Physicians and blocking: can we tear down this wall?

A patient was brought to the emergency department (ED) by family complaining of chronic headaches and a question of new neurological abnormalities. A week prior, this patient had been hospitalised at a nearby institution and diagnosed with a large intracranial tumour with associated bleeding, with plans for neurosurgery follow-up after discharge. Imaging in the ED confirmed the haemorrhaging brain tumour; images from the prior hospitalisation were not available for comparison. The neurosurgery service was paged for admission but deemed that emergent surgery was not indicated and thus declined to admit the patient to their team, though offered to serve as a consultant. However, they also did not recommend discharge. The neurology service was then paged for admission but after evaluation declined because of the haemorrhage associated with the brain tumour. The oncology service was then called to admit, but per policy deemed it inappropriate to admit a patient with a primary brain tumour to their team. An ED change of shift occurred, neurosurgery was paged again, and on repeat assessment deemed the patient suitable for discharge with follow-up at the previously scheduled clinic appointment. Hours had passed between the initial admission page and discharge. The above patient’s fate highlights an unfortunately common phenomenon in academic teaching hospitals, one that current physician trainees are closely acquainted with and which more experienced physicians easily recall—‘blocking’. Blocking, the denial of patient admission by a hospital team to their own service, is not without reason. Specialty teams may be paged for consultation or admission when a patient’s …