8 Respect Your Turf, Their Turf
Dr. Manjarrez says the best way to ensure the hem-onc specialists respect the hospitalist’s turf, and vice versa, is to discuss the treatment parameters ahead of time.
“Try and negotiate comanagement deals with your hematologist-oncologist colleagues before you enter into comanagement relationships with them,” he says.
One particularly sticky situation is when a patient is admitted with the expectation that the hospitalist will be caring for acute issues like infection or cancer-related pain, but then the hospitalization is extended because the oncologist wants to start chemotherapy.
“That can be a problem,” he says. “Agree with your hematology-oncology colleagues what you’re going to do in advance, as much as you can.”
“Oftentimes, hospitalists can be undermined by the oncologists that they’re managing their patients with. Make sure that you stick to your guns and make sure that you’re strong about giving DVT prophylaxis to these patients, unless they truly meet exclusion criteria for that prophylaxis.”
—Efrén Manjarrez, MD, SFHM, assistant professor of medicine, interim chief, division of hospital medicine, patient safety officer, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine.
9 Be Cautious in Using Granulocyte Colony-Stimulating Factor (GCSF)
The medication is used to stimulate the body to produce more white blood cells, which sometimes is needed after chemotherapy. They are good for certain situations but should be handled with care, says Lowell Schnipper, MD, clinical director of the Beth Israel Deaconess Medical Center Cancer Center in Boston.
“Because it’s unnecessary and very expensive,” says Dr. Schnipper, who is chair of the American Society of Clinical Oncology’s Value of Care Task Force. “If this is a chemotherapy regimen that has a risk of fever and neutropenia in the context of the chemotherapy, [and] the odds of having that complication are 20% percent or higher with a chemotherapy regimen, we suggest using GCSF.”
If not, then GCSF should be avoided, he says.
Such decisions likely will fall to the treating oncologist, but Dr. Schnipper says it is a topic with which hospitalists should be familiar.
10 Rethink Imaging
“If you get a PET scan in the hospital and a patient is admitted for a different diagnosis, there’s a good likelihood that it’s not going to be reimbursed,” Dr. Ramalingam says.
Plus, he says, a scan done in the hospital could cloud the radiographic findings used to make decisions.
“For instance, for someone with pneumonia, the infiltrate might be difficult to differentiate from cancer,” he says.
Tom Collins is a freelance author in South Florida and longtime contributor to The Hospitalist.