I want to draw readers attention to a brilliant essay in JAMA by Jason Karlawish. He describes a new concept of medical practice that he calls “desktop medicine.”
Historically, we have used “bedside medicine” to diagnose pathological diseases. Bedside medicine incorporates the standard elements of the history and physical: the chief complaint, the history, review of systems, physical exam, and diagnostic studies. Bedside medicine is focused on diagnosing the presence or absence of disease: does this patient with dyspnea have heart failure or COPD? Is this pain due to cancer or osteoarthritis? Answers to these questions inform treatment decisions (e.g. lasix or albuterol, opioids or nsaids).
Desktop medicine, in contrast, uses different tools for different ends. The focus of desktop medicine is management of risk. Clinicians gather evidence from the patient and laboratory values, and use these to generate risk estimates, often with the help of a desktop computer. These risk estimates are the basis of treatment decisions aimed at minimizing risk. The questions addressed are different: what is the 10 year risk of heart attack? What is the 10 year risk of fracture? Answers to these questions also influence treatment decisions (e.g. statins or no statins, bisphosphonates or no bisphosponates).
These concepts are not mutually exclusive. Initial diagnosis of illness is made using traditional bedside medicine techniques. But most of the care we provide in geriatrics is management of chronic conditions, minimizing the risk that these conditions will result in catastrophic disease: heart attack, stroke, hip fracture, or cancer.
As Dr. Karlawish notes, Desktop Medicine is already what we do in most of geriatrics:
Desktop medicine does not so much change medicine as explain the way it is. Educating and training physicians to practice desktop medicine is especially important for the care of elderly patients who have competing risks.
Training in desktop medicine requires a different skill set from bedside medicine. Desktop medicine relies on understanding epidemiology, statistics as they apply to individuals, and communication of risk to patients.
How does this apply to palliative care? We increasingly rely on desktop medicine to help us decide hospice eligibility. Does this patient with dementia residing in a nursing home have less than 6 months to live if the disease takes its usual course? Let’s use a prognostic index to help (desktop medicine). Palliative medicine providers will also begin to use desktop medicine more and more to make every day decisions about treatment: Should we continue this statin? Should we anticoagulate for this deep venous thrombosis? These decisions are based on risk of an event (e.g. heart attack, pulmonary embolism), in light of the patient’s expected prognosis and goals.
How can we do a better job at our desktops? We need better training in the clinical skills mentioned above. We also need better tools for estimating risk.
Here is a teaser: look out for the launch of a new desktop tool for GeriPal users soon!!!
by: Alex Smith