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.