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Medicine departments at many academic institutions have created Medicine Consult Services that provide consultative and perioperative care in the hospital. At some institutions consult services are engaged in both pre- and postoperative care, providing continuity for patients. At other institutions, solely preoperative evaluations and recommendations are provided for surgeons to incorporate into their care. In yet another model, consultations are available only postoperatively. Newer models have included comanagement agreements for certain situations, commonly with orthopedic or neurosurgical colleagues.

At the University of Washington Medical Center, where most of the complex surgery is elective, there is a consultative, teaching, and continuity model. The Medicine Consult Service is staffed by internists specializing in perioperative medicine. The patient has a comprehensive outpatient medical consultation at the request of the surgeon. The same internist who performs the outpatient consultation follows the patient daily when admitted to the hospital for surgery, serving as a consultant (not a comanager). The internist advises and teaches the surgical teams about the medical aspects of perioperative care such as diabetes management, etc. New inpatient perioperative consultations are also performed and followed by the Medicine Consult Service physicians. The continuity model minimizes handoffs and enhances satisfaction for patients, surgeons, and the medical consultant.

At Harborview Medical Center, our county hospital run by the University of Washington, we have a smaller, but growing, preoperative practice that was modeled after the University’s clinic. Our larger practice at present is our inpatient consultative service. Our county hospital is a regional level 1 trauma center and thus many of the surgeries are unplanned. When surgical patients are identified as medically complex and when medical complications arise postoperatively, a medicine consultation is requested. This is a teaching service with medical, surgical, and anesthesia residents overseen by an internist who specializes in perioperative care.

In community hospitals, hospitalists and primary care providers often incorporate perioperative care into their daily work. This can be through caring directly for surgical patients admitted to the hospitalist service, but can also be through providing consultation and recommendations to surgical colleagues. Some hospitalist practices have a specified individual available daily for consultations; others perform both primary and consultative care within any given day. Comanagement is also entering into some community practices where a hospitalist may work on a surgical unit or with a particular surgical service. Some preoperative clinics are run by anesthesiologists or in partnership with medical practitioners.

The optimal method of medical consultation is unknown, and is likely best tailored to meet the needs of each hospital’s patients and care delivery structure. It is hoped that as this field grows we will continue to develop the art and science of best perioperative care practices to improve testing strategies, avoid unnecessary cost, minimize complications, and optimize patient outcomes.