attachment whose results would be transferred instantly to your doctor. This would not only be easier for patients but could provide more accurate results for the physician.

As Shiv Gaglani, a Johns Hopkins medical student and the curator of the "Smartphone Physical" exhibit, notes: "Some of the smartphone devices are already being used by patients to collect and store their data, so when they see their clinicians they can have productive and informed conversations."

Smartphone medical applications are also, on average, less expensive for physicians and clinics than traditional diagnostic tools. Some insurers charge $50 per EKG to insured patients; uninsured ones, though, can pay over $1,000 for one. By contrast, the mobile EKG attachment has a one-time cost of $199, which means doctors will be able to charge their patients less.

As difficult as I find them, the otoscope and other traditional tools will remain a large part of medical practice for the near future. And to be fair, doctors grew up training with these tools; learning the smartphone physical would come with time and opportunity costs. But doctors should also realize the deficiencies in some of these older technologies and how smartphones can address them. Hopefully, the "no cellphone" policies will then also turn into a relic of the past.



Parikh, a student at Harvard Medical School and the John F. Kennedy School of Government, is an editor of MedGadget, the blog that co-organized the "Smartphone Physical" exhibit at TEDMED 2013.