My apologies

I read the article in the New York times, because someone on Twitter was upset about how emergency physicians were portrayed in it. So I tried to figure out what the article was about. I think it is about how the advice doctors give to patients can have life changing effects. It’s a scary thought. We often worry about patients not following our advice, rather than the opposite. I remember a young patient patient with a functional disability who did martial arts. Because of a shoulder joint instability his orthopedic surgeon had recommended him to stop training and competing. His whole life revolved around his sport. It’s where he spent all his free time and where he had all his friends. Saying that he should stop was easy for his doctor and made sense from a medical point of view. But life style choices are so much more difficult than weighing medical evidence. I could write a blog post on that. Maybe another time. It’s an important subject for all medical providers. For the public, too, I think that’s why the column in the New York times was published.

This post is, however, about something else. It’s about how Twitter exploded with comments by emergency physicians upset with the article, demanding an apology from dr Caplan and from the New York Times. I tried to raise another perspective, but failed. – ”No matter how you slice it, the article does not show respect for our skill set. Universally demeaning…”

”Thoughts on the danger of a widely read column telling stroke pts to be afraid of the ED?” 

This seemed to be the common interpretation of the article. Or common among ED physicians that is. I read the comments to the article and found very few comments about poor performance in the emergency department. Instead the most common theme was about the importance of universal health coverage and how everybody should have the right to a second opinion. Some shared their experience of stroke or expressed gratitude for being informed about the condition itself. The biggest fear of the emergency physicians – that patients would be scared to go to the ED in case of a stroke – seems unjustified.

There are many ways of interpreting an article. I have read articles about emergency medicine in Sweden that I have thought well balanced, respectful of other specialties and positive in general, only to hear that other specialists have been terribly upset with the people writing the article or portrayed in it. It makes me very careful about what I say to journalists. I therefor thought it almost unnecessary when a journalist offered me to read my quotes for an interview recently. One of the quotes, where I was trying to make a certain hospital sound like a good example of how to set up EM training, had been phrased in a way that I myself found very critical of the previous organization. I’m glad I got the chance to change it, rather than having to apologize and explain after it had been published.

The comments dr Caplan makes about emergency physicians and the emergency department definitely sound disrespectful to me. At the same time they don’t make sense. They don’t apply to the case described where the advice to avoid physical activities was given by ”doctors”. It’s hard to imagine, and it doesn’t say in the article, that those doctors were emergency physicians.

The negative comments don’t fit into the context and it looks to me like the journalist chose to put them there because they were provoking and added some spice to the story.

And here is the lesson I learned from this case: I am constantly disrespectful to my colleagues. I could easily have uttered the same kind of comments, especially if they were extracted from a longer conversation. I want to do better.

Dr Caplan says that if you have a stroke, you should see a neurologist specialized in stroke. For a young person with a stroke, I most certainly agree. But I am tirelessly arguing that neurologists are not experts in acute headaches, bringing up examples of when patients being triaged to their section of the emergency department (the way it works in some European countries) ”is dangerous”. Of course the problem is not that they are neurologists. The problem is ”that neurologists get little emergency training”. We call them ”organspecialists”, as opposed to us emergency physicians whose specialty springs from the patient’s need. We ”have had a hard time getting the message across” that stroke patients can have stroke mimics and need to be assessed before they are entered into the thrombolysis algorithm, a treatment that the neurologists can’t even properly evaluate the evidence behind. When I hand my patient over to them for thrombolysis, I ”worry about the quality of treatment” we as a hospital provide for the patient.

When I read this last paragraph I first thought that my point had been lost. That is not disrespectful. It’s true! And this is what I say to everyone who is willing to listen. When talking with fellow emergency physicians the stories of other specialists’ inability to understand emergency medicine are more colorful and vivid. It feels so good to be among peers who understand. This is why I objected to the Twitter discussion. Because there were only emergency physicians there, confirming each other’s belief that this article was about disrespect for emergency physicians and would decrease the public’s trust in their work in the emergency department. No neurologists were involved in the discussion, no gas station attendants and no people without medical training at all, sharing their interpretation of the article.

Everyone has the right to feel offended by whatever they feel offensive. It’s all in the eye of the beholder. (I wonder what dr Caplan thinks about dr Newman’s response that seems so balanced and polite to me.) But if this was just an old neurologist speaking his mind, I don’t think the whole community of emergency physicians would have been so upset. There must be an underlying problem. Is there a distrust between different specialities? I try to tell patients that their primary care physician is the most competent specialist to assess and coordinate their health care needs, but I hear a lot of doctors bad-mouth primary care physicians. Is there a disregard of certain specialties? Do we see some specialties as less cool, less complex or even less valuable? Do we express those thoughts to our colleagues? To our students? To our patients? What does that do to their trust in the medical profession as a whole?

That’s the discussion I wanted to bring up yesterday, but 140 characters wouldn’t allow it. I sincerely apologize to anyone who felt offended. By me, that is.