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What that story illustrates is known in hospital lingo as blocking an admission—the resident in internal medicine stopped Mrs. Jones from being admitted to his service, hoping to leave the problem to another department.
Blocking is one term for patient avoidance; turfing is another. To turf a patient is to take a patient already admitted to one service and punt them to another. My favourite internal medicine resident, Dr. Nathan Stall, remembers hearing those words in an emergency room.
“I was with this emergency doctor and we were examining someone who had lower-limb weakness. He said he was just going to ‘punt this patient to neurology.’ The emergency physician got up, made a kicking motion as if he were kicking a football, in front of the patient and the family, and then walked out.”
To get patients ready for turfing to another service, the admitting team needs to clean up any obvious lingering medical problems. If patients are dehydrated, they’re given a bag of IV fluid to rehydrate them. If they’re anemic, they’re given a transfusion to bump up their hemoglobin. In slang terms, that’s known as buffing the patient.
Sometimes, the team that receives the turfed patient punts the patient back to the original team. That’s known in hospital parlance as a bounceback. A fourth term you hear in hospitals is dumping a patient from one service to another. Think of a dump as a flagrant or egregious turf. The patient is considered undesirable by the admitting team, which manages to turf the patient to another team, which finds the patient just as undesirable.
These terms aren’t found in medical textbooks. But every doctor and nurse who works in a hospital has heard them and has a sense of what they mean—thanks to the slangmeister himself, Dr. Stephen Bergman.
In The House of God, the senior resident known as The Fat Man explains what a turf is to an intern named Potts. “To TURF is to get rid of, to get off your service and onto another, or out of the House altogether. Key concept. It’s the main form of treatment in medicine.”
And where did Bergman learn the word? I was startled to find out that he and his fellow interns invented it at Boston’s Beth Israel Hospital in the early 1970s.
“I codified it,” says Bergman. “I wrote about buff and turf and then, as I always do, I took it further. I’m sure I thought of the bounce—you know, when you turf a patient somewhere else and you haven’t buffed him enough so he bounces back to you.”
And the words flowed like a river from the slangmeister’s pen to the lips of residents from generation to generation. Unlike many other bits of slang, turfing, dumping and blocking are known to all and done by everyone.
Dr. Nooreen Popat says she first heard these slang words when she was a resident in internal medicine at McMaster University in Hamilton, Ontario. “If you ask anyone who’s a doctor they’ll tell you they love their job,” says Popat, who’s now completing her training in respirology. “But sometimes in the middle of the night, when everything’s really busy in the hospital, people are trying to do less work. So they may turf to one another or dump on one another and that was how I first came into contact with this. I was sort of surprised at what was going on and the connotation of the language that was being used.”
I’m not surprised one bit. Unlike unacceptable slang such as harpooning the whale, words like blocking, turfing and dumping are known and used widely by administrators of hospitals and managed health-care plans, directors of residency programs and even by researchers as genuine phenomena to be studied and understood. In other words, they’ve become an institution.
Do a search on Medline, the database of the National Library of Congress, and you’re certain to find them. In an article published in 2007 in the journal Perspectives in Biological Medicine, Dr. Catherine Caldicott, an internist and bioethicist, wrote that turfing is a “widespread phenomenon in medical training programs.”
One of the experts trying to understand what words like these mean and what and how they reflect on the culture of modern medicine is Dr. Vineet Arora. Associate program director for the Internal Medicine Residency at the University of Chicago, she is one of the bright lights in the emerging field of medical professionalism. Arora and her colleagues set out to determine just how commonly the tug-of-war between the ER and other services takes place. “We asked students and residents if they occur in the workplace and they all said they do,” says Arora. “And they all recognized the terms blocking and turfing.”
Because The House God—the original manual of turfology, if we can call it that—was a novel about junior doctors, one might assume that they are the only practitioners of turfing. Surely attending physicians don’t do that sort of thing.
Oh, but they do. Arora co-wrote a study published in 2012 in the Journal of Hospital Medicine that surveyed unprofessional behaviour among hospitalists, doctors who practise in hospitals. Nearly 8 percent said they had participated in blocking an admission to hospital and more than 9 percent said they had participated in turfing a patient to another service. A much higher percentage of hospitalists surveyed said they’d witnessed blocking and turfing by colleagues.
Arora says you need inside knowledge to execute a turf . “People that had administrative jobs like running the clinical service (supervising residents on the wards) were more likely to engage in those behaviours,” says Arora. “That really highlights the fact that you’re unlikely to be able to block and turf if you don’t know how the system works. I think that it’s something you see more with senior residents and attending physicians.”
Even more disturbing is the fact that 21 percent of respondents in Arora’s study said they had celebrated a blocked admission and nearly 12 percent had celebrated a successful turf.
When it comes to turfing and blocking, there are winners and there are losers. That’s what is going on in the minds of many residents and a surprising number of attending physicians too. It’s about aggressors foisting their unwanted patients on someone else.
Blocking a referral during a night on call is one payoff. Bragging about it to your colleagues the next morning is another. Dr. Nathan Stall says boasting happens a lot. “I’ve shown up in the morning and that’s being thrown around,” he says. “‘You had one consult and sent back four last night. Wow, that’s impressive,’ is what colleagues will say. ‘Nice work. Now the team only has to pick up one new patient. Less work for everybody else [on the team].’”
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About a decade ago, organized medicine invented the phrase patient-centred care. In a 2001 report titled Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine (IOM) defined patient-centred care as “health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.”
The IOM is one of the most respected medical institutions in the world. Established in 1970, the IOM is the health arm of the National Academy of Sciences, which was founded in 1863, when Abraham Lincoln was president of the United States. To me, the very fact that the IOM felt the need to articulate something as obvious as patient-centred care serves notice that the culture of modern medicine has other priorities in mind.
Think of it. You come to the hospital with chest pain, trouble breathing, or some blood in your bowel movements. Or maybe you bring your mother or your father with a cracked pelvis or a broken hip caused by a fall. The first doctor you see is an ER physician like me. I take a history, do a physical examination and order some tests. If I think you need admission to hospital, I call the appropriate attending physician.
From your vantage point in an ER cubicle, the attending or the resident comes to see you, agrees to accept you, and off you go to a bed upstairs on the wards. But from what I’ve told you about turfing, dumping, buffing and bounce-backs, th
e picture I just painted is anything but patient centred.
While you or a loved one wait to be admitted to hospital, just a few metres away from your cubicle, yet well outside of earshot, physicians may be verbally duking it out over your immediate future. The aim is not so much to care for you as to find a clever way to jettison that responsibility by finding someone else to do it.
Let’s take a closer look at what might make you or your loved one undesirable. The likeliest candidate for turfing is any patient who isn’t young, or interesting in a clinical or diagnostic sense. Often it’s a patient who can no longer live independently. Being unable to control your bodily fluids is another strike against you.
The thing is, you or your loved one can’t go home. You need to be admitted to hospital. To get an internist to admit you, the trick is to make you look as sexy as possible in a diagnostic sense. Often I play up a patient’s clinical issues, such as low serum sodium or a slight increase in their liver tests, to get the internist to say yes. In medical slang, we call that making the sale.
“You get a referral in which fictitious medical problems are made up to justify seeing the patient,” says Nooreen Popat. “You discover there are no real medical problems but there are some social issues, and they just can’t go home. So that could be kind of like a dump.”
Turfs or dumps—whatever you call them—involve two parties: the doctor or team transferring the patient and the one receiving the patient. Of course, the patient makes three, but in the give-and-take of hospital admissions, patients are often little more than passive participants—no matter how much their lives are on the line.
This phenomenon exposes a secret about the culture of modern medicine that few outsiders appreciate. When patients are being shopped around, different kinds of specialists view each other with deep suspicion—especially surgeons and internists. Just ask Dr. Andrew Burke, a resident in internal medicine.
“My ‘Spidey sense’ starts to tingle when another specialty service—for example, general surgery—says a patient is more appropriate for me but will not mention anything related to the gastrointestinal or the abdominal or any of the areas that they normally specialize in. So you can just kind of tell that’s being played down. It’s all about emphasis. That’s when you start to smell a hint of a turf,” says Burke.
There is a rough division of labour between internists and general surgeons. The surgeons admit patients with abdominal pain caused by conditions that often but not always require an operation. Appendicitis, inflamed gall bladder and bowel cancers immediately come to mind. Internists admit patients with non-surgical conditions. They don’t want each other’s patients because they don’t want to tie up a hospital bed that could be used to admit someone more appropriate.
But that’s not all. Though they seldom admit it, internists and surgeons alike feel lost at sea caring for each other’s patients—and are terrified such patients will die on their watch. An internal medicine resident remembers a patient with a complicated history of internal medicine problems who would ordinarily have been referred to an internist on call. But because the patient had abdominal pain, a referral was made to a surgeon.
“Then I got a call from the surgery team a few hours later saying they wanted me to see the patient,” the resident recalls. “They said it seemed like the patient had an infection [as opposed to a surgical condition] and could I look after him?”
The surgeons didn’t talk about the patient’s abdominal pain or get into the reasons the surgeons were asked to see the patient in the first place.
“Foolishly, I said I would go see the patient, no problem,” she says. “As it turned out, two or three hours later, the patient actually needed to go to the OR urgently.”
Fortunately, one of the junior residents on her team was experienced in surgery and recognized that the patient urgently needed an operation. She says they were able to persuade the surgeons to take the patient back in time to save his life.
