The Benefits
To Latha Sivaprasad, MD, hospitalist at Beth Israel Medical Center in New York City, there are three main advantages of hospitalists’ involvement in perioperative co-management:
- Hospitalists typically perform comprehensive, multisystemic patient evaluations;
- Hospitalists are extremely accessible; and
- Hospitalists are up to date on inpatient medicine.
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How up to date?
“Periop isn’t routinely taught in residency,” says Ali Usmani, MD, a hospitalist at the Cleveland Clinic. “In fact, I had little information about perioperative care.”
When he joined the hospitalist group after a three-year residency at Cleveland Clinic, Dr. Usmani did preparatory reading. Later, the hospitalist group gave him a helpful collection of essays.
“I was very nervous because, of course, I had never done this before,” he says. “Surprisingly, I also had not done a general medicine consult service where we see postoperative patients. It was scary to some extent, but I found out that it is easier than I thought because there are guidelines you can follow from the AHA/ACC that are fairly straightforward. It also meant a nice schedule change from being on the floors.”
Although conducting preoperative evaluations with patients was technically outpatient work, it was not like he was seeing patients with such simple illnesses as a cold or a sore throat. Also, he says, there were no new surprises postoperatively because either he or a hospitalist colleague had seen the patient preoperatively.
Dr. Usmani, also a clinical assistant professor of medicine at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, believes patients are happier when seen by hospitalists because they get a standardized, holistic preoperative assessment. And, helping to reduce the number of unnecessary tests ordered by primary care physicians or surgeons makes him feel as though he’s making a valuable contribution.
New Niche
Dr. Sivaprasad, who is also doing a one-year fellowship in quality improvement and patient safety at Beth Israel, has practiced hospital medicine in four hospitals ranging from 500 to 1,000 beds. “The primary reason we are consulted by surgeons is for perioperative cardiac risk assessment,” says Dr. Sivaprasad. “Other reasons include co-managing a patient with comorbidities such as a history of diabetes, hypertension, or renal failure.”
From 2003-2006, Dr. Sivaprasad was one of 14 hospitalists consulted often by surgeons at St. John’s Mercy Hospital in St Louis, a 1,000-bed Level I trauma center. “We were consulted for postoperative co-management, preoperative evaluation, or more urgent cases such as a patient experiencing hypotension, atrial fibrillation, shortness of breath, decreased urine output, or renal failure,” she says.
Dr. Sivaprasad recently attended the Johns Hopkins conference on Perioperative Management. The session made it easier for her to do a systems-based consult.
“All hospitalists differ to the degree of perioperative medicine they feel comfortable with,” she says. “Hospitalists understand perioperative medicine on different levels. They all can do an acceptable consult; but there is a spectrum of how detailed one can be and what service one can provide for the surgeon and the patient.”
Dr. Jaffer finds his work in perioperative care fulfilling and considers it another way hospitalists can increase their influence.
“Often when you manage medical patients in the hospital, it’s you, the medical patient, and the patient’s primary care physician,” Dr. Jaffer says. “But when you start to manage surgical patients, you are really being looked at by your surgical colleagues as an expert in managing medical problems, just as you view them as experts in managing surgical problems. What I realize from this is that I can be a perioperative medicine expert as well.”