Doctor and Patient: The Rise of Desktop Medicine - NYTimes.com

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."

http://well.blogs.nytimes.com/2011/03/31/the-rise-of-desktop-medicine/?pagemode=print

At Home in the Hospital - NYTimes.com

Some patients cope with long hospital stays by bringing in a few books and a favorite pair of slippers. For others, an incandescent lamp can offer light that looks more like home. A favorite Steelers blanket may adorn a bed. The mother of one young woman brought in a sewing machine and worked happily and busily during her daughter's monthlong hospitalization.

But some patients go even further, transforming their hospital rooms and their hospital lives into as much a version of home as they can.

One patient, in her 20s and struggling with a very bad diagnosis, turned her room into an oasis from the clinical feeling of the hospital. Pictures and cards were taped up everywhere. Her sister stuck paper flowers to the walls, making a swirl of color and warmth amid the bland hospital white. She used oils, with diffusing sticks, to perfume the air, so her room actually smelled good. Even the IV pole got decorated with ornaments, including ceramic angels there to wish her well.

And of course she had her own clothes, her own pajamas, her own blanket. Her charming boyfriend slept over. Family and friends came often, bringing not just comfort and support but a flavor of the outside world — of the full life that was waiting for her.

Her room was small, but all the personal touches made it feel less like the hospital and more like home. It was a pleasure to take care of her because it meant going into her wonderfully transformed room.

Beyond the room, though, she lived her hospital life like a person, not just a patient. She and her boyfriend went for walks, holding hands. Her family brought in food she liked. She would stay up late, refuse to have vital signs taken during the night, and then sleep late the next day, confidently defiant of our structured, early-to-rise practices in the hospital.

Her dog was the one thing from her life outside the hospital that could not cross that rigid hospital barrier. Many of the pictures taped to her walls were pictures of her beloved pet, a tiny dog with floppy fur that fell over its eyes. She really, really wanted to see her dog.

Lydia, our amazingly kind patient relations representative, decided to bring the dog to the hospital.

The first hurdle in pulling this off was the doctor. Would the patient's attending physician agree to a visit with the dog? The answer turned out to be yes, so the next question was where to hold the meeting.

Because many of our patients have suppressed immune systems, bringing the dog onto the oncology floor was not allowed. Lydia arranged to use a meeting room one floor below ours. She had the walls and floor wiped down with bleach and thoroughly scrubbed as a precaution to protect the young woman, whose immune system was also suppressed.

Her mother was bringing the dog, and when the time came, I went with the patient down to the meeting room. Because of her vulnerability to infection, she was not allowed to hold her dog. But she sat in a chair, wearing a yellow isolation gown and latex gloves, and watched while I held out toys for the dog to chew on, shake about and growl at.

The dog seemed content just to play. And even though the patient couldn't hold her dog, she also looked happy, the way I imagined she probably looked away from the hospital.

Soon, it became clear that having time with her beloved pet wasn't really just about the dog. We had been sitting in a windowless hospital room in the middle of winter, yet it felt like someone had opened a window on spring, letting the light and the smells of wet earth and budding flowers come flowing in. Somehow, that little floppy dog had brought the outside world into the hospital.

In the book "The Cancer Journals," the poet and activist Audre Lorde reflects on her experience coping with breast cancer, writing that each woman responds to the crisis that cancer brings to her life "out of a whole pattern, which is the design of who she is and how her life has been lived. The weave of her everyday existence is the training ground for how she handles crisis."

That certainly seemed to be true for my patient, who coped with cancer treatment by weaving her everyday existence into her life at the hospital, whether it was pictures from home or time with her dog. Now that patient is out in the world. She isn't completely well, but she is back to living her life.

http://well.blogs.nytimes.com/2011/04/01/bringing-home-to-the-hospital/

Federal Dialysis Program Is Questioned by Kidney Specialists - NYTimes.com

Of all the terrible chronic diseases, only one —end-stage kidney disease — gets special treatment by the federal government. A law passed by Congress 39 years ago provides nearly free care to almost all patients whose kidneys have failed, regardless of their age or ability to pay.

But the law has had unintended consequences, kidney experts say. It was meant to keep young and middle-aged people alive and productive. Instead, many of the patients who take advantage of the law are old and have other medical problems, often suffering through dialysis as a replacement for their failed kidneys but not living long because the other chronic diseases kill them.

Kidney specialists are pushing doctors to be more forthright with elderly people who have other serious medical conditions, to tell the patients that even though they are entitled to dialysis, they may want to decline such treatment and enter a hospice instead. In the end, it is always the patient's choice.

One idea, promoted by leading specialists, is to change the way doctors refer to the decision to forgo dialysis. Instead of saying that a patient is withdrawing from dialysis or agreeing not to start it, these specialists say the patient has chosen "medical management without dialysis."

"That is the preferred term," said Nancy Armistead, executive director of the Mid-Atlantic Renal Coalition, a Medicare contractor that collects data and patient grievances.

The phrase, she says, "acknowledges that death is imminent," but it also sends an important message: "We are not just sending people home to die. We are offering palliative care."

A committee of the Renal Physicians Association recently formulated guidelines to use in deciding when dialysis is appropriate. It provides questions that doctors should ask themselves before suggesting the treatment. One is the "surprise" question: Would I be surprised if this patient is dead within a year?

But, said the committee's chairman, Dr. Alvin H. Moss, a nephrologist and ethicist at West Virginia University, the task ahead is like turning around an ocean liner.

"Clearly, when the program was initiated in the 1970s, the hope and expectation was that this program would return otherwise healthy people back into society so they could work and be productive," said Dr. Manjula Kurella Tamura, a kidney specialist at Stanford. But, she added, "dialysis at the end of life is a different sort of treatment."

More ...

http://www.nytimes.com/2011/04/01/health/01dialysis.html?