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Louis Caplan, Maureen Dowd, and Lack of Professional Ethics

With the flurry of Twitter posts about Maureen Dowd’s article “Stroke of Fate” in the New York Times, it almost seems as if the subject is already stale.

Maureen Dowd is the Pulitzer prize-winning op-ed columnist for the New York Times who tells a compelling story about a young patient who suffered from a stroke. The patient was a healthy triathlete and she initially attributed the symptoms of her stroke to a migraine headache. Ms. Dowd’s article also touched upon the frustration and fear that patients feel after the diagnosis of a stroke which was an important part of the article. However, somewhere in the middle of the article, Ms. Dowd does a journalistic faceplant that probably had Joseph Pulitzer doing a few backflips in his grave.

Ms. Dowd accompanied the subject of her story – her niece – to Boston in order to be evaluated by a national stroke expert. There they met 78-year-old Dr. Louis Caplan, a Harvard professor of neurology. Dr. Caplan made several inflammatory quotes regarding emergency departments which Ms. Dowd was only too happy to publish. She doesn’t appear to have fact checked the statements, she doesn’t appear to have asked the professor for the basis behind his statements, nor does she appear to have asked other experts in the field for their comments on the topic. Of course, Ms. Dowd may argue that her failure to check her sources was an innocent mistake or that was part of her journalistic expression, but in either case, she was irresponsible and unethical. She used one of the largest forums in the United States to provide misinformation about emergency medical care. As I read through Dr. Caplan’s quotes and the comments to the article, I can’t help but wonder whether or not Ms. Dowd’s actions were intentional. It doesn’t take much insight to realize that comments from a medical “expert” who denigrated another medical specialty would result in an avalanche of clicks to the New York Times web site. The problem is, Ms. Dowd, your article generated interest not because it was good journalism, but rather because it was hack reporting. You could have used your niece’s misfortune to provide information to your readers about the signs and symptoms of vertebral artery dissection, the treatment, and the outcomes. Instead you threw your integrity out the window to create just another piece of clickbait. Shame on you.

It isn’t just Ms. Dowd who failed at the New York Times. The New York Times editors failed. Again. Ms. Dowd’s article is eerily similar to a sepsis article written by Jim Dwyer in the New York Times several years ago. Mr. Dwyer told the story of his nephew, Rory Staunton, who, in the midst of influenza season, went to the emergency department with fever and vomiting. Rory received treatment in the emergency department, his symptoms improved, and he was discharged, but he later died from sepsis. Mr. Dwyer went on a crusade against the hospital and the emergency medical providers. In the process, Mr. Dwyer failed to note many of the circumstances regarding Rory’s care, made many inappropriate comments, misapplied sepsis guidelines that were not designed for children, and then tried to hide the fact that those guidelines were not designed for use in children. When called out on his selective reporting of the facts, Mr. Dwyer made excuses such as Rory may have been a child, but he “was the size of an adult.” That episode of drive-by journalism didn’t work so well, either.
So the New York Times editors allowed yet another poorly researched and inflammatory article to be published in their paper. That’s editorial negligence. Shame on each and every one of you, as well.
When the comment section to the article started exposing Ms. Dowd’s journalistic shortcomings, the New York Times turned off comments to the article the same day that it was published. Not only are the New York Times editors negligent, they’re spineless.

Then there’s Dr. Caplan. During his interview with Ms. Dowd, Dr. Caplan asserted that all of us “E.R. people … get very little neurology training.” Dr. Caplan also chided “E.R. personnel” for failing to perform enough vascular imaging during suspected strokes, stating that “if a stroke is suspected, a vascular image must be taken as well as a brain image, because it shows up first in the vessels that supply and drain the brain.”
Dr. Caplan then gets creative with his explanation why emergency medical care is “dangerous.” He expresses his fear of “dangerous” “emergency rooms” when patients should instead be going to academic medical center neurologists for their care, then he laments that patients need to “worry about the quality of treatment” once they arrive in the “dangerous” “emergency rooms,” and compares emergency physicians to cud-chewing country bumpkins in “local gas stations” who see a Rolls-Royce roll into their shop, pull off their motor-oil stained baseball caps, scratch their heads with dirty fingernails, spit into a spittoon, and ask each other “gee Cleatus, what’s that?”

First of all, it isn’t an “ER”. It is an emergency DEPARTMENT. The fact that Dr. Caplan still uses such an outdated term merely demonstrates his ignorance about the specialty of emergency medicine. Despite his obsolete medical lexicon, Dr. Caplan then provided Ms. Dowd with his intimate knowledge of the insufficient quality and quantity of neurology training in emergency medicine residencies throughout the country. Ms. Dowd doesn’t appear to have asked Dr. Caplan if there is any basis for his assertion, but hey, why does Dr. Caplan need to have any basis for his opinions? He is an “expert.” Heck, he even has his own Wikipedia page.

