 every time we needed to look up information on a medication? More often than not, we had to run down to the nearest desktop computer in the hospital or university to browse through information, or at times visit the neighborhood library. Now, there are thousands of medical mobile applications that can provide quick access to information.

	So why is it necessary for hematology and oncology fellows to know more about mobile apps? Life as a fellow is extremely hectic, and mobile apps can help us save an enormous amount of time when conducting research. These apps can also help us become more efficient. However, they should all be regarded as accessories.

	For the medical fraternity, life has just become more efficient, more accurate, and much faster—all we need to know about medicine is literally at our fingertips.

	When you use a mobile app on your smartphone, lo and behold, everything you want to know appears instantaneously. We now have the opportunity to access information while sitting with patients, rounding, and moving from one floor to another. However, in this information age, there is an abundance of information that can make it difficult to access the most pertinent and reliable medical information. Therefore, I have developed this article to help you understand which types of mobile apps may be most useful during fellowship, as well as throughout your medical career.

	As a hematology-oncology fellow, I find medical calculation apps like MediCal extremely useful. These apps perform several types of important calculations (eg, 4T score, carboplatin dosing). They are also very helpful in grading patients’ performance statuses and when staging diseases like myelodysplastic syndrome with the International Prognostic Scoring System.

	When managing care for my cancer patients, I like to refer to the NCCN Guidelines and UpToDate apps on my phone. These apps help me make reliable and fast decisions about how to treat and care for my patients.

	And because memorizing steroid and opioid conversions can be so difficult, yet so important to understand and perform correctly when treating patients, I like to use apps such as CortiConverter and Opioid Converter. Making errors when converting drugs from one type to another can lead to serious issues such as opioid overdose.

	In addition, several mobile apps now help patients better collaborate with their cancer care team. When used correctly, patient-friendly mobile apps can make it easier to review enormous amounts of patient data related to their diagnosis, treatment options, outcomes, and survivorship issues, and can help us make more informed decisions.

	Apple recently launched ResearchKit, which enables medical research in real time. Patients choose to submit their health parameters in a predefined format using specific apps on their smartphones. ResearchKit is expected to help professionals access important patient-related health data that can make it easier to deliver more personalized care to their patients. High-value and insightful patient data, so hard and tedious to collect in the past, is now readily available to us.

	When suggesting patient-friendly mobile apps to your patients, it is important to remember that they have a strong say in sharing only the data they are most comfortable sharing, as protected by the Health Insurance Portability and Accountability Act. However, patient-friendly apps are extremely useful and have the potential to enrich the research that has been primarily survey-based in the past.

	Some applications, although not designed specifically for use in the medical world, still go a long way in providing medical-related servi-ces and support. For instance, I use Genuis Scan to create a snapshots of important documents. These snapshots can quickly be converted into PDFs or JPEG files and shared instantaneously.

	I also find the Fax Burner mobile app helpful. Fax Burner makes it possible to send and receive faxes right from your smartphone. Isn’t it fascinating that a phone in the palm of your hand can replace a 20-pound facsimile machine?

	As a fellow, it can be difficult sifting through the most recent and important medical articles and keeping up-to-date on cancer research. However, I find mobile apps such as Evernote, Slack, and BaseCamp helpful when reading up on or sharing the latest in oncology, and when collaborating with colleagues.

	During fellowship, storage and quick retrieval of important medical articles you access often is essential. I find apps like iBooks and Pocket helpful for storing, sharing, and referring back to articles of interest.

	Additionally, Cloud Storage—free for limited use&mdash;provides access to this information on-the-go on all mobile devices, and across all geographies. Our call schedules, lecture schedules, notes, pictures, and even Doodle are available on the go.

	Dropbox, OneDrive, and Google Drive have almost eliminated the need for CD/DVDs, pen drives, and even hard disks. You need not be tethered to a desktop anymore. Apps such as File Manager work like a pen drive, enabling you to store any type of document for access at a later time.

	This is just the beginning. With the “smart wearable” market exploding, technology like smartwatches, JawBone, or FitBit bands further help us navigate through our busy day. But can using all these applications make us dumber? Over time, will we forget doses, formulae, and chemotherapy regimens? Are we too dependent on these electronic tools? 

