Surgical comanagement done right
Make a difference without catching the scut
From the March ACP Hospitalist, copyright © 2009 by the American College of Physicians
By Stacey Butterfield
Anyone who follows trends in hospital medicine knows that surgical comanagement is big. The more important question: Can they tell you what it is?
“If you ask 10 people what comanagement is, you might get 10 different answers,” said Christopher M. Whinney, FACP, a hospitalist at the Cleveland Clinic.
“It could mean anything from the hospitalist consulting the surgeon or vice versa to the hospitalist taking over almost everything in the management of the patient except for the technical procedures. It really needs to be defined a little bit more,” said R.W. Donnell, MD, an Arkansas hospitalist and blogger.
Without even a clear definition, it’s no wonder that hospitalists disagree on which patients should be comanaged, how arrangements should be structured, and whether the whole movement toward comanagement is a boon or bane for hospitalists and their patients.
Shortage of evidence
When in doubt in medicine, the answer is usually to go to the evidence. But as a new field, surgical comanagement has been relatively unexamined. It’s logical but unproven that more collaboration between specialties would lead to better patient care, said Alan K. Halperin, MD, a professor of medicine at the University of Florida who wrote a review of comanagement last year in Northeast Florida Medicine.
“The few studies that have been done have demonstrated that. There just aren’t enough studies to make any recommendations,” Dr. Halperin said.
In fact, the studies that have been done may just add to the confusion. Conventional wisdom among interviewed hospitalists is that the sickest surgical patients are the best candidates for comanagement. Some hospitalist programs comanage only geriatric patients or those with significant comorbidities (including diabetes, heart disease, etc.) while others let surgeons pick out those most in need of hospitalist attention.
“There is little doubt in my mind that hospitalists add value to patients who are medically and socially complicated. Where I think the value of hospitalists is dubious at best is in the care of surgical and specialty patients who are medically straightforward,” said Eric M. Siegal, ACP Member, a veteran hospitalist who is currently doing a fellowship in critical care at the University of Wisconsin.
Yet when Jeanne M. Huddleston, FACP, instituted a surgical comanagement service at the Mayo Clinic and studied its impact, the greatest benefit turned out not to be among the most complicated patients. “We found to our surprise that the people we had the biggest impact on were the people who were less sick,” Dr. Huddleston said.
In the study of hip fracture patients (published in the July/August 2007 Journal of Hospital Medicine), those on the hospitalist service had shorter lengths of stay than controls. The hospitalists were able to reduce the stays of healthier patients by discharging them as soon as they were ready to go, Dr. Huddleston explained. “The surgeons all round really early and go to the operating room. Because I’m on the floor I can do the discharge.”
The benefits of comanagement have been hard to predict in other cases, as well. At the University of California, San Francisco, neurosurgeons were eager to have hospitalists comanage their patients, but the hospitalists hesitated to sign on. Once they did, though, they were surprised by the difference they could make.
“The day we started on neurosurgery, it was transformative. Bang for the buck, we’re probably saving more lives doing comanagement than virtually anything else we’re doing,” said Robert M. Wachter, FACP, chief of the hospital medicine division.
Surplus of work
In situations of such clear benefit, Dr. Siegal, a skeptic of hospitalist comanagement, agrees that the collaboration is worthwhile. His—and many other hospitalists’—concern is with wider applications of comanagement.
“Too often, hospitalist comanagement morphs into activities that either add no value or even detract from patient care. Hospitalists are frequently called to do things that they are not qualified to do, to perform scut work for somebody else, or patch a care delivery problem because it’s easier to plug in a hospitalist than fix the problem,” said Dr. Siegal.
Shortages of surgeons and specialists, combined with pressure to increase procedure volumes, can drive the expansion of hospitalists’ responsibilities beyond where both hospitalists and the evidence would dictate, Dr. Siegal noted.
“Hospital administrators and specialists quickly figure out that they can generate more procedural revenue if hospitalists take over the medical management. Taken too far, we risk disengaging specialists from patient care, not to mention putting hospitalists into situations that they are not qualified to handle,” said Dr. Siegal.
He favors comanagement, and even does it himself, in cases where there is a clear need for medical expertise. But he worries that opening the door to comanagement without any preconditions invites specialists to pawn off unpopular tasks like latenight admissions on hospitalists.
Although Dr. Siegal has perhaps been the most outspoken critic of comanagement, speaking at the Society of Hospital Medicine’s annual meeting and writing in the Journal of Hospital Medicine, he’s not the only one with concerns.
Dr. Donnell is highly leery of the expansion of hospitalists’ roles. “The hospitalist model started out as an internist who devoted 100% of his time to caring for inpatients. That was what a lot of us originally signed up for. We’re moving to a model where the hospitalist is a house doctor, managing everybody and everything. We need to be careful of that,” he said.
