Turfing is the medical slang term for transferring a patient the original doctor is qualified to care for but doesn’t want to for some reason. That doctor then “turfs” a patient to another doctor for no good medical reason. This is very important to patients because turfing in Teaching Hospitals almost always results in poorer care or a more negative experience for the patient. It is important to note that those with lower levels of insurance are more likely to get transferred or turfed, another relatively unrecognized aspect of the current argument over medical insurance in Congress.

Why Turf?

Turfing can be the result of various things but almost always occurs in one of two circumstances, either a private hospital dumping patients, or Doctors in teaching hospitals dumping patients on interns.

So, why does turfing occur? First, the doctor may not like the patient, in which case the patient may be better off with another physician. Second, the original doctor may be overwhelmed with patients at the moment - too many to give proper care to all of them. This may also be beneficial to the patient. Third, the doctor may be “punishing” another doctor (usually an intern or student) by pushing undesirable cases on them. This is almost always bad for the patient.

In a study reported in the May 2012 issue of AMA Journal of Ethics and conducted by Catherine V. Caldicott, MD, Dr. Kathleen Dunn, and Dr. Richard Frankel, patients were surveyed as to their satisfaction with the care they received.

The result from both turfed and non-turfed patients was overall satisfaction with their treatment, but the turfed patients universally expressed more negative feelings about how they were treated, while this was rare or non-existent in the patients who stayed with their original doctor or service. It is important to realize that this study applies to teaching hospitals where many of the younger doctors who get stuck with the turfed patients are on a fixed salary.

Community hospitals

In private practice and community hospitals the practice of transferring patients is treated differently. Doctors are happy to get referrals, transfers, or requests for consultation because they make more money by treating more patients. The financial incentive means that turfing is unlikely to occur and that if it does, the receiving doctor would be pleased instead of feeling that an additional burden was placed on them.

Turfing from private to public or teaching hospitals

The practice of sending critical uninsured or pregnant patients from private hospitals to teaching hospitals (another form of turfing) was made illegal in the U.S. in 1986. But, turfing can still happen in non-critical cases where patients with Medicare, Medicaid, or no insurance are often shipped off to public (non-profit) hospitals -- in part because the physicians can’t make any money from treating them, or not as much as they can with other, better insured patients.

Recent changes in how doctors in teaching hospitals are compensated, that is, they get paid additional amounts above their salary for treating more patients, is beginning to reduce turfing for financial reasons.

Another change which will probably reduce turfing is the alteration in work schedules for Interns. It the past doctors could be on duty for days at a time, leading to mistakes as well as weeding out the less capable doctors. Other countries such as England don’t do this and now there are time restrictions in terms of how many consecutive hours a doctor can be on duty before they are required to go home.

Ethics of Turfing

The ethical considerations are many and depend in great part on the reason for turfing a patient. If it is intended to give them better care and actually has that result then there is nothing wrong with turfing and that term probably shouldn’t be applied. If, however, turfing results in negative results for the patient or the doctor on whom the patient is dumped, then it is clearly unethical.

Moves to make turfing less desirable -- including hospital policies assigning complex or expensive cases to a team comprised of multiple specialists with a coordinating physician to manage the case overall -- are being made.

Turfing came to be a major concern after a fictional 1978 book “House of God” by S. Shem (pen name) was published.

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