	I recently read a study that examined the smartphone addiction. A survey of 1600 managers and professionals by Leslie Perlow, PhD, the Konosuke Matsushita professor of leadership at Harvard Business School, found that:

		70% check their smartphones within an hour of getting up; 

		56% check their phone within an hour of going to sleep; 

		48% check over the weekend, including Friday and Saturday nights;

		51% check continuously during vacations;

		44% said they would experience “a great deal of anxiety” if they lost their phone and couldn’t replace it for a week. 

	It is very important to maintain a good balance when using all the new technology available at our fingertips. We should NOT lose our knowledge base, especially when providing care to our patients. We should use technology as an accessory but not rely on it to make all our decisions. 

	Mobile Medicine: Apps for the Healthcare Professional

	Endorsed by the End-of-Life Nursing Education Consortium and renowned palliative care physician Diane Meier, the Health Communication app provides access to theory-driven and evidence-based communication tools that are useful in difficult conversations with patients during moments of tension, sorrow, fear, anxiety, awkwardness, and hesitancy. Health Communication provides over 100 different communication strategies (searchable by scenario) to help clinicians provide compassionate and culturally sensitive care to seriously and critically-ill patients and their families. 

	The American Society of Clinical Oncology’s Cancer.net Mobile app provides accurate, oncologist-approved cancer information on 120 types of cancer including information about treating cancer, managing side effects, managing the cost of care, and living with cancer. Healthcare professionals can suggest this app to their patients to help them save information about their prescribed medications, including photos of labels and bottles, and track the time and severity of symptoms and side effects. 

: Free download preview; $39.99 in-app purchase

: Android, BlackBerry, iPhone, iPad, and iPod touch 

	The Pocket Guide to Diagnostic Tests app can be used by healthcare professionals who need to review accurate recommendations for ordering and interpreting laboratory, diagnostic, and imaging tests. This app provides immediate, evidence-based information on the selection and interpretation of more than 450 commonly used laboratory and electrocardiographic tests, diagnostic imaging tests, and therapeutic monitoring tests. Additional features include a universal index search tool to help professionals quickly locate information and a “Favorites” tool for bookmarking important entries. 

	Docphin is designed to help busy healthcare professionals keep up with the latest in medical research. Currently trusted by medical professionals in over 400 hospitals in more than 15 countries, this app allows users to create a personalized medical newsfeed and receive alerts when their favorite medical journals publish articles on specified medical topics or by particular authors. With Docphin, users can access full-article PDFs, save them, and e-mail them to colleagues. 

	My Cancer Genome is designed to help medical professionals keep track of the rapidly evolving world of genetically informed cancer medicine. App users can search for and save information on cancer types, cancer-related genes, and specific cancer-related genetic mutations. The app also provides information on drug classes, drug targets, and drug names for antineoplastic agents, either FDA-approved or being studied in clinical trials. 

	1. Breaking the smartphone addiction. Harvard Business School website. 

. Published May 14, 2012. Accessed May 7, 2015. 

Articles

Life as a fellow is extremely hectic, and mobile apps can help us save an enormous amount of time when conducting research.

Smart Apps for Smart Docs

My path to becoming an oncologist was a little different from most, but like so many others, I was inspired by a practicing physician who showed me what medicine truly can be. While in college, I worked during the summers as a medical assistant for an orthopedic surgeon in an effort to reduce my ever-increasing educational loans. Upon completing my bachelor’s degree in Spanish literature and language, I continued my work in medicine as a medical assistant and interpreter in an urgent care office close to home. While there, I developed a true love for medicine and frequently wished that I were the physician treating patients and making the treatment decisions that would set them on the path toward recovery. I therefore decided to apply to a master’s program that offered the courses I needed in order to apply for medical school.

While enrolled in the master’s program, I worked in a hematology and oncology clinic. On the first day in that office, I knew where my medical career would lead. During the first patient visit, I was amazed when the oncologist spent most of it discussing the upcoming birth of the patient’s grandchild and the health issues of the patient’s wife. He started each subsequent medical visit with conversations like these, which indicated to me how well he knew each of the patients.

