Experience, availability make HM the perfect comanagement choice
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
Establish rules of engagement before agreeing to share responsibilities
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.
Job Description Defined
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