Larry Weed Quote
Disconnected Facts

He not only insisted on an excellent — and completely documented — medical history, a thorough and complete physical exam, an analytical differential diagnosis, and cautious therapeutic recommendations, he commanded it. I was a medical student; I knew close to nothing. He was sharing the big picture; he knew what was important, and it was the patient and the care you delivered.

This towering, insistent voice hammered away that the medical schools had it all wrong by using board scores for evaluating students and rewarding their ability to memorize disconnected facts. “This is a pretense of knowledge,” he would say. “You wouldn’t get on the plane if the pilot was memorizing the route and had no instruments in the cockpit, so why are they training you and encouraging doctors to practice solely by memory?”

Weed understood that more and more students were going into specialties, not because they were chasing a larger paycheck, but because they wanted to feel mastery. In the 60s and 70s and earlier, the best and brightest in medical school were attracted to competitive residencies in internal medicine and primary care, which is no longer the norm. Weed realized that the sheer volume of medical knowledge, and the over-reliance on the brain for clinical thinking in general medicine, would shift students into specialties.

It is difficult to feel mastery when medicine is no longer like flying an openair biplane, but more like flying a 747. The challenge of primary care and emergency medicine, where patients present with an enormous range of undiagnosed complaints and physicians jump to premature conclusions or make other cognitive mistakes, is a fundamental problem Weed was trying to solve.

Tolerate the Ambiguity

Weed predicted and created the idea of using evidence at the point of care by building the evidence into tools designed around patient problems. He did not believe clinicians could memorize and keep up to date on all the randomized controlled trials and store all the literature in their heads. He railed against arrogance and certainty in medicine. He repeatedly instructed me to “tolerate the ambiguity” inherent in clinical decision-making and to be able to say to a patient “we are not sure yet.” He had this beautiful tapestry in his head of how to organize information and rethink medical knowledge so it could empower patients. He was designing and writing about patient empowerment decades ago.

He also believed medical schools are deeply flawed, and that students should not be rewarded for a “core of knowledge,” e.g., high board scores, but rather a “core of behavior.” He insisted we need to measure students on performance-based metrics. Foremost, he wanted to see our students (and physicians) be exceptionally thorough, precise, and caring with their patients, use tools to guide history and assessment, be analytical, and have logical competence. The mention of patients today receiving full body CT scans in some emergency departments before the history and physical exam depressed him.

Larry did not believe that physicians would lead the effort to fix the problems of medical care delivery. He was sympathetic to how overworked, in debt, and overwhelmed many physicians are, particularly those in primary care. However, he was optimistic about the role of the patient, and the possibility of an open source medical knowledge repository designed to improve decisions in the home and at the point of care.

He strongly recommended that the National Library of Medicine spearhead an effort to organize clinical knowledge beginning with patient inputs. He had a comprehensive vision of a new universal medical knowledge system, a repository of information leading to purposefully designed tools for patients and physicians. The envisioned open source system would have measurable inputs and outputs and would have feedback loops to improve the data and learn from the population.

Weed felt the focus of the great majority of health information technology tools were fragmented and misdirected, and too frequently about the commerce of medicine, rather than improving care for people. He would frequently caution, “If you misstate the problem, you cannot fix the problem.”

The near feverish media attention on what is new and amazing in medicine, such as genomics, biomics, proteomics, and precision medicine — without attention to all the error, resultant harm, and inconsistent performance in clinical medicine — drew his constant ire. The focus on electronic health records as financial optimization tools discouraged him, as it does many of us. He would use more colorful terms and his great wit to characterize the poor outcomes we have in the United States for the $3 trillion we spend annually on healthcare. He never stopped trying to advocate for fundamental change. His sense of humor, intellect, drive and purpose were a force of nature. I am glad I had lunch in a bag that day.

Written by Art Papier, M.D.'88

Art Papier, M.D.’88, is the co-founder and CEO of VisualDx. A dermatologist and medical informatics expert, Papier is also an associate professor of dermatology and medical informatics at the University of Rochester School of Medicine and Dentistry. He is a thought leader in clinical informatics and healthcare solutions that improve diagnostic accuracy.