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AAEM Letter to the NYTimes - Response to "Stroke of Fate"

May 3, 2015
Dear Editor,

I was dismayed to read Maureen Dowd’s op-ed “Stroke of Fate” in the May 3rd issue of your newspaper. In the op-ed, Dowd interviews neurologist Dr. Louis Caplan, who appears more focused on disparaging emergency departments, than on educating the public on stroke. Caplan says “I’m afraid to go to the emergency room. I think it’s dangerous.” If Caplan has an issue with the quality of care in the emergency department (ED) at his hospital, he should address it through proper channels. Instead, he makes a baseless, sweeping generalization about the quality of care delivered in 4,000 EDs in the U.S. This type of unprofessional behavior is not new for Dr. Caplan, who published a similar inaccurate attack on emergency department care in Mayo Clinic Proceedings, November 2007.

Emergency physicians, nurses, and staff have a difficult job. They care for over 140 million patients a year in the U.S. In my ED, we see ~90,000 patients a year. At peak times, more than 30 patients an hour will present to our ED, many with critical illnesses and injuries. Patient volume in U.S. EDs has increased in the past 15 years at double what would be expected by population growth. During the same time, the number of inpatient hospital beds has steadily decreased, causing inpatients to be boarded in the ED. This results in significant crowding which creates many additional challenges. EDs act as our nation’s safety net for not only emergency care, but also for care to society’s most vulnerable patients, and play a vital role in our medical response to disasters. Emergency physicians, nurses, and staff are available 24/7/365 to provide quality care to those who need it most. 

Many decades ago, as hospitals began establishing EDs, there were significant quality variations in the U.S. Based on Dr. Caplan’s age of 78, I assume he trained in neurology during the 1960s, and practiced for a portion of his career at a time when most hospitals emergency departments were staffed by physicians not trained in emergency medicine. However, ED care has become increasingly sophisticated since specialized residency training in emergency medicine became available, starting in the 1970s. Since 1988, in order to become a board certified emergency physician, one must complete at least three years of specialized emergency medicine training after medical school. The vast majority of emergency physicians practicing today are board-certified in emergency medicine and virtually all (98%) of emergency physicians who have graduated within the past five years have completed emergency medicine residencies. The American Academy of Emergency Medicine (AAEM) requires board certification to become a full member.

Caplan remarks that emergency physicians “get little neurology training.” As the director of an emergency medicine residency training program, I assure your readers that emergency physicians do receive significant neurology training in the acute presentation of neurological emergencies. Caplan also notes that “If you have problems with the brain, ask for a neurologist.” Emergency physicians certainly will consult a neurologist when appropriate. However, it is important to recognize that many community EDs do not have access to an on-call neurologist. In those that do, typically the neurologist does not have the time to be routinely involved in the care of all patients with neurological complaints. The vast majority of patients seen in the ED can and are evaluated and treated appropriately by the emergency physician without specialty consultation.

The optimal care of patients suffering an acute stroke, like that of many true medical emergencies, is best delivered by a team of physicians (including emergency physicians, neurologists, radiologists, hospitalists, etc.), nurses (emergency, inpatient, rehab, etc.), EMS providers, technicians, therapists, etc. working together in a coordinated fashion. Collaboration and mutual respect by members of the health care team play an important role in maximizing good patient outcomes. Dr. Caplan’s groundless, derogatory remarks are an insult to the hundreds of thousands of emergency physicians, nurses, and staff who are committed to quality patient care. 

Sincerely,

Mark Reiter, MD MBA FAAEM
President, American Academy of Emergency Medicine
Director, University of Tennessee-Murfreesboro Emergency Medicine Residency Program
CEO, Emergency Excellence