Chapter 8: Medical Comanagement and Consultation

INTRODUCTION

Consultation and comanagement roles are still evolving for the pediatric hospitalist in the United States. Typically, hospitalists provide direct care for inpatients, seeking consultation from specialty colleagues as needed. For the past few years, however, hospitalists been called upon to provide consultation or comanage patients with another physician. The 2012 State of Hospital Medicine Report states that over 75% of pediatric hospitalists provide surgical or medical comanagement, with consultation roles less commonly (14% medical and 63% surgical, respectively).¹ In the broader milieu of patient care, hospitalists practice comanagement daily. When a primary care provider asks a hospitalist to care for one of his or her inpatients, the hospitalist is in many respects comanaging the patient with the primary care provider. Rather than doing this simultaneously during the hospital stay (as is typically envisioned with comanagement), the patient is comanaged by the hospitalist and primary care provider sequentially. For the patient to receive optimal treatment, it is crucial that the two systems integrate. Viewing this relationship as comanagement rather than care transfer serves as a starting point for the concept of two physicians jointly managing patients, whether horizontally along a timeline, or vertically during a single episode of care.

In other countries, hospital-based generalists have long been viewed as consultants to outpatient general practitioners. Studying the United Kingdom’s system of pediatrician hospitalists as consultants may aid in defining how hospitalists can serve as consultants in the United States. Specialist registrars in the United Kingdom who were asked to define key attributes of “the ideal hospital doctor” named the following eight areas as essential for the consultant: clinical knowledge and skills, clinically-related non-clinical skills, self-directed learning and medical education, change management implementation, application of strategic and organizational skills, consultation (history and physical) skills, research, and key personal attributes.²

In the United States, pediatric hospitalists are more commonly now serving as clinical consultants and comanagers during a given hospital admission, working with other providers who serve as attending physicians of record. Pediatric hospitalists are called upon to provide a pediatrician’s view of global issues such as child development, pain management, and home health care, as well as to aid in the diagnosis and management of medically complex children.¹ For hospitalists to provide optimal service to patients and providers in these consultant and comanagement roles, it is essential that definitions, expectations, and goals be clear.

Consultation is defined as “a deliberation between physicians on a case or its treatment”³ to address a problem that has emerged.⁴ Management, on the other hand, is “to handle or direct with a degree of skill … the whole system of care and treatment of a disease or a sick individual”³ and is initiated at the onset of a care episode⁴ with provision of direct medical care in addition to advice.⁵ Comanagement implies that care is managed by more than one physician. ...