Placement

Abstract

The first “Placement” patient I (T.D.B.) took care of during my intern year was an older man, Mr. B, admitted for that most medical of euphemisms: failure to thrive. Although we did not know much about him, his recurrent aspiration events, shuffling gait, and gnarled, contracted fingers bespoke a long history of cerebrovascular disease. The degree of his cognitive impairment was not entirely clear because he was aphasic and did not respond much differently if the nurses spoke to him in English or Tagalog. Yet he had a marvelous, uncanny twinkle in his eye. When Mr. B started wandering the halls, opening every door such that we worried he was trying to abscond, it turns out that, chafing at his pureed diet, he was just looking for a spare food tray. I have never seen someone eat a peanut butter sandwich with such gusto!

Four weeks later, no progress had been made on his disposition and I rotated off service. But I would see him again in the months to come, shuffling soundlessly down the hall in his hospital-issued slippers, a nursing assistant dutifully in tow. And when it was my turn to be on night float, I would take his sign-out from my co-interns: “Mr. B is an 82-year-old male. Stable, full code. ‘Placement’ patient. Nothing to do.”

Even if I had not already been familiar with his case, that is all I would need to know, because the odds are that his nurse will not page me overnight, and if they do, it will be for something innocuous, like melatonin to help him sleep or Tylenol to soothe his chronic low back pain. And yet, so much is conveyed by those few words. By one word, really. Placement: the act of putting something, or in this case someone, somewhere. The implication being that where they are now is not where they belong (Figure 1).

The modern hospital's antecedent was the almshouse, long-term residences for the indigent, disabled, and elderly who did not have adequate family or community-based support.¹ Accordingly, they were often charitable endeavors, funded either by public or philanthropic contributions. Around the turn of the 20th century, however, spurred by the development of anesthesia and antisepsis, surgery helped make hospital care profitable, which incentivized a greater emphasis on acute rather than chronic medical care. Admission rates rose and lengths of stay fell, trends that would continue through the second half of the 1900s and into the new millennium, as payers leaned on providers to contain rapidly ballooning healthcare costs.¹

As resident physicians, we are largely immune to the financial pressures that impel us to expeditiously discharge patients from the hospital when they no longer require acute medical care. This is almost certainly in part a product of where we work, a major academic medical center affiliated with a Veterans Administration and public safety net hospital, rather than a smaller community or for-profit institution. Surely our attendings shield us from the baleful admonitions of the dreaded Billing Department as well—but is their chronic kidney disease Stage 3a or 3b? No, there are other factors that weigh more heavily in our considerations, and on our consciences.

For one, being in the hospital is an unpleasant experience, to say the least. Incessant alarms, vital sign checks every 4 h, shared rooms with nosy neighbors, and pre-dawn blood draws are just some of the features that range from the inconvenient, to the painful, to the potentially humiliating. What is more, more patients equal more work; and although we hesitate to put this in writing, we know the sentiment is widely shared. After all, the resident who manages to discharge their entire list is said to have “won the game.” Of course, this is not only solipsistic, it is illogical. Given the inordinate strain borne by our healthcare system, empty beds do not stay that way for long. Which raises the issue of resource utilization—that zero-sum contest between the patient who has been languishing on a gurney in the ED for the last 3 days, and the admitted patient upstairs who, if they just had somewhere to go, is otherwise medically ready to discharge.

All this creates an insidious undertow, pushing us to get people out the door. It also evokes the line, repeated in one form or another by bartenders for time immemorial, and further popularized in the song “Closing Time” by that quintessential 90s rock band Semisonic: “Closing time, you don't have to go home/But you can't stay here.”²

Regular bar patrons may fit one of several phenotypes. Some are looking to escape: work stress, a marriage on the rocks, unruly kids, the repo man. Sadly, they are like the patient who is suspected of malingering: the woman experiencing homelessness who comes to the ED reporting a tightness in her chest when it is raining and all the shelters are full; or the man brought in from jail with inscrutable, intractable, physiologically inexplicable abdominal pain. Then there is the customer who goes to the bar for community. They are akin to the patient with frontotemporal dementia who hangs out by the nurses' station like an old timer sitting on the front porch, passing his days bantering with everyone who walks by. Finally, there are those who go to a bar to feel better, to ease some physical or psychic pain, and to know that someone will be there—in fact, is being paid to be there—to minister, to listen. Which, stretching this analogy to its limits, casts us, the physician, in the role of bartender.

Confidant of patients' deepest, darkest secrets. Taker of keys—just as bartenders can be held legally liable if they serve alcohol to someone who subsequently gets behind the wheel, doctors are required to report to the DMV conditions such as syncope, seizures, dementia, or visual impairments that could hinder one's ability to drive. Bartender and physician both, in the end, charged with making a final disposition: Placement. You do not have to go home, but you cannot stay here.

Occasionally, patients get stuck in healthcare limbo. Perhaps, after scrutinizing their chart, a skilled nursing facility (SNF) determines that they are “un-rehabable.”^{3, 4} Perhaps their care requirements are too acute for an SNF but not acute enough for a long-term acute care hospital—an especially cruel predicament. Maybe a patient does not have anyone to care for them at home. Or maybe they have a home, and they have friends and family who can help, but the latter are burned out, overwhelmed—staggering under the weight of their responsibilities, desperately trying to empower their loved one to age gracefully in place, victims of the caregiver unaffordability crisis.⁵ And they are scared. At least, with its regular cadences—visiting hours, shift change, daily rounds—the hospital provides a semblance of order and stability. So the individual circumstances may differ, but the result is the same. They are now a “Placement” patient.

Despite modern medicine's incredible achievements, these are problems beyond the ability of any single healthcare team to solve. So every morning, when we meet at our multidisciplinary conference we repeat, “no medical updates.” And every day at sign-out we intone, resignation ringing heavy in our voices, “Stable, full code. ‘Placement’ patient. Nothing to do.” Ordinarily, “nothing to do” means that there are no labs to follow-up, no medications to be re-dosed. But in this context, coming after that word Placement, the phrase “nothing to do” works double time, serving as a singularly apposite coda.

Our intention is not to write another “healthcare is broken” story? Nor is it to propose or advocate for specific policy solutions, which are at once both self-evident (e.g., greater access to paid family leave) and seemingly intractable (i.e., political gridlock). Instead, our aim is more circumscribed and personal. This is a call—particularly to trainees such as ourselves who are developing their professional identities—not to surrender to the cynicism, burnout, and moral distress associated with “Placement” patients, their complicated dispositions, medicine, and the healthcare system writ large.

Near the end of my (T.D.B.) intern year, I passed Mr. B's room only to find it had a new occupant. Back at my computer, I opened up my list of former patients, scrolling until I found his name. A wave of relief rushed over me when I saw the word discharged and not deceased. Opening his chart, I filtered for the case manager's notes. They would prove to read with all the drama of a John le Carré novel. The Department of Public Health had managed to identify his family in the Philippines, coordinate with the American consulate, secure a tourist visa, purchase airfare, and drive Mr. B to the airport where he met his niece who had come to escort her uncle home.

I smiled. Never mind the bureaucratic insanity, the hundreds of thousands of dollars spent on his months-long hospitalization when, for less than the price of a CT scan, a couple of plane tickets to and from Manilla had secured that Holy Grail: Placement. The system had worked. He was home.

Teva D. Brender drafted and edited the manuscript. Audrey A. Tran created the figure.

We have no conflicts of interest.

We had no funding sources to report.

We have no financial disclosures to report.