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Co-managing surgical patients: New opportunity or “mission creep” for hospitalists?
While pre-operative assessments are quickly becoming routine, some hospitalists worry they are being asked to do surgeons’ scut work
by Deborah Gesensway



Published in the June/July 2004 issue of Today's Hospitalist

While co-managing surgical patients with medical conditions may seem like an obvious opportunity for hospitalists, it requires planning to be successful. At a session on creating surgical co-management systems at the annual meeting of the Society of Hospital Medicine (SHM) in New Orleans, panelists warned of the pitfalls of such endeavors.

According to survey data from the SHM, about half of all hospitalists have worked with surgeons to co-manage patients admitted to the hospital for surgical procedures. Most of these arrangements take place on an informal basis, explained Andrew Auerbach, MD, a hospitalist
“Orthopedics wanted service and we wanted collaboration. We couldn’t provide the service, and we underestimated the scut work.”

Andrew Auerbach, MD
UCSF
at the University of California, San Francisco (UCSF).

If not set up carefully, however, surgical co-management can fail. Inpatient physicians may be left feeling like they are nothing more than glorified residents doing scut work for surgeons. They can also find themselves dodging run-ins with government auditors concerned about fee-splitting, double-billing, abrogation of care and even kickbacks.

A little help for surgeons

While many hospitalists attending the session said surgical co-management is gradually becoming “the standard of care” and an assumed part of hospitalists’ duties, others said they view co-management as merely “mission creep” for hospitalists.

“If the problem is bad DVT prophylaxis by surgeons,” asked one participant, “why isn’t the answer continuing medical education for surgeons?” The answer for too many problems that revolve around quality of inpatient care, he added, is being put squarely on the shoulders of hospitalists.

In fact, the drive toward co-management of surgical patients by hospitalists is being fueled by a number of studies that found that surgeons generally do a relatively poor job of appropriately providing everything from beta-blockade and embolism prophylaxis to post-operative antibiotics. There are also now several studies that suggest that hospitalists can do a better job, explained Shaun Frost, MD, a hospitalist at the Cleveland Clinic Foundation and Pennsylvania State University College of Medicine.

He pointed to a 1994 study in the Journal of General Internal Medicine that examined whether co-management makes a difference. Researchers found a decrease in everything from hospital length of stay to the mean number of drugs a surgical patient was taking at discharge when surgical patients were co-managed by a hospitalist.

A forthcoming article about a hospitalist-orthopedist team at Mayo Clinic, he said, similarly found that surgical patients whose care was co-managed suffered fewer “minor” complications, such as electrolyte abnormalities and urinary tract infections. They also were discharged from the hospital a little more quickly than other patients not treated by a multispecialty team. That study also found that both surgeons and nurses liked the team approach.

Pitfalls

Nonetheless, Dr. Frost said, there are pitfalls to be avoided. The main problem, he explained, revolves around concerns about fee-splitting, or the fee paid to one physician by another for the referral of a patient. Because surgeons are paid a global fee for their services that is supposed to cover pre-operative care and post-operative care for 90 days following surgery, this issue is critical.

Dr. Frost said that in his interpretation of the federal law governing the surgical global fee, there are specific exceptions that allow surgeons to co-manage care. The other doctor in these instances, however, must specifically be taking care of issues “unrelated to the diagnosis.”

One example mentioned in the law, he explained, describes allowing a surgeon to call in a cardiologist to manage the underlying cardiovascular conditions of a patient.

The law is not as clear, Dr. Frost continued, when hospitalists are asked by surgeons to manage a surgical patient’s general, not specific, medical problems. He added that the law distinguishes between inpatient post-operative care and outpatient post-operative care.

Spell out the details

His bottom-line recommendation to hospitalists? Establish a contract that you work out with the surgeons with whom you are going to co-manage patients. This document, which can be short, should lay out the ground rules and state specifically that the surgeon still has primary responsibility for all surgery-related issues.

The agreement should spell out clearly who has specific responsibility for what work, define how hospitalists and surgeons will communicate about all issues, specify how long the hospitalist will be involved, and name the specific doctor that nurses and other providers will work with. Dr. Frost added that it is important to inform patients about the co-management arrangement and make sure they agree to it.

“I think that proactively discussing arrangements with surgeons and nurses is key to avoiding ethical and legal pitfalls,” he explained.

Dr. Auerbach explained that UCSF established a surgical co-management program for orthopedic trauma and spine service patients. But because many of these issues were never thought out in advance—specifically how the surgeons and hospitalists communicated—the effort was doomed.

The endeavor failed, he explained, because of a lack of “co” in co-management. “Orthopedics wanted service and we wanted collaboration,” he said. In the end, he added, “We couldn’t provide the service, and we underestimated the scut work.”

Dr. Auerbach recommended against forcing surgeons into this type of model. He instead urged hospitalists to work only with physicians who are truly interested in collaboration.

By working with willing participants, he said, “you can avoid the perception of abrogation of care” that some surgeons and patients see with co-management models of care.

Anesthesiologists stretched thin

Participants at the SHM session also heard from the Cleveland Clinic’s Amir Jaffer, MD, who leads the group’s internal medicine pre-operative assessment consultant and treatment center. Dr. Jaffer described how hospitalists can successfully take on the business of providing pre-
operative evaluations, which are lucrative for physicians and beneficial for patients.

Currently, he said, most pre-anesthesia clinics, which conduct most of the medical evaluations before surgery, are stretched too thin to do a good job for many older and sicker complex patients having surgical procedures. In his experience, he said, anesthesiologists are welcoming hospitalists because they do not have time to concentrate on both anesthesia and medical issues.

Dr. Frost echoed that sentiment, adding that the anesthesiology literature recently has featured discussions about how more and more anesthesiologists are uncomfortable with the responsibility of handling complicated medical issues by themselves during their pre-surgery work-ups.

Dr. Jaffer said his hospitalist-run pre-operative clinic helps surgical co-management work better. In addition to preparing patients for surgery, he said, the pre-operative work-ups let hospitalists identify for surgeons which patients will likely need medical post-operative care.

He noted that it is then up to the surgeons to call the hospitalists in, as consultants, to help co-manage these patients.

Deborah Gesensway is a freelance writer specializing in health care. She is based in Glenside, Pa.


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