This study represents primary research for the UK, the first formal survey to investigate smartphone ownership and usage in a junior doctor and medical student population; this data adds valuable insight to an evolving UK healthcare system. This research is timely since the UK Department of Health have recently published a Framework for Technology Enhanced Learning
 in which the potential for the use of innovative technologies including smartphones is recognised:
"‘Innovative educational technologies, such as e-learning, simulation and smartphones, provide unprecedented opportunities for health and social care students, trainees and staff to acquire, develop and maintain the essential knowledge, skills, values and behaviours needed for safe and effective patient care.’ (pg 6)"
It is therefore important to capture patterns of smartphone use in healthcare education and clinical practice in order to develop and recommend appropriate learning materials and activities for delivery on smartphone platforms.
Numbers owning a smartphone and frequency of medical app use
A systematic review by Garritty et al. concluded that PDA usage among healthcare providers varied from 45% to 85%, noting younger physicians or residents and those in large hospitals were more likely to use a PDA
. Although this data was derived largely from the United States, with no data from the UK, our results do corroborate their findings and demonstrate a large number of respondents owning and using medical apps on their smartphone. A hospital based survey undertaken by Dasari et al. who questioned British anaesthetists across a breadth of training grades, reported that 59% owned an iPhone. 80% of those owning an iPhone actively used medical apps, with 60% using them for clinical activities and 47% for educational activities
. In comparison, our data points towards higher medical app usage rates within a comparable doctor group, with 72.4% of doctors using medical apps, to varying degrees, during clinical activities (Table
Within a US medical student population, Grasso et al. reported 52% of medical students using handheld computers, however displaying a clear divide between pre-clinical and clinical years (28% and 76% respectively)
. In contrast our data displayed equal smartphone ownership within pre-clinical and clinical years (76% and 80% respectively), with overall app usage as high as 83.3% (for educational purposes). This change should be interpreted cautiously, taking into account the inherent difference between a handheld computer and a smartphone, and the varying postgraduate structure of US and UK medical degrees.
Within the student group, educational use of apps starts in pre-clinical years and appears to follow into clinical years, with both year groups using apps more for educational than clinical purposes. However there appears to be no pattern relating to frequency and time spent using apps specific to clinical and educational environments (Tables
3). If we acknowledge the touted benefits of handheld technology in the clinical environment for clinicians, we would expect a higher frequency of app use in a clinical environment also within a student population. Students are using apps to learn at all stages of their studies, and this factor should be taken into consideration when designing or developing further apps in these settings.
Comparing student and doctor groups: smartphone ownership and frequency of app use is similar, however time spent daily using apps is reduced within the doctor group. The majority of doctors reported using apps daily for between 1 and 20 minutes, with very few using apps for longer than 30 minutes (Table
3). In contrast to students, who display a more even spread, especially for medical school educational activities. It is unclear if this pattern is due to external time pressures of the environment within which the app is used (i.e. a busy hospital setting for doctors), or the true intention or need of students to use apps for longer. It suggests doctors are using apps for quick reference as opposed to prolonged educational reading.
Number and type of medical apps used or owned
The findings suggest that students and doctors are selective about the medical apps they download and/or purchase, the majority owned 1 to 5 apps which they used on a regular basis. Similar to previous studies, the most frequently used apps in the student cohort were those detailing medication/drug reference
 and those involved with disease diagnosis/management (Figure
2). In slight contrast, the doctor cohort used clinical scoring apps more often (Figure
1). The nature of apps used reflects the manner in which smartphones appear to be utilised. In the clinical environment smartphones are often used at point of care
; thus for a doctor, apps that increase efficiency by saving time and allow ‘mobile’ rapid decision making are going to be popular
. For a student, disease diagnosis/management related apps are more likely to fullfill their educational needs when compared to more simple clinical scoring/calculator type apps.
In both groups apps used for procedure/case documentation scored very low, with over half of participants not using these apps (Figures
2). This is perhaps attributable to the lack of apps currently available in this area, and that for an app of this nature to be regularly used it would likely need to be linked to the relevant medical school or regional postgraduate healthcare organisation. The finding that both medical students and junior doctors own relatively few medical apps, but use them often, has key ramifications for the development of future organisational Medical School or Hospital linked apps. For an app to be used by a medical student or junior doctor it clearly needs to be of high quality and be fit for purpose to avoid user neglect. On the other hand, as medical students and junior doctors appear to own a relatively small number of apps, the chance of integrating such an app into regular use is increased.
