Weed’s Problem
Oriented System of Medical Record Keeping
Daily Observer
S.Q.
Lapius was at the blackboard in his study.
He ignored my hello, didn’t even turn his back. “Hard day?” I asked. No answer.
“Anything
bothering you?” I said in a louder
voice. Naught to be heard but the
squeaking of chalk on the board, and the distant humming sound, like katydids
in the brush that Lapius emitted when lost in concentration.
I
gave up and went to the kitchen, clinked some ice in a short glass, and poured
some gin, in the process of making myself a martini, when Lapius woke up. His voice bored in from the den.
“Make
one for me too, will you Harry, like a good fellow.”
I
did, but had finished half of mine before he emerged from his caverns of
thought. He sipped the drink and nodded
approvingly, then said, “Yes, no.”
“Yes,
no, what?” I asked puzzled.
“The
answers to the questions you asked when you burst in.”
“I
didn’t think you had heard.”
“I
always hear, Harry. I don’t always
answer.
Actually
I was transferring some case histories into Weeds terminology, you know, the
problem oriented record.”
“I’ve
heard about it. How did it go?”
“Not
bad. You know what Weed says. He feels that doctors are scientists, and that
good records are basic to good science.
He feels that science demands precise thought and logical pursuit, so he
has devised the problem oriented system to deal with a medical record.”
“I’ve
seen some of his work. I guess there’s
some advantage to it, but I don’t see it as much more than changing the term
‘diagnosis’ to problems. After all, when
a doctor gets through taking a history, he lists the diagnosis. Weed would have him list the problems, number
them, and then refer to the problems by number in follow up notes.”
“It
is more sophisticated than that. In
addition to the problems listed, there must be a plan for managing each of the
problems. If a patient has chest pain,
belching, is a heavy smoker, and drinks too much, these would be listed as
problems from 1 to 4. Then in the
follow-up, there would be a plan to deal with each of the problems, and
finally, the progress with each problem would also be categorized accordingly. Of course it would lend itself to
computerized data collection on a population basis, if each doctor accomplished
the task according to the precision that Weed would like.”
“The
doctors will be working for Weed, so he can correlate all the data for the
problems of a given population?”
“Harry,
you are young and cynical.”
“Maybe. But I get skeptical of all plans that tend to
unite patients into population groups.”
“Don’t
be. There is much good in the Weed
method. Principally it would help to
correct one of the grievous flaws in medical record keeping. For instance, Weed proposes a flow sheet, a
crosshatched page which would list the medical parameters, such as lab work,
pulse, blood pressure, and more sophisticated data, in columns, so that the
changes in these values during a given period of time, and perhaps treatment,
can be compared. Look at the average
hospital form now, with it’s hodgepodge of laboratory data pasted in random
fashion to pages wedged into the metal chart holder. It is impossible to get a clear-cut idea of
how the same data progresses from day to day.
Weed is asking for order in the record keeping, so that it has
coherence, and develops a theme.”
“I
take it you favor this Weed system.”
“Not
entirely,” Lapius said, sipping slowly at the martini.
“Simon,
you are doing mental cartwheels. You
just about sold me on its merits. Now
you’ve spun off. Is the martini too
strong?”
“Maybe
it’s nostalgia, Harry, but I still feel some addiction to the old method. Talk to the patient, get a medical history,
present illness, past illness, review of systems, family history. It’s all there. Weed doesn’t add to it, but just promises to
organize it better. The trouble is that
Weed promises to revolutionize medicine with it. He’s at the University of Vermont now where
he has computerized his system. He feels
that it will serve as a model for the computer led revolution in medical care.”
“Aha,
Simon, I told you so. These guys come
along and create new systems that lump everybody together, and then they have
visions of becoming health czars of some such thing.”
“Why
imply base motives, Harry?”
“Not
base, Simon, simply subconscious motives.
Anyway, how does the Weed system progress?”
“Well,
of course, a lot of schools have adopted it but also it is meeting resistance,
from the traditionalists in medicine. Weed says ‘—who are the people less likely to
accept a new a ballgame? The people who
were magnificent in the old ball game.
The people who could memorize a lot, the people who became professors
--. We’ve got to take memory-dependence
out of the system.’
“Of
course Weed goes further,” Lapius continued.
“He feels that his system will be perfect for peer review and medical
audit. After a while he sounds like a
functionary setting up systems whereby the performance of doctors can be
audited and compared. This worries me.
The
concept of reviewing a doctor’s efficiency slowly is being
institutionalized. It sounds good, but
in the long run it is I feel, dangerous.
First it casts a slur on the physicians as a group, and sets up systems
and precedents where the subtleties of medical practice will be evaluated by a
computer a rule book and a clerk.”
“So
now you are against Weed?”
“Perhaps
I am against what I think Weed wants to be.
I am also against measures that depersonalize medicine, because
fundamentally you can’t just put people into some medical equivalent of a
McCormack Reaper, separate components, and reassemble them again. This doesn’t solve the problems of patients,
nor does it assuage their fears. But it
probably would not be a bad idea to adopt into our record keeping some of the
organization inherent in Weed’s concepts.
Weed is not telling us anything new.
What has actually happened, is that the process of medical diagnosis has
become more complex, as has treatment, even as it has become more
effective. I think it is true that
doctors take less time with each patient than they did in the past, and Weed
has insisted on a new system to adapt to this change. Perhaps the old system was just as good. Maybe doctors should slow down a little and
use it, with some minor modifications.
The fact is, that although all of us have problems in common, each
patient has problems in particular, and in a computerized system, these might
get short shrift.”
“I’m
not sure I see what you mean.”
“Simple,
Harry. In the problem-oriented system, I
say to you that I have a problem. You
note it and ask me what it is. I tell
you I need another martini. Of course
you’ll make one for me, and duly note the fact that you’ve solved the
problem. But in the traditional medical
system, we’ll chat a bit, and you’ll graciously ask me whether I would like
another martini. The end result might be
the same, but in medicine, as in life it is the approach that counts.”
“Simon,”
I said companionably, “Would you like another Martini?”
“No
thank you Harry. I’ve had enough.”