EM Doc: *Cringes before picking up the phone*
“Hey…it’s Dr. SaltySweet from the ED. I have a placement patient for you…”
Admitting Doc: *Cringes. Sighs. Shakes head.* (This is all one smooth motion, typically.)

I know you dislike calling your (usually) friendly neighborhood hospitalist for the “placement patient” about as much as the receiving hospitalist dislikes receiving that call. However, I would argue that you should never be making that call in the first place. Let me explain.

One of the most dangerous cognitive errors we can make as physicians is premature closure. This is the concept that when the “diagnosis” and disposition are decided, the thinking stops and one disengages from the diagnostic reasoning process. As a hospitalist, I see this happen all too often to patients who are characterized as “placement patients” in the ED. Once the premature closure occurs, the work up frequently comes to a grinding halt. When the patient is labelled as a “placement” in the ED, the admitting physician may be deleteriously biased about the patient before even seeing him or her. As a result, the admitting physician is at higher risk for glossing over important details about the case due to anchoring bias and diagnosis momentum. As you might imagine, this does not promote optimal patient care. On occasion, it can even be dangerous.

As a former EM fanatic myself, one of the reasons I ultimately did not pursue emergency medicine was because I enjoyed continuity of care. I (usually) like knowing what happens to my patients and following them through their hospital courses. As a hospitalist, I have watched the hospitalizations of innumerable “placement” patients play out which is a perspective that EM physicians do not have by nature of their jobs. Sometimes these “placement” hospitalizations are very boring, but that often is not the case. Unfortunately, I have seen “placement” patients unintentionally misdiagnosed and/or misrepresented as more stable than they actually were due to premature closure. I have witnessed these patients become quite ill during their hospital courses through no one’s fault; they were just sick. On a side note, I contend that you should chart check your admitted patients at least once to see if you were correct or incorrect in your initial clinical reasoning and treatment approach; being wrong often feels just the same as being right when you do not see the effects of your actions.

In my career, I have cared for “placement patients” with missed spinal cord injuries, infections, fractures, and intracranial bleeding to name a few diagnoses. I have seen “placement patients” go into respiratory failure and/or shock. I have seen “placement patients” die. I am not saying any of this to place blame, but rather, to contend that physicians should consider looking at the “placement patient” a little more closely before admitting them upstairs. Ask yourself if you might be missing something. Keep your eyes, ears, and “Spidey sense” open. Roll them over and look at their backs and bums; you might be surprised by how many wounds and ulcers you find. You might even find Fournier’s gangrene!

All of this is why I want to educate young EM physicians on why you are doing patients a disservice when you label them as “placement patients” at the very beginning of their hospitalizations. These days, I cringe when I am called about a “placement patient” because I know there is likely more to the story than meets the eye. These patients have illnesses and social situations that are decompensated enough to land them in an emergency department and warrant admission to the hospital. They are not healthy people. They often are (unintentionally) very good at hiding occult illness that later becomes, well, not so occult. Lastly (and this is the superstitious, non-evidence-based part of me speaking), I swear calling someone a “placement patient” brings bad juju into the equation.

In closing, please remember that these so-called “placements” are human beings who are spouses, significant others, parents, brothers, sisters, aunts, uncles, friends, etc. to someone. I would not want my mom or dad labelled as a “placement” if they were admitted to the hospital, and I suspect most of you would feel the same way about your own loved ones. I challenge you to reframe how you evaluate and treat these “placement patients.” Keep an open mind and do not anchor on the idea that the only thing wrong is that they need “placement.” It is almost never just that. Ask yourself questions like: My patient is debilitated and can’t walk, but WHY is that? WHY is it that they laid on the ground for 3 days and could not get up? WHY is their potassium 2.8? WHY do they have altered mental status? Is there something reversible that I can diagnose and treat? In the end, you will do yourself and your patients a favor by reframing how you think and talk about them. Even if your patient truly just needs “placement,” find a more creative and fact-based way to present the patient to your admitting doc. Everyone will be happier, and arguably, safer!