Real-time medical and scientific communication and information is already at our fingertips (1).  However, while the potential for computers and information technology to influence fundamental changes to medical education are recognised, these innovations are often initially realised as general consumer products.  By their nature, these products quickly appear in teaching settings and it may not be apparent whether the pedagogical imperatives of medical education are served by such developments.  As a consequence, understanding of how best to use technological innovations and associated information sources to support heath care providers and patients continues to stimulate considerable debate (2).

Furthermore, access to computers and online information is no longer bound to a desk-based system with a fixed Internet connection, mobile devices with continuous data connections have allowed students to access information while on the move especially in a clinical setting. (3) (4) However, it is important to be cognisant of the fact that the use of Internet based information or any other technology in a teaching context represents a challenge that needs to be tempered with reference to sound pedagogical principles. (5)

A Change to RCSI laptop scheme
At the start of the 2014 academic year, the RCSI laptop scheme was revised to offer clinical medical students two choices, a MacBook Air Laptop or an iPad mini with 3G connection (connection fees fully subsidised RCSI). Whilst the Mac Book Air was a smaller more portable laptop than previously offered to students, it was felt that the iPad could be more amenable for immediate portability and access to information on clinical placements. This ploicy change afforded a research opportunity to explore student experiences of the pedagogical benefits and drawbacks of the aforementioned devices with a view to proposing guidelines and future research-led recommendations for RCSI educators in relation to curricular incorporation of tablet technology. Specifically, the study focussed on positive or negative impact on learning approaches, motivation to learn, engagement, and academic performance. 

Approach
We wanted to explore clinical students’ choices and their use of these different devices in the first year of clinical medicine: what they used, how they used it, and why they used it in a particular way. We devised a mixed methods study to investigate this.  All students newly entered into the clinical years, who elected to participate in the study (n=93) were issued with an online questionnaire which was based on a review of the literature and our previous experience with students and IT at RCSI.  This questionnaire explored personal technology device ownership and use.   Subsequently, two different online questionnaires were issued to those students who had opted for either a MacBook Air or an iPad.

We then invited a maximally variant sample (heterogeneity selected on the basis of device and reported use) of these responders to individual semi-structured interviews (n=19) with staff of the Health Professions Education Centre to explore the survey findings in more depth. Interviews were conducted at the time and place of the student’s choosing and continued until saturation of major themes was attained. Field notes and memos were also collected and used to inform the development of major themes.

• Actual patterns of students’ use of various devices and online information are not uniform and are deeply influenced by the presence of patients, which students usually find inhibitory and this is coupled with a sometimes confusing variety of approaches modelled by clinical teaching staff.
• All tools used in the clinical setting signal professional identity and competence, particularly so those associated with the physician personally such as white coats and stethoscopes.
• While these tools have specific functions and may require little explanation to the patient, Internet enabled mobile devices have almost limitless functionality and are directly linked to a multitude of tasks in everyday life.

Diverse use of devices

• Our results portray students as online, mobile and fluently exploiting data and services from a wide variety of sources in both their academic and personal lives.
• While the presence of technology in a medical student’s life may appear to be ubiquitous, our results also highlight differences when technology is used in clinical settings with or without a patient.
• This difference in use is influenced factors such as personal and non-academic experiences rooted personal convictions that using electronic devices with a patient is rude or may be viewed as unprofessional.
• The type of devices that students choose to bring into a clinical setting is diverse and it may not be possible to neatly categoirise a student in technical terms.  However, we have found that there are several factors that influence a student’s decision to use a device and in what context. 

Use of defvices in a clinical setting

• While students bring a wide variety of devices into the clinical setting, their actual use is linked to personal feelings based on the student’s perceptions of how patients will perceive the use of the device in terms of acceptance and professionalism.
• Guidance to students from teaching staff on the appropriate use of devices is clinical settings can be variable, ranging from total prohibition to direct and open use to support teaching.
• Variability leads to confusion and loss of potential, which could be addressed by institutional guidelines and clear policy. 
• Mobile technology is disruptive by its very nature and use in some social settings may be considered inappropriate or have a negative impact. 
• The problem arises from the fact that the same device that is such a powerful clinical tool is also connected to social media, email, and other non-medical outlets, posing the potential for inappropriate use in the workplace (6)