Monday, June 02, 2008

What the heck is surgical co-management, anyway?

Co-management is one of the latest buzzwords in hospital medicine. Like other buzzwords it is often used by people to impress other people even when no one quite knows what it means. The folks at SHM 2008 cranked up the volume about co-management of surgical patients. Whatever it means Bob Wachter, in his address about the changing world of hospital medicine, said “If you don’t like it, find other work. Don’t bother trying not to own this.” Wow. OK, please define what I’m about to own.

Years ago we moved away from the turf battles of The House of God to a more collegial and collaborative relationship with surgeons. Yet, present day use of co-management as a buzzword suggests it’s something new and special, an emerging megatrend in Wachter’s words. It’s a concept in need of definition. Here are some of my questions:

Is the relationship between hospitalist and surgeon going to be one of co-attending or consultant? If it’s a consulting arrangement who’s the consultant and who’s the attending? These questions are important not only in how the fees are allocated but also in terms of the boundaries of clinical responsibility.

How will we demarcate clinical responsibilities? Who’s responsible for what? Whom should the nurses call for what problems? We’re already taking care of surgical patients’ diabetes and cardiopulmonary problems and have been for a long time. So, if co-management is something new and special does that mean we’re about to take over post op pain management? Are we supposed to start fiddling with wounds, NG tubes and chest tubes? After abdominal surgery does the hospitalist decide when the patient can resume a diet and how fast it can be advanced? How long do we observe a patient’s post op ileus before deciding it’s time to get a CT scan to look for an abscess? Will the hospitalists now be making that decision?

Who will be responsible for discharge details? Traditionally the surgeons write discharge orders for dietary restrictions, wound care, suture removal and activity restrictions. Will hospitalists be expected to own those things now?

What about healthy surgical patients with no medical problems---the 20 year old with appendicitis? Who admits that patient? Do hospitslists do it just because they’re in house and available to be an admission and discharge service?

Those are just a few of the questions. I’m not naive. I know this issue is facing us and we’ll have to adjust and adapt. But unless we’re very, very careful how we define it this idea of co-management seems risky to me. There are liability issues. Should you as a hospitalist assume the principal care role for a problem outside your scope of training if there’s someone around who is better trained, whether or not they’re there 24/7? Will plaintiff attorneys be asking that question? You bet they will.

There are also issues of professional satisfaction and burnout, already problems for many programs. Many internists and internal medicine trainees become hospitalists because it’s the only way to still be an internist in the original sense in which the specialty was defined. If that goes away because hospitalists are asked to manage things outside that chosen specialty hospital medicine may become a less attractive career choice. There’s already too much turnover in our field. Dr. Wachter suggests that if we don’t like taking ownership of surgical patients we should find other work. If this co-management thing gets out of hand hospitalists will do just that---in droves.

Dr. Wachter thinks some new level of hospitalist responsibility for surgical patients is a given. Another leader in hospital medicine, Scott A. Flanders, MD, quoted in this article in Today’s Hospitalist, isn’t so sure:

Dr. Flanders said he is also concerned that the explosive growth of co-managing all patients, not just high-risk ones, may hurt the appeal of hospital medicine to medical students and residents. “Giving Colace to a cadre of hip fracture patients—-is that going to be attractive to a trainee?” But the bottom line issue? Manpower. “There are not enough well-qualified hospitalists to care for medicine patients in this country, let alone all these surgical patients,” Dr. Flanders said. That’s why he has resisted expanding Michigan’s orthopedic co-management arrangement to other surgical specialties that have inquired about the service, including urology, orthopedic trauma,
psychiatry and the inpatient physical medicine rehab unit.

“We’ve had to say ‘no,’ ” Dr. Flanders pointed out, “to everyone.”

Before you get too excited about co-management, read the article. It can work, but only if appropriate limits are applied and well defined.


Anonymous said...

When did Dr. Wachter get elected to decide what all hospitalists do?I have noticed that all surgeons in training learn, along with operative techniques, how to manage wounds,drains,ivs,diet,pain medication and ambulation. Internists may pick up some of that along the way but when I get my abdominal surgery I want the surgeon to manage those aspects of care not an internist who knows much less about it.

Anonymous said...

Why don't you recognize this for what it is? You're being asked to assume the old role of "house doctor" with a few upgrades. You do the admission H&P, take care of diet, laxatives, pain meds, sleepers, etc., and do the discharge summary and other associated paperwork. If in the process you want to tackle a complex diagnostic issue, go for it. However, you'll probably be so worn out from the patient volume that you'll quickly decide to request a nephrologist for that electrolyte problem or an ID specialist for antibiotic decisions. This is what Dr. Wachter is seeing in his crystal ball, and he's probably correct. You will quickly become the "PCP" inside the walls of the hospital. Suck it up and negotiate the best financial package you can get.

BladeDoc said...

This is the un-fun parts of surgery, the part we had to do in order to get to the fun part (the cutting). Then the orthopods learned that by acting dumb they could get someone else to do the boring stuff and the other surgeons laughed at them and called them stupid and lazy. And then we noticed that the only group of surgeons whose income has gone up in the last 10 years are the orthopods. Hmm, not so stupid, really. And then they gutted the residency work hours and the rest is history.

dr_dredd said...

No thanks. Sounds like the surgeons are once again entering the turf wars. Reminds me of when I was a resident and the vascular surgery admitted to medicine someone with a purple, cold, pulseless left foot. Nice, guys.

Co-management is code for "dump on the internist." If a surgeon wants help managing complex patients, fine. Consult me. There's no reason for me to become a co-attending unless someone's trying to duck responsibility.

Ian Furst said...

Go back to handing patient an itemized bill which can include the hospitalist fees for approving basic medical care for the patient. I'm not talking about the complex cases but otherwise healthy people that get sick or need surgery. You'd think the hospitalists would be going crazy over this -- are they not busy enough as it is?