The excellent ICMCC daily newsletter just alerted me to this item from Permanente Journal: Interview with Lawrence Weed, MD — The Father of the Problem-Oriented Medical Record Looks Ahead.
I hope to absorb it in the next day or two, and I invite people who know this history to do the same. It’s deep, and it’s connected to our roots here: when I went googling for the photo at left I discovered that our “Doc Tom”‘s Ferguson Report gave Weed an Outstanding Achievement Award. In 1999. To wit:
“Dr. Larry Weed is a pioneering visionary of Information Age health care. He deserves a Nobel Prize in Medicine–maybe two. After reinventing the patient medical record as the Problem-Oriented Medical Record and developing one of the first systems for computer-based patient records from 1956-1982, he set out to develop a computer-based tool, the problem-knowledge coupler, to provide just-in-time computer support to the provider and the patient as they work through the process of diagnosing and treating a n ew medical problem. His vision of a coherent health care system based on a new generation of computer tools points the way toward the next generation of medical thinking.”
In this new interview, 12 years farther down the road, computers are immensely more powerful than what he had then, and he has a decade more experience working with knowledge couplers. What has he seen, and what does he see looking forward? Wow.
(The other awardee in that Ferguson Report is none other than ACOR founder and SPM co-founder Gilles Frydman. Time capsule!)
A taste of the interview:
The true depth of the knowledge problem in medicine occurred to me when I found myself doing basic research in biochemistry at a university medical school. As a scientist in the laboratory I was dealing with one problem at a time, making time and tasks the variable and achievement the constant. … I was asked to teach clinical medicine on the wards a couple months a year. It was at this point that the true nature of our predicament dawned on me. …
The multiplicity of problems the physician must deal with every day constitutes a principal distinguishing feature between a physician’s activities and those of many other scientists.
These realizations led me to develop the POMR [problem oriented medical record] so that medical students and practitioners could function in a structured, rigorous way more like that of workers in the scientific community. The POMR cannot change the multiplicity of problems that physicians face. But the POMR enables a highly organized approach to that complexity.
I cheated and skipped to the end of the piece, for his “look ahead,” and found these:
I have heard you eloquently make the case that the present practice of medicine is flawed in that it primarily depends on the physician’s limited memory and processing capacity when dealing with complex patient issues. What is your solution?
LW: I have spent more than 30 years developing and implementing what I have called “knowledge couplers.” Medical knowledge is used to select and analyze patient data, coupling the data in a matrix fashion with medical knowledge developed through research. The output of this coupling process is an organized display of options and evidence. …
… any automation that reliably couples patient data with the world’s medical research will be dramatically better than the unaided human mind.
The “knowledge couplers” are to be used, he says, in conjunction with the POMR and reform of medical education and credentialing. (I’d be laughed out of the discussion circuit if I proposed that – will Dr. Weed be marginalized for it?)
You have expressed concerns with both the type of individual accepted in medical school as well as how medical students are taught in their first two years. Could you tell our readers what you see as the issues and the implications to preparing these students to practice medicine?
LW: Today, students are recruited on the basis of how well they memorize and regurgitate facts. In the future because knowledge will be in information technology tools instead of in heads, students should be trained in the reliability of performance of given tasks that will be part of a complete medical care system. Students should be selected for their hands-on skills and interpersonal skills and not on the basis of their memory and regurgitation of facts.
Your writings make a very compelling argument for these changes in medical education. Yet, such changes are largely absent from health reform debates. Why do you think there has been such a complete lack of a dialogue on the subject? If educators disagree, why aren’t they saying so?
LW: The system that I just described is very threatening to many educators who are now in the business of moving knowledge through heads instead of using information technology such as knowledge coupling tools. They are judging students on how much they know instead of how well they perform in a well-defined and audited system of care. …
Enough – if you’re interested in this examination of the very nature of a doctor’s work, please read the whole article, and we’ll discuss.
This is both an inspiring and a troubling post.
Dr. Weed’s ideas are incontrovertible (to me at least) – we have long surpassed the ability to be all-knowing (even the smartest of clinicians). Moving forward we will need to nurture critical thinking and sense-making in the medical professions…emergent information will need to be found/analyze/synthesized into new knowledge and action. This will create a wholesale shift in the way medicine is practiced and will likely change the way society looks at the medical professional – for better or worse.
