The aim of this study was to explore hurdles in the adoption of iPads in the clinical phase of the medical degree, as well as to examine differences in hurdles faced by the three consecutive years of iPad-cohorts entering clinical education. This was to get an idea of how well the clinical environment was receiving the tablet computers given their value as aids in learning clinical medicine. The response rate of the first cohort in 2016 was as high as 90% which is in line with the novelty of the use of iPads in the clinical setting. Decrease in the response rates with subsequent cohorts is likely due to questionnaire fatigue. The use of mobile phones, tablets, and laptops by new students at the beginning of their degree studies largely mirror overall adoption of mobile technology in the general population.
The same type of research on the use of new technology by successive medical student cohorts in the early stages of clinical courses had not been conducted before. However, our results were consistent with previous research findings (1, 3, 15). Both previous research literature and our own previous research on the first cohort of medical students reported challenges in incorporating devices into clinical settings (13, 17, 18, 19). For students, this was problematic because they were accustomed and proficient in using mobile devices in the biomedical science courses in their first two study years (19), and it was in the clinical setting that the importance of online information sources increased as they participated in patient care and needed immediate access to e.g. clinical databases. Eventually, they ended up using their personal smartphones for this purpose. Resistance did not end completely with the first cohort, but the use of mobile devices for information retrieval, in turn, increased significantly among students in the second and third cohorts. This may be due to the general increase in the use of mobile devices, good practices passed on by older students to their younger colleagues, reporting preliminary results to teachers on the clinical phase challenges of the iPad project (19), and tailored support for clinical teachers (18).
As reported in previous studies (13, 14), students experienced ambivalence in mobile device use with patients. We observed that any mobile device use in direct patient contact raised serious concerns among students. They were also worried that using the device might deteriorate their communication with the patients (2, 7, 13, 14). In addition, they feared that senior physicians and other health care professionals would construe their behaviour as unprofessional or misinterpret their online information seeking for personal communication on social media (13, 14, 15). The few studies exploring the patients’ own perceptions of bedside usage of mobile devices reported positive attitudes among patients (6, 10, 12). We have not yet collected data from a patient perspective, but we believe that using the new technology together with patients would be an important target for future research. In addition, the use of mobile devices in a clinical setting requires open guidelines and codes of conduct (7, 14).
Previous studies reported that poor Wi-Fi access and therewith problems with accessing the Internet and digital learning materials in the clinic were major barriers to benefiting from mobile devices in the clinical context (12, 16). In our own earlier study, students who were accustomed to receiving learning materials in biomedical courses on time and in a format suitable for mobile devices complained that in clinical courses, materials were delivered too late and in an inappropriate format for taking notes (19). Because clinical teachers rarely used digital pre-assignments or online assignments in the courses, several students eventually left the iPad at home. Comparing the results between the three cohorts entering the clinic, there was a slight positive trend towards more active use of the digital learning environment and better reception of the mobile-savvy students in the clinical context over time.
We found a significant discrepancy between students’ own reported ability to use iPads for study and their teachers’ ability to apply these devices to teaching. Both improved with the following cohorts. A comparison of the three cohorts showed that the ability of teachers to apply the digital environment effectively and accept students’ mobile devices improved relatively slowly. This suggests that it is important that teachers receive adequate training and support in the use of new technologies. On the other hand, it is important to support teachers in gaining practical knowledge of the format in which the learning materials should be distributed electronically, evident by the lower incidence of format-appropriate materials used compared to preclinical courses (19). The knowledge of how to create and implement digital assignments as part of the course is central for executing a mobile friendly curriculum.
An important finding of this study was the fact that practically no students seemed to use the iPad for backing up clinical reasoning. This despite a majority reporting using it for seeking information. The results may be in part explained by difficulties in interpreting the questionnaire statements. Some students might also be unfamiliar with the concept of clinical reasoning so early in their clinical studies.
Another noteworthy finding lies in the mobile devices use for taking notes on patient information. Whilst students almost unanimously reported never taking notes on patient information with their mobile devices, ca 20% of students from each cohort reported never deleting patient information from their device. The discrepancy may indicate that more students used their iPad for taking some notes on patient information than cared to admit it in the questionnaire, or some students simply felt they would not need to delete patient information if they took notes of them using their iPad. The possibility of difficulty interpreting the question remains. In our medical faculty, students are only allowed to write patient record information under supervision, but they participate in bedside instruction and examine patients, and are allowed to fill out paper forms when interviewing and examining a patient.
Mobile devices are in themselves powerful devices, even using only a web browser. However, the mobile revolution has also been based on the development of innumerable medical applications. In line with previous research (16, 17), our study showed that teachers provided students with very little information about high-quality medical applications (19). These results remained similar in all three cohorts. The novelty of mobile devices in clinical teaching may be one explanation for this, but over time the question arises as to why so few clinical teachers recommended good medical applications to students or used applications as part of their clinical teaching (16, 17, 19).
Strengths and weaknesses of the study
The strength of this study is found in part in the duration of the iPad research project, having started in 2013, and data having been gathered on all subsequent student cohorts until 2020. No similar study has yet been found to track cohorts of medical students using their mobile devices throughout the degree. Furthermore, a total of three cohorts were analysed for this study, which provided results on the use of mobile devices in clinical courses from their introduction to routine use. The response rates of the study were satisfactory. With the lead author being a student of one of the studied cohorts also unique insight into the phenomenon studied was utilized. The research project has actively collaborated with both students and faculty, yielding benefits from the iterative process. This study delivers on previously identified interesting results that have been reported in international conferences and published in peer-reviewed articles (18, 19).
There are also limitations in this study. We did not find a validated questionnaire in the research literature on the use of mobile devices in medical education, so we designed the survey ourselves. In addition, one limitation was that it was performed in a single medical education unit. However, as no such study had been published, we thought that a detailed study of students’ perceptions of barriers to mobile device adoption in a clinical setting would provide useful information for units incorporating new technology into their teaching. The Covid-19 pandemic has also likely increased interest in online learning in all medical education units.
Future directions
A large amount of both quantitative as well as qualitative data has been collected as part of the iPad research project from 2013 through 2020. The next step is to analyse the students’ answers to the open-ended question using qualitative content analysis. In addition, it is interesting to study how these student cohorts responded to mobile learning surveys in later courses.
Further topics to look into will be patients’ perception of the use of mobile devices in clinical encounters, particularly by involving patients in the development of the use of digital devices and applications in healthcare. The use of social media by students and young doctors as sources of medical information is also an important topic that should be examined.