f you ask internists older than 70 how the Problem-
Oriented Medical Record (POMR) and SOAP
(Subjective, Objective, Assessment, and Plan) note
format came to be, they can likely tell you how, when,
and who promoted the idea. If you ask a medical student,
resident, or young physician today, they will likely say,
“That was invented?” and then admit they do not have a
clue. In fact, very few physicians today understand why
the SOAP format and Problem List were invented and
how they are an architecture to guide thinking and care.
Before the late 1960s, paper records were not
only illegible, but they had no organization and
no common format or structure. Lawrence
Weed, M.D., realized that a record organized
around patient problems could guide diagnostic
and critical thinking. He traveled across the
United States evangelizing for a universal
structure to medical records, and in doing so, he
So with deep sadness, I mourn the passing
of Weed, the father of the POMR, the SOAP note
and Problem-Knowledge Couplers. He was also
a father, a spouse to the late wonderful Laura
Weed, and my friend.
Weed was slightly ahead of his time. From
1969 to 1981, while professor of medicine at the
University of Vermont, Weed led a multimilliondollar
federally funded research project, the
computerized Problem-Oriented Medical
Information System (PROMIS). In thinking now
about the idea of implementing an electronic health record in the 1970s, it is hard to grasp not only
how forward-thinking Weed was, but also the courage he must have had.
After leaving PROMIS, he founded a medical software company, Problem-Knowledge
Couplers (PKC). Until the age of 93 and even just a month ago, he soldiered on, tirelessly
advocating for a completely different approach to medical education, medical care, organizing
medical knowledge, and patient engagement.
The 8 x 11 sign on our lecture room door said, “Brown Bag Lunch Series: Speaker Lawrence Weed,
M.D.” It was 1984, I was a first-year medical student at the University of Vermont, and atypically, I had a lunch in a bag. As a result of his lecture, I went on to have two medical educations between
1984 and 1988: one at the medical school, and the other two miles away in the cramped attic office
of the newly founded, three-employee PKC Corp.
I had two lives and lived in a perpetual state of cognitive dissonance. During the day, go to class,
read, study, and take exams. Evenings and weekends, read more medical textbooks, probe Index
Medicus, and input medical literature knowledge into the PKC “Knowledge Net,” all while listening
to Weed critique my training at the medical school just down the road.
Tom Sawyer never had anyone painting fences as quickly as Larry Weed had me painting with
him. As a first-year medical student, I had no context or experience to reflect on the importance of
the development of the POMR and SOAP, and what it took to transform the medical record from an
unstructured, ad hoc mess to an aid for medical thinking.
However, in this small attic office, I was introduced to the problem of cognitive biases in
medical decision-making and the limitation of the human mind in handling complexity. I began
to appreciate that individual practitioners could not possibly store every single diagnosis in their
heads and — just as important — it was impossible to know all the right questions to ask for each
potential complaint the patient might have.
I was experiencing something completely different from medical school, conversations ranging
beyond medicine to history to philosophy to educational psychology to art, music, and more.
Quotes from Shakespeare, Bacon, Whitehead, and Dewey would roll off his tongue, followed by a
joke. You might describe the genius brain as a parallel processor, having multiple gears spinning at once. It is hard to describe the sheer volume
of ideas and the speed with which Weed’s
brain worked. These were not gears, but
massive flywheels of knowledge and thought
constantly purring along in his head. You
would be immediately transfixed by his
enormous personality, his passion for ideas,
and the rapid and humorous flow of
Beyond my awe of Weed’s intellect, early
on I appreciated his humility and emphasis on
what made a physician. He evaluated students
and residents on how they investigated and
solved the patients’ problems and not by how
many facts they could regurgitate (although he
seemed to have them all in his brain).