But what troubles me is that so little progress has been made to date. While these are notions that resound loudly within our echo chamber, they seem to fall largely on deaf ears in the general population and certainly seem silenced within the broadest demographics of the medical and medical education communities.
The bottleneck and shortcomings of eminence-driven healthcare are quickly undermining medical innovation…this has lead to a culture clash. Those that see the future as Dr Weed sees it must begin building a body of science that answers the critiques offered by defenders of the status quo.
I believe we are losing this battle b/c we have yet to galvanize our beliefs w/ science…and we will not drive such a massive culture change with anecdotes and hypotheses.
Great to hear from you, Brian.
I hear you about “troubling”; what I hear in Dr. Weed’s words is that the entire medical education establishment has an enormous amount invested in the status quo, and quite likely can’t imagine (literally) how to reinvent itself.
And, if other industries are any indication, won’t be able to imagine it, until someday it ghets undercut entirely.
I think of Digital Equipment’s founder and longtime heroic leader responding to PCs by being unable to imagine anyone wanting a computer in their home. And indeed his view was just fine, until people started getting computers in their home, and then he was in deep trouble. A few years later he got bought by Compaq.
I think, conversely, of IBM going through the wrenching transition of killing off part of itself, to create the PC division, utterly and totally different in its culture and values. How likely do we think it is that medical education will do that?
BUT – the question then arises, what WILL happen?
If we think it’s never going to change, do we give up?
Or can we sit in a transformed world out there, 3 or 5 or 20 years from now, and look back and see how the change happened?
>>>> Mind you, all, I’ve never been through med school so I don’t have a clue about the following wonderings:
– What (who) stands in the way of a medical school adopting Dr. Weed’s approach?
– What (who) is stopping us from certifying and hiring such doctors, if the school did exist?
And then the serious disruptive question:
As more and more patients fall out of the system economically, and are totally uninsured or virtually uninsured (high-deductible, like me), will they be able to get their hands on Knowledge Couplers, and cut out the intermediary, who they consider to be over-priced?
Here’s an interesting post: Will The Great Recession Create Millions of e-Patients?
It’s from two and a half years ago, by the other guy in that Ferguson award: Gilles Frydman…
Gilles is a mentor and for good reason – he walks the walk. Thank you for that link.
As for disrupting medical education, I have a few ideas here – just see the current cover of Medical Meetings (http://bit.ly/tsuteu). I have every intention of blowing up the current system and starting over.
We treat physicians like they are customers in a grocery store, providing an excess of updated knowledge ready for them to go pick up when necessary. This information has little relevance to their needs and zero context to their setting. This model of store bought (expert driven) content fails to impact behavior, fails to improve healthcare quality, and wastes $100’s of millions of dollars annually on keeping the shelves stocked.
But while I am working on the back-end of medical education (the lifelong continuing professional development of clinicians) we have to lean on the innovators at Mayo, Cleveland Clinic (and Kaiser, perhaps) to build integrated medical schools. We need some very public pilot programs that build clinicians who are prepared to operate in the new healthcare system. (I find the AAMC to be both the greatest source of knowledge and friction herein)
But, this is a good is the enemy of great challenge. Small changes overtime pacify critics and suggest that transformational change is always right around the corner – but it isn’t and we need more people (like you and Gilles) pointing fingers and holding the system accountable. For medical schools it is likely that the disruptive innovations ARE the ex-US programs that can re-engineer professional education and then prove to the US for once and for all that our system is broken…this statement is sad-but-true.
Most healthcare institutions manage clinical problems today without the use of meaningful computerized records. The records have become perversely converted to billing uses. Problem lists are often omitted and complete physical history and exam is often forgotten. Medical education has retrogressed rather than advanced. Parochial faith based hospitals are on the rise. Nowadays doctors rarely attend medical school nor see patients. Instead they sleep through the boring classes on chemical cycles and are presented patients through assistants and technicians.
I don’t know what planet you’re from, but “doctors rarely attend medical school” is one of the weirdest non-spam comments I’ve seen … if you have any documentation for any of these assertions I’d love to see it…
Dr. Weed is a stand alone doctor and victim of his medical profession. Not unlike others who have tried to “make change.”
I studied Dr. Weed’s POMR while studying at Western (BScN) & the nursing profession could see value in the POMR where doctors did not!
I have written a handbook (which was shared with Dr. Weed) that was developed based on the POMR and it is available to anyone who wishes a copy.
Contact me at: firstname.lastname@example.org