I learned over the next days and weeks that the majority of his conversations with patients were centered around their personal lives rather than their medical health. He knew the patients so well that he could tell how they were feeling by their tone of voice, their facial expression, or even slight changes in mannerisms. There is a true connection between the patient and the doctor during such a challenging time in the patient’s life. This is exactly what I wanted. I decided within days of working with this oncologist that I would follow the same career path in hopes of building these kinds of relationships with my own patients.

Now, 10 years later, that is exactly what I have done. I am a hematology and oncology fellow, and my work life is exactly how I imagined it would be. When I see Mr Harris walk down the hall slightly slower than he walked during each of his last 8 weekly visits, I know he has gotten weaker. I see Mr Edward with his shoulders slightly hunched and his head hanging down and know he is still struggling with the recent death of a grandchild. From the big smile on Mr Ray’s face, I know that this week he is able to concentrate more on his grandson winning a cross-country meet than on the pain that is a daily part of his cancer.

In so many ways, I am more capable of treating these patients because I truly know each of them as a person. I was told recently by a mentor that I should know my patients well enough for me to spend the majority of the visit speaking with them about their personal and social lives, because each personal story my patients tell me gives me a clue about any changes in their cancer, their pain, or the side effects of their treatment.

I am often asked, when I say I am an oncology fellow, why I chose such a gloomy field of work. The truth is that, although it can sometimes be heartbreaking, I don’t think it is sad. It is true that some of my patients do not survive for years, but I am still able to spend the majority of my time as a physician feeling joyful about the time I have with them. I am able to get to truly know my patients and help them through a time that is likely one of the most difficult and vulnerable in their lives. I could easily treat a patient in the short term, as is the trend in some other specialties, or treat a patient so infrequently that I cannot bond over stories of their current and past life experiences. Then, however, I would miss out on the true joy of medicine. For this reason, I chose hematology and oncology, so that I can truly treat a patient and not a disease.

My path to becoming an oncologist was a little different from most, but like so many others, I was inspired by a practicing physician who showed me what medicine truly can be.

Why I Chose a Career in Hematology & Oncology

A world of personal discovery often opens up during medical training. While in medical school, we endure high-volume, intensely pressured learning and discover an inner work ethic previously untapped. In residency, we learn to “practice” medicine and discover a new confidence that only emerges from real experience. For those of us who embark on fellowship training, this is where we settle in to learn the field of medicine to which our passion has delivered us.

This is akin to entering the cockpit after years of flight training on the ground. The first few weeks of fellowship are spent in awe of actually being chosen, knowing this is where we will finally get to experience the thrill of flight. As weeks progress, we sputter through a few rough takeoffs and landings, some so discombobulating that we forget the excitement we felt only weeks before.

About 6 months into fellowship we begin to soar, still guided in flight by peers and mentors. The thrill returns at this point and we find a rhythm. This is important since without a rhythmic undertone to the intensity of our days, the winds are choppy and the flight is chaotic.

As my first year of fellowship concludes, I feel like I’ve got rhythm. And I know it’s in large part due to the solid flight crew keeping me in time.

While recently rotating as the “inpatient” fellow, getting to know my crew has helped me immensely. I found this new role to be one of the most draining of my entire medical training. The hours were long and food seemed scarce, but comfort came from my supportive team and family. If not for them, this would have been a “What have I gotten myself into” month from hell. Instead, I managed to learn and even get a thrill from practicing cancer medicine from a new perspective.

As is often the case with cancer patients in a hospital, most of mine were nearing the end stages of their disease and life. Some patients entered this phase after years of struggle. However, the majority of them were newly diagnosed, diffusely metastatic, and far too young. In 4 short weeks, there were at least a dozen patients with whom I conducted a weighty conversation about their advanced, soon to be terminal, cancer.

Each discussion, patient, and family pulled at a separate heartstring. Upon meeting a patient for the first time, I would brace myself for this new role as the stoker of fear and mortality rather than the gatekeeper to hope. And each time, I called upon our palliative care nurse practitioner to help me guide my patients in their new reality. She was the copilot I needed to help provide care for these patients for whom cure was impossible and palliation essential.