Future app development
From the analysis of open text entry data, there is a clear trend that both students and doctors want apps linked to their respective organisations. For students the desired purpose of these appears to be to receive administrative information relating to timetabling and lecture content, and secondly the need for revision and quiz type apps. This does align with previous studies describing using mobile devices to enhance competency sign offs
, and student case logbooks
. No studies have explored the benefit of incorporating lecture timetabling and lecture objectives into a smartphone format.
Doctors are concerned about clinical information relating to patient management and care, with administrative apps relating to rotas and annual leave receiving less attention. Using a search on the Apple appstore, we were able to find relatively few doctor orientated UK hospital associated apps (this method does not take into account apps distributed directly to workers through Apple’s commercial app license). Among these were a Microbiology app
, a Paediatric Drug dosing app
 and a Thromboprophylaxis app
. This suggests that the needs of British junior doctors, relating to smartphone apps, are currently not being fully addressed. As an example of full smartphone hospital integration; the Samsung Medical Center in Seoul, Korea has launched a smartphone app that allows doctors access to both inpatient records and lab results
. They provide evidence of a positive response from doctors, with regular use of this app during working hours. With the evidence that our doctor group reported regular use of disease diagnosis/management apps and drug reference apps (both areas for which hospitals develop individual clinical guidelines), the possibility of these guidelines being linked to smartphone apps specific to UK hospital sites should be explored in future research. This would remove the medico-legal risk of hospital staff using smartphone based clinical resources not referenced or reviewed by accepted authorities.
Negative aspects of using smartphones
Concern about the cost of a smartphone and medical apps is an important finding among both student and doctor groups. There are policy implications around the expectation that all students and doctors should be expected to have a smartphone to support their education or professional practice. Furthermore what policies should be in place to prevent discriminating against those, who for whatever reason, choose not to endorse this technology?
One obvious solution to this problem of incurred costs for the individual is for the organisation to provide smartphones and free access to apps. This solution is currently being evaluated within the Wales Deanery (UK regional healthcare organisation) among all Foundation Doctors (American ‘Intern’ equivalent)
, with the results not yet published in full. As our data points to the majority of students and doctors owning smartphones, it could be argued that the cost of scoping, designing and developing suitable high quality apps and advertising the utility of free apps that are available, is the more pertinent issue to be immediately addressed.
Not to be overlooked are the personal concerns of doctors relating to the experience of using smartphones in a clinical environment and the effect on the doctor-patient relationship/communication, and the negative connotations associated with doing so. This re-iterates physician concerns regarding patients’ perceptions of mobile phone use in the clinical environment as previously identified
 and clearly requires further in-depth qualitative investigation. Use of smartphones in clinical areas may well require a shift in service user attitudes towards this mobile technology. Overcoming this barrier will require an investment in doctor education at all grades, and a definite policy from organisations to endorse smartphone technology.
This study focused on students and young doctors, both are groups which may be more ‘IT savvy’ and likely to use smartphone technology. Higher trainees and consultants were not questioned within this study. The chosen site for conducting this study comprised a large population fitting the inclusion criteria however the response rate was relatively low (15% and 21.8%, in student and doctor groups respectively), and limits the level to which these results can be generalised to other similar groups. The number of responses received is comparable to similar regional surveys of this kind
; in a published review of hand held device use by healthcare providers, the average response rate in 4 of the most up-to-date published studies was 27.6%
, with one study using an online questionnaire (as in our study) obtaining an 11% response rate. Many study articles in this review did not report a response rate.
The increased likeliness of smartphone users to answer a survey related to smartphone use is noted as a definite source of non-response bias and voluntary response bias and using an online questionnaire may have contributed to this study design limitation. However the prevalence of smartphone ownership was only one objective of the survey and it does provide a snapshot at just one point in time providing a useful benchmark for future studies.
This survey was intentionally conducted during university term time to ensure a representative student response