Comanagement commandments

Keep consultation relationships well-defined to avoid problems down the road.

The comanagement trend involves hospitalists with more patients than ever before. That's not necessarily a good thing, according to Eric M. Siegal, ACP Member, regional medical director of Cogent Healthcare in Nashville, Tenn.

“I do comanage, and I do think comanagement has its place,” Dr. Siegal told attendees at Hospital Medicine 2008 in San Diego this April. “I just want us to think critically about what we do.”

The standard definition of comanagement is shared responsibility, authority and accountability for the care of a hospitalized patient. But that often drifts to incorporate things it shouldn't, like being subordinate to another physician or service, making recommendations that are later ignored, caring for patients when you have little to add, serving as a thinly disguised admission service, or replacing subspecialists, Dr. Siegal noted.

“I really think that all of these things to some extent have been encapsulated under the big tent of comanagement, and in my opinion, none of these things are comanagement,” he said.

Where's the evidence?

Conventional wisdom says hospitalist comanagement allows problems to be caught earlier and leads to better outcomes, but there's no evidence it works for everyone, Dr. Siegal said. In the 2004 HOT trial at the Mayo Clinic in Rochester, Minn., hospitalist care reduced only minor complications, didn't reduce actual length of stay, and was as expensive as standard care. But in a 2005 study at the same institution, hospitalists significantly reduced use of services.

The difference, Dr. Siegal said, was in the patients. The first study involved patients undergoing elective joint replacement, while the second involved those with incident hip fractures. In other words, sicker patients did better with hospitalist care. For younger patients with relatively few comorbid conditions and for whom care is usually clear-cut, “I would argue hospitalists have little to add,” Dr. Siegal said. “And I would even argue that comanagement could be detrimental in some of these patients.”

For example, comanagement could delay appropriate care for an unstable gastrointestinal bleed, or could disrupt established lines of communication among staff members. In addition, comanagement risks disengaging subspecialists from their patients' clinical progress.

“Just showing up and saying that you're the consultant isn't going to do anything to make the care better,” Dr. Siegal said. “There's no magic about coming by and simply waving your stethoscope at somebody.”

Making comanagement work

When establishing a comanagement relationship, make sure you get answers to the following questions, Dr. Siegal said:

  • Why are we being asked to participate?
  • What are the “rules of engagement”? Do I make suggestions or decisions?
  • What responsibilities are mine versus yours?
  • Where do our responsibilities overlap, and how do we manage these overlaps?
  • What happens if we disagree?
  • Who makes the final call?

“If you haven't at least thought these through and talked these over with the people with whom you're working, you're setting yourself up for a problem at some point down the road,” Dr. Siegal said.

Dr. Siegal also stressed the importance of group uniformity. “Nothing drives specialists and nurses more crazy than to see one hospitalist come in and do one thing [in a group] and the next hospitalist unable to do it or doing it radically differently. You've got to be consistent.”

Watching for danger signs

There are warning signs when comanagement is starting to cause problems for your practice, Dr. Siegal said. For example, he noted, be wary if you begin to become a replacement for subspecialists. One sure sign of this, he said, is if you're doing things after hours that no one would let you do on the weekdays, or if the ED defaults to you because it's easier than calling a specialist.

“There is some expectation that that's what we do as hospitalists. They pay us for our availability [and] our superior service mentality—our willingness to jump in, roll up our sleeves and get things done. And that's great. That defines our specialty, and there's a lot of good there. But there's a lot of danger in that, too,” he said.

Another warning sign is finding that others, such as specialists or administrators, define what you do in your practice and when you do it. You may find yourself managing diagnoses that are outside of your competency or training, or “managing” cases where your input is either irrelevant or ignored. All of these things can lead to burnout, Dr. Siegal said. “Hospitalists are a scarce resource, too,” he said. “We're struggling to staff our own programs, let alone help other people staff theirs.”

Dr. Siegal urged hospitalists to think carefully about whom they comanage and why, stay within their preestablished parameters, and periodically review the ground rules they've set to make sure they're still working. Comanagement is not something hospitalists should rush into, he concluded.

“‘Just do it’ is a great slogan if you're selling sneakers,” he said. “I'm not sure that the ‘Just do it’ mentality for comanagement is the right model.”