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.
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.