Friday, March 20, 2009

Taming the monster of hospitalist comanagement

When you give something a catchy name, like hospitalist, it takes on a life of its own. Sometimes you end up creating a monster as it morphs into all sorts of things you didn’t intend. That seems to be what’s happening with the idea of hospitalist comanagement.

What are some of the negative consequences? Here are a few.

Specialists become disengaged from all the non-procedural aspects of their area of expertise. Procedure done, then it’s adios! It not only leaves the hospitalist holding the bag with issues h/she is not qualified to address, but it also relegates the specialist to the status of technician.

It can quickly turn your hospitalist program into an H&P and discharge service, majoring in what I call “clerical scut.” It’s a sure recipe for burnout and increased turnover in your program.

As a corollary, it diverts time and focus from what hospitalists do best---caring for the really, really sick patients.

It blurs the demarcations of responsibility. Who’s responsible for the pain management? Wound problems? Who decides when the post laparotomy patient can have his/her NG tube removed? Who should be called by the nurses for what issues?

Those are some of the things Bob Wachter, Eric Segal, I and others grappled with in an article in the latest issue of ACP Hospitalist. A tip of the RW hat goes to Stacey Butterfield for taking a diverse, all-over-the-map collection of ideas from the group and putting together something coherent.

There were a few things (I think) we agree on about comanagement:

From the get go be clear on what “comanagement” (a term which is lacking in definition and means many different things to different people) means for your group and your hospital.

Define the boundaries of responsibility in areas such as mentioned above and make sure the nurses have it down pat.

Before making a commitment to expand services make sure you are adequately staffed and set appropriate limits.

Find out what your group members feel about what’s being proposed and protect them from getting bogged down in clerical scut.

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