Medical Revolution 50 years early | Dr Larry Weed's Original 1971 Lecture

0:00 last week there was a number of posts talking about the future of health care about the great revolution in computer aided diagnosis and medical informatics but everyone knows that an overnight success story is actually a story at least 25 years in the making and in this case is a story of well over 60 years this presentation I want everyone to watch is by dr. Larry weed it's online on YouTube and in the 55 minutes he

0:30 discusses the future of healthcare but this was recorded in 1971 dr. Larry weed tried to shine a light into the field of medicine over half a century ago and show us how sloppy unscientific and unartistic we actually were many of his observations went unheeded until now he knew something was coming and in this lecture he talks about quote and now when the computer people move in and the

1:00 non-medical people move in they can hardly believe what they see and there is a crisis of major proportions what I would encourage you to do is to stop this podcast open up YouTube type in dr. Larry weed internal medicine Grand Rounds and watch his original 45 or 54 minute lecture and it was uploaded by dr. art Papp PA and visual DX they're a very innovative company in trying to

1:33 diagnose and make computer-aided diagnostics it's kind of a Palantir for medicine I definitely recommend you check out their website but this lecture I'll just play the his closing two minute comments and then pull out a few of the quotations which I found most memorable but the reason we don't like

2:03 to do it is because your faults are so out of these your mistakes are so obvious the lack of purity of your approach is so obvious you can't stand it so you say it's unimportant or it's not scientific but that's not why I came into medicine for cowards it's perfectly clear that's what the problem is society is unreasonable it's frustrating it's irrational the cell was to the centrifuge was to those mitochondria were they weren't pure but the only

2:34 difference was is they couldn't talk back and we couldn't see it and we didn't devise methods to see how badly off we were all right now let me make one closing remark about what this is all got to do with done with the art of Medicine where the art of medicine gonna go with all this equipment if you have lists and numbers well art is style structure form discipline it's Andrew Wyeth making Jamie Wyeth through the painting fifty

3:06 times until it's like unbelievable discipline about technique he made that boy tear up a painting a hundred times it's George Szell if you ever watched him without Orchestra the same passage 30 times until it was perfect and no violinist it up said this is interfering with my art nor did box type three beats in every measure home one it interferes with my creativity that's too good - that's 100 bein no heart is Hemingway

3:39 three weeks on a single pair of s it's Bach recording in detail everything you did a couple hundred years ago so we can hear it today it's not a scribble in the middle of the night it's not saying I took good care of her leaving absolutely no trail for us to ever find out whether you get or do not we do base the word art itself what we call what we've been doing art and it's not science so we have to be extremely

4:12 careful when we defend what we're doing we don't reveal to others that we don't even didn't even get out of a liberal arts education this prevents key says that art is nothing more than placing limits and working against them rigorously and if you refuse to place them and try to work within them but just flail out you do not have art you have chaos and to a large extent that's what we've had thank you very much

4:47 that's the excerpt online you'll get the other 50 minutes of the presentation just like to pawn a few quotations on a few different themes that were addressed the first was on patient resilience and diagnostic ere he states well you realize I'm sure that the Lord and the chiropractor's can get eighty-five percent to the people better the only reason you run these fantastic hospitals is to get the other 10% and the only

5:19 reason you have a professor of medicine is to pick up the final two percent on patient care and specifically on patient-centered care he had this idea that in the record there should be a deliberate spot in the plan where you write what you told the patient he said no in no place in American records do we organize an approach to where we are going to tell the patient did you tell her that her hypertension was serious or

5:50 not did you say we were going to study it why or why not now of course interesting comment is that we still don't have a place for the sinner record over half a century later on discussing the fal ability of doctors he states the way that interns and residents and doctors work if they worked perfectly it would be one thing or if they didn't work at all it would be another but they have work we have gas and we have understand

6:18 and we have no yeah the problem with this is that we it's hard for us to know how when we're doing things correctly or when we're doing things incorrectly which is one of the big drivers of why improving our records was so important when commenting on the source orientated medical record which is sorting a paper chart with all the radiology images together all the notes together all the labs together which is by the way the

6:48 way we still over half century later sort of records he comments why do you put the x-ray of the ear with the x-ray of the hip what's the year got to do with the hip and why do you have all those ear cultures with those urine cultures is she urinating her inner ear why are you doing that for yeah he instead proposes a problem orientated medical record on discussing medical data and medical thought he says that

7:19 this is not an idle discussion on technical bookkeeping details but that the practice of medicine is the way you handle data and think about it and the way you handle it determines the way you think and so the structure of our data determines the quality of our output and that is so hard for medicine to accept he goes on to discuss the issue of physician memory stating that you might say why don't you call up the doctor and

7:51 ask him to which he would reply well that was two months ago you can't be serious you wouldn't tell a bank teller do you remember mr. Jones he came in two weeks ago how much money did he put on the shelf if you received an answer you would think that the bank teller was crazy but in medicine as he says we write discharge summaries three weeks later we were a preoperative notes after the operation someone may write

