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Comanagement: revisiting the rules of engagement

May 2009

Medical—surgical comanagement has always been a cornerstone of inpatient care, with several studies documenting improved patient outcomes when the model is properly utilized. Over the past several years, spirited discussions have revolved around the question of “who should be the attending physician?” While publications like Today’s Hospitalist have documented some of the dialogue, I still do not see any consensus about the hospitalist’s (or PCP’s) role in admitting surgical patients.

In the past, primary care physicians filled the attending role when the reason for admission was purely surgical, even for patients with stable medical issues. We still see this practice in smaller community hospitals, but similar dynamics exist in some academic centers where surgeons are consulted, then operate and follow up for post-op care. Historically, in many of these cases, primary care physicians knew these patients very well. Having those physicians at the center of inpatient care undoubtedly comforted both the ailing patients and their families.

But that paradigm has shifted, and most primary care physicians now belong to large (sometimes multispecialty) groups, trying to salvage a better quality of life. With hospitalists emerging as major contributors to inpatient care, the chance of patients finding a familiar face diminishes even further.

Many if not most hospitalist programs across the country are involved in some form of surgical comanagement. Some are distinct entities with specific order sets and detailed rules of engagement, while others are less formal. Many of my colleagues identify orthopedic comanagement as being most straightforward, and neurosurgery cases as the most challenging.

But given the increased societal demands for improved access and the ever-growing need to focus on our bottom line, we need to re-visit the question of who should be the attending. Currently, we have a huge shortage of hospitalists, a trend that has no end in sight. Certainly, there is no surplus of surgeons either.

Our imperative is to therefore find innovative ways to utilize resources and not subject hospitalists to being well paid H&P scribes. There is no reason for hospitalist or PCP involvement in a 22 yo with acute appendicitis unless overriding medical issues have an impact on the perioperative period.

Many facilities are in the midst of this very battle. In fact, my home institution is now wrestling with this issue. For years, the PCPs did almost all admissions including surgical cases. Recently, with the development of a hospitalist program, the mostly younger hospitalists have begun to question this practice of always being the admitter of record. Our discussion will undoubtedly continue for the next several months.

Here are a few of what I see as guiding principles for colleagues having similar discussions:

1. Patients with primary surgical presentations–with or without medical comorbidities–should be admitted by the appropriate surgical service. Clearly, many of these cases fall into a gray zone. When patients will likely require surgical intervention within 48 hours of admission, they should be admitted to the surgical team.

2. Because there are no evaluation and management codes for comanagement, we can bill these encounters only if we are providing a consult. So patients who need surgery but have no medical issues do not need medical consultation–unless their surgeon requests a medically necessary preoperative clearance for planned surgery.

3. On the other hand, an immediate medical consultation should be ordered if patients have unstable medical comorbid conditions and require intensive preoperative medical stabilization before surgery.

4. Patients who present with surgical problems such as hip fracture but who are not surgical candidates due to pre-existing or unstable medical comorbidites or age can be admitted to either the surgical or medical service, with the option of appropriate consultation to guide some non-surgical options.

5. The surgical and medical teams need to hold daily meetings to achieve the best patient outcomes. Team meetings should include midlevels and nurses.

6. Family meetings should be managed on a case-by-case basis, but the default physician should always be the attending unless specifically deferred.

These are merely guidelines, and some institutional cultures will function well with alternate arrangements. For way too long, however, inpatient primary care–whether provided by primary care physicians or hospitalists–has been tasked with the burden of keeping the surgeons happy.

How often do we hear the nurses cower for fear of upsetting a surgeon? Our surgical colleagues should be respected for the important contribution they make to patient care, but let’s not continue to do so at the expense of our own respect or by simultaneously placing ourselves in the path of potential medico-legal nightmares.

We are not surgical interns, residents, physician assistants or nurse practitioners. We bring a valued skill set to the care of our patients, and we need to keep our focus on what we were trained to do, not on what surgeons don’t want to do.