Jun 22, 2017

Larry Weed's scientific approach to the practice of medicine

Sad news, Larry Weed a true pioneer in medicine has passed away. He was one of the major figures in medicine to emphasize the importance of science in the practice of medicine. He created the problem-oriented medical record and SOAP note approach to clinical practice out of what he considered an unsystematic practice during the 1950's. The New York Times has a great article about him, here's an excerpt:

In the early 1950s, Dr. Weed was a professor of medicine and pharmacology at Yale, where he spent most of his time doing research on microbial genetics. On occasion, though, he would accompany students on their hospital rounds and watch as they struggled to interpret the often chaotic patient notes left by doctors.

It was a sobering experience. “I realized then — and it was very upsetting — that they weren’t getting any of the discipline of scientific training on those wards,” Dr. Weed told The Journal of the American Medical Informatics Association in 2014. “When I pick up a chart that is a bunch of scribbles, I say: ‘That’s not art. It certainly isn’t science. Now, God knows what it is.’”

In his 1964 article regarding the scientific approach to the practice and teaching of medicine Weed states:

  • Basic science professors who rightly hold a graduate student to every detail in a scientific article under discussion, or in the performance of his research, somehow in the interests of "coverage" turn out undisciplined hordes when it comes to medical students. Basic science professors and their graduate students have a guaranteed audit, because they must eventually publish the fruits of their daily work in order to survive and this involves editorial review by outside observers._ The charts of patients are not published and medical students therefore need to leave their basic science training with a highly developed sense of self-discipline. The manner in which some laboratories and lectures are handled with a "cook book" and a syllabus to memorise does not develop this capacity for self-discipline in the organisation of a problem and the collection of the data involved. It must be remembered that the very students whom basic science professors launched into the field of medicine, are the ones who a mere four or five years later are keeping charts that do not even suggest the scientific recording of data. It is no excuse to say that the problems are different, the emergencies greater and the patient cannot wait. Indeed the greater the emergency and the more complex the problem and the more multiple the variables, the greater the discipline needs to be.
  • The teaching of medicine and the practice of medicine are a public trust. The records of medical practice should be audited to ensure at all times that the public is always served and never exploited. The medical schools should set the standards for medical records in the example they provide and the principles they teach. Scientific training not only does not detract from humanitarian behaviour, but it may at times be necessary to implement it. Doctors should be trained as scientists and should be subjected to all the intellectual discipline demanded of good scientists. As physicians, they should not, in the name of medical ethics, be allowed the preposterous position that they have the right to set their own standards, keep records as they please and audit themselves.

He continued to criticize the unsystematic approach to medical practice and training throughout the years. I would like to list a few major highlights from his 1968 article Medical Records That Guide and Teach. In this article, among other things, he justifies a scientific approach to the practice and teaching of medicine via the problem-oriented medical record framework.

  • Those who provide total care or who are trying to learn how to provide it, and who naturally integrate findings into well formulated problems should not, and usually do not, feel threatened by a request for a complete list.
  • The structured, problem-oriented medical record provides a focus for constructive action in a variety of "trouble" areas in medicine: medical problems dealt with out context; inefficiency in medicine; lack of continuity of care; inapplicability of "basic science" facts and principles; "off-the-cuff" and undisciplined rounds and conferences; and, finally, meaningful audits in the practice of medicine.
  • Whereas a good scientist focuses on a single or very limited number of problems, pursuing each until he finds a solution, the physician is asked to accept the obligation of multiple problems in a given clinical situation and yet to give each the single-minded attention that fundamental to developing and mobilizing his enthusiasm and skill. The university education a physician receives suggests that his attitude should be scientific in focus, but the multiplicity of tasks that confront him during his clinical training often defeats this goal. He can act as a scientist, however, if he is able to organize the problems of each patient in a way that enables him to deal with them systematically.
  • Basic-science training could have contributed to clinical performance through the teaching of systematic approaches if the physician had been, as a student, required by the basic scientist to formulate problems and write protocols as well as to perform experiments. It is this capacity to formulate and pursue a problem that distinguishes a good clinician, and a teacher of basic science has failed the physician if he does not teach this discipline but merely dispenses facts through lectures and “cookbook” experiments.
  • There is one fundamental aspect in the preparation of the physician that the basic scientist is not prepared to teach, Basic scientists are themselves taught to choose and focus on a single or limited number of problems, and they teach neither the philosophy nor the technic for coping with the multiplicity of problems that patients inevitably present. The failure of clinical teachers to develop and articulate an approach to multiple problems has led to a serious discontinuity in the scientific training of the physician. The chaotic medical record is a symptom of this philosophical blind spot the degree to which we organize the record and elevate it to the level of a scientific document will be a measure of our capacity to develop and teach a workable philosophy of multiple problems.
  • How many teachers of medicine labor under the delusion that they can convey to physicians in one hour or a grand round the factual content or the wisdom of their 10, 20, or 30 years of personal experience and evolution in a field? A more realistic goal in teaching is to discipline the physician in the most effective application and growth of his own developing store of factual information through his own disciplined study of actual cases. [See Evidence-based medicine and Problem-based learning]

Here's one of his grand rounds given in Atlanta. Much of what's covered in this grand rounds is still applicable these days.

VisualDx. "Larry Weed's 1971 Internal Medicine Grand Rounds." YouTube, 22 June 2012. Web. 22 June 2017.

I have great admiration for the works of those who advance the practice of medicine towards a more systematic approach, Larry Weed's work is definitely at the top of the list.

Bold text are my emphasis

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