Physicians have used mobile devices in clinical care for the last two decades [1-4]. Portable digital assistant devices (PDAs) were among the first widely adopted hand-held mobile devices, used by 15% of physicians in 1999 and by 60% in 2005 [1]. In the late 2000s PDAs were replaced by smartphones, and by 2011 the prevalence of clinical smartphone use by physicians in Accreditation Council for Graduate Medical Education (ACGME) programs in the United States was estimated at 88% [3]. As of 2013, smartphone technology provided access to more than 100,000 medical applications (apps) on the two main mobile device software platforms (iOS, Apple, Cupertino, CA, USA; Android, Google, Mountain View, CA, USA), 15% of which were directed at healthcare professionals [5]. These apps have functionality ranging from providing access to medical reference materials to electronic medical records and population health surveillance tools [1,3,5,6]. As of 2013, the United States Food and Drug Administration regulates apps that are used as an accessory to a medical device or to transform a mobile device into a regulated medical device (e.g., a phone used to record echocardiograms) [7]. However, the great majority of medical apps used by medical professionals remain unregulated. Several studies have further characterized the clinical applications of smartphones, including information gathering, communication between providers, and tracking usage by interns [8-10]. One study highlighted the perils of smartphone use during inpatient rounds, including distraction [11]. More general descriptions of smartphone use exist, including surveys of medical students and junior physicians in the United Kingdom and Ireland, and a study of clinical app usage by ACGME trainees noted different rates of adoption of smartphone use among specialties [3,4,12]. These studies have documented a rising rate of clinical adoption, including increasing opportunities for general and personal use, but no recent analysis of the general usage of smartphones by the United States medical trainees has been carried out.

Internal medicine trainees comprise the largest category of physicians in residency training in the United States [13]. While emergency medicine resident physicians provide care for medical conditions similar to those encountered in internal medicine, they do so in a different work environment, without the same continuity of care or participation in outpatient clinics [14,15]. The characteristics of these specialties allow for a unique comparison of smartphone use. In this study of two academic medical centers in the United States, we surveyed trainees in internal medicine and emergency medicine about their use of smartphones in clinical care with the objective of characterizing current clinical smartphone use, comparing patterns of usage between these two specialties, and identifying the frequency of prior training in smartphone utilization.

Our study presents the findings of an online survey about residents’ smartphone use in two major academic centers. The descriptive results suggest that although the study participants have adopted smartphone technology, their clinical use of smartphones mostly involved general features (email, web access, and text communication), with less frequent use of patient-specific apps (medical calculators or clinical scoring systems, disease diagnosis or management, and electronic medical records). Other studies have highlighted the use of general features in clinical care [9,10], but we were surprised by the degree to which residents used general features in clinical care more frequently than patient-specific apps. We hypothesize that this may be due to residents using laptops on wheels and tablets at the patient’s bedside and/or desktops in clinical workspaces to access patient-specific resources such as clinical calculators and electronic medical records. Since our study only focused on smartphone use, we are unable to characterize the other options that residents had to access these resources and their use thereof. However, due to the constant demands placed on residents during clinical activities, they may switch among these various modalities. Since residents use these resources to learn and provide care, further investigation into how these resources are utilized could yield areas for focused teaching to improve the efficiency and quality of care.

We found interesting differences between the frequency and types of usage of internal medicine residents and emergency medicine residents. Internal medicine residents used smartphones more often during clinical care than emergency medicine residents. The survey responses showed a higher rate of use of general features by internal medicine residents, including texting and email, which have previously been highlighted as important modes of communication for the medical team and obtaining medical advice [12]. Thus, internal medicine residents may be utilizing this modality as an important form of communication. Another potential explanation for the variation in use between these two specialties is the difference in environments and work flow. In the emergency department, the volume and acuity of patients are variable and unpredictable, leading to frequent interruptions of clinical tasks [15]. In contrast, internal medicine residents participate in work rounds in the hospital, admit patients on a predetermined schedule, and see patients in clinic in a lower acuity setting [16]. These circumstances might shape the frequency and type of smartphone usage of trainees. Due to its potential impact on quality improvement and patient safety, this is an area that should be further explored to understand the individual and systematic factors affecting these choices, as well as the associated outcomes for patients and providers.

We highlight the paucity of formal training regarding smartphone use in clinical settings. The lack of education and training in the usage of this technology is particularly important in light of the frequent use of functions that can result in breaches of patient privacy, including photos of patients and texting other providers [17]. Similarly, the lack of education regarding smartphone use can have a direct impact on quality of care and, potentially, patient safety. A recent study of common medical calculator apps found that only 43% of apps tested were 100% accurate, and in the rest, errors were often clinically significant [18]. The appropriate usage of such apps should be addressed in medical education by teaching students and residents how to recognize high-quality apps and how to use them responsibly in practice. In addition, medical institutions can recommend and/or develop apps that facilitate communication between providers while maintaining patient privacy.

This is the first study to present findings regarding residents’ smartphone use in two major academic centers. Although the study participants have almost completely adopted smartphone technology, their use is mostly for general features instead of patient-specific features. While we recognize that a relative increase of smartphone usage by the general public took place during the period encompassed by this survey, our study highlights a similar increase in smartphone usage by the United States medical trainees in academic centers [3,11]. Finally, prior training experiences in our survey were reported at a lower rate than described in a recent survey of University of Toronto medical students, suggesting that institutional variance may be present in learning opportunities [17].

The main limitation of our study is our descriptive analysis of a convenience sample of trainees in only two academic centers. In addition, recall bias could result in over-reporting or under-reporting of clinical use, especially of general features. However, we do note that our results can inform future studies of this highly relevant topic. Another limitation is that it some institutional variance in smartphone use is likely due to institutional culture and access to resources. Our response rate is comparable to those of prior studies, but response bias could be present, resulting in the under-representation of non-smartphone owners. Finally, as pointed out above, we surveyed two primary care specialties, and variance of use may be present within other specialties.

In conclusion, internal medicine residents and emergency medicine residents in two major academic medical centers have almost completely adopted the use of smartphones and clinical apps in their professional careers. The results of this study show a greater use of smartphones for general purposes in comparison to patient-specific functions. Respondents reported a perceived lack of education, training, and regulation of this technology as it relates to medical education, patient safety, and electronic medical information security. These results have implications for the ongoing integration of technology by medical professionals into patient care and raise issues for medical education training programs and chief information officers.