Formal consult vs co-management
Formal Definition
Two distinct models of subspecialty involvement in patient care: formal consult (consultative) — the consulting service evaluates the patient and provides written recommendations to the primary team, who retains primary responsibility and decision-making authority for implementation; co-management — both the primary and consulting services share primary responsibility for the patient's care, with shared decision-making, joint orders, and joint documentation, typically in a defined clinical context (e.g., hospitalist co-manages with orthopedics for total joint patients; intensivist co-manages with surgery for ICU patients; medicine co-manages with psychiatry for complex comorbid patients).
How It's Used on the Ward
"Consult" vs "co-manage" — when you call cardiology, sometimes they'll come see the patient and write recommendations that you act on (formal consult), and other times they'll actually be following along and writing orders with you (co-management); traditionally consult implies "they're recommending therapy but the primary team writes the orders," while co-management means both teams write orders and the consulting service shares accountability.
Example
""85-year-old admitted with CHF exacerbation and new hip fracture needing ORIF. Orthopedics Consult vs Co-management discussion: traditional model — ortho comes, recommends ORIF timing, postoperative weight-bearing and DVT prophylaxis; medicine team implements and remains primary. New co-management model — both ortho and hospitalist share decision-making, joint documentation, ortho writes ortho-specific orders (mobility, weight-bearing, DVT prophylaxis) while medicine handles volume status, comorbidity management, transitions; both teams see the patient on rounds.""
Clinical Context
Formal consult: typically for single question or episodic specialized care input. Service writes consult note with recommendations, may or may not follow daily. Primary team retains decision authority — often has the final say. Co-management: deeper collaboration with shared authority, often protocol-driven, both teams see the patient daily and document. Examples: ortho + medicine on geriatric hip fracture service, hospitalist + OB on high-risk OB patients, intensivist + primary surgical service in "open" or "closed" ICU models (closed = ICU team is primary; co-managed = both teams input). Billing and coding differ — formal consults typically bill with consult CPT codes (or subsequent visit codes if follow-up); co-management is shared/split billing. Risk of conflict: clearer delineation of responsibilities at start of co-management reduces friction (e.g., "who handles K+ replacement" — write into co-management agreement). Trend: increasing co-management models due to increasing medical complexity of surgical/ procedural patients.