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In This Episode:
The patient must have a copy of his own record. He must be involved with organizing and recording the variables so that the course of his own data on disease and treatment will slowly reveal to him what the best care for him should be.” — Dr. Lawrence Weed, “Your Health Care and How to Manage It” (1975)
Dr. K discusses the flaws of healthcare and how medicine could be improved, per the insights of visionary healthcare reformer Dr. Lawrence Weed, who died earlier this month at age 93. She covers:
- What is optimal medical care, and why doctors often fail to provide it to their patients
- Why usual medical care — which relies mainly on doctors using their own internal knowledge and mental processes — leads to disorderly healthcare and frequent errors in diagnosis and management
- Dr. Weed’s seminal insight that “Any system of care that depends on the personal knowledge and analytic capabilities of physicians cannot be trusted.“
- Why Dr. Weed believed that healthcare professionals should use “knowledge couplers” and other more reliable tools to guide the process of evaluation and diagnosis, instead of relying on their own mental processes
- Dr. Weed’s belief that the patient should be much more involved in his or her care, and that doctors should help patients make choices, rather than choose for them
- Why Dr. Weed advocated for a better medical record, and why he wanted patients to have access to it
- Dr. Weed’s lifelong advocacy for a healthcare system that would be orderly and reliable for evaluation, diagnosis, and documentation, but then would be flexible and individualized when it comes to treatment for individual patients
- Tips on how older adults and their families can get better care from their doctors, and support the improvements that Dr. Weed envisioned
Related episodes:
006 – Interview: Surviving Cancer & Better Healthcare Through Being an e-Patient
018 – High Blood Pressure Treatment in Older Adults: Research Findings & Practical Tips
Related Resources:
- Medicine in Denial (2011)
- Medicine in Denial Review: A book on how to really leverage technology to improve healthcare (Geritech.org)
- 4 Steps to Get Better Advice from Doctors
- Dr. Lawrence Weed, Pioneer in Recording Patient Data, Dies at 93
- Dr. Lawrence L Weed, MD (Burlington Free Press Obituary)
- The Heroism of Incremental Care (New Yorker article by Atul Gawande)
- Larry Weed’s 1971 Internal Medicine Grand Rounds
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Bill Stocker, MD says
I had good fortune to be med student at case western in late 60s. Dr.Weed was inspirational. I used the.POMR throughout my career in dermatology. The lecture on Utube from 1971 was typical Dr. Weed. You mentioned that unfortunately his ideas were not widely adopted. Certainly the POMR has become a world wide success.
One question, when he refers,to couplers, what data base can physicians tap into with the patient sxs and clinical data? Perhaps this is discussed in his book on Denial.
Thanks for the podcast. Bill Stocker
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Leslie Kernisan, MD MPH says
Thank you for your comment, how wonderful that you were able to learn directly from Dr. Weed while in med school. I also went to Case Western but he was long gone by then, alas.
Some of Dr. Weed’s ideas did disseminate, but as far as I can tell, he didn’t think the POMR was being used as he envisioned. I recently found this 2009 interview, which is relevant: Interview with Lawrence Weed, MD— The Father of the Problem-Oriented Medical Record Looks Ahead.
Of note, Dr. Weed is quoted as saying “It is important to understand that the discipline imposed by the POMR has not been fully embraced. Too often the POMR is sporadically employed as a convenience, not consistently enforced as a discipline. One reason is that medical education is fundamentally incompatible with the underlying philosophy of the POMR.”
Regarding couplers, Dr. Weed and his interviewer discuss this at some length in the interview linked to above. I’m not sure if a suitable one currently exists for easy use by physicians; if you find one, let me know about it!
Dan says
Excellent episode as is the whole series. Keep up the good work. Thank you!
e-Patient Dave says
I’ve been thinking a lot about all this.
In the podcast you say he was a bench scientist (running lab experiments) before he got into clinical medicine. I wonder if that background was both his strength and his limitation about how to do healthcare.
A bench scientist runs experiments, which is not at all the same as diagnosing an unknown problem, right? Experimenters need to do things in a carefully controlled way, with known ingredients, and methodically record what happens. But in walks a patient with heaven-knows-what going on, and the clinician’s job is to figure it out. I’m all for having a standardized approach, but doesn’t it run into limits?
