Remembrance of Larry Weed

Art Papier apapier at VISUALDX.COM
Wed Jul 12 19:25:04 UTC 2017


Mark,

I don’t think this article alone put a “stake in the heart” of Problem Knowledge Couplers.  Larry realized that for knowledge couplers to be successful they would have to be used by trained paraprofressionals.  At he believed that doctors, particularly generalists and emergency physicians, are taking a superfical history and doing a shallow cursory exam, and then documeting it all poorly.  Weed argued that the adhoc questions that doctors ask their patients when they present with a symptom, is a broken, self-fulfilling prophecy.  He relaized the physician work-up was essentially a spontaneous flow  of questions around symptoms and other findings related to the diagnoses the doctor knows and thinks about,  not the findings related to the diagnoses the doctors does not know or is not remembering.  Problem Knowledge Couplers by definition asked for the highest level of thoroughness in history taking.  The challenge is that this cannot be done efficiently by doctors.  So Larry believed this work of obtaining the “full dataset” of history and physical exam could be done by the patient with a trained person that was an expert in history taking and physical exam (not a doctor).  He had already been working on couplers 10 years when I met him in 1984, and at that point he had a deep skepticism that we could transform medicine by teaching doctors to be thorough.  There is an efficiency – throughness tradeoff.    You could argue that doctors are way on the side of speed (not efficiency because efficiency suggests accuracy) , and Larry was all the way on the side of throughness.  Fee for service medicine obviously does not reward thoroughness.  I was not at the time at all surprised that the study did not show quality improvement for couplers.  IMO there was no “nose dive”, there was  actually was no “altitude” at that point in the flight of point of care decision support.   Now that we have graphical computing,handheld computing, and widespread EHR’s it is a new day.  

 

Foremost, people need to understand Larry’s critique.  One example is he talked for 50 years about the critical nature of getting the full dataset on the patient, yet the media, (and some doctors) pay little attention to this core message but instead, for example, are in a trance about Watson and AI.  The technophiles don’t understand these core ideas that Weed worked so hard to promote.  Though hugely promising, there is currently a huge garbage in, garbage out problem inherent to deep learning and artificial intelligence as an over-arching solution to diagnosis.  How can we train a computer using deep learning on copy and pasted, innacurate medical records?.  On the positive side some innovators in health information technology are working on Larry’s ideas.   Fortunately we are seeing this new generation of residents and phsyicians embrace the idea that doctors should use information tools as they see patients depsite the lack of leadership by many of their teachers.  I have said it before, and I will say it again.  Medical educators with gray hair are unlikely to solve this problem.  There is a vested interest in the medical schools to continue with closed book exams, and evaluating our students for feats of memory.  If we want to instill life long learning behaviors, and point of care knowledge acquisition in our students and residents, why do so many educators using tools would be “a crutch” as one dean said to me at a recent AAMC meeting??  Listen carefully to Larry here:  http://www.bravenewhealthfoundation.org/the_film

 

It’s his critque and clear articulation of the fundamental premises of what a diagnosis is, how doctors should think and practice with tools,  that we should pay attention to.

 

Best

Art Papier MD

From: Mark Graber [mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG] 
Sent: Wednesday, July 12, 2017 9:39 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Remembrance of Larry Weed

 

Its interesting to consider how different our world might be if the Apkon article hadn’t put a big stake in the heart of Weed’s decision-support tool.  It seems like interest in decision support for diagnosis took a major nose dive as a result of this publication, and ultimately the use of ‘problem-knowledge couplers’ never caught on.  

 

Although they selected 24 different quality metrics in evaluating the impact of Weed’s PKC’s, none of these directly evaluated the most important outcome of interest, the accuracy of diagnosis.  

 

Mark L Graber MD FACP

President, SIDM

Senior Fellow, RTI International

Professor Emeritus, Stony Brook University 



 

 

From: David Meyers <dm0015 at ICLOUD.COM <mailto:dm0015 at ICLOUD.COM> >
Reply-To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> >, David Meyers <dm0015 at ICLOUD.COM <mailto:dm0015 at ICLOUD.COM> >
Date: Wednesday, July 12, 2017 at 8:45 AM
To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> >
Subject: [IMPROVEDX] Remembrance of Larry Weed

 

Harlan Krumholz reflects on Dr Weed’s legacy. 

 

http://healthaffairs.org/blog/2017/07/11/what-larry-weed-understood-about-the-medical-profession-a-remembrance/

 

David

David L Meyers, MD FACEP

Listserv Moderator/Board member

Society to Improve Diagnosis in Medicine

Save the Date: Diagnostic Error in Medicine, October 8-10, 2017, Boston, MA

 

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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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