Medicine in Denial, a book review

A difficult but essential read, not for the answers but for the questions it raises about the future of the profession.

Larry Weed famously invented the problem oriented medical record (POMR) back in the sixties. He deserves to be heard with this new read, Medicine in Denial. The Affordable Care Act encourages change in the structure of medical care, much of it coming from the highly subsidized shift towards electronic medical records.  This book champions one of those trends.

Weed was born in 1924, graduated from Columbia Medical 1947. He has been prominent in medical education in many teaching positions.  I first heard of him at Dartmouth Medical School teaching Family Medicine. He has publications as long as my arm and several books, awards and recognitions. Recently, Weed applied his talents to medical informatics and administrative medicine. Weed founded Problem-Knowledge Coupler Corporation (PKC) of Burlington, VT, a company dedicated to developing the information coupling software and medical information database that the Weeds advocate in this book. Sharecare® of Atlanta, GA, the health and wellness social network acquired PKC June 12, 2012. Dr. Oz, the television host co-founded Sharecare®. Dr Oz plans to make his social technology platform, together with PKC's clinical knowledge management system available to patients and providers to enable clinically informed communications. Weeds version of connecting the vast database of medical knowledge with clinical decision support (CDS) and much of his research may live on in that wellness format.

In the beginning of his book, Doctor Weed and his son Lincoln Weed, an attorney, argue that a lack of complete patient data from the history and physical lead to false assumptions, waste and unnecessary procedures. The Weeds give compelling examples. Here and throughout the book the authors compare the present disorganized medical record keeping and subjective judgment of physicians to the regimented standards of CPAs or airline pilots who follow standard operating procedures. The book is a cry for healthcare reform. Both educationally and clinically Weed would have the standards and decision making dependent on an electronic repository of medical information rather than having the electronic record reflect the judgment and intuition of the provider.

Weed argues that medical information is so vast that it is not possible for the doctor to remember all of the lists of possibilities associated with each symptom, sign or physical finding. The Weeds argue that medical education must change its approach from teaching judgment and diagnostic skills to technical training enabling the provider to be scrupulously consistent and accurate in developing the clinical data base. They further suggest that non-MD providers with this more technical yet patient centric approach will be more easily supervised and more adherent to standards of procedure devised by experts. Evidence based data will presumably define diagnostic criteria with a vast medical database that in turn couples to the clinical record. Two way communications between medical information and the clinical record affords both clinical decision support (CDS) for the provider and a more graphical representation of the choices facing the patient. Coupling the electronic database of medical knowledge with the precisely defined clinical data -- according to the Weeds -- provides a complete list of possible diagnoses, together with, rather precise criteria.

The later chapters offer an excellent description of the discipline and mechanics of the POMR, and where better than from the originator. Larry is alive and well in Underhill, Vermont. Weed is as energetic and thought provoking as ever.
            ----------------------------------------
Opinion: Although not easy reading, this book certainly encourages thought and speculation about the future of medicine. At times one can tell which Weed is doing the writing. A lawyer often views medical practice with skepticism. The number of wrong diagnoses and medication errors do not improve that view. The success of nurse practitioners in the primary care setting, especially in Europe, may lead to an environment dominated by competent NPs in the US as well. That might be a slippery slope.

Weed makes a valid argument in favor of collecting the vast sum of medical knowledge in an open scalable, dynamic and accessible database. To whom that data is accessible becomes a question for our time. Weed appears to favor individual patient autonomy and care with the vast information base available to the patient for shared decisions. One wonders however how widely that database should be shared. An old adage suggests that a doctor who treats himself has a fool for a doctor. With the vast store of medical knowledge available to everyone, one indeed risks having a fool for a doctor. Hippocrates insisted that the profession be limited to only those worthy of the privilege. Theodorico in 1250 at Salerno and later UNIBO insisted that physicians share medical science freely among themselves and not hold  their knowledge secrete. In today's tension between the profession and: many competing interests, much of the traditional ethic has been lost. Patents and copyright too effect the access to medical information.

As for standards of care, the responsibility for both law and accounting rests with the profession not the government. The FAA’s management of airspace is a different matter, but nonetheless, demonstrates an unwieldy, slow to modernize bureaucracy. The shift in medical schools from state supported institutions to self-sustaining commercial operations substantially weakened their credibility to set standards. The standards for doing an H&P or managing diagnostic criteria, however, can only come from medical schools preferably universities -- prior to graduation and sustained through CME. Furthermore, the American Hospital Association’s success in removing the requirement for physicians to be in good standing with their local medical society in order to maintain hospital privileges ended the profession’s ability to enforce their own local medical standards.

Medicine needs a BAR such as found in the legal profession. The ABFP requires a review of records, but the review is trivial. University based schools of medicine, might audit the clinical practice of their graduates on a continuing quest for excellence and quality improvement. The authority for such an audit, however, might only come from a salaried relationship with the state sponsoring the school and the audit. Electronic health records might come into play.

Intriguingly, the University of Michigan recently established a department shared between clinical medicine and the engineering school. The surprising synergy of such cross-pollination may prove a meaningful step in the quest for continuous quality improvement.  The enforcement of standards, however, should return to the profession but with another kind of cross-pollination between University, medical society and law schools. Non-clinical PhDs simply cannot set standards or enforce them.

On the other hand, a valid argument exists against any standardization. Standardization represents the antithesis to the scientific method. In either event, the profession more than ever needs an open, rich and dynamic scientific culture, not a cloistered standardized and orchestrated one. Three things characterized the great advances in medical science of the past: diversity, travel and the gout. One could forgo the gout. With the explosion of biomolecular discovery and accelerating change, the science of medicine depends more than ever on inductive reasoning, diversity and openness. Scientific medicine will no doubt continue in the specialties, in pathology and in research. In the meantime, the profession must not lose sight of its pursuit of excellence and the education of great humanitarian physicians.

Eight hundred years ago, Universita di Bologna, UNIBO, established a medical school, freeing itself from cleric interference embracing a revival of Roman law. With the help and protection of their successful new law school, they established a medical school embracing objectivity  and disection. Like the synergism of engineering and medicine, law schools might help clinical academicians maintain the open probing diversity and inductive reasoning that is the scientific method. In the meantime, we should not close our eyes to the computer, but rather use it as a tool. The physician thinks; the computer remembers.