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Feeling pressure to admit surgical patients?
Hospitalists work to set limits on co-management arrangements
by Deborah Gesensway



Published in the January 2008 issue of Today's Hospitalist

A patient comes to the emergency department at 2 a.m. complaining of abdominal pain. He may have a perforated bowel and he may need surgery, but the on-call general surgeon wants the hospitalist, who is in-house, to admit the patient. The hospitalist is already there, after all, and the patient may be able to be managed medically. Because the surgeon plans to see the patient as a consultant in the morning, he suggests “co-managing” the patient with the hospitalist.

If this story makes you cringe, you’ve got plenty of company. While surgical co-management
“Our 24/7 presence creates a mentality for people to say ‘Well, you are there. Can’t you just do it?’ ”

–Lauren Fraser, MD
Colorado Permanente Medical Group
has been generally viewed as a boon to hospital medicine, physicians are discovering that there can be some distinct downsides to managing surgery patients.

Kenneth Onyali, MD, for example, a hospitalist who works at two community hospitals in Tacoma, Wash., regularly fields requests to co-manage every kind of surgical patient who walks into the hospital’s emergency room, whether it’s a hip fracture, an intracranial bleed or possible appendicitis. While he has no problem co-managing many orthopedic patients, he’s found that balancing the near-constant stream of requests from surgeons of all stripes is becoming increasingly difficult.

“We have come to the conclusion that we need to sit down with all the surgeons and the emergency room,” says Dr. Onyali. “If we allow ourselves to get into a situation where we are seen as an easy option, we can easily get into a lot of trouble both for ourselves and for patients.”

That trouble can come in many forms, from concerns that handoffs will become more complicated to worries that hospitalists will be overwhelmed with surgeons’ scut work.

But probably the biggest single fear is that hospitalists may be setting themselves up for legal trouble by taking on too much care of subspecialty patients.

All of these concerns combined are leading some hospitalist groups to reconsider their role in surgical co-management. And while few programs are willing to walk away from co-management altogether, they are looking for ways to set limits and better define their role when working with surgeons.

Beyond scope of practice
Although many hospitalist programs view surgical co-management as an essential line of business, individual hospitalists say they are feeling pinched by not only the volume of requests, but the way they are expected to manage those patients.

Part of the problem is that some hospitalists find it nearly impossible to say no or to set limits. They may be anxious to please, or they may feel pressured by hospital administrators.

Or they find that success with one type of co-management doesn’t translate to other types of surgeries. Dr. Onyali, for instance, says his group has no problem admitting uncomplicated hip fractures.

But for other types of surgery patients, it is often not clear immediately if they “are going to need surgery or can be treated medically—and the person who has to decide whether the patient needs surgery is not the hospitalist, but the surgeon,” he says. “We want the surgeon to admit the patient, make that decision and then consult the hospitalist to manage medical problems.”

In a community hospital in suburban San Francisco where Heather A. Harris, MD, used to work, hospitalists likewise faced challenges when moving out of their clinical comfort zone. Neurosurgeons, hoping to attract patients to a new neuroscience referral center, would accept transfers from other hospitals over the phone. They would then expect the hospitalists to meet the patients at the emergency room, usually admit them, and assume all the non-surgical primary management of these often acute, highly complex inpatient neurology cases.

“We were being pushed outside the realm of what we thought our training had prepared us to do,” Dr. Harris says. Despite those misgivings, however, the hospitalists felt it was their job to do all they could to help the referral center succeed.

“Pushed to fill the gap”
A big challenge, says Dr. Harris, was the lack of adequate advance planning, particularly when it came to ensuring neurology backup. “An issue plaguing hospital medicine in community settings is a lack of providers in some subspecialties, like inpatient neurology,” she points out. “Hospitalists are really being pushed to fill the gap.”

Complicating that situation, she says, was the fact that many neurology patients were uninsured, suffered from great disabilities, and required complicated, time-consuming discharge planning.

“The surgeon would sign off and disappear, and we would be left caring for patients with profound physical disabilities who needed transitioning and didn’t have insurance,” she says. Many patients, she adds, had trouble being discharged so ended up sitting on the hospitalist service. But the tipping point-issue for the group was the feeling that “We were being pushed to care for patients when we weren’t the appropriate people to provide the care.”