Palliative care is a relatively new field of medicine, but one that has grown quickly for a multitude of reasons. The term “palliative care” was first used in the 1970s by Dr Balfour Mount, who became the father of the palliative care movement in North America. Dr Mount, a Canadian urologic cancer specialist, leveraged the work of Elizabeth Kubler Ross and Dame Cicely Saunders. These women studied the care of the dying in North America and helped influence palliative care’s incorporation into modern practice through hospice care and the analysis of patients’ distinct physical, emotional, and psychosocial needs.

	Integrating Palliative Care Into Oncology

Palliative care is now a globally established medical specialty aimed at relieving suffering. The World Health Organization defines palliative care as “an approach that improves quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”

 In my experience, a conceptual definition often used by practitioners is that palliative care is a mechanism for “an extra layer of support.”

Not all doctors work with dying patients. Almost without exception, in hematology and oncology, we do. Our relationships with our patients are complex. They are sometimes very brief and sometimes long term. Our conversations with patients are complicated and we rarely know in advance how the information we plan to convey will be interpreted.

In our clinics, we dance between exam rooms—in one, performing as the gladiator charged to annihilate the eternal enemy of cancer, and in the next, as the wise healer, charged to embrace, not cure, the deepest wounds at the heart of the human condition.

After attempting these roles as a new fellow, many of us come to recognize the impossibility of mastering these roles in the same way we mastered taking test after endless test in medical school, and managed hypertension, diabetes, and infections ad nauseam in residency—which is to say, competently and alone.

It was during my recent rotation in the inpatient oncology service that I quickly became aware of the impossibility of performing these roles alone. After nearly a dozen consults to palliative care, I got it.

Their work is the fulcrum of my balancing act. With their help, I could aim to cure, heal, and comfort with less inner conflict. But more importantly, vulnerable patients could get the full attention of mind, body, and soul they deserved.

The results of a landmark phase III randomized control trial demonstrating this benefit for patients with advanced non-small cell lung cancer who received early palliative care referral were published in 2010. While the primary end point demonstrated a change in quality of life at 12 weeks favoring early referral to palliative care in addition to standard oncology care, rather than standard oncology care alone, several other interesting and statistically significant findings were made. Patients receiving palliative care understood their prognosis and incurability more clearly, opted for less aggressive end of life care, and chose less aggressive treatment at the end-of-life. These patients also survived 2.7 months longer than those in the non—palliative care group.

In the American Society of Clinical Oncology (ASCO) Provisional Clinical Opinion (PCO) article, published in 2012, other trials were referenced in their call to arms for integrating palliative care into standard oncology care. Several older trials that found a lack of significant benefit in early palliative care were pronounced to lack scientific rigor. More recent trials, however, consistently showed fewer dollars spent on end-of-life care and greater completion of advance directives. In fact, several trials revealed that early palliative care referral results in fewer emergency department visits, better quality of life for patients and caregivers, and better communication. While ASCO’s PCO favoring early palliative care referral for any patient with metastatic cancer and/or high symptom burden reflects expert consensus based on studies concluded in 2012, the report highlighted these priorities for continued research:

		The optimal timing and venue for provision of palliative care (inpatient, outpatient/community)

		Evidence-based reimbursement models to support palliative care provision

		Which components of palliative care have an impact

		Interventions in other diseases besides lung cancer

		The impact of palliative care across the continuum of care, especially during the delivery of antitumor therapy

There is no timeline that rules when to engage palliative care for patients. All patients need support when faced with illness, and establishing that support early on can prevent angst when emotional and physical needs become volcanic.

		Table. NCCN Palliative Care Guidelines — Version 1.2015

					Screening For Palliative Care Referral

					Moderate to severe distress related to cancer diagnosis and cancer therapy

					Serious comorbid physical and psychosocial conditions

					Patient/family concerns about course of disease and decision making

					Patient/family requests for palliative care

		Adapted from National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: palliative care. Version 1.2015.

Often, clinicians begin palliative care too late, when symptoms are severe and end-of-life is measured in days to weeks.

 The National Comprehensive Cancer Network (NCCN) has published guidelines for integrating palliative care with oncology care. These guidelines are categorized into screening, assessment, interventions, reassessment, and after-death interventions. Patients who fulfill any of the 7 screening criteria (

) are recommended for referral to palliative care.

