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. To provide the “whole system of care” that patients deserve, physicians must work synergistically as a team. This chapter reviews consultation and comanagement in the current literature, defines goals of each, explores existing models, and examines future directions.

Over the past 5 or 6 years, a number of studies have been published on the specific issues of hospitalist as consultant or comanaging physician. Though still limited in number, these studies address hospitalist and non-hospitalist physician experiences, opportunities and barriers, and impact on patient care outcomes.

The literature regarding the use of hospitalists as consultants continues to be limited. One retrospective chart review of patients on which adult hospitalists were consulted by orthopedic surgeons for care of non-pathologic hip fractures did not demonstrate significant improvements in osteoporosis treatment as defined by “addition of a medication for osteoporosis that strengthened treatment.”⁶ However, these patients had more comorbid illnesses and were significantly older than those receiving no consultation. One study of perioperative patients receiving a hospitalist medical consultation noted longer length of stay, higher cost, and no change in glycemic control and venous thromboembolism prophylaxis.⁷ However in this study only 9% of patients received consultation, and these patients more often had an American Society of Anesthesiologists score of 4 or higher, diabetes mellitus, vascular disease, or chronic renal failure. Moreover, consultations were requested due to a problem identified, which may have impacted the ability to anticipate and abate events. Literature on pediatric consultation is sparse.⁸ Canadian publications do note that consultation roles for inpatient (ward and interventional radiology)⁹ and ambulatory (hospital follow-up and general)¹⁰ settings exist, but no program or patient outcomes were reported.

In addition to formal consults, hospitalists may be engaged in “curbside consultation,” defined as asking for advice, suggestions, or opinions about a patient’s care without asking the hospitalist to see the patient.¹¹ In one recent study of 47 consultation events comparing curbside to formal consults performed by adult hospitalists on the same patients, curbside consults resulted in fewer questions asked and inaccurate or incomplete information received in 51% of cases.¹¹ Formal consultation changed management in 60%, with the change deemed major in 36% of these cases.

Although communication and leading a healthcare team are part of the pediatric hospital medicine core competencies,¹² specific expectations for consultation are not highlighted. Implementing a formal curriculum may be a valuable consideration for hospitalists wishing to hone these skills.¹³

Results from comanagement studies are varied. Hospitalists and specialists in one model held different opinions regarding how the model should be implemented and whether the model improved patient care outcomes, but agreed on the need for “ownership of patients.”^14,15 While reported impact on postoperative complications, mortality, and 6-month readmissions rates are conflicting,^5,16,17 perceived improved communication by surveyed nurses and non-nursing staff has been noted.¹⁸ Pediatric literature on comanagement is as limited as that for consultation. One small pediatric study of comanaged spinal fusion patients reported decreased length of stay and frequent information updates given to families as reported by hospitalists.¹⁹ Patient and family centeredness, medical errors, timeliness of care, and discharge coordination are other elements central to pediatrics yet not well studied.^20,21

By definition, a pediatric hospitalist acting as consultant focuses on a specific question involving a given patient. Most consultations involve a single interaction. The goals should be to provide either diagnostic and therapeutic treatment options or a single comprehensive pediatric screening examination. Discussion of the findings and options with the requesting physician and communication with the family after that discussion are essential. When the pediatric hospitalist is consulted for a specific question but is interacting on a daily basis in a more broad capacity, the service requested is actually comanagement. The factor distinguishing consultation from comanagement is the lack of expectation for longitudinal care and coordination of all patient care needs. Pediatric hospitalist consultation almost always addresses one or more of the following questions: