Tuesday, October 25, 2011

Turf wars.

"Admit to Medicine!?!"

There's this thing that happens in teaching hospitals everywhere that I'm slightly embarrassed to admit even exists.  It's what many have referred to through the ages as the "turf war" -- which is more like a tug-o-war between two different teams of doctors, usually from different disciplines.


Now that I think of it, in tug-o-war the competitors are pulling toward themselves in an effort to keep the rope or the prize or the flag or whatever it is.  In that case, a "turf war" isn't much of a tug-o-war at all.  It's more like a "push-o-war" where one service thinks that the other service should be responsible for the care of a particular patient.

Case in point:

A patient is brought to the emergency department after slipping on a patch of ice in her driveway. She unfortunately breaks her hip.  That hip needs to be surgically repaired by an orthopedic surgeon.

Simple enough, right?

Well, not so fast. Said patient happens to be a diabetic with a fancy insulin regimen and also happens to have a pretty labile blood pressure. She has smoked nearly all of her seven decades and has quite the case of emphysema to boot.  The list of medications in her pocket is equivalent to a grocery store receipt at Thanksgiving. . . .long.  The surgeon sees all this medical stuff going on and tells his Emergency Department colleagues at the time of admission, "Admit to Medicine."

This is the point where the (Internal) Medicine team (us) gets the phone call from the ED telling us of our surely lovely patient and her (surgical) cause for admission.

"Yeah, so she has a bunch of medical problems so they said that they'll consult and you all can be the primary team."

"But she has a hip fracture. A hip fracture. This is what got her admitted, no?"

"I mean, yeah. But . . .look. . . I . . .honestly? Dude, I thought it was for Ortho but they refused.  I guess they balked at all those medical issues."

"Balked at her medical issues?  She is almost eighty years old. And her medical problems aren't warranting her hospitalization. I'm balking at that broken hip."

"You're preaching to the choir, dude."

"Tell them that MEDICINE will consult and they can be primary -- considering her primary issue is a surgical one."

"They refused."

"What do you mean 'they refused?'"

"Just what I said. They refused."

"Okay, well then we refuse, too."

"You do? Wait--can Medicine even refuse anything?"


Turns out that Medicine rarely refuses to care for patients under most circumstances. We are the ultimate nerdy destination for all issues requiring major head scratching and prophetic waxing. Okay, I take that back--the Neurologists can be equally nerdy, but that isn't the point. The point is that the Emergency guy was right--Medicine rarely refuses and other services know that. For this reason, we lose a lot of of these battles.

Anyways. This is exactly what a "turf war" looks like.  Which now that I type it, makes me feel kind of like I should delete the whole thing.  It sounds really terrible when I reread it. . . . . this thought of tossing someone's loved one back and forth like some searing hot potato. Not cool.

The whole term "turf war" was made popular by this book called "House of God" that nearly all medical students, residents and faculty have either read or heard of at some point. The book was written back in the seventies and blew the cover off of so many aspects of residency training (back then) that the author published it under a pseudonym to keep from getting jumped in a dark alley by somebody's mama.  In this story he spoke of "turfing" between services and even "bounce backs" -- the patient that gets discharged and has to quickly return for readmission.  The "turf" became this term used to describe one service getting their patient's care to be assumed by another service which isn't always done willingly--hence the term "turf war."

As you might guess, referring to these situations as "turf wars" is probably not exactly p.c.  So I don't walk around describing them as such. In this instance, however, I'm simply admitting that this is probably the best way to tell you what most people are thinking of when they hear of such a thing. At least, people who work in teaching hospitals.


I guess I'm reflecting on this today because of a bit of a disagreement we found ourselves in yesterday with a surgical service.  Without going into too much detail, I'll simply say that one of our patients was waiting for a surgical procedure after all of the medical problems had been dealt with. In fact, had there not been a surgery planned, the patient would have been long gone.  Well, the patient has this complex surgery and usually afterward the team of surgeons assumes the care of the patient until discharge. But not this time.

