New limits on resident work hours and the graying of the U.S. population are putting hospitalists in the forefront of helping surgeons manage their patients.
Because the Accreditation Council for Graduate Medical Education restricted resident duty hours, surgeons can no longer rely automatically on residents to medically manage their patients on the floors, says Amir K. Jaffer, MD, a hospitalist and an associate professor of medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in Ohio.
Meanwhile, the population over age 65 will double, increasing to 70 million over the next 10 to 15 years.1
“More patients living longer means an increase in surgeries along the way,” says Dr. Jaffer, who is also the medical director of the Internal Medicine Preoperative Assessment Consultation and Treatment program in the section of hospital medicine at the Cleveland Clinic. For him, the first place hospitalists need to co-manage is in the postoperative setting.
“Studies have suggested that as patients age there is an increase in cardiological complications, noncardiological complications, pulmonary complications, and overall mortality,” he continues. “In my opinion there is going to be a crisis in regard to managing medical issues and complications surrounding surgery.” (See Table 1, p. 24)
Medications issues are another major reason hospitalists are called for surgical consults, says Benny Gavi, MD, hospitalist at Stanford Hospitals and Clinics in Calif. “I got consulted for a patient with tachycardia in the inpatient setting,” says Dr. Gavi. “By the time we saw the patient, the orthopedic surgeon had already ordered an echocardiogram and added a beta-blocker. When I looked at the patient I realized he had a gout flare; the colchicine that he took daily for his gout was never started in the inpatient setting, which ultimately delayed his physical therapy and added three additional days to his hospital stay.”
Co-management makes sense for still other reasons, he says.
“The knowledge base of both surgery and medicine is growing rapidly; no one person can remain on top of what is needed for both fields,” says Dr. Gavi. “In the last 20 years there has been a dramatic rise in the number of medications and some are very complicated. Also, physicians and surgeons both are being approached to participate more in quality initiatives and increasing throughput. As a result, physicians have to work faster and do more.”
In the United States, approximately 100,000 surgeries are performed each day and 36 million surgeries are performed each year at a cost of $450 billion annually. More than 1 million serious surgical adverse events each year cost $45 billion. Within two decades, the surgeries will increase by 25%, the associated cost will increase 50%, and the cost of in-hospital and long-term complications will increase 100%.
Along with postoperative care, there are increasing opportunities in the preoperative setting.
“At our institution, which is a tertiary care center with a huge surgical hospital, we determined that there was a need for hospitalists to provide medical management of surgical patients 10 years ago,” Dr. Jaffer says. “Patients were often not adequately prepared when they went to surgery, and sometimes in the morning of surgery the anesthesiologists would cancel their cases.”
The traditional model of physicians calling in consultants when problems arise might need to change.
“We are increasingly looking for ways to identify patients who have a high likelihood of developing medical problems and proactively getting involved,” says Dr. Gavi.
To co-manage, hospitalists must take ownership of some medical issues under specific conditions (diabetes, anticoagulation, blood pressure), says Dr. Jaffer.