It was only after the fact that the resident learned exactly why the surgeons had turfed the patient to her team.
“What I found out is that the surgeons had another urgent OR case,” she says. “The surgery team didn’t want to take care of a patient that they didn’t know [for certain] was surgical, so they turfed it to us. That way, they could go deal with something that they knew was surgical. But that was a turf that could have gone wrong.”
The most dangerous examples are turfs in which the turfing physicians omit critical details or even lie about the patient’s condition to make the sale. This is often true when a doctor working at a small community hospital requests that a patient be transferred to a major urban referral centre.
A different resident in internal medicine remembers the time she received a referral from a physician who said his patient was having a heart attack. When the patient arrived by ambulance, it was clear to the resident that the patient was not having a heart attack but was suffering from a life-threatening infection called sepsis. In the resident’s view, the referring physician underplayed the gravity of the patient’s condition to guarantee that the patient would be accepted for transfer. “That was an example of buffing or shining up a patient,” she says.
Sometimes the referring physician does the exact opposite and executes a turf by overplaying the gravity of the patient’s condition to make it seem more urgent than it really is. “They’ll say the patient has chest pain at rest,” says the resident. Chest pain that occurs while a patient is at rest might indicate an impending heart attack.
“That’s a red flag that tells us we need to run and see the patient,” she adds. “When you get there, you realize it was an exaggeration on the part of the person handing the patient over because they wanted you to take the patient.”
Sometimes, the tensions between physicians on competing admitting teams can run so high that fights actually break out.
“I’ve seen a cardiac surgeon and an ICU doctor screaming at the top of their lungs as to who was going to take a patient,” says a recent graduate who was in his final year of med school when he witnessed the argument. “Then one of them turned to the other—and there’s family members in there and a young person dying—saying, ‘Do you want to take this outside?’ I couldn’t believe it. It was so childish.”
Stories like these keep Dr. Vineet Arora awake at night.
“When you start blocking or turfing, you’re engaging in a long battle for a marginal patient that it’s easier for you to keep,” she says. “When you’re engaging in that long battle, time is passing. What often happens is that the patient gets worse because nobody is paying attention to them because they’re too fixated on where the patient should go in all that blocking and turfing.”
A big part of Arora’s interest in turfing, blocking and dumping is the risk posed to the safety of patients. Arora, who analyzes the root causes of medical mistakes, says she makes a point of asking doctors involved in medical mistakes if the time spent blocking a referral caused the patient to suffer.
“The answer is almost always yes.”
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Why has a form of behaviour introduced in Bergman’s novel evolved into such a problem? The answer is a mélange of issues to do with the health-care system as well as personality factors common in people who become physicians.
In the U.S., patients who are a financial drain on a hospital are at risk of being turfed or dumped elsewhere. It doesn’t seem to matter whether the hospital is private, Medicare and Medicaid, or part of a managed health-care system.
For instance, it’s been said that these shenanigans happen mainly in teaching hospitals, where doctors are on salary as opposed to getting a fee per admission, so they aren’t that motivated to accept new patients. By contrast, in private practices doctors get a fee for each patient, which provides an incentive to see the patients that docs in teaching hospitals turf. But that’s not the way it goes.
The practice has been so widespread in the U.S. that in 1986, a federal law called the Emergency Medical Treatment and Labor Act was passed to prevent hospitals from turning away patients with emergency medical conditions.
Even so, a 2012 article published in the journal Health Affairs shows that twenty-five years after the law was passed, patient blocking and dumping continue largely unimpeded. The article focused on Denver Health, a highly integrated health-care system, which has experienced a steady growth in the care of uninsured patients, much of it provided at Denver Health Medical Center. Among the charges, the article documented the fact that other hospitals were discharging unstable patients and specialists were refusing to treat uninsured patients. In April 2013, Nevada Governor Brian Sandoval was forced to defend his state after a report that psychiatric hospitals in Las Vegas sent hundreds of discharged patients by bus to California and other states.
The system of managed health care has also increased the temptation to turf, according to Peter Kongstvedt, an authority on the health-care industry, health insurance and managed care. In his book The Managed Health Care Handbook, Kongstvedt describes a doctor who removed sick patients from his practice. Since sick patients require more tests and treatments, removing them makes the doctor appear not to overuse health services.
Dr. Caldicott says some of what appears to be turfing behaviour may not be that at all. She says the U.S. health-care system is so fragmented and complex that most doctors who work in it feel pressure to move patients through the system as quickly and as efficiently as possible. “I think most physicians feel constrained to do only a small thing every time they see a patient and only think narrowly and only answer the one specific question,” Caldicott said in an interview, “because there are so many pressures to see a large number of patients in a short amount of time and to make the bean counters happy.”
The Secret Language of Doctors Page 23