Desktop medicine shifts focus from disease diagnosis to rooting out risk

Bedside medicine is a staple of health care. But a University of Pennsylvania School of Medicine professor suggests an emerging trend toward 'desktop medicine,' which shifts the emphasis from disease diagnosis to identifying health risk factors.

Bedside medicine is a staple of health care. But a University of Pennsylvania School of Medicine professor suggests an emerging trend toward 'desktop medicine,' which shifts the emphasis from disease diagnosis to identifying health risk factors.

I spoke recently with Dr. Jason Karlawish, an associate professor of medicine and medical ethics, about where desktop medicine fits into health care -- and how technology plays a role in the emerging field.

What is desktop medicine and how does it fit into the way medicine is practiced now?

Desktop medicine is a new model of medicine that reflects some fundamental changes that have occurred in the nature of disease and in the practice of medicine. It doesn't replace the bedside model -- the dominant model of the 20th century -- but it stands beside bedside medicine. Desktop medicine reflects how concepts of disease that rely upon ideas of risk have increasingly taken hold in medical practice. What follows from that are some fundamental differences in how doctors and patients interact and in how we should select, educate and train doctors and conduct clinical practice. Desktop medicine isn't something that changes things, but rather explains the way things are.

Does this signify a shift toward preventive medicine?

Reducing it to [just] prevention oversimplifies the issues. The preventive term puts people in an arbitrary category: there's nothing wrong with you, but we should do something to reduce your future risk. The problem is after patients suffer an illness like a heart attack, they fall into the category of 'secondary prevention.' There are also concepts of tertiary prevention. The problem with the prevention term is it takes what essentially is a dimensional quality -- risk -- and attempts to put it into a category.

Desktop medicine embraces the full continuum of risk. It captures ideas not only of primary, but secondary and tertiary prevention. Diseases that have relied on signs and symptoms, like disability, are increasingly being converted into diagnoses on the basis of something other than signs or symptoms. This is the desktop transformation of what have been previously known as bedside diseases.

A good example would be Alzheimer's disease. Right now Alzheimer's disease is based on disability -- a person has to have impairments in their memory and other cognitive domains that are severe enough to meet the criteria for dementia. In the last few years, the field of Alzheimer's disease has been aggressively pushing discoveries of what are called 'biomarkers' in an effort to try to identify the disease before a person is disabled. I call that a desktop transformation -- an earlier diagnosis [potentially during] pre-symptomatic or asymptomatic stages.

How does technology play a role in desktop medicine?

It plays a huge role. Concepts of these desktop diseases exist because of fairly recent advances in technology. In particular, the ability to look at large and longitudinal databases quickly and efficiently and using better statistical techniques has allowed us to identify and model risks. Those developments have been only in the last 20 years or so. In addition, advances in the discovery of biomarkers are also relatively recent in technology and science. Fusing the discovery of biomarkers with the kinds of electronic databases that I've described has allowed us to re-conceptualize and to discover diseases that are based on these concepts of risk.

This very much reflects the same kinds of changes in medicine that occurred in the 19th century. The discovery of the stethoscope allowed physicians to begin to incorporate the physical exam into patients' assessments and diagnose diseases in different ways and identify new diseases. It does reflect a historical epoch in so far as a convergence of a variety of technologies have led to the discovery and the reshaping of a variety of diseases.

If the desktop medicine concept is correct in its description of the way things are, what falls from it are some substantial practice and policy implications. One of them is the need to embrace a national electronic medical database. [This is] not simply a record where documents are scanned in as PDFs that you can read. But rather [it is] a database where information about each patient -- test results, medications, outcomes -- is search-able and can be studied. When you start thinking about these desktop medicine diseases, we have a warrant as a nation to have the kind of electronic medical database that will allow us to more coherently and validly identify new risks, monitor the success of our risk reduction and examine the costs and outcomes of care.

How do you think medical training should be changed to integrate desktop medicine?

We're talking about concepts of disease that rely on notions of probability theory, which translates into ideas of risk. When you start thinking about concepts of risk, you begin to recognize the value of the sciences, such as probability theory, statistics and psychology. There is a wealth of data from the psychological sciences that show how people do and don't think correctly through risk information. If you take those scientific facts and think about the doctor of the future, you recognize that you need to have people going into medical school who have an interest in and talent for fields such as probability theory, statistics, psychology and also economics. During medical school you want to better integrate those sciences into the training program. At the end of medical school, make sure people show proficiency in the sciences relevant to the practice of medicine. This isn't to say that we have to drop other sciences. But the degree to which we emphasize laboratory sciences to the exclusion of these sciences means that we have physicians who are perhaps good at bedside diseases, but they're probably not as good at taking care of desktop diseases.

Image: Jason Karlawish

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