Knowing which model you are functioning under and who is responsible for which problems can be tricky. In the first case, who owned the decision-making for the patient’s DVT work-up?
The orthopedist may assume his role is focused on the care of the hip fracture surgery, while all else is the hospitalist’s purview. The hospitalist may assume DVT is a complication of the hip fracture surgery and is the orthopedist’s responsibility.
The second case seems easier as the hospitalist was clearly functioning as a consultant and therefore his obligation ends with his recommendation to further evaluate for DVT.
Or does it?
Lesson three: Communication is imperative.
The role we are functioning in—consultant versus co-manager—is not always intuitive. This perplexity can be further exacerbated by poor communication.
In both cases the hospitalists’ role was not established up front. Further, the hospitalists and their colleagues never spoke directly about the case or the management decisions.
In the second case the surgeon saw the recommendation but presumed the hospitalist would write the order for the ultrasound because they were co-managing the patient. He argued that he is not expert in the care of DVT and could not determine if the recommendation was sound. He assumed the hospitalist would appropriately evaluate this situation and complete the work-up if warranted. Because the hospitalist did not, the surgeon assumed the hospitalist was no longer concerned about DVT.
The hospitalist countered that she was specifically consulted to answer a question about depression. The recommendations regarding the swollen calf were also done in a consultative fashion, and the decision to obtain the ultrasound would fall to the surgeon.
The hospitalist argued that because the surgeon did not consult her again for this specific issue, she assumed he was comfortable evaluating and managing DVT.
This foray into the legal system reminded me that our patients trust we will give them the best care. When system and communication inadequacies get in the way of this, we can get sued—but our patients can lose their lives. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.