But this is not just a product of a dysfunctional U.S. health-care system. Turfing, dumping and blocking of patient admissions are well known to physicians in Canada. I had no trouble finding residents north of the forty-ninth parallel to dish stories on the phenomenon.
Financial issues may explain the practice of turfing and dumping between hospitals. What they don’t answer is why such horse-trading goes on between doctors who work at the same hospital. That has more to do with individual factors such as resident fatigue.
Onerous work hours were once thought to be the reason residents block admissions and turf patients. But the trouble with that argument is that the past few years have seen resident duty hours cut fairly dramatically. If long duty hours were the main factor that encouraged turfing and dumping, then the problem should be in the rear-view mirror.
Unfortunately, it isn’t. For one thing, I’ve spoken with many residents who choose not to leave when their shifts end. Residents in general surgery tell me they stay because they don’t want to risk a bad evaluation from their attending surgeon. The ones who do leave when their duty hours are complete may be even more likely to block referrals near the end of their tour of duty because they don’t want to have to work overtime taking care of the patient.
In a 2012 paper published in the journal Virtual Mentor, Catherine Caldicott expressed skepticism that reducing resident hours had any effect. “Despite the absence of hard data, anecdotal reports substantiate that turfing persists,” she wrote.
Caldicott looked at turfing and dumping as issues of power between residents. In a revealing study published in 1999 in the Journal of General Internal Medicine, she and co-author Dr. David Stern analyzed audiotapes of residents’ discussions on turfing and concluded that the language of turfing is born of emotions among residents in internal medicine. They wrote: “Residents can feel angry and frustrated about receiving patients seemingly rejected by other doctors, while feeling powerless to prevent the transfer of patients for whom they can offer neither effective treatment nor continuous relationship.”
Dr. Vineet Arora is a mentor to residents. Not too many years removed from her own residency in internal medicine, Arora can still see things from their point of view. “As a resident, you have so little control over most of your life,” she says. “If you’re able to have control over the number of patients that you admit, that’s at least something that you can say you did for yourself. It definitely happens and it’s more likely to happen when people are burned out and lacking the systems to promote wellness and at the brink of being overworked.”
One of the things I’ve noticed over the years is that turfing and blocking tend to ebb and flow with the arrival and departure of new residents. Why is that?
“All it takes is one bad egg for this to start occurring,” Arora says. “Every residency has somebody that’s known for blocking. People develop reputations. So if you know you’re going to call a resident who has a reputation for blocking, you’re going to make the patient sound as sick as possible to get accepted on the resident’s service.”
In The House of God, a resident with a good reputation for blocking admissions was known as a wall. And it’s not just residents who develop such reputations. “I work with hospitalists and we see this behaviour in hospitalists too,” says Arora.
Catherine Caldicott says the bad egg Arora was talking about might even be an attending physician. “Where do you think the residents learn it from?” she asks rhetorically. “I remember hearing and seeing residents doing high fives over turfing a patient and having the attending bring the team a case of beer to celebrate not taking a patient on their service.”
In turn, those residents grow up into attending physicians and teach that sort of behaviour to their residents. And so it goes.
* * *
In some instances, it’s actually in a patient’s best interest to get transferred from one hospital or hospital ward to another. There are days when the internist or the team of residents on call admits as many as 30 patients. That’s a lot of new and acutely ill patients to workup and possibly misdiagnose and mistreat.
“You’re basically guarding against more work for your team because you know you’re already at the tipping point where you may actually be very unsafe,” says Arora.
And sometimes, a patient is admitted to hospital by a surgeon who, after looking for a surgical problem, discovers there isn’t one.
“Let’s say there’s a patient I’m taking care of who is no longer interesting to me,” says Dr. Christopher Kinsella, a resident in general surgery in St. Louis. “They don’t need surgery but they’re sick. The patient needs to be in a hospital, and needs to be taken care of by someone. The last thing you want is to have a patient being taken care of by doctors who are no longer interested in that patient.”
True enough, but sometimes the turfing happens only once the surgeon has operated on the patient, who has not gotten any better. Now the patient’s diabetes and high blood pressure are getting worse. And the patient is getting sicker and sicker. Slowly, it dawns on the attending physician that the patient may not make it out of the hospital alive.
In an era of managed health care and increased accountability for results, a death on your service looks bad and may result in financial penalties for the attending physician or surgeon as well as the hospital.
“And so they transfer the patient to a medical service so that the patient dies on medicine rather than on surgery so the [surgeon’s] numbers look better,” says Caldicott, quoting a belief often stated by attending physicians on the receiving end of such transfers. “I can’t prove any of this at all, but you and I have both seen and heard people behave in ways that would make it sound like these things I’m saying are plausible.”