8:19 all their notes for on progress notes Sunday morning this is he says fiction not science in discussing quality in medicine he states if you can't audit a thing for quality it means you don't have the means by which to produce quality they're inextricably linked and you can't evaluate what you're doing then it's a very serious possibility that you don't know what you're doing on

8:49 systems-thinking he states when someone says I take care of that patient I'm her doctor that's fraudulent no one points at a Pontiac and says I made that car a system made the car it's like Henry Ford saying I personally am going to make an automobile for everyone in the population I don't believe in systems and assembly lines I'd rather buy a personal touch on it he would make an automobile for two or three people a year and the other 200

9:20 million would have none and this is the basis for a revolution the medical record is the basis for a system the record has to be and he goes into the presentation discussing something which is called problem orientated medical record the first part is a focus on something called the database which is the collection of all the information about the patient and the problem and the big issue is that the way we do this as physicians is we take a Sherlock

9:52 Holmes approach asking questions and then cutting to the next follow-up question when instead he says we should take a much more systematic approach to collecting the a comprehensive database which is standardized for all the patients and this would then ensure that we actually have evaluated all the potential questions which we should look at and the rebuttal of courses that doctors don't have time to do this and so his reply is you should get

10:23 paramedical people to do so and you can use computers to aid in branching logic questions and you need to get the database and to get the same database every time we know that the database we get for a patient is dependent on how many admissions we've had that day how tired we are whether it's the morning or the evening whether we like to talk to the patient or we don't and these variables shouldn't impact a patient's care Hiba quotes his

10:50 own study where they took a questionnaire with 32 questions and they got vital signs and they had para medical personnel do this entire process it took nine to eleven minutes and when they compared the database that they got from the para medical personnel they found an additional five point two problems per patient that the doctors had missed and some of those problems were quite serious the second part of the problem or intended medical record is going on to the problem list now the

11:23 key thing is that he's interested in a problem list which is not an impression list he wants no ambiguity in what the problems are he goes through an issue for instance where someone had written down as we often are prone to do query organic heart disease and he said well what's the problem and the person replied that they had a funny echocardiogram and he said well you know you don't want me to write funny echocardiogram down as the problem but

11:55 in fact that's exactly what dr. weeds wants a person to write down is that the cardiogram looks funny because now we know what the problem is to suggest that the person query may have organic heart disease is to essentially make up BS and as dr. Huy says if that's the level at which you understand the problem put it down that way if that's the level in which your care is being given there's nothing to be ashamed about all you have

12:22 to do is be honest which moves us then into the third part which is the plan and one of the key concepts was that no one should ever be able to write an order without coupling it to a problem again this is such a crucial part when designing medical record systems in the electronic system we still don't do this for instance it's like walking into a room of throwing darts he suggests and someone that might ask

12:49 we're the target and the response is well wherever the Darklands and he proposes we need to be much more thought-out in her plans it needs to have three components the first is to rule out what could be causing the problem and to investigate the problem and to have a stepwise approach to investigations the second is to identify what the treatments will be based on the results of investigation and the third is then finally tell the patient what do

13:22 you found and what you're going to do about it and to document all three of these steps and to lay out all three of these steps when we follow patients in a clinic or in hospital of course we can use something such as a soap note structure which I think most people are probably familiar with that's the where you right through subjective findings your objective findings your assessment and then your plan and you do that underneath each of the problems and one

13:52 of the key concepts that dr. weeds goes into is the fact that he says now what I'm saying is that a doctor has to be a guidance system he is not an Oracle that knows answers and once he accepts the concepts of being a guidance system then he knows that the data system is the basis for which all of his work must take place we have a perception in medicine for centuries that it's the doctor which has the answer whereas even

14:22 half a century ago dr. weeds knew that the key role of the doctor is to really be the guy in system to ensure that the database has collected properly to ensure that the problems are identified to ensure that the plan is in place and then to watch the trajectory as the patient's condition unfolds as the it is investigated and as the condition unfolds to see where it goes and helping to guide the the patient and the medical

14:56 record through the system and of course with the augmentation of artificial intelligence augmented care through computer systems more and more of the actual medical diagnostics and more of the predictions as far as what the patient likely has on what the best treatment options are is going to be better done by in the computer and so by putting a physician into more of a role of a guidance system

15:26 in ensuring that this is operating properly actually is a right metaphor to be using as he applied it in 1971 if you're interested as they say highly encourage you to go watch this whole lecture online I want to thank again dr. art Papp PA and visual DX for uploading it you can find I got a copy of the transcript online and embedded at the

15:57 bottom of the post and highlighted a few of my favorite sentences from it it's a little bit hard to read because it's a verbal lecture which is now being transcribed into paragraphs but it has as I say some of my favorite sentences picked out and in bold if you're interested ocular we'd say also has written several books as well as there's a few other short YouTube videos with him online and there'll be a documentary which is still in production on his life

16:28 career and works