The query came from the audience: “But isn’t comanagement really about us becoming the surgeon’s waterboy?” Encouraged by the chortling crowd, he furthered, “I mean, think about it: How much more demeaning can it get than to be the admit-ologist and discharge-ologist for the surgeon? They make all the coin and we just follow after them picking up their jock straps.”

Slack-jawed, I mustered what was, under the circumstances, a rather confident “Umm … ?”

This comment, from a talk I gave a couple of years ago at an SHM annual meeting about comanagement, took me a bit by surprise. Not because of the sentiment; that I get. It’s easy to feel that the comanagement we do suffices only to sate the surgeon at the hospitalist’s expense. Rather, I was taken aback because of its indication of the distance with which we’ve missed the comanagement bull’s-eye.

New Comanagement Data

A recent article regarding the comanagement of neurosurgical patients drudged this oratorical memory from its peaceful cerebral resting place between the 1982 Milwaukee Brewers’ starting outfield (Ogilvie, Thomas, Moore), my wife’s least favorite Beatle (Ringo), and the number of macaroni noodles my grade-school friend Mike could stuff into his nostril and cough up through his mouth (nine with aspiration, five without). In the paper, Auerbach et al report a retrospective, before-and-after study of 7,596 patients admitted to the neurosurgery service at the University of California at San Francisco Medical Center.¹ The authors compared administrative, financial, and survey data for 4,203 patients before a hospitalist-neurosurgery comanagement arrangement to 3,393 patients after the program implementation—by far the largest trial of hospitalist comanagement to date.

They found:

• Shockingly, surgeons (“hospitalists make it easier for me to do my job”) and nurses (“I can easily and promptly reach a physician”) liked having us around.
• Curiously, patients were rather indifferent (measured via patient satisfaction indicators) to our presence.
• The cost of care decreased by about $1,500 per patient after the intercalation of hospitalists—this despite the fact that the length of stay was unchanged before and after model implementation.
• Unfortunately, such traditional markers of quality as mortality and readmission rate remained stubbornly unchanged.
• Encouragingly, nontraditional-but-likely-important indicators of quality (e.g. nursing and physician perception of improvements in care provision) were achieved.

Perspective

This study adds significantly to our understanding of the comanagement model. The finding of costs savings is as expected (nearly all studies of hospitalist programs have shown cost savings) as it is unexpected (prior studies of comanagement models reported no cost savings).² Likewise, the lack of improvement of hard quality endpoints (mortality and readmission rates) is consistent with most studies of hospitalist programs, including a previous report of comanagement of orthopedic patients that showed improvements only in minor complications, such as rates of electrolyte abnormalities, while improvement in the softer quality endpoints—nursing and surgeon satisfaction and perceptions of quality—is consistent with most reports and conventional wisdom.²

Within hours of publication, the blogs were throbbing with discussion of what this meant for the field of hospital medicine. Did this prove comanagement to be the godsend many believe (perceptions of improved quality), the complete farce that many believe (no evidence of mortality benefit), or was this just further confirmation that hospitalists are really nothing more than cost reduction-ists?

My opinion? This is just the comanagement MacGuffin.

MacGuffin Explained

Fans of film will know that the MacGuffin is a Hitchcockian plot device that uses a meaningless but often mysterious and intriguing element to drive the plot. So while everyone, it seems, is concerned with the MacGuffin, the MacGuffin exists only to help the story unfold. Think of the “government secrets” driving the plot in Hitchcock’s North by Northwest, or “unobtainium” in the movie Avatar. In both cases, the MacGuffin preoccupied the cast (they had to have it, or defend it), but in the end, the MacGuffin was insignificant except to move the plot forward.