Hospital Turf Wars

There’s really no war in hospitals. As colleagues, generally (and it’s best) all work together in a mutually beneficial relationship. You win, I win. Win-win.

All patients in hospital are admitted under a consultant, under a discipline. Sometimes it’s not a suitable discipline (e.g. diabetic ketoacidosis admitted under General Surgery because of abdominal pain), but usually this gets sorted out quickly with a mutually accepted transfer of patient to the department best equipped, in terms of equipment, knowledge and manpower, to treat the patient.

Take for instance, a hypothetical patient who has an infection. Infectious Diseases does not usually accept all patients with infections because that would be manifestly impossible for them, especially considering the number of referrals (‘blue letters’) they see. They are, however, involved in the co-management of a remarkable number of patients and are an essential, essential department. J.’s learnt a great deal from ID. Anyway.

So let’s say this patient has sepsis, with septic arthritis of the knee and a liver abscess, admitted under General Surgery. The joint is aspirated, grows MRSA and Ortho fires off 2 blue letters to Orthopedic Surgery and Infectious Diseases accordingly. They help to co-manage the patient, who is still listed under General Surgery. The patient’s septic arthritis resolves and remains that way, unlike the liver abscess which recurs. Basically, there are no active GS issues, but Ortho feels that the knee abscess will resolve soon and refuse to take over the patient. ID agrees to take over the patient, but only after Ortho has no outstanding issues. So GS is stuck with the patient.

So although GS technically has no more part to play, given the subspecialised nature of medicine nowadays… the patient is still listed under General Surgery. This means that the GS house officer, in this hypothetical situation, is responsible for the changes for this patient. Drawing of vancomycin trough, monitoring of inflammatory markers, removal of drains, etc are all the responsibility of this GS HO, even if there are no outstanding GS issues. See? This is the accepted way.

However, let’s say in the case of a Neurosurgery referral for a Neuro patient presenting with seizures secondary to an arteriovenous malformation in the brain, the consent and listing for operation could and probably should be performed by the Neurosurgery HO/MO because they know the op best, they konw the surgeon’s listing schedule, and are best able to describe the operation and its pros/cons to the patient. Other changes and pre-op arrangements should be still under the Neuro HO/MO until such time as the patient is transfered to the other department.

Now, J. was in a similar situation a long time back, drawing GXM for a patient for which his department had nothing left to do, checking on the patient on a regular basis, etc. while waiting for resolution of the patient’s illness. And it’s an accepted part of his work, because the patient is under his department.

What he was irritated about was when out of the blue, people called him to do changes on a patient NOT under his department on the basis that ‘they’re considering transfer to your department’. Later on, on seeing the patient (and taking consent) he finds out that they haven’t even contacted his superiors (only Registrars can accept patients). So they’ve already made the decision to push their work (the changes) to the other department pending the deicision to transfer? That’s not right.

Furthermore, it’s plain good manners to finish your work before handing it over to the next team.

Sure, J. could do the changes. It’d be easier, in fact. But the principle of the situation demands that you cannot push work to other people in this fashion. It’s just not done.

What then? Does the patient suffer? And again, where do you draw the line before people start dumping work on you?


2 responses to this post.

  1. Posted by cheekysalsera on May 29, 2008 at 12:09 am

    If principles are more important, just tell them you’re not in a position to do anything for them until they’ve got your superiors’ approval, and if they don’t budge, get your superiors’ attention on this matter so that at least it can be resolved quickly.

    Of course, that’s an ideal solution, and not always workable, particularly with very busy superiors. Furthermore, it may not be the best thing to do if your patient requires immediate attention.. which is rarely the case?


  2. omg this happens SO COMMONLY in the hospital. We all get dumped work all the time! maybe eventually all the dumping evens out… so just… suck thumb.


Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s

%d bloggers like this: