Nailing down the extent to which comanagement has expanded HM’s scope of practice as a medical specialty is a slippery exercise. Some HM groups handle comanagement well; others do not. Dr. Kealey says that admitting and comanagement patterns are dependent on the culture of the institution. For example, in one of HealthPartners’ home hospitals, all internal-medicine subspecialties, including neurology, are admitted and managed by hospitalists with a subspecialty consult.
The 2012 State of Hospital Medicine report survey revealed that 85% of respondent hospitalist groups provide surgical comanagement services (see Figure 1, below). That figure has not changed since SHM’s 2005-2006 survey, the last time the question was asked.
Another 20% of respondent hospitalist groups reported providing medical subspecialty comanagement, according to the 2012 report. Dr. Kealey, who is board liaison to SHM’s Practice Analysis Committee, says plans are in the works to add specific questions to the survey to assess another big change in the comanagement arena: a shift from hospitalists acting as consultants with the specialist serving as attending physician to a model in which the hospitalist admits the patient and serves as attending, with the specialist/proceduralist in a consulting role.
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Figure 1. Surgical Comanagement Roles Groups Serving Adults Only
So What’s the Problem?
Hospitalists have been both the utility player and the superstar, providing great value to their healthcare teams, says Ken Simone, DO, SFHM, a hospitalist practice-management consultant and CEO of Hospitalist and Practice Solutions in Veazie, Maine. He believes hospitalist program expansions are typically a positive thing.
“Historically, most hospital medicine programs have embraced the call for assistance from both their colleagues and the C-suite,” says Dr. Simone, a Team Hospitalist member.
Dr. Siegal, in his HM07 presentation “Managing Comanagement: How to Play in the Sandbox without Having to Eat Mud Pies” and in journal articles, has cautioned against assuming that all hospitalized patients, irrespective of diagnosis or comorbidities, should be seen by a hospitalist.3 Such a directive can produce a host of unintended negative consequences. Most notably, it can:
- Confuse patients, families, and the care team about who is ultimately responsible for oversight of the patient’s care;
- Place hospitalists in the position of assuming responsibility for patients whose conditions are outside their scope of practice;
- Delay the initiation of appropriate, specialized care;
- Overwork an already stretched hospitalist team, which can lead to burnout; and
- Increase exposure to medical liability by placing hospitalists in situations where they are in over their heads, or by creating novel opportunities for miscommunication between hospitalists and surgeons or specialists.
Pressure Points
Scope creep’s root cause has multiple layers. It can be driven by overworked physicians; by local shortages in a particular specialty; by the bottom line, when procedure-focused physicians and surgeons want to divest themselves of day-to-day management of hospitalized patients; by lifestyle preferences; or by hospitalists’ success.
Jerome C. Siy, MD, SFHM, department head of hospital medicine for HealthPartners and recipient of the 2009 SHM Award for Clinical Excellence, believes the single most important factor behind the pressure to manage more hospitalized patients is the necessity to provide more thorough care when specialists or residents cannot.
“The hours of coverage are expanding in every specialty to a 24/7 model,” he says. “Since we hospitalists were in the hospital already, it became more routine for other services to ask us to get initial orders and the history and physical started, as a bridge to a better coverage model.”