Are there any downfalls to co-managing surgical patients?
“Sometimes the surgeons order unnecessary lab tests such as PTTs [partial thromboplastin time] because they are concerned about bleeding and complications,” Dr. Usmani says. “The next day if there is a deranged PTT, we need to figure out whether to suggest postponing the surgery or go ahead with the surgery based on the patients’ past medical/family history. We try to get our surgeons and our colleagues to work together with us in that regard because they don’t want to postpone surgery either.”
Drs. Usmani, Gavi, Jaffer, and Sivaprasad all say that when surgeons can observe firsthand their hospitalist partners exhibiting expertise in acute care it appears to improve surgeons’ attitudes about the role and value of hospitalists.
In fact, says Dr. Usmani, surgeons call him or one of his colleagues to thank them. “They say, ‘We really appreciate what you’ve done for this patient,’ ’’ he says. “Even if we suggest canceling surgery, they respect that we have seen a potential problem instead of letting it go ahead. They are happy to receive this advice.”
Another new relationship is between anesthesiologists and hospitalists. “I spend a lot of time calling anesthesiologists in regard to patient cases, and a good many of them are surprised to get a call from a hospitalist,” Dr. Gavi says. “We especially work closely together when we get complicated patients ready for surgery.”
A recent encounter proved to Dr. Gavi the complementary nature of the hospitalist-anesthesiologist relationship.2
“A patient came to the hospital two weeks ago to have an elective total knee replacement,” says Dr. Gavi. “She was an older woman with severe pulmonary disease. When the anesthesiologists saw her in the preoperative waiting area and realized how sick she is, they wanted to cancel the surgery. But the surgeon told the anesthesiologist that this patient had been seen in our own preoperative clinic and cleared by a hospitalist.”
Dr. Gavi had done what is customary for an internist. He took a more in-depth look at her pulmonology and cardiac records, called her cardiologist for further history, and reassured the anesthesiologist and surgeon. The patient had her surgery.
“Perioperative co-management is becoming more of a visible need,” says Dr. Sivaprasad. “It bridges the gap between surgeons and internists.”
To those of his hospitalist colleagues who have little information and are a bit afraid to begin perioperative care practice, Dr. Usmani recommends attending a perioperative summit conference.
The session should teach how to set up a perioperative center and what to do when managing patients with certain conditions.
“Although you meet with patients preoperatively in an office setting, you don’t feel like a primary care physician,” Dr. Usmani says. “You feel as if you are a specialist. You are respected, and you are contributing to postoperative outcomes to the benefit of the patient.”
Perioperative patient management is also financially rewarding because reimbursement is higher than customary hospital medicine duties.
Dr. Jaffer, soon to be chief of the division of hospital medicine at the University of Miami Medical Center in Florida, is proud of the work he and his colleagues have done to grow the Cleveland Clinic perioperative summit. This third summit, in September, was organized in collaboration with the Society of Perioperative Assessment and Quality Improvement.
“I think this is something that every hospitalist should try,” Dr. Usmani says. “It is definitely a niche.” TH
Andrea Sattinger is a frequent contributor to The Hospitalist.
- Mangano DT. Perioperative medicine: NHLBI working group deliberations and recommendations. J Cardiothorac Vasc Anesth. 2004;18(1):1-6.
- Adebola O, Adesanya AO, Joshi GP. Hospitalists and anesthesiologists as perioperative physicians: Are their roles complementary? Proc. (Bayl Univ Med Cent) 2007 April;20(2):140-142.