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Morning Report at an Intersection: iBook Therefore I Am

Morning Report at an Intersection: iBook Therefore I Am

The Rose of Tradition (Dr. Ross Morton cradling his 1980 edition of Harrison’s) between the Thorns of Technology (Dr. Jeff Wilkinson and Evan Wilson-two of our 3 co-chief residents, sporting iPads)


fig 2poem

Intersections, whether physical, cultural or technological are interesting. Here, decisions must be made, like Robert Frost’s famous choice between sylvan paths (spoiler alert: he took the one less traveled). For Frost, the choice led to profound personal change and made all the difference.

At Queen’s University in Kingston, Ontario, we have built a new three-way intersection. At this nexus, afig 3 venerable stalwart of medical education, Morning Report, the ability to self-publish eHealth media and a technological platform (the iPad) meet. It is at this intersection that we are choosing how doctors are trained. In 2010, iBooks® emerged from Apple® as a proprietary electronic book (e-book) distribution and reading application. This was a moderately interesting advance - your entire library on a slim, portable tablet. It had style and presented texts using a medium that was user-friendly, at least for some. All the experience required was that you invest a few hundred dollars in an Apple product, such as the iPad. Of course, not everyone was happy … many letters to editors were written (electronically) praising the traditional reading experience and the smell and feel of ink and paper. More recently, lawyers have entered the fray, with claims from five conventional publishers that Apple conspired to raise the price of eBooks. But I digress. Our story begins is with the launch of iBooks Author in Jan of 2012.

fig 4At the risk of sounding like an advertisement for Apple (sadly, I own no stock), this free application, fig 5available in the App store, allows one to publish a book to Apple’s online bookstore where it can be viewed in iTunes and then be distributed freely or for profit. The quality and ease of the publication are remarkable. This App offers the average doctor the opportunity to publish a book, which is as revolutionary in 2013 as were the “illuminated texts” of the Middle Ages (right: Book of Hours, ca.1400).

In an iBook, text and images can be entered into templates and unlike a paper book, one can add video, interactive images and widgets. For those who work with Macs, this is essentially a variant on the iWorks software®. One can add questions at the end of sections and test the reader’s understanding of everything from chest X-rays to 3-D anatomy. At the moment this technology is exclusively viewed on iPads; however a less elegant version can be created as a pdf export. So how does this relate to Medicine? Readers of this blog will know that we have started an iPad program for the internal medicine interns and residents. One of the first fruits of this has been a change in how Morning Report runs and how its teaching lessons are transmitted. Morning report is run by Dr. Ross Morton, Chair of Nephrology. Each morning a recent patient’s case is presented and residents are grilled on the history, physical, interpretation of laboratory and imaging tests.

morning report in progress

Here, residents are prepared for their Royal College exams, and for the practice of Medicine. They are asked to frame and defend a differential diagnosis, outline a course of investigation, discuss triage strategies, and implement a plan of therapy. The residents had begun to record interesting cases and distribute them, creating a semiformal account of the Morning Report. With the iPad program afoot it was suggested that they create an iBook which would be a living, sustainable and beautiful proceedings of these rounds. The goal is that this will become a teaching tool for future residents and inspire publication of case reports and case series and stimulate original research. Jeff Wilkinson, one of our 3 Chief Residents, noted, “Since our Internal Medicine program meets most weekday mornings at 7:45 AM, we regularly have interesting and media-rich case presentations. Recently, we've been collecting the case details and any imaging, pictures, or ECGs to publish as a teaching tool for residents. To do this, we first get patient consent and de-identify the case. We then take the collected case details and format it in iBooks Author. We decided to use this program because of its ease of use and for how well it can present videos, pictures, and include interactive elements. With the help of Dr. Morton and Dr. Archer, we have been including review questions throughout and summary guidelines at the end of each Chapter. With our next iBook, we hope to submit it for publication on the iBook store for a wider audience in September.” fig 7 They are still refining style and content but have already overcome many hurdles. For example, they now seek informed consent for case presentations even though cases are anonymized. This clip (right) gives you an idea of how such a Morning Report book is constructed.   To provide an example of what a commercially available iBook looks like (for sale online), I chose The Making of a Surgeon.

fig 8

I love the fact that people who bough a book on how to become a great surgeon also bought two other books: the Art of War and Winnie the Pooh. Surgical colleagues: discuss amongst yourselves! I look forward to the explanation for that pairing. Of course books are the first step. The more complete implementation is creating entire courses using these eHealth resources. One implementation of this is called iTunes U. Queen’s University is already using this new media - see a sample form our History Department here. In my view, it is time we in the Faculty of Health Sciences embraced iTunes U it as well. Whether it is Morning Report, Grand Rounds, the Podcast of a great lecture or a ‘How-to’ simulation, the time to embrace your inner author is now. For faculty at Queen’s we will be running a ‘How-to’ half-day retreat on the use of iBook Author, iTunes U and the like this fall in conjunction with Apple Canada (for info email Jen Valberg for the details: < or visit our website. At Queen’s we have chosen the path less traveled and it is starting to make all the difference.

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