In your review(s) of Medicine in Denial on THCB you wonder about the practicality of following his methods in geriatrics, when the interaction between problems, and interactions with circumstances, can render it impossible to hunt down everything, right?
btw, while the idea of problem-knowledge couplers is GREAT, a constant problem faced by e-patients is when the published / approved / ordained “knowledge” base is out of date, often by years. I long for a Watson-like up-to-the-minute knowledge FINDER that will dig up a new slide deck that was presented in Budapest last Tuesday …. but IBM has allowed Watson customers to systematically EXCLUDE new info, limiting it to only examining info its doctors have agreed is okay to look at.
I could go on and on, but I wonder what you think about both of those issues.
What I take from all this is the sense, which is mentioned somewhere in this, that the only really sane thing to do is say in many cases (together, pt & clinician) “This LOOKS like it could be X, so we’re going to try Y and see how it goes.”
And it’s abundantly clear that families must indeed take responsibility for gathering and coordinating all records, and being able to “present” the patient to every new clinician … such a chore!!
Leslie Kernisan, MD MPH says
I think Dr. Weed was correct in advocating for physicians to be very systematic in how they initially evaluate a person’s health complaint, and in how they document what happened during the evaluation encounter (e.g. what they asked the patient, what the patient said, what the clinician observed on physical exam, etc). This kind of rigor is common in laboratory science, and also in rigorous clinical trials for that matter. But most healthcare is not provided in the context of trials.
My concern regarding the application of this type of rigor to geriatrics is that you could easily end up with a very extensive lengthy process of collecting data and documenting it…and often both patients and clinicians are resistant to processes that are lengthy and tiring. So I think Weed’s idea is conceptually sound, but could be tricky to implement in practice. We can and should still try to do better, however.
Re the knowledge coupler and out of date knowledge: this is certainly a concern. However, my impression is that rare diseases and uncommon presentations are overrepresented among epatients. The bigger problems that affects most people is that good enough knowledge exists in the “ordained” knowledge base; the problem is that it’s just inadequately and inconsistently applied.
So yes, although the ideal is to have a knowledge coupler that can incorporate the latest bleeding edge of knowledge, I’d be happy if most people could access the “ordained” and well-established base, because that would already be a huge improvement.
Lastly: a large part of Weed’s book addresses the need to help patients go through this journey of “this is what it seems to be, let’s try this and see what happens.” He really was for standardization at the beginning and then customization to the preferences and circumstances of the individual. But he wanted clinicians — and perhaps patients as well — to be very diligent in documenting our process and observations.
e-Patient Dave says
> But he wanted clinicians — and perhaps patients as well —
> to be very diligent in documenting our process and observations.
And pretty much nobody wants to pay for that. Which blocks this from ever becoming a learning health system, eh?
Leslie Kernisan, MD MPH says
Yes, it’s often tricky to make a financial case for better care. Better care has proven to save money in several studies, but usually that’s when it’s delivered to a subset of people who are at high risk for ER/hospitalizations.
Terry Graedon says
Dr. K, this is a WONDERFUL summary and discussion of Medicine in Denial. When I finished reading it several years ago, I wondered why doctors and patients weren’t talking about it.
Leslie Kernisan, MD MPH says
Thank you, I’m glad you liked it.
I think the ideas in Medicine in Denial might have gotten more traction if the material had been packaged and directed a little differently. Or perhaps promoted differently…one would like to believe that good ideas will spread on their own, but often they need a little help.
e-Patient Dave says
I completely agree. Much has been written about Larry and his passing and about his works, but nothing gets the point across like Leslie’s telling of the issues.
Yes, beyond a doubt the message will get across better if it can be distilled to something far more granular, far less “thick.”
I myself was unable to get far into it … it seemed to me that the book was written for people not like me – academics who can absorb long paragraphs and unpack deep thoughts. We can all long for the days when most people had that ability, but I think it would be great if someone could repackage it in morsels that match the modern method (for better or worse) of knowledge dissemination.
Like, wouldn’t it be great to have a Neil DeGrasse Tyson telling of all this??