But on the other end of the spectrum is Michael Doerflein, MD, a hospitalist with IPC The Hospitalist Company in Florida who does a lot of comanagement. “Sure, there are a lot of things that [surgeons] could in theory do themselves and we pick up the slack for them, but I don’t feel resentful about that. I just feel like that’s part of our work. I think it’s part of our service obligation to the patient community and the medical community,” he said.
Talk, talk and write it down
What Dr. Doerflein and the other experts agreed on is that good communication between hospitalists and surgeons is the key to making comanagement work for everyone involved.
He suggested catching surgeons at the nursing station to chat about shared patients’ care plans. “On an informal basis, just make sure you’re staying on the same page. Let the surgeon know what you’re thinking as far as medication management and discharge planning.”
If you’re just starting a comanagement program, more formal communication is required, others noted. “You ought to have a shared basis of understanding, some clear-cut objectives and some way to objectively look back at it and say, ‘Did this get better?’ And if it didn’t, ‘What are we doing wrong?’ said Dr. Siegal. He has created a list of six questions hospitalists should ask themselves before embarking on comanagement (see sidebar).
“I know there are such demands on your time that you may not be in touch with your colleagues, but that’s imperative. If you say to the surgeon, ‘That’s not part of my scope of practice, I will help you do whatever, but I’m not going to write discharge, I’m not going to admit your patients,’ you draw the line,” said Dr. Whinney.
The discussion should also include financial arrangements, which can be complicated if hospitalists’ reimbursement is bundled into surgical fees. “A clinical care partnership is easy. Figuring out the finances can be challenging,” said Dr. Huddleston.
Hospitalist group leaders—one of whom should be directly responsible for managing comanagement—need to remember that it’s best for all concerned to be assertive about their role. “We try to demonstrate the value of the program by setting a new standard of service. Unfortunately, this often morphs into ‘Let’s be a doormat,’” Dr. Siegal warned.
“At the end of day, if we feel like we’re being abused or we feel like we’re not being compensated adequately, then this won’t work. It’s not in anyone’s interest for hospitalists to take it on if it won’t work,” said Dr. Wachter.
And it’s not enough just to talk about the rules of engagement, said Dr. Huddleston, describing her program’s setup.
“Everything was written down. If the nurse has a question with fever, she calls this person. If the nurse has a problem with pain management, she calls that person.”
The bright side
For all the grim talk of setting rules and protecting yourself, comanagement can also have some big benefits for hospitalists, according to the docs who do it. The clinical benefits to patients may be unproven, but the effects on colleagues are clear, said Andrew Auerbach, MD, a UCSF hospitalist who has studied comanagement. “What is very striking is how happy the surgeons and nurses are with this model,” he said.
Happy surgeons, then, are more likely to return your phone calls. “When you need surgical assistance with one of your medical patients, you have a much easier path to tread,” said Dr. Whinney.
Comanaging hospitalists are often happy and fulfilled, too, proponents of the practice agreed. “The teamwork is fun. You’re each appreciated for the skills that you have,” said Dr. Huddleston.
But the costs and benefits of comanagement really depend on the situation at each individual hospital. “The way we manage this issue in our practice may not be the best for someone else,” said Dr. Doerflein.
Specifically, if a hospitalist program is already short-staffed and overextended, comanagement will only exacerbate the problem and replace surgeon shortages and discontent with the same problems on the hospitalist side.
There’s also a question of priorities. The UCSF hospitalists have opted to comanage instead of providing night coverage. “You’re always going to make decisions about what is the most important thing,” said Dr. Wachter.
Nonphysician providers may prove a partial solution to this dilemma, he added. “There are certain tasks that maybe surgeons shouldn’t be doing, but maybe neither should hospitalists. Maybe they can be done equally well by physician assistants or nurse practitioners at a lower cost.”
“A lot of post-op care is very protocol-driven,” agreed Dr. Auerbach. “There may be a better role or more sustainable role for NPs or PAs in that setting than on the regular medical ward where things are much more heterogeneous.”
He’s counting on comanaging hospitalists to figure this question out. “Perioperative medicine is incredibly understudied and having a bunch of hospitalists focusing on it, developing protocols, is a huge opportunity.”
Of course, the funny thing about this new opportunity is that it’s been around for years, Dr. Auerbach noted. When he first began practicing, all the surgical patients at his hospital were admitted by their internists and the surgeons were the consultants.
Dr. Donnell, who sees comanagement as somewhat of a “promotional gimmick,” noticed the same thing. “I’ve enjoyed cordial and collaborative relationships with surgeons long before anybody dreamed up comanagement,” he said.
Hospitalist Eric M. Siegal, ACP Member, recommends asking the following questions before signing on to a comanagement service:
- Why are we being asked to provide this service?
- Do the patients have comorbidities that require our input?
- Is there a legitimate quality or efficiency case to be made to support our participation?
- Do we have manpower to provide the service? If not, what will suffer as a result?
- Will the relationship be equitable?
- What might go wrong?
Source: “Just Because You Can, Doesn’t Mean That You Should: A Call for the Rational Application of Hospitalist Comanagement,” Journal of Hospital Medicine, September/ October 2008.
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