I hear of this and prepare my mouth to say, "Oh hell naw!"  Okay, maybe not actually say it, but surely, surely some very diplomatic version of the same thing.  My resident explains the whole thing to me and tells me that the person speaking to him was both rude and unprofessional about it all. Alright, alright. . .I'll admit that maybe I wasn't exactly diplomatic because seriously? This sounded like an inappropriate load of horse manure to me and I'm pretty sure I made that fairly clear. That's when this happened:

"Dr. Manning, I didn't see the point in arguing. I really didn't.  If someone doesn't want to take care of our patient then they won't do the best job. I don't want our patient in the middle of that."

And I just sat there silent because really? My resident was so right. This was about a human being not a . . .well. . turf war.  He had decided to simply take the high road. . . . spending his energy on coordinating care for this human being and not fussing with someone who didn't have time for dealing with any of it.

Let me be clear--I have had countless encounters with my surgical and non-Internal medicine colleagues at all levels who have taken the exact same position as my current resident. The position of focusing first on what the patient needs and ultimately on what is best to meet them.  Yesterday I was tired and I felt myself forgetting that.  I was ready to put up my dukes, tie up my boots and march on Washington.  I was two beats away from calling that surgeon's attending physician to tell him or her exactly what was on my mind.  . . . but was I really just trying to win? Win a . . .turf war? And like any war does anyone really win?

My resident had it on the money. Who wants to be cared for by a person who does so begrudgingly? Not me.  He clearly decided that there would be no war. A discussion, perhaps, but no war. Imagine that. Well, I thought of this a lot yesterday evening. And you know? Thinking is a funny thing. You actually realize other perspectives when you do it which is why I highly recommend thinking to my kids and my learners.  After my thinking, I decided that maybe the surgeon wasn't as wrong as I initially thought. In that surgeon's defense, once I looked at things more closely the active issues post-operatively were arguably medical problems instead of surgical ones.  But it took me sleeping on it all night to see it this way.

Now I'm not saying I excuse the rudeness of the way he did it. But I am woman enough to say that having this patient cared for by internists isn't exactly as far off in left field as I initially made it out to be.

So, yeah.  That whole thinking thing? I highly recommend it.  

Next time? I think I'll try to channel my resident:

"Okay. Let's just try to focus together on what the patient needs instead of ourselves."

Preach, brother.

Happy Tuesday.


  1. Oh...thank you for this post. This is something I've thought about blogging about in the past, but have hesitated to do so lest it give a bad impression about the field of medicine or get me in trouble with my program if my blog were discovered. (I feel slightly more vulnerable as a resident than I hope I would as an attending.)

    As part of our residency training, we do two-week-long "night float" rotations in which we screen all the patients who may be admitted to the medical wards. A huge part of this, unfortunately, is "turf wars". I often find myself fielding inappropriate consults that should really go to surgery or another service, and when I try to refuse them as inappropriate for medicine I'm met with the same response that medicine can't really refuse them. One of my personal triumphs was to send a patient with broken ribs to a surgical ward instead of the medicine ward. When the ER physician asked where the patient should go given that medicine had rejected him, my response was "The patient is a trauma. He should go to the trauma service." It seems so simple, and yet it's such a huge battle.

    For me, one of the worst parts of the turf wars is that it causes me to view even legitimate consults as turf wars. I've been mildly snarky about some of the consults I've received, thinking them to be inappropriate, and then I've felt like an idiot when I've actually gone to see the patient and realized that they're very appropriate to medicine. I hate that the turf wars have conditioned me to be suspicious of the consults my colleagues give me.

    Thanks again for the post.

  2. You are truly a wonderful human being. Your resident was correct in his or her stance regarding doing what is right for the best care of the patient. However, as so eons who did an intern year in medicine, I know the burn of what can only be classified as laziness by the service who is taking care of the ADMISSION problem - in their refusal to place the patient on their census. I hate to generalize, but ortho was a prime offender.....GOD bless you, lady.

    A Felow Meharrian named Maria

  3. I remember those turf wars very well... Your resident was exactly right. I know your pt was in great hands!

  4. I imagine that the same sort of conversation/conflict happens with the FBI and the CIA.

  5. oh lord have i been witness to these and even sometimes have been witness to doctors straight up yelling about it in the middle of the unit. that really is such a great attitude to have though... cause seriously if you don't wanna take care of my patient than i don't want you taking care of him either.


"Tell me something good. . . tell me that you like it, yeah." ~ Chaka Khan

Related Posts with Thumbnails