Should HM Be in the Comanagement Business?

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.

Rules of Engagement

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

References

1. 2007-2008 Bi-annual Survey on the State of the Hospital Medicine Movement. SHM Web site. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=Surveys2&Template=/CM/HTMLDisplay.cfm&ContentID=18419. Accessed July 26, 2009.
2. Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111:247-254.
3. Glasheen JJ, Epstein KR, Siegal E, Kutner JS, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
4. Linzer M , Gerrity M, Douglas JA, McMurray JE, Williams ES, Konrad TR. Physician stress: results from the physician work life study. Stress and Health. 2001;18(1)37-42.
5. SHM Career Satisfaction White Paper. SHM Web site. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Practice_Resources& Template=/CM/ContentDisplay.cfm&ContentID=14631. Accessed July 26, 2009.

The opinions expressed herein are those of the authors and do not necessarily represent those of the Society of Hospital Medicine or The Hospitalist.