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In 2010, U.S. President Barack Obama signed into law the Affordable Care Act (ACA), complex health legislation that came to be known as Obamacare. Obamacare is the first substantive update on legislation related to the provision of health care in the U.S. since the introduction of Medicare in 1965. The legislation seeks to provide health insurance for 35 million of the 50 million Americans without it, making a step toward the type of universal coverage enjoyed by Canadians.
The ACA proposed to do that by expanding Medicaid. So far, twenty-six states are going ahead with the expansion, fifteen have opted out and the rest remain undecided.
Though it’s too soon to gauge its full impact, the hope is that Obamacare will reduce the financial pressure to turf patients by increasing the number of insured Americans. There’s some evidence that increasing the number of patients on Medicaid is improving accountability. The U.S. Centers for Medicare and Medicaid Services has the power to investigate and penalize hospitals that practice patient dumping.
These measures may help reduce turfing and dumping at the system level. But so much of the practice takes place between individual physicians. Fixing that requires a different approach.
Catherine Caldicott has called for educational workshops to teach doctors that turfing is unprofessional. If one medical student’s experience is any indication, we have a lot of educating to do. During a rotation in surgery, the student remembers caring for a man in his fifties who was developmentally delayed and was living in assisted housing. The patient had been diagnosed with rectal cancer and had an ostomy pouch—an external bag—for his bowel movements. He arrived in the ER with abdominal pain and soon developed life-threatening problems that required emergency stabilization.
The man was critically ill, the student says, and the ER physician summoned a phalanx of residents in surgery, internal medicine, gastroenterology and the ICU to stabilize him. Then one of the residents took the family aside and asked them what they wanted for the patient.
“They decided that this gentleman with developmental delay had a hard life and that the rectal cancer hadn’t been easy,” says the student. “They didn�
��t want anything done to him.”
And with that, every resident who had been trying to save the man’s life just walked away.
“No one wanted to take this patient on,” the student adds. “I felt terrible.”
Vineet Arora has no doubt what patients and their families would think about what was done to the student’s patient. “They would think it’s horrible,” Arora says. “I would be embarrassed to tell a patient [about turfing and blocking]. I think that patients have a right to high-quality care. They are hoping that they just get a plan and get good care and get home safely. To not feel wanted is, of course, going to be tragic.”
Given his role in introducing residents and medical students to terms like blocking, turfing and buffing, I wanted to know what author Stephen Bergman thinks of the fact that these concepts have become institutions in the culture of modern hospital medicine.
“The reality was that we would never turf a patient who we thought really needed our care,” says Bergman, who is more than a little astonished that turfing has become such an institutional practice. He points out that what he wrote was a novel. “You can’t let the jokes be the reality. You can’t let the slang be the reality.”
But turfing and dumping are the reality of modern medicine. Surprised though he may be, Stephen Bergman captured and reflected something in the attitude of residents and attending physicians back then. It’s probably even worse today.
12. Cowboys and Fleas
By now, you’ve grasped the notion that physicians and other health-care professionals use slang to tell each other just how much they dislike or—more charitably—feel frustrated treating certain kinds of patients. What you may not know is that their antipathy for colleagues also runs very deep. The myth of physicians and surgeons of various kinds riding off to war together to battle disease and injury—like the Knights of the Round Table—is just that: a myth.
Listen carefully inside the Bunker or at a nursing station late at night and you’ll hear surgeons rip internists, internists moan about surgeons, residents complain about attending physicians and seemingly everyone diss family doctors and ER physicians like me.
“I think that doctor-to-doctor slang is probably a lot more brutal than doctor-to-patient slang because there’s no confidentiality here,” says Dr. Grumpy, the neurologist blogger. “The other doctor isn’t sick and seeking help. It’s just another person you have to deal with.”
Dr. Grumpy says it’s not uncommon to hear doctors refer to each other as “morons” and words that are much worse.
“Usually it’s just plain insulting—like dipshit or dumb fuck or bozo,” he says. “I think bozo is probably the most commonly used one. You try not to use that with patients. I’ve never used it directly with another doctor. Usually it’s more in passing, where I’m looking over someone else’s notes and I’m thinking, ‘God, this guy is a bozo. What he’s doing makes no sense.’ I think it’s pretty common.”
Dr. Grumpy remembers using the term to describe a fellow neurologist who specialized in managing patients with headaches such as migraines. Dr. Grumpy says the doctor, who trained at a celebrated medical clinic in the U.S., opened an office near his and sent out a letter announcing the opening of the practice and asking for referrals. Dr. Grumpy decided to send one of his most hard-to-treat headache patients to see if the new doctor had any suggestions for how to control the patient’s symptoms.
“He sent me back this incredibly crappy letter,” Dr. Grumpy recalls. “He didn’t give me any information on what medications I should use aside from telling me not to use the ones I had already tried. He suggested I do tests that had already been done. It was a remarkably worthless and unpleasant experience and the patient was horribly disappointed. She said she felt he was rude—obviously a bozo.”
The way Dr. Grumpy talks about other doctors is pretty typical. It’s embedded in the culture of medicine that one kind of doctor disses another.