Saying no to admissions
Hospitalist Andy Fedorowicz, MD, says he goes to great lengths to work with surgeons who admit their patients for elective surgeries.

Dr. Fedorowicz works as a hospitalist at Denver’s Porter Adventis Hospital as part of Sound Inpatient Physicians, which has more than two dozen locally-managed practices. He says that he has forged relationships with several surgeons at his hospital, beginning with orthopedists.

Early on, Dr. Fedorowicz says, he and his surgical colleagues agreed that each would continue to manage patients within their respective areas of expertise. The surgeons evaluate the wound, determine weight-bearing status and manage pain, while the hospitalists manage baseline chronic medical conditions and any other medical issues that arise.

“Keeping the surgeons as primary attendings, with hospitalists as consultants, keeps everyone involved,” Dr. Fedorowicz says. He adds that “surgical co-management is a natural fit” for hospitalist groups, and points out that co-management arrangements—with orthopedic, spine, transplant and other surgeons—make up about 35% of his group’s business.

A case-by-case approach
Lauren Fraser, MD, is the regional department chief for hospital medicine for the Colorado Permanente Medical Group, which includes 60 hospitalists working at two Denver hospitals, Exempla St. Joseph and Exempla Good Samaritan.

According to Dr. Fraser, hospitalists’ increasing “24/7 presence creates a mentality for people to say ‘Well, you are there. Can’t you just do it?’ ”

She feels strongly that hospitalists should not admit for surgeons, even though “surgery would like it if the hospitalists did admit for all the surgeons.” She points out that the Colorado Permanente hospitalists now automatically consult on—but do not admit—every orthopedic surgery patient older than age 65. They write orders, not recommendations, and they helped build a special discharge template for the orthopedists, with hospitalists providing discharge information on a co-managed patient’s medically related issues.

Staffing issues
As Dr. Fraser sees it, the unique nature of orthopedic surgery—the fact that the procedure often is not urgent, patients generally follow a similar course of recovery and many patients are elderly—makes it ideal for hospitalist co-management. Problems usually arise only, she says, with other types of surgical patients.

“A common scenario is a subdural hematoma where the patient appears stable and surgeons ask that we admit,” she says. “Sometimes we will, but we really don’t want to.” But while she says the group goes out of its way to not create turf battles, “that is an ongoing issue.”

The hospitalists are “happy,” she adds, to co-manage other patients when asked, including urology and general surgery patients. Those surgeons are clamoring for the same type of automatic co-management arrangement that the hospitalists now have with the subset of orthopedic patients.

But “that would be a huge increase in our census, and I would need more FTEs,” Dr. Fraser says. In the meantime, she urges hospitalists to use caution when agreeing to co-manage, even when practices are building their business.

“Eventually, you are going to be plenty busy,” she says, “and we should not be doing things that the neurosurgeon or the urologist should be doing. Our expertise is medicine, and that is what we should be delivering.”

Possible solutions?
One possible solution for some hospitals may be the nascent trend toward hiring “surgicalists,” general surgeons who remain on-site to treat ED patients. (See “Look what specialties are turning to the hospital medicine model” in the April 2007 Today’s Hospitalist.)

In Tacoma, Dr. Onyali says he has heard that some general surgeons in his community may evolve into being surgicalists, allowing their colleagues to concentrate on elective or office-based surgeries. And while no surgicalists have come yet to her Denver hospitals, Dr. Fraser says that a local neurologist may drop his outpatient practice to focus on being a hospital-based neurologist only.

In the meantime, hospitalists should expect pressure to continue to build to expand their co-management role. And some experts say that role is problematic, even when hospitalists serve as only consultants.

During a presentation on surgical co-management at the University of California, San Francisco’s annual meeting for hospitalists, for instance, panelist and veteran hospitalist Scott A. Flanders, MD, voiced his concerns.

Dr. Flanders, who runs the hospitalist program at the University of Michigan, said his program has for four years been co-managing (as consultants) orthopedic joint-replacement patients who have comorbidities. One problem, he pointed out, is clinical autonomy as a consultant.

“You want to order ultrasound to rule out DVT, but the surgeon says no,” he points out. “Who’s got the final say?”

Then there are problems with multiple signouts. “We’ve had situations where we’ve signed out to three different people: the surgeon there during the day, the surgeon there at night, and then our own hospitalist in-house at night,” he explained. “Who’s ultimately responsible?”

