Diagnosing Diagnostic Error: An appreciation of the work of Lawrence Weed, MD (1923-2017)

By Art Papier, MD

This first appeared in the August 2017 Society to Improve Diagnosis in Medicine Newsletter.

As we mourn the passing of Lawrence Weed, the father of the problem-oriented medical record (POMR), the SOAP note format, and problem-knowledge couplers, (1,2) we also celebrate his life and ideas. Weed is known best, even in the SIDM community, for those contributions and for his travels across the country in the 1970s, during which he advocated standardizing the medical record as an aide to guide thinking. However, even in our diagnostic error community, some may not be aware of Weed and his life’s work and accomplishments, including important messages about reducing harm from diagnostic errors.

Close to 50 years ago, Weed began to articulate ideas that put him well ahead of his time:

1. The unaided human mind is insufficient to handle the complexity of diagnosis.
2. In addition to not being able to recall all the relevant diagnoses within a differential diagnosis, the unaided human mind cannot remember all the questions to ask around presenting complaints. Software can and should be used to collect a complete data set.
3. Without feedback loops, there is little accuracy and no true learning.
4. Patients need to be central to their care and participate in the diagnostic and management process.
5. Students and doctors should be scored on a core of behavior and skills, not on a “core of knowledge.”

This is a short list. There are dozens more pearls in Weed’s writing and critique. I recommend starting with “Diagnosing Diagnostic Failure,” which appeared in the first issue of SIDM’s journal, Diagnosis.(3) Those who want to dig deeper should consider reading his book, Medicine in Denial,(4) written with his son, Lincoln Weed.

I strongly recommend watching Weed’s 1971 Internal Medicine Grand Rounds at Emory University, which is available on YouTube,(5) and a 7-minute remembrance of Weed(6) produced by my colleague Noah Craft, who is also producing a documentary about Weed and his ideas.

I believe that if Weed had participated in a Diagnostic Error Meeting, he would have taken our community to task. He did not believe that fixing diagnosis would come through modifying medical education, and he certainly did not believe in “cognitive de-biasing.” Weed believed we need an information architecture and software to augment our brains. He did not mean artificial intelligence, but a standardized system to help gather patient data and process it, with the patient at the center and the care team as partners.

Larry Weed was an incredible human being who had a lasting impact. I was lucky to know him.(7)

Art Papier is CEO of VisualDx, associate professor of dermatology and medical informatics at the University of Rochester in New York, and a member of the board of directors of the Society to Improve Diagnosis in Medicine.

References & Suggested Readings

1. Weed LL, Hertzberg RY. The use and construction of problem-knowledge couplers, the knowledge coupler editor, knowledge networks, and the problem-oriented medical record for the microcomputer. In: Dayhoff RE, ed. The Seventh Annual Symposium on Computer Applications in Medical Care, 1983. Proceedings. Silver Spring, MD: IEEE Computer Society Press; 1983: 831-836. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2578206/pdf/procascamc00007-0861.pdf. Accessed July 24, 2017.

2. Jacobs, L. Interview with Lawrence Weed, MD – the father of the problem-oriented medical record looks ahead. Perm J. 2009; 13(3):84-89. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911807/. Accessed July 24, 2017.

3. Weed LL, Weed L. Diagnosing diagnostic failure. Diagnosis. 2014;1(1):13-17. https://www.degruyter.com/downloadpdf/j/dx.2014.1.issue-1/dx-2013-0020/dx-2013-0020.pdf.

4. Weed LL, Weed L. Medicine in Denial. CreateSpace Independent Publishing Platform; 2011.

5. Larry Weed’s 1971 internal medicine grand rounds. https://www.youtube.com/watch?v=qMsPXSMTpFI. Published June 22, 2012. Accessed July 24, 2017.

6. Remembering Larry Weed (1923-2017). Brave New Health Foundation website. http://www.bravenewhealthfoundation.org/the_film. Accessed July 24, 2017.

7. Papier A. Remembering Larry Weed, MD – meeting at a brown bag lunch changed author’s life. MedPage Today website. https://www.medpagetoday.com/PrimaryCare/GeneralPrimaryCare/66102?xid=nl_mpt_DHE_2017-06-19&eun=g822772d0r&pos=0. Published June 18, 2017. Accessed July 24, 2017.