“There’s the joke about orthopedic wards being the place where internal medicine patients go to die,” says Dr. Donovan Gray, an ER physician and author of Dude, Where’s My Stethoscope?
Gray cites the oft-told story: A patient is admitted to an orthopedics ward for an operation to fix a broken foot bone. The patient also happens to have diabetes, but the orthopedic surgeon fails to diagnose or even recognize the symptoms of a diabetic emergency. “The orthopedic surgeon comes around to look at the foot and says that [it looks] good—and off he goes. Meanwhile, the patient’s in a coma.”
It’s startling for outsiders to hear doctors talking about each other that way. I found it so when I first heard that sort of dissing during residency. That’s when we learn the secret language of collegial insults. Now I’m used to it.
Five metres from your gurney or hospital bed, doctors discuss each other like that all the time. It’s just that you never hear it. That’s because complaining publicly about a colleague’s clinical skill, judgment, competence and attentiveness is considered unethical—perhaps even a breach of professional conduct. Hospitals and physicians may be inching slowly toward coming clean and apologizing for medical mistakes. But the unofficial hospital code of behaviour says that if you’ve nothing good to say to a patient about a colleague, say nothing.
Your only clue that something’s not right with your medical care may be found in the secret language we use to talk about each other.
* * *
The slang used by doctors to disparage each other may vary with the hospital. But certain terms are remarkably common.
Surgeons are cowboys. Internists are fleas. And ER physicians—like me—are often referred to derisively as “triage nurses.” That’s a rare example of slang that demeans not one but two colleagues—ER physicians and triage nurses—at the same time. And make no mistake: slang words like these are seldom compliments.
To begin to understand the meaning and the antipathy behind the slang, we need to go back to the origins of medical specialization. Although physicians had specialized since the time of the Romans, by the 1880s it was considered a necessity so that doctors could advance medical knowledge more quickly by observing many cases of only one or two diseases.
The unintended effect of specialization is that it created rivalries between specialists, born to a large extent out of insecurity. The more specialized doctors became, the less they knew about what each other did, and the more they had to depend upon fellow specialists who possessed skills they did not have and practices they knew increasingly little about, to help care for their patients. For decades, that insecurity bubbled under the surface. Then, in 1961, Peter Hukill and James Jackson co-wrote an article that was the first to capture argot or cant used by doctors to describe their colleagues. Most of it was pretty tame. Urologists were referred to as plumbers or as doctors whose specialty was the waterworks. Anesthesiologists were called gas passers, a slang term still used today.
“I find that an offensive term, and I would never use it in my practice,” says Dr. Katherine Grichnik, professor of anesthesiology and critical-care medicine in the department of anesthesiology at Duke University Medical Center in Durham, North Carolina. As associate dean for continuing medical education in the Duke School of Medicine, Grichnik is a thought leader in the evolution of professionalism among physicians. “I would never use it with a patient and I would never allow a surgeon to say it to me because it’s trivializing the profession.”
To prove her point, Grichnik outlines the complex knowledge anesthesiologists acquire to deliver safe and effective anesthesia care. It involves mastering the latest anesthetic drugs and techniques for a growing number of increasingly sick patients with complex and burgeoning medical problems. Anesthesiologists also have to worry about “what the surgeon’s going to do, and the complexities of the operation,” adds Grichnik. “Passing gas doesn’t convey any of that at all.”
Her colleague Dr. Peter Kussin, a respirologis
t at Duke University Hospital, doesn’t disagree with Grichnik; he just thinks slang isn’t all that demeaning. Kussin, Duke’s most notorious slangmeister, openly uses argot to refer to other specialists and he uses those terms with unconcealed delight.
Like pecker checkers—otherwise known as urologists.
Sometimes, Kussin springs slang like this on his residents just to see the looks on their faces. He recalls being on rounds in a medical intensive care unit and needing to know what urologists had said about a patient. He says he asked his team of residents, “Well, what do the pecker checkers think?
“Their eyes opened wide and I repeated: ‘Have you talked to the pecker checkers?’ One of the residents pointed behind me. I turned around and there was the senior urologist! And he says, ‘Well, the pecker checkers are here, Peter.’
“We laughed because he was about my age, and it was okay,” says Kussin.
Kussin has lots more where that one came from that he likes to teach his residents.
“The one they never know is pitchforks, which is one of my favourite slang terms for psychiatrists.” Aside from the reference to the devil, the slang was completely lost on me until Kussin explained that the open end of a pitchfork looks a lot like the Greek letter psi, which in medical circles stands for psychiatry.
“I’ll say, ‘Get the pitchforks in’ and my residents will say, ‘What?’” says Kussin. “And I’ll say, ‘Get a psychiatry consult.’ They love that because it’s a pure symbolism, wordplay thing and it’s very poetic.”
The Secret Language of Doctors Page 24