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Saudi Journal of Kidney Diseases and Transplantation
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DOCTORS DIARY Table of Contents   
Year : 2005  |  Volume : 16  |  Issue : 4  |  Page : 603-605
The Strong Territorial Instincts of Doctors

Division of Nephrology Hypertension & Renal Transplantation King Abdulaziz Medical City, Riyadh, Saudi Arabia

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How to cite this article:
Al-Sayyari AA. The Strong Territorial Instincts of Doctors. Saudi J Kidney Dis Transpl 2005;16:603-5

How to cite this URL:
Al-Sayyari AA. The Strong Territorial Instincts of Doctors. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2022 Aug 12];16:603-5. Available from: https://www.sjkdt.org/text.asp?2005/16/4/603/32851
It was at a very early stage of my career as a doctor that I realized that many physicians have a territorial instinct that can be on the verge of insanity at times.

I was just a newly appointed intern when I heard the following conversation between a consultant and his registrar:

Consultant: Why did you give one of my beds to the cardiology service?

Registrar: Well sir, they had an emergency case waiting in the ER who required admission and their ward was full.

Consultant: Well you know they have twice the number of beds allotted to them than I have. They should have discharged one of their patients to accommodate their own patients; they always do that to us. You should not have done that when you know we are a busy firm.

Registrar: Well sir, we do have one vacant bed in ward 4A and we could discharge Mrs. Robinson from ward 3A today.

Consultant: Look. Do not discharge Mrs. Robinson just yet until I figure out who I can get in from my list of patients waiting to come in. If you discharge her, some other consultant will admit a patient from the ER to her bed. The damage you did yesterday by losing one of my beds is enough. How long will this cardiology patient be in my bed? I want you to call the cardiology service right away and ask them to take their patient immediately.

Registrar: I will do that Sir. The patient is really quite sick. I believe he has severe heart failure and may even have a pericardial effusion.

Consultant: I don't care what he has. Just get him out of my bed and don't do this again.

Registrar: Yes Sir.

I recalled this particular event one year later when I was an SHO rotating through the endocrinology service. I was on emergency duty for medicine and I was called to see a patient in the ER with such a severe asthmatic attack, that he simply couldn't talk. It took me over two minutes to get him to tell me his name. I treated him with the necessary emergency therapy and he became moderately better but clearly he required admission as his respiratory defect was not normalized yet.

There was only one bed empty in the entire medical service and it happened to be in the cardiology Service.
"Right" I said to the patient, "we will get you in to watch over you for a couple of days?"
"Which ward will that be, doctor?" the patient's relative asked.
"Ward 3:4".

The ER sister who was looking on suddenly looked grim and took me by the arm away from the patient.
"Do you realize what Ward 3:4 is?" She asked in a rather condescending manner.
"Yes. It is the cardiology ward".
"Well you can't admit him there", she said in a decisive tone.
"And why is that? It is the only available bed in the service", I asked innocently.

Well Dr. Tomlinson won't like it. He simply does not allow any patients except his to be allowed in there. He left clear orders with me here in the ER about this.
"Well where can I admit the patient, then? You see he needs admission don't you?
"Yes he does; but not in Dr. Tomlinson's ward if you want to avoid trouble".

I would have spoken to Dr. Tomlinson but I was simply scared of him. He was the head of cardiology and a powerful person in the hospital chairing all sorts of important committees. He also had a bad temper, some may even describe it as vulgar, and everybody knew that and wanted to avoid him at any cost. To wake him up and to talk to him at 3 AM wouldn't be a good idea, I thought.

I really was at a loss as to what to do being a junior doctor. It was rather painful to me to decide. I even seriously thought of discharging the patient.

Finally, I decided to call the consultant on call. I barely finished telling the story when he interrupted, "Abdulla. I will give a general advice which will help you in the future in similar decisions in the future. Wherever you struggle with a decision, think of yourself in court being asked to justify your decision by a judge or a coroner about why you did this or did not do that. Good night, Abdulla" and he put the phone down.

I sat down and I was really very tired and sleepy. I started thinking and thought of what he said and I thought well suppose this patients is discharged and sent home instead of being admitted and then he died an hour later and his cases reached the courts, I must have dropped asleep and I imagined (or might have dreamt) the following conversation with the judge:

Judge: "Doctor, was your patient sick enough to require admission to the hospital?"
"Yes sir, I did" I will have to answer.

Judge: "Doctor, was it your judgment that he may have been liable to have serious deterio­ration in his condition if he went home?
"Yes sir I did" I will have to answer again sheepishly.

Judge: "Was it your judgment that he might even die on going home?
"Yes sir I did" I will have to answer again and I would be now sweating and trembling like hell.

Judge: "So, doctor, why in hell did you not admit him? Weren't any beds available at that time?
"Yes there was one your honour but it was under Dr Tomlinson who never allows any­body admitting anyone in his beds"

Judge: "Look young man that is no excuse at all. Dr Tomlinson does not own the hospital as far as I know, and in any case he is not under investigation now. You are. I believe that by your inappropriate actions, you have led to an unnecessary death of young person when he could have survived if only you had the common sense to admit him in an available bed. I have decided to send your papers and the details of this case to the GMC with a recommendation that you be struck off the registrar and that…"

It was at this stage that I suddenly woke up in complete sense of terror with my shirt drenched wet with sweat although it was a cold gloomy and snowy night in London in early January.

I admitted the patient to ward 3:4 and I was lucky. Dr Tomlinson was on leave at the time.

The lesson I learnt and which I have not stopped passing on to generations of residents was: whenever you find yourself in a situation of a decision that you worry about, specially those questions with ethical or moral dimensions, think of yourself in court"

This sense of empire building and territorial gains and territorial grapping continues to the present day among senior doctors. I had my fair share of territorial wars when I became a consultant myself. I still do.

I think it is acceptable for every consultant or specialty to try to get more beds, facilities or services but this sometimes takes the form of pure territorial wars and empire building as the above examples show; this, in my view, sometimes verges on insanity.

Strangely enough an equal but opposite "I am not accepting this patient war" commonly occurs. This is more serious and probably even commoner than the previously described phenomenon. It can be a source of confusion and nightmare for the junior doctors and can and does cause the patients to suffer

Its setting is usually, but not always the ER. The ER doctor calls that kidney specialist who says "look this patient may well be on dialysis but her presenting symptoms clearly suggest a classical heart attack She should be admitted under the cardiologists"

The cardiologist promptly responses "No. The chest pain is unlikely to be of heart origin. Moreover, I can't have a dialysis patient in my ward. The nurses don't know the first thing about looking after dialysis patients. In any case she also has fever; why don't you call the infectious diseases people to see her".

The infectious diseases people immediately respond, "look from what you are saying the fever is due to simple acute bronchitis. From our point of view this could easily be treated as an outpatient. What really needs to be sorted out now for her is her chest pain and kidney failure".

Twenty four hours later the patient is gasping for breath and the consultants are accusing each other but still refusing to accept the patient and the poor ER and the junior doctors do not know exactly what to do.

Correspondence Address:
Abdullah A Al-Sayyari
Saudi Center for Organ Transplantation P.O. Box 27049, Riyadh 11417
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

PMID: 18202515

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