Manpower and appeal
Dr. Flanders said he is also concerned that the explosive growth of co-managing all patients, not just high-risk ones, may hurt the appeal of hospital medicine to medical students and residents. “Giving Colace to a cadre of hip fracture patients—-is that going to be attractive to a trainee?”

But the bottom line issue? Manpower. “There are not enough well-qualified hospitalists to care for medicine patients in this country, let alone all these surgical patients,” Dr. Flanders said. That’s why he has resisted expanding Michigan’s orthopedic co-management arrangement to other surgical specialties that have inquired about the service, including urology, orthopedic trauma, psychiatry and the inpatient physical medicine rehab unit.

“We’ve had to say ‘no,’ ” Dr. Flanders pointed out, “to everyone.”

Deborah Gesensway is a freelance writer reporting on U.S. health care from Toronto, Canada.

Co-management: Making it work the second time around

When hospitalists at the University of California, San Francisco were approached by the UCSF Medical Center to co-manage neurosurgery patients with medical problems, they were wary. Only a few years before, a co-management program with orthopedic surgery was abandoned due to a mutual lack of interest.

If the team was to take on the added service, it would need to design the program differently in every respect, from funding to staffing. And the hospitalists would have to make sure that both they and the surgeons had the same realistic expectations.

No housestaff allowed
Hugo Quinny Cheng, MD, a hospitalist and director of the program, says that he specifically designed the service so hospitalists wouldn’t feel as if they are “running scut” for the surgeons while maximizing the number of patients they could see. For example, the hospitalists consciously decided to co-manage only as consultants, not admitters.

Dr. Cheng says that one key step was ensuring that everyone understood that the co-managers were attending hospitalists, not replacements for nurse practitioners or neurosurgery housestaff. To make sure that the neurosurgeons didn’t mistake hospitalists for housestaff, internal medicine residents don’t rotate through the co-management service. In addition, Dr. Cheng says, the neurosurgeons had to agree up front that they would retain all of their nurse practitioner and physician assistant positions.

“They already had plenty of people who could pull drains, order physical therapy and write for routine postoperative care,” he explains. “They had pharmacists who could do their medication reconciliation and discharge prescriptions.”

What they needed from hospitalists was “someone to evaluate patients for medical problems, manage those problems and very quickly do a preop evaluation at a moment’s notice if they had to go to the OR immediately,” Dr. Cheng explains. “We had to be clear that we are not there to run scut.”

Financial and staffing incentives
Another major problem with the former service, Dr. Cheng says, was that there was no financial motivation to do co-management. The hospitalists had to see more patients, the work wasn’t that intellectually stimulating and they were paid nothing extra for doing it.

Before agreeing to the new program, he explains, the hospitalists insisted that the medical center pay for the service entirely. In addition, the hospitalists hired to staff the service would be paid a “disproportionately large” salary so the hospitalist program could “recruit and retain faculty who wanted to do this.”

The medical center agreed to fully fund two full-time hospitalist positions plus associated administrative support. That allows the hospitalists to provide 365-day, 12-hour coverage, Dr. Cheng says, plus partial funding for a moonlighter for overnight coverage.

“We call ourselves ‘embedded consultants,’ ” Dr. Cheng says. “We are consultants who live on the neurosurgery floor, and in addition to consulting, we are co-managing their patients with significant medical comorbidities.”

A balancing act
Since starting in July 2007, the hospitalists now co-manage about 40% of the neurosurgical patients and care for a daily census of 18 to 19 patients.

The balance isn’t quite right yet, Dr. Cheng says. The hospitalists are often busier than they would like, and a week of 12-hour days doing nothing but surgical co-management can be grueling.

And although the hospitalists have done a good job of getting the neurosurgeons to have realistic expectations, Dr. Cheng says, it has been trickier to do the same with the hospitalists.

“What I didn’t realize was going to be such a challenge was managing the expectations of the hospitalists themselves in terms of what they should and shouldn’t be doing,” Dr. Cheng says.

Working up all medical issues—chronic anemia or hypercalcemia, for example—on perioperative patients may not be the best use of time and may contribute to excessively long workdays.

And some hospitalists on the service are frustrated by the feeling that they are not fully co-managing care. That’s in part because they have no role in discharge planning or other day-to-day aspects of patient care.
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