MEDICAL MATTERS:'Running the numbers' no way to diagnose, writes MUIRIS HOUSTON
HOW WOULD you feel if your doctor, rather than asking what your main concern was at the beginning of a consultation, went straight to a list of your risk factors for certain diseases? The discussion would then focus on how you could reduce these risks, and on specific treatment if a particular risk factor was at a critical level.
If that sounds like a major sea change, that’s because it is. But it is a serious proposal laid out in the current issue of the Journal of the American Medical Association (JAMA). Called “desktop medicine” the new approach is a direct challenge to “bedside medicine”, where a physician listens carefully to your concerns and symptoms before addressing a number of possible diagnoses and, by means of physical examination and possibly some tests, makes a definitive diagnosis.
Jason Karlawish, an associate professor at the University of Pennsylvania School of Medicine, has defined this new model of care: “Desktop medicine describes how a desk with a networked computer is transforming medical science and, in turn, medical practice. The desktop is the space in which researchers discover risk factor-based diseases and where physicians and patients go to gain information to diagnose and treat diseases. In developed nations, desktop diseases such as dyslipidaemia [high cholesterol] occupy a substantial portion of a physician’s practice, are leading causes of morbidity and mortality, and have attracted the attention of policymakers.”
He says desktop medicine will change how doctors are trained and how they practise medicine. “Medical training should teach how to help patients appreciate their relevant risks and manage these risks, as many patients fail to adhere to a long-term intervention intended to prevent disease.”
Hmm. When I hear language such as “patients fail to adhere” and “the desktop encounter begins with an approach called running the numbers first”, I become uneasy. It sounds terribly doctor-centric and smacks of a predetermined agenda in which the physician decides what is important for the person sitting beside them.
Bedside medicine originated in this country; the influence of Robert Graves and William Stokes in developing a bedside approach to both teaching and practising medicine has been acknowledged throughout the world. Apart from defining disease in individual terms, it places a premium on listening to a person’s concerns. A good doctor will listen to your story before asking questions based on what you have said.
With a desktop approach, your doctor will calculate various risk factors before you enter the room. The problem I have with this approach is that it turns you into a machine and your doctor becomes a mechanic. Karlawish concedes the doctor may then wish to turn to the person’s own concerns and follow the more traditional route.
The JAMA commentary makes some sense when it says: “Bedside diseases are categorical. Disease is either present or it is not. In contrast, desktop diseases are dimensional because risk is a continuum. The argument follows that when risk data are available, physicians should discuss disease not as a category but as a probability. Rather than a disease label compelling treatment [eg, I have cancer, remove it], a risk estimate allows patients and physicians to practise clinical-actuarial correlation [eg, my chance of cancer death is too low to justify surgery].”
However, giving primacy to a desktop approach will do patients no favours. By all means emphasise the role of risk calculation and reduction as part of a successful consultation. As Dr Karlawish points out, risk measurements encompass progressively milder stages of disease. But to put them before a person’s immediate concerns would surely place the cart firmly in front of the horse.
** Following a recent column on the swine flu, the HSE has been in touch to say it is very likely many five to 14 year olds have either had the disease or the vaccine last year and will therefore be protected.