In much the same way, the debate about whether the shared-care model of surgical patients is a good thing is comanagment’s MacGuffin; it definitely drives the plot but ultimately it misses the point. The real comanagement story—indeed, the story of the whole of hospital medicine—is our need to fundamentally improve outcomes through systems improvements. The true benefit of comanagement is not in one doctor (hospitalist) taking over the medical care of another doctor (surgeon). That will only slightly improve outcomes of the medical issues at which the hospitalist is more expert (e.g. minor electrolyte disorders). Meanwhile, this model continues to allow the same harms that the underlying unsafe hospital system imparts. The comanagement model itself won’t fix this. Rather, the model simply acts as a mechanism for us to accomplish our desired goals of system redesign.
Put another way, I am better at internal-medicine care than a neurosurgeon is. As such, I have no doubt that if I manage the medical issues of neurosurgical patients, I will do it better. However, this system of hospitalist provision of internal-medicine care can ultimately only lead to the type of marginal, not meaningful, improvements these comanagement studies have shown.
The real potential for the comanagement model comes when I take off my internal-medicine hat (diabetes care, electrolyte management, etc.) and put on my HM hat (ability to execute systematic quality and process improvements that result in safer systems that effect ALL patients, ALL the time, and is not dependent on the individual provider to do the right thing).
In doing this, the MacGuffin—the comanagement model that cohorts a lot of patients in the hands of a relatively few hospitalists—affords us the opportunity to truly advance the patient-safety plot by building better systems, the type of systems that ensure that every patient systematically gets appropriate VTE prophylaxis, avoids medication errors, has unnecessary urinary and central venous catheters removed, avoids pressure ulcers, doesn’t fall or get delirious, and has expert transitions of care. I have no doubt that if we achieved these kinds of interventions, rather than just managing patients’ medical issues, we’d see the kind of profound changes the comanagement model can offer.
MacGuffin or not, comanagement is likely here to stay. The challenge, then, is to find a way in which these care arrangements can go beyond scut to systematically and comprehensively improve the flawed systems of care that envelop our surgical patients.
Doing this will vastly improve patient outcomes, add significant value to the care we provide, and clearly signal to the surgeon that it’s time to bring us the water bottle. TH
Dr. Glasheen is physician editor of The Hospitalist. He is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.
References
- Auerbach AD, Wachter RM, Cheng HQ, et al. Comanagement of surgical patients between neurosurgeons and hospitalists. Arch Intern Med. 2010;170(22):2004-2010.
- Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141(1):28-38.
