In Context

36 www.thelancet.com/neurology Vol 9 January 2010

Profi leLouis Caplan: bedside neurologist The medical curriculum in universities should have a greater emphasis on patient communication, thinks Louis Caplan, professor of neurology at Harvard Medical School and chief of the Stroke Service at the Beth Israel Deaconess Medical Center, Boston, MA, USA. Back in the days of Caplan’s neurology training, diagnoses were generally made at the bedside. Although this was mostly out of necessity, because modern tests and technologies were not available, Caplan insists on the value of such patient interaction.

These days, says Caplan, many students do not learn how to communicate properly. At 72 years of age, Caplan is certainly no curmudgeon, but he worries that young doctors have too much faith in modern technology and do not spend enough time talking to and examining their patients. Thorough examination is essential, and Caplan’s hope is that “the technology will be added to it, and not substituted for it”.

Caplan has always had a natural fl air for communication, which he thinks helped him when it came to talking to patients. He’s written numerous books over the course of his career, and at college he considered becoming a teacher. So what swayed him to choose medicine? “My uncle”, says Caplan.

His uncle, who had studied medicine himself, apparently told Caplan: “If you’re a doctor you can do a lot of diff erent things. You can see patients, you can write, you can teach, you can do research.” Caplan was convinced.

Caplan’s interest in neurology developed during medical school (at the University of Maryland, MD, USA), partly thanks to one of his neuroanatomy lecturers. Walle Nauta’s lectures were apparently so good, “students would arrive a half hour early to get a good seat”. His interest was further cemented during his military service in Hawaii, partly thanks to a lazy colleague. “I was in the internal medicine clinic but I volunteered for the neurology clinic”, explains Caplan. “The neurologist was very lazy so when he heard that I had volunteered for the clinic, he never showed up. So I ran the clinic.”

Being fl ung in at the deep end did not deter Caplan; it just made him want to know more. He took a neurology residency at Boston City Hospital with Derek Denny-Brown, followed by a fellowship in stroke at the Massachusetts General Hospital with Charles Miller Fisher. Caplan credits Miller Fisher with having taught him the importance of listening closely to patients. Miller Fisher would milk every patient for information: his ethos was, “the patient is my laboratory”, says Caplan.

With Caplan’s internal medicine experience, stroke was a natural choice of specialty. “Many of the patients with

stroke also have heart disease and high blood pressure—they have internal medicine conditions”, he explains.

Among the fi rst patients with stroke who Caplan saw were a few who had had posterior circulation strokes. Only about a fi fth of the brain’s blood supply comes from the posterior circulation, so such strokes are rare. At the time, very little was known about posterior circulation strokes, and Caplan’s interest was piqued by these patients’ unusual symptoms. “One was a woman who suddenly lost the ability to read but retained the ability to write”, he recalls. “And there was another man who suddenly became very hyperactive, blind, and lost his memory.” He reported his observations and, almost by default, became a specialist in posterior circulation. “If you write some reports, people begin to think that you might know something about it”, he explains, “so they send you [more] cases.”

Besides his work on the posterior circulation, Caplan is also famous for establishing the Harvard Cooperative Stroke Registry, in 1978. “That was the fi rst registry set up for any disease”, he says proudly. Together with fellow stroke specialist Jay Mohr, Caplan collected a wealth of data on patient backgrounds, and the symptoms and signs associated with diff erent stroke subtypes. The registry became a valuable source of information about risk factors for stroke, and about how certain symptoms relate to outcome and recovery. “We had to use a huge computer called the PDP11”, says Caplan. He’s not exaggerating; the PDP11 was about the size of an upright fridge-freezer. The fact that Caplan and Mohr achieved their task in these early days of the digital age makes the accomplishment all the more impressive.

In addition to the rise of the computer, over the 40 years that Caplan has worked on stroke, he has seen great advances in treatments and in technology for diagnosis and monitoring. “The ability to image the brain and do it without hurting people and do it quickly and safely has been a dramatic change”, he says.

Most of the changes are for the better of course, but Caplan is less keen on one particular development. “It’s become very fashionable to focus everything on trials. The problem with trials is they homogenise and merge things together in order to get enough patients”, he says, adding that “the answers from [a trial] might be useful for grant strategies…but that doesn’t tell you what’s good for an individual patient”. His message, as always, is clear: there’s nothing more important than getting back to the bedside.

Ruth Williamsruth.williams@absw.org.uk

See Review page 105