At this time in my training/career, palliative care is a phone call away. Access may not be so easy for those at smaller institutions or in community private practices. A survey of 101 cancer centers in the United States published in 2010 showed that despite the value of palliative care, access had not yet become universal. This survey revealed that National Cancer Institute (NCI) centers were significantly more likely to have a palliative care program, at least 1 palliative care physician, an inpatient palliative care consultation team, and an outpatient palliative care clinic. Poor reimbursement and limited institutional resources were cited by survey participants to be the factors limiting access to palliative care.

 Compounding the problem of the lack of resources to fund palliative care services are the estimated shortage of palliative care practitioners (6000-18,000) and the limited number of available training programs.

Among the benefits demonstrated in studies of palliative care, the financial savings at end of life are certain to effect changes in practice for end-of-life cancer care. One bill addressing both the shortages and the financial savings, the Palliative Care and Hospice Education and Training Act, has been proposed.

Various models of palliative care have been designed and can be applied to cancer centers based on available resources. Bruera et al defined 3 models: the solo practice model, the congress approach, and the integrated care model. In each, the layers of integrated care increased stepwise—from the oncologist being the sole practitioner addressing patients’ palliative needs to the integrated model involving multiple medical specialties with the palliative specialist coordinating care.

	Fellowship and Beyond: With Palliative Care at My Side

Participants in a Leadership Development Program called into existence by ASCO have sought to identify the critical elements of a palliative care service model. Their recommendations for implementing a dynamic, real-timemodel of patient-centered care were crafted with an understanding of the wide variety of established cancer care models. In this program, a symptom assessment tool of various levels of sophistication was used to capture patients appropriate for palliative care referral. Results of this assessment would then trigger the clinician to address symptoms and/or make a referral to palliative care.

 In fact, tools to trigger an algorithmic approach to provide evidence-based care for supportive management interventions are already being utilized in practice.

Medical training is a whirlwind of knowledge, struggles, accomplishments, and personal growth. Hematology/oncology fellowship training adds to this with layers of complex human interactions unique to the field. Mastering the demands of this profession requires mastering an ability to enlist the skills of others at the right time. Enlisting palliative care at the right time is a critical step that must be taken by any team striving to provide expert cancer care.

			The Ottawa Citizen. A moral force: the story of Dr. Balfour Mount. Canada.com website. www.canada.com/ottawacitizen/story.html?id=896d005a-fedd-4f50-a2d9-83a95fc56464. Published April 25, 2005. Accessed April 29, 2015.

			Cancer: WHO definition of palliative care. World Health Organization website. www.who.int/cancer/palliative/definition/en. Accessed April 29, 2015.

			Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. 

			Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. 

			Hui D, Elsayem A, De la Cruz M, et al. Availability and integration of palliative care at US cancer centers. 

			NCCN Clinical Practice Guidelines in Oncology: palliative care: version 1.2015. National Comprehensive Cancer Network website. www.nccn.org. Accessed April 29, 2015.

			Lupu D; American Academy of Hospice and Palliative Medicine Workforce Task Force. Estimate of current hospice and palliative medicine physician workforce shortage. 

			S.641 - Palliative Care and Hospice Education and Training Act. Congress.gov website. https://www.congress.gov/bill/113th-congress/senate-bill/641. Accessed April 29, 2015.

			Bruera E, Hui D. Integrating supportive and palliative care in the trajectory of cancer: establishing goals and models of care. 

			Partridge AH, Seah DS, King T, et al. Developing a service model that integrates palliative care throughout cancer care: the time is now. 

			Cancer Care Ontario, Action Cancer Ontario. Palliative care program: our vision. Cancer Care Ontario website. https://www.cancercare.on.ca/ocs/clinicalprogs/pallcareprog. Accessed April 29, 2015.

Kathryn Bollin, MD, writes about the importance of enlisting palliative care at the right time, as a critical step that must be taken by any team striving to provide expert cancer care.

June 2015 | Oncology Fellows

Smart Apps for Smart Docs

Why I Chose a Career in Hematology & Oncology

A Comprehensive Look at Palliative Care: What Every Fellow Should Understand