Dr. Ruhlen
As patient care grows ever more complex, driven by demographic shifts and regulatory trends, hospitalists around the country continue to worry about the “dumping” practices of referring surgeons and other specialists. Negative nicknames like “admitologist,” “dischargologist,” or “glorified resident” reflect the concerns of some veteran physicians who find themselves doing what they perceive as “scut work”—merely processing the surgeons’ patients through the hospitalization.
Comanagement has been proposed as a solution to improve both patient care and professional satisfaction. But its promise can be eroded if the arrangement isn’t well planned and executed, experts say. Comanagement requires clearly defined roles, collaborative professional relationships, and some sense of equal standing with the surgeons or other specialists who call on hospitalists to care for their hospitalized patients’ medical needs.
“The growing formalization of comanagement agreements stems from prior tendency by some to view hospitalists as glorified house staff,” says Christopher Whinney, MD, FACP, FHM, director of comanagement at The Cleveland Clinic. “Hospitalists feel this is inappropriate, based on our skill set and scope of practice. There is also a concern that if a hospitalist group jumps in to do this without a clear service agreement in writing, that is where dumping can become a problem.”
Dr. Whinney is one of two expert mentors for hospitalists under a new SHM demonstration project called the Hospitalist Orthopedic Patient Service Comanagement Program, which is gathering data to evaluate its effectiveness on clinical and other outcomes. He has been working with five of the 10 participating HM groups, helping them define what it means to institutionalize formal comanagement relationships.
“Whatever your personal feelings about the comanagement relationship, pro or con, comanagement is going to be part of most hospital medicine groups’ repertoire of services,” says Hugo Quinny Cheng, MD, director of the comanagement with neurosurgery service at the University of California at San Francisco (UCSF) Medical Center. “You can try to avoid it, but if the medical center and the surgeons want it, there’s going to be pressure on your group to do it—or else they’ll look for another hospitalist group to do it.”
Dr. Cheng advises hospitalist group leaders make themselves aware of the trend and position themselves in a way to take advantage of it—or, at the very least, not be blindsided by it.
According to SHM data, 85% of hospitalist groups have done some kind of comanagement.1 It’s not explicitly listed by SHM as one of The Core Competencies in Hospital Medicine, but it might as well be, says Leslie Flores, MHA, SHM senior advisor, practice management, because aspects of comanagement are addressed throughout.2
Defined, Distinguished, Delineated
Comanagement is different from traditional medical consultations performed by hospitalists upon request, and also differs from cases in which the hospitalist is the admitting physician of record with sole management responsibilities while the patient is in the hospital. According to an SHM white paper, A Guide to Hospitalist/Orthopedic Surgery Comanagement, the concept involves shared responsibility, authority, and accountability for the care of hospitalized patients, typically with orthopedic surgeons or other specialties, and with the hospitalist managing the patient’s medical concerns, such as diabetes, congestive heart failure, or DVT.3 (SHM’s website is full of comanagement resources, including sample service agreements; visit www.hospitalmedicine.org/publications and click on the “comanagement” button.)
But just as HM programs can be diverse in their organization, structure, and leadership, there is no single definition of comanagement, says Sylvia McKean, MD, SFHM, senior hospitalist at Brigham and Women’s Hospital in Boston. “You can have a very formal relationship where there’s a contract and where people are paid by whatever group is initiating the comanagement. There may be clear definitions in terms of their roles,” says Dr. McKean, an SHM board member who chaired the advisory panel that developed the comanagement white paper. “At the other extreme may be an informal relationship where you have a group of people in a community hospital who are available to manage medical problems when requested by specialists on a subset of patients.