Hospitalists face difficult decisions every day, including situations that don’t always have clear-cut answers. This month’s “HM Debate” looks at the tricky business that is comanagement. The question: Should hospitalists pursue opportunities to comanage hospitalized patients?
by Jeanne M. Huddleston, MD, FACP, FHM, and Eric Siegal, MD, FHM
Hospitalists should be in the business of comanagement, especially the comanagement of surgical patients. Thanks to modern medicine, people are living longer with a higher burden of comorbidity. Comanagement is intended to bring clinical acumen and experience to the bedside of a complex medical patient who is having surgery and needs acute medical care. Hospitalists must bring their extensive clinical experience and on-site availability to ensure the best outcomes.
The most important aspect of comanagement can be summed up in one phrase: right person, right place, and right time.
The interaction between pre-existing comorbidities and the physiologic stress of anesthesia, volume shifts, narcotic therapy, sleep deprivation, postoperative anemia, and any number of other stressors can be complex.
Frankly, it is more appropriate for an experienced hospitalist to evaluate and manage these intricacies than a specialty surgeon, although general and critical-care surgeons are likely exceptions. Our internal medicine and geriatric training, not to mention experience, positions us to best meet the needs of these complex patients.
Hospitalists are in the hospital and prepared to handle the unexpected. Surgeons cannot be in two places at once; they cannot leave the operating room with another patient on the table. Likewise, a general internist in a consultative role usually cannot leave the clinic on short notice. Hospitalists are physically present and available to go to a patient’s room when there is an immediate clinical need.
Early evaluation and treatment are indicated when most postoperative complications occur. One of the defining characteristics of hospitalists is availability. Relying on a surgeon to be at the bedside immediately is inappropriate.
In traditional consultative roles, the medical consultant might also have clinical duties in an outpatient setting. Neither model allows an experienced physician to reliably get to the bedside, then evaluate, monitor, follow up on test results, and manage patient care. Hospitalists are available and can participate in all aspects of care until resolution of the complication.
Another aspect of the comanagement model is the opportunity to extend beyond the postoperative setting to the preoperative evaluation. This brings with it the opportunity to identify possible problems before surgery. In addition, the business model for the preoperative consultation is quite strong.
Meeting patients’ clinical needs is the most important reason for engaging in a comanagement model of care in the perioperative setting. This model brings timely experience, evaluation, and management when and where it is needed. TH
In the wee hours of a recent busy call night, the ED called me to admit a patient whose automatic implantable cardioverter cefibrillator (AICD) had fired repeatedly. The patient had no other active medical issues. When called, the electrophysiologist, who was on staff, demanded that I admit the patient for “medical comanagement.” The specialist agreed that I probably would have little to add to the care, but his firm expectation was that hospitalists admit his patients and he “consults” … especially at 2 a.m.
Comanagement, defined as shared responsibility, authority, and accountability for the management of a hospitalized patient, is an HM mainstay and a primary driver of the explosive growth of our field.1
While it stands to reason that surgical and specialty patients with active medical comorbidities likely fare better if hospitalists are integrated into their care, comanagement has broadened in its application to include scenarios in which the benefits are more dubious. Hospitalist comanagement now encompasses “management” of patients for whom hospitalists have little, if anything, to add.
At the other comanagement extreme, hospitalists, despite little or no formal training, primarily manage patients with acute neurologic, neurosurgical, psychiatric, and orthopedic diagnoses, often with inadequate surgical or specialty involvement.2,3 Although it makes sense for a hospital with only one neurosurgeon to have its hospitalists manage carefully selected neurosurgical patients, the justification for such scenarios becomes harder to reconcile at hospitals where there are no staffing shortages. I suspect the primary justification for hospitalist comanagement in such circumstances is to keep specialists doing lucrative procedures by day and in bed at night, and to ensure that someone manages the paperwork, discharge communication, and patient logistics that are often otherwise ignored.
In well-designed comanagement arrangements, hospitalists and specialists work equitably under clearly defined and mutually agreed upon rules of engagement. They share responsibility for patients, collaborate to improve care, and teach and learn from each other. Unfortunately, in many instances, the power structure has tilted.
Practicing hospitalists frequently complain about their subordinate status and inability to control their working conditions; both are identified risk factors for career dissatisfaction and burnout.4,5
Before entering a comanagement relationship, hospitalists should gain a clear understanding of why they are being asked to comanage, what problems they are expected to fix by doing so, and what the consequences, intended or unintended, might be as a result. There should be mechanisms to ensure that the relationship is equitable and serves the best interests of the patient, rather than the care parties involved. TH
The opinions expressed herein are those of the authors and do not necessarily represent those of the Society of Hospital Medicine or The Hospitalist.
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