Thursday, June 12, 2008

More on hospitalist comanagement

Judging from the web casts and blog of SHM 2008 there was a lot of buzz about hospitalist comanagement of surgical and other specialty patients. The speakers and panelists of the organizational sessions indicated hospitalists would soon be taking over everything from the surgeons and subspecialists but their procedures. No one seemed concerned that this was the wrong direction to be going. No one, that is, until Eric Siegal got up to speak. Eric Siegal, M.D., a hospitalist and regional director for Cogent Health Care, announced to the audience that he would be offering a contrarian view on comanagement. Watching his talk the other day gave me a moment of self-aggrandizement. Siegal made some of the same contrarian points I made in my post from several days before.

The general definition of co-management, shared responsibility, is vague and varies markedly from one hospital to another. Siegal stressed that if you’re going to co-manage, the specifics must be hammered out at your hospital. Comanagement should not mean being an admission service (H&P provider), caring for patients for whom you have little to add or replacing a subspecialist.

He went through the outcomes data on comanagement, and they are mixed. When you parse the studies any real benefit of comanagement seems to be in the more severely ill patients with complex medical problems. The healthy patients don’t seem to benefit from having us around.

Other points:

Define who’s doing what. Have it posted in the ER and at the nurse’s stations. (You don’t want the nurses calling you about the patient’s wounds and chest tubes, do you?).

Don’t consider it your mission to turn the subspecialists into proceduralists. Sometimes they need to drop what they’re doing and see the patient at the bedside. Their have cognitive skills in their specialty that are superior to yours.

Comanagement has unintended consequences that may be detrimental in some patients, especially those who don’t have complex medical problems that benefit uniquely from a hospitalist’s expertise. Subspecialists become disengaged, nurses are confused about who’s responsible for what and patients may be saddled with an unnecessary bill.

There is a shortage of hospitalists. Our manpower resources should be applied selectively, where they are needed most.

Before considering a comanagement arrangement ask lots of questions.

1 comment:

Theresa said...

Good advice. Would it be helpful to have standardized orders for co-management? To direct nurses to call the surgeon for chest tube, advancing diet, staple removal, etc.? Food for thought. Thanks for the great posts.