The metabolic syndrome & smoking-related diseases
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House of God by Samuel Shem is full of many sorry truths of hospital medicine, of General Medicine in particular. One of those is the art of the “buff” and “turf”.
No-one wants extra work. It is an eternal rule of human nature (unless you are a workaholic such as myself and find work somehow interesting, exciting or, heaven forbid – fun). And it is true that being in hospital for too long is bad for patients. The “buff” is the polishing up of the patient so that they are as healthy as you can get them from your point of view. The “turf” is the act of sending them to another medical team, to rehab or home or to a nursing home. And you want to do this in such a way that they don’t “bounce” – otherwise known as a failed discharge.
On the whole this can be an effective system. Certainly it is the kind of system that everyone seems to like – administrators, consultants, registrars, residents and the patients themselves. Less work, less costs, less time in hospital- you can see the advantages right there.
Sadly though this leads to the very predictable problem wherein no-one wants patients unless somehow the rules state they can’t be discharged or turfed. Usually the “buff” is very incomplete at this stage. Because we are all just focussed on the turf.
So we have some 75 year old patient with an uncomplicated heart attack being admitted under general medicine rather than cardiology because she has a urinary tract infection as well. Or no-one has bothered to check liver function tests and someone with ascending cholangitis ends up on general surgery instead of gastroenterology. Or neurosurgery takes a patient who “definitely has an acute disc prolapse” because overnight no-one wants to argue with the emergency registrar who wants to get patients out of a full emergency department and they turn out to have septic arthritis.
It is well documented that admitting patients under the appropriate speciality unit leads to significantly improved outcomes – in particular coronary care units and acute stroke units are cited as examples. It leads to shorter hospital stay, lower complication rates and marked improvements in morbidity and mortality. This is relevant to both speciality and general units, I feel. Often general medicine is better for complex or geriatric patients because rehabilitation and multiple referrals are streamlined, while speciality units can be very focussed- and can miss multisystem disorders.
Perhaps what will happen in the futures is that we will have speciality multisystem units- those dealing with “metabolic syndrome and smoking diseases”, those dealing with disorders of immunity and infections and such-like.
Either way, appropriate unit protocols can be a way of reducing fighting over rejecting patients. It certainly simplifies the process of admission. Another thing that must be done is reducing bed pressures and simplifying routine task management for junior doctors. It is high (and unnecessary) workloads and often very unfair bed concerns that mean the “buff” is not complete.
And so they bounce.