Devil in Brain CT Scan

Despite Dr. Caplan’s contentions to the contrary, vascular imaging is standard for patients suspected strokes routinely undergo vascular imaging. Again, Dr. Caplan provides no data to support his contention that the studies are not being routinely performed and Ms. Dowd either didn’t know or didn’t care to ask him for such data. In fact, both brain imaging and vascular studies were performed on Ms. Dowd’s niece, but according to neurology expert Dr. Caplan, they were “misinterpreted” by the non-ivory tower doctors at the ordinary Maryland hospital that initially diagnosed the patient.

Dr. Caplan’s gas station analogy is perhaps the most silly of his comments. Dr. Caplan infers that “local mechanics” are incapable of handling anything but common mechanical problems on common motor vehicles and analogizes emergency physicians as the “local mechanics” of the medical community. How condescending. I have several friends who are “local mechanics” and I’m pretty sure that each of them has more useful knowledge in their brains than Dr. Caplan. But I get his point. All of us “E.R. people” are glorified triage personnel. If we see anything more than ear infections and sore throats we’re out of our leagues. Even then, we should probably get ENT consults at academic medical centers just to be sure. Because of our tremendous lack of knowledge, we make the emergency department a “dangerous” place.
The knowledge and skills of an average emergency physician would put those of Dr. Caplan to shame. Sure, Dr. Caplan can use some fancy picture cards to check a patient’s memory and can stomp on his ivory pedestal declaring radiologists incompetent in their interpretation of brain scans. But could Dr. Caplan properly use a slit lamp, deliver a baby, properly dose children’s medications, interpret an EKG, reduce a dislocated shoulder, insert a chest tube, resuscitate a coding patient, suture a complex laceration, manage a violent psychiatric patient, or coordinate care for a patient needing emergency surgery? Of course not. Yet emergency physicians all over the country routinely perform these tasks … without the help of ophthalmologists, obstetricians, pediatricians, cardiologists, orthopedists, surgeons, intensivists, plastic surgeons, psychiatrists, and administrators. Yeah, emergency physicians diagnose and treat more strokes than Dr. Caplan does, too. Emergency physicians even made the right call on Ms. Dowd’s niece. The article noted that in the emergency “room,” the doctor told Tara that she had suffered a stroke. Her appointment with Dr. Caplan was more than four months after she suffered her stroke. Dang it if those dangerous “E.R. people” don’t get things right once in a while.

Dr. Caplan uses the label “dangerous” to describe emergency departments and he is entitled to his opinion. I use the label “dangerous” to describe people who spread misinformation under the guise of expertise. Dr. Caplan, Maureen Dowd, and the New York Times editors all fit that definition.

Dr. Caplan’s myopic view of medicine has jaded not only his perceptions of emergency departments, but may have influenced the perceptions of people who believe the tripe in Ms. Dowd’s article. I’m thinking it might be in Dr. Caplan’s best interests to have his eyes checked.

Or even his brain.

I hear that Harvard has specialists for that.

 

UPDATE 05/14/2015

I just found a letter that Dr. Caplan wrote to the chairs of the Beth Israel Deaconess Medical Center emergency department. Can’t really call it a letter of apology, perhaps more of a letter of explanation. He doesn’t really address many of the disparaging remarks he made including the alleged lack of neurology training in emergency medicine programs, the alleged lack of vascular imaging in stroke patients, and how patients need to “worry about the quality of treatment” once they reach the emergency departments.
At least he got the point and hopefully the backlash has caused him to readjust his britches a little.
You can read the whole letter here (.pdf file): Louis Caplan Letter to Wolfe Edlow regarding NY Times Article Emergency Department Strokes

17 comments

  1. Hack journalists use hack experts to garner pageviews.
    In other news, dog bites man, page B 328.

    Moron Dowd (not a typo) has been credibility-challenged for decades, as if merely drawing a check from the NYTimes wasn’t sufficient proof of the charge in and of itself.

    IMHO, the only people reading the Fishwrap Of Record any more do so for the same reason people can’t take their eyes off a train wreck or a house afire, or because of a perverse delight in watching either such event, and are thus probably beyond the pale as far as grasping rational counterpoint anyways.

    But don’t hold back on prize-winning idiocy like hers or Caplan’s, please.

    BTW, what’s the wait time to be seen for stroke symptoms at Caplan’s clinic?
    My ED and shadetree garage mechanic shop just got certified as a national stroke center (1 of 50 coast to coast) with oak leaf clusters without even busting a sweat, and IIRC, I think we’re door-to-CT in <5 minutes, and door-to-TPA in <45 minutes, so I'd looooooove to hear what the response is at a clinic like Caplan's, where scheduling a CT scan is a multi-day (or week) event.

    Which is why the standard answer of such "experts", and the exact advice actual experts give their patients a mere 300M times a year nationwide is, without fail, "Go to the Emergency Department."

    Which troubling little realities Caplan and Dowd seem to have left out of their vacuous and fatuous little screed. The normal term applied to people who can tell such whoppers for a living and sleep soundly at night is, I believe, "sociopath".

  2. NYS Department of Health: “based on document review, interview and an independent physician review, the facility failed to provide care in accordance with acceptable standards of practice for both medical staff and nursing services, as well as a systemic failure related to the reporting and follow up of abnormal laboratory results.”
    PS: The subject of the column was not my nephew; he was the nephew of a friend.

  3. After a massive stroke 9 years ago Dt Louis Caplan is my bounce stuff off of guy! He told me my little local hospital did perfect medicine. when I emailed him regarding an unusual day from Florida, he responded a few hours later from Barcelona where he was giving a conference to re assure me, I think he is fabulous!

  4. Let’s leave Dr. Caplan alone for a moment and consider this a case of a follow up who presented to your ED with symptoms consistent with a stroke syndrome. An emergency physician and neurologist did brain AND vascular imaging. Later review of the imaging revealed the patient’s stroke was actually due to a dssection. Dissections of the carotid and vertebral arteries can lead to stroke symptoms but the treatment and management are very different. This article could have educated us about the presentation of dissection. (Strokes don’t present with pain complaints.) It could have looked at reasons to image the vasculature. (Younger, non-hypertensive pt.?) It could even have had a discussion of the rising stroke rates in the young and the public health scourges of DM and HTN. But it didn’t.
    So, I agree, we have not learned much from Ms. Dowd and Dr. Caplan. But we can still learn from the case. We can still perform the education that the article lacked.

    Ischaemic strokes don’t cause pain. No edema? No bleed? Then why is there H/A, neck pain, shoulder pain? Get an angio.

    • Agree. Might be a good article but even if published here, would have nowhere the reach that Ms. Dowd’s article had. Maybe I’ll put it on the list of posts that has been sitting on my desk for the past few months.

    • Posterior fossa ischemic strokes often do cause pain,

  5. I wouldn’t see a seventy-eight year old doctor for a hangnail! Time for retirement, Dr. Caplan!

  6. Wholeheartedly agree.

    Unfortunately will lose many doubters with two typos in the first three sentences. As much as our disdain Ms. Dowd, she’s a columnist, not communist (well, as far as we know). Further, “the patient was (A) healthy triathlete.”

  7. I am a neurologist and feel ashamed on behalf of my specialty for Lou Caplan’s comments. He is a legend in the field of stroke but publicly putting down emergency medicine is not acceptable not even correct. I trained at an academic hospital with a legendary EM department and they had some of the finest doctors I’ve ever had the pleasure to work with. Yet I was surprised when we offered to do joint education sessions together and were turned down. (internal medicine, psychiatry and neurosurgery had no such isolation policies). I wonder if there is some natural enmity between neurologists and EM docs? Neurologista are all about taking the time to do a lengthy examination, then lecture about the nature of the problem, where EM. Docs are all about action. I have a close friend who is an ER doc who dislikes the tendency of neurologists to lecture when giving a consult, but this is in our culture. Anyways, just so you know, most of us don’t think you are ‘glorified triage nurses.’ I don’t think it’s ever acceptable to put down someone else’s specialty.

    • Thanks for the feedback.
      No enmity that I’m aware of. I love the neurologists at our program and at our referral hospital. All are excellent diagnosticians and very responsive.
      My biggest problem with Caplan’s comments is that they are baseless. If he wants to say “I think EDs are dangerous and here’s why …”, fine. We can discuss the issues he has. Instead he takes generalized baseless jabs at emergency medicine, paints an inappropriate picture in people’s heads, and then creates a call to action – patients contacting a neurologist for stroke symptoms instead of going to the “dangerous” ER – which may delay care and worsen patient outcomes. Not smart.
      Hopefully everyone can learn from this event.

  8. Great response! Thanks from all of us working in the trenches.

  9. Hey – great heartfelt response to this ridiculous article – do you have an updated link for the PDF file of Dr Caplan’s response letter? (seems to be broken)

  10. oops – can answer my own question – LINK = http://bit.ly/1WJcNDx

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