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Bridge the Attending Divide

From: The Hospitalist, March 2009

HM evolution extends to orthopedic asmissions and many other diagnoses

by John Nelson, MD, FACP

I always wear a sport coat and tie when I’m speaking, but I thought I knew the orthopedic psyche well enough to know they would be very casually dressed for their conference on a warm Saturday this past fall. I was stunned to see about 40 of the 60 orthopods in attendance wearing jackets and ties—a very dapper bunch. While I misjudged their fashion sense, I’m still confident I’ll fit in wearing a bow tie (borrowed, since I don’t own one) to a neurology conference or a Mickey Mouse tie to a pediatric conference.

I had been invited to speak at the Washington State Orthopedic Association last fall. (Maybe they spell it “orthopædics,” but that seems a little pretentious to me.) They wanted to hear about the latest trends in how orthopods and hospitalists collaborate in the care of patients, and how this interaction might evolve.

It seems to me that the pressure to serve as attending for these patients is similar to surviving a riptide: You shouldn’t try to swim directly against the riptide toward shore, and instead should swim across it or even go with the flow.

Attending or Consultants?

I told them that, in my experience, determining the best doctor to serve as attending for certain types of patients generates a wide range of sometimes passionately held opinions among hospitalists. In my consulting work with practices around the country, I’ve come across some hospitalists who are insistent that they should never serve as attending for patients whose primary reason for admission is:

  • Hip fracture due to osteoporosis and fall from ground level;
  • Nonoperative low-speed or low-impact trauma, such as pelvic fracture; and
  • Limb infection with potential for compartment syndrome.

Interestingly, I’ve found that hospitalists almost universally admit patients with osteoporotic vertebral compression fractures, even if they strongly believe that they shouldn’t admit patients with pelvic fractures.

My own experience leads me to believe that hospitalists in most settings should plan to serve as attending for all of these patient types, if they aren’t already. For example, a hip fracture is essentially a marker for a sick and frail person with complex medical needs. While it is the marquee event of the hospital stay, surgical repair of the fracture is just one of many important things that need to happen before discharge. Most of these patients need attention for medical comorbidities—such as a urinary infection or decompensated heart failure—which often are the proximate cause of the fracture. The patient might need a discussion of medical directives, which usually is an area in which orthopods usually don’t excel (and I’m being kind to the orthopods).

Let me be clear: Reasonable people can conclude hospitalists should not serve as attending for the diagnoses listed above. SHM does not have a position on this, and I’m not speaking for all hospitalists. But don’t you think hospitalists opposed to admitting these types of patients will find themselves in a small and shrinking minority? It seems to me that the pressure to serve as attending for these patients is similar to surviving a riptide: You shouldn’t try to swim directly against the riptide toward shore, and instead should swim across it or even go with the flow.

Popular Term, No Universal Definition

I went on to talk with the orthopods about the concept of partnering with hospitalists to co-manage patients. Orthopods and hospital executives usually are enthusiastic supporters of the co-management idea, and hospitalists usually are supportive, though sometimes with a little less excitement than the others. In public, all three parties usually express confidence that co-management will be good for patient outcomes and have other benefits, such as improved efficiency. But in private, orthopods sometimes let on that their support of the idea is largely based on their belief that it relieves them of tedious paperwork and late-night phone calls.

A hospital CEO might not know the details of the co-management model, so the CEO’s public support of it often boils down to an analysis along the lines of “Isn’t co-management just a euphemism for hospitalists doing more of the scut work to keep the hospital’s money-making specialists—like orthopods—happy?” Even hospitalists themselves sometimes express public support for the idea, but privately are thinking, “These guys want me to do what?”

My view is that co-management is a broad term and can mean very different things from one institution to the next. The term “co-management” has a connotation of something new and progressive, and might help steer conversations about who does what in a more positive direction than the old vocabulary of who is dumping on whom—you know, the traditional role for the doctors in each specialty.

A terrific entry in “Debates in Hospital Medicine” that runs periodically in the Journal of Hospital Medicine offers two points of view. In the September/October 2008 issue of JHM, Christopher Whinney, MD, and Frank Michota, MD, of Cleveland Clinic took the stance in favor of co-management, and Eric Siegal, MD, SHM’s Public Policy Committee chair (and formerly in private and corporate hospitalist practice), raised concerns about co-management.1 The articles review what little—and in my view inconclusive—research exists on this topic but provide some thoughtful advice and opinions.

Issues to Address

As I have written in the past, I’m convinced hospitalists’ scope of practice will broaden and grow to include patients we don’t commonly admit today.2 But we will need to think carefully about how to mitigate the potential problems created by changes in how doctors divide responsibility for who does what. In the case of hospitalists serving as admitters and attending for hip fracture patients, I have concerns, such as:

  • Will there be delays in going to the operating room or confusion regarding which orthopedist is responsible for the patient?
  • Will the orthopedist be less available to talk with the patient and family post-op?
  • How long before the orthopedist stops making post-op visits?
  • Who decides about transfusion and manages post-op and discharge pain control, wound care, and rehab?
  • Who gets the nighttime call regarding a laxative or sleeping pill?
  • Who handles discharge paperwork?

Your list of concerns probably differs from mine, but you should take the time to write down the issues that concern you any time duties and responsibilities shift from one specialty to another. Keep that list handy the next time you talk with another specialty about co-management or other new ways of dividing the work to ensure good outcomes for patients, doctors (including hospitalists), and the healthcare system as a whole. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospital practice management consulting firm. He is part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official SHM position.

References

1. Whinney C, Michota F, and Siegal EM. Surgical comanagement: a natural evolution of hospitalist practice. Just because you can, doesn’t mean that you should: A call for the rational application of hospitalist comanagement. J Hosp Med. 2008;3(5); 394-402.

2. Nelson J. Hip fractures to head bleeds: The hospitalist’s ever-changing scope of practice. The Hospitalist. 2006; 10(9);77.


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