Recently, a colleague lamented a change she had noticed among the young doctors at her hospital. "They are always in front of the hospital computers," she said. "I never see them with patients, but I can always find them sitting at a terminal."
She paused for a moment, then added uncomfortably: "These days I probably spend as much time looking at the office computer as I do looking at patients. It's just not like the old days."
Doctors have a tendency to veer toward nostalgia; but lately a kind of mass sentimentality has overtaken the profession. At conferences, in medical journals, and even within the pages of fiction, doctors from all generations are found longing for one vestige of their clinical past: bedside medicine.
With stethoscope and reflex hammer in hand, leaders of this movement to bring bedside medicine back have warned of the demise of the patient-doctor relationship while lovingly describing the details of the healer's art – encounters in which patients recount symptoms and doctors search for physical signs, tapping deep into their wells of clinical judgment to deduce the causative diseases and prescribe the appropriate treatments. Like artisans of an ancient guild, these master clinicians can ferret out the strawberry tongues (scarlet fever), the candied breath (liver failure) and the Sister Mary Joseph signs (widespread abdominal cancer), while lesser doctors can manage only by relying on expensive laboratory tests, statistical models and desktop computers.
Unfortunately, the reality is that it's not so easy to jettison the lab results and technology. Most of us might dream of employing our clinical acumen while sitting at our patient's bedside, yet more and more we find ourselves in front of our computers.
But it's not, according to a recent commentary in The Journal of the American Medical Association, because we are failures or have given up on practicing good medicine. Rather, it is a result of a shift over the last 20 years in how doctors and patients think about health and disease.
"We can't sit here and throw up our hands and say that medicine is going to hell in a handbasket," said Dr. Jason Karlawish, author of the commentary and an associate professor of medicine and medical ethics at the University of Pennsylvania School of Medicine in Philadelphia. "There has been a fundamental change in how we think about what health and disease are and how we practice medicine."
That change revolves around the computer. While health care was once premised on the physical exam and a physician's diagnostic skills, it has become increasingly reliant on computer-based syntheses of clinical findings and measurements, complex statistical models and risk factor calculations. "Now we look at various factors that put a patient at risk, then calculate whether it is worth treating that patient," Dr. Karlawish said.
In other words, we have gone from bedside medicine to desktop medicine.
One example of a disease in the new desktop medicine era is dyslipemia, or abnormal blood cholesterol and blood fat levels. Cholesterol-lowering drugs were initially used to treat patients who suffered from inherited diseases that prevented them from processing cholesterol, putting them at risk of hardening of the arteries and heart attacks. Over time, though, clinical trials revealed that the same drugs could reduce heart attack risk in some otherwise healthy individuals who simply had high cholesterol.
What was once a natural variation became a full-blown disease. Or at least a chronic condition that needed to be managed.
"Contrary to the bedside medicine model, where diseases are based on discrete symptoms and clinical findings," Dr. Karlawish said, "desktop diseases are contingent on the results of a clinical trial showing that some intervention can influence how patients will do over time."
With these new "diseases," physicians and scientists can design computer-based programs that tap into a vast network of data and calculate an individual's risk of doing poorly and the need for treatment. For example, doctors can now enter information into specialized Web sites (or, in one case, an iPad app) that, with a single click, can spew out a patient's 10-year risk of bone fractures from osteoporosis, or of a heart attack from high cholesterol and high blood pressure.
While those who advocate a return to bedside medicine may shudder at the image of a doctor turning to her iPad for clinical wisdom, refusing to acknowledge this new model of disease and care has its own perils. "There's been a lot of progress in health care because of desktop medicine," Dr. Karlawish said. "We can't laugh like it's the next generation of goldfish swallowers, because it won't go away."
Moreover, in the world of desktop medicine, larger social forces influence which health risks are deemed worth identifying and reducing; and the political, economic and personal repercussions can be enormous. Cholesterol-lowering drugs, for example, are now the most widely prescribed medication in the United States; and a single brand may save one patient out of several hundred from a heart attack. But that medication will also cost several dollars per pill for patients and generate billions of dollars in revenue for a pharmaceutical company.
"We need to be cognizant that certain individuals or groups of individuals may have control over the very numbers that define disease," Dr. Karlawish said.
The real challenge for doctors will be taking advantage of the technology without losing the art of diagnosis and bedside manners. "If doctors change simply into some kind of hybrid of a financial analyst risk broker," Dr. Karlawish said, "we will have lost an essential part of what doctors should be doing."
"At the same time," he added, "we can't pretend that desktop medicine isn't here. We have to be aware so that it serves our patients and not other interests."
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