Patient Dumping And Hospitalist Co-Management.

A reader asks the question:

Has hospitalist co-management simply turned into outright, legitimized patient dumping?

I get called from the ER to admit a perforated viscous in a 80 year old woman with abdominal pain, and copious free air on CT.  General surgery was called, told the ER "admit to the hospitalist" and refused to even call our service to discuss it as he/she "not seen the patient yet" and told the ER when pressed when he/she would be in, it would be "some time tonight" rather than the 1 hour required by our medical staff bylaws.

This is how not to form good working relationships.  I swear, sometimes it seems like subspecialty groups consider hospitalists the enemy.  You try and do the right thing by having physician to physician communication and some doctors find themselves above the process.  Almost as if they are too good to be bothered with such annoyances as patient consults.  I have stopped counting how many times I have had a doctors yell at me for "only consulting me (CPT 99253, 99254, 99255) on the uninsured patients" or "only consulting me on the complicated patients".  I have stopped counting how many times certain doctors yell at me for asking for their help in evaluating patients that I have no formal training.

   

I even cared once for a patient with a surgical problem where in I was forced to go through  four surgeons of varying subspecialties whom were all qualified to evaluate the surgical condition for which I was requesting assistance.  It took me 45 minutes to hunt down a doctor, who finally agreed to see the patient after their surgical and clinical rounds, the following day.  

When you don't have back up to evaluate and manage conditions for which you are not trained to handle, you simply stop accepting them to your primary service until that changes.   I would not put myself into a position as an attending where I would accept a dying patient and no subspecialist to help evaluate conditions for which I am not trained to manage.  It would be like me transferring the patient from Happy's regional referral center to a small town community hospital.   I do not  agree to admit a patient with a primary condition for which I am not able to manage unless I am guaranteed  immediate access to a subspecialist who can help me in co-management. 

I have no problem admitting surgical patients when I know the surgeon is available immediately. When I see the  patient as a consultant or a primary, nothing is different for me.  But making sure the doctors are available without jumping through hoops is key.