What is co-management?

by rcentor on April 21, 2011

Kudos to Stalwart Hospitalist for sharing this link – The Co-management Conundrum

This wonderful article expands on many of the ideas discussed here over the past week.  These quotes should whet your appetite for reading the entire article:

As patient care grows ever more complex, driven by demographic shifts and regulatory trends, hospitalists around the country continue to worry about the “dumping” practices of referring surgeons and other specialists. Negative nicknames like “admitologist,” “dischargologist,” or “glorified resident” reflect the concerns of some veteran physicians who find themselves doing what they perceive as “scut work”—merely processing the surgeons’ patients through the hospitalization.

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“What really seems to distinguish comanagement from traditional medical consultations is that it implies equality in the relationship, even though the surgeon is often the attending of record,” as is practiced at Brigham and Women’s, Dr. McKean says. The comanaging hospitalist might follow the patient until discharge, rather than just seeing the patient once regarding the consultation question. “It’s more of a robust involvement of the hospitalist or internist, who really takes responsibility to make sure that medical conditions are actively managed, ideally before complications emerge.”

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“A fair and robust comanagement structure is an optimal delivery model,” says Christopher Massari, MD, hospitalist at PHMG/PeaceHealth Hospital in Springfield, Ore. “But because most hospitalist services are staffed 24/7, there’s a tendency for specialists and nurses to take advantage of hospitalists because they are ‘available.’ ”

Dr. Massari says he has experienced the “dumping” phenomenon firsthand. “It happens frequently. In the past few years, I have gradually developed the confidence and experience not to let it happen to me,” he says, “but I may inherit patients admitted by my hospitalist colleagues who may not feel as empowered or as skilled at avoiding it.”

The article has more good stuff.  This problem infects many hospitalist programs.  We understand why it happens, but understanding does not excuse bad behavior. 

Co-management makes sense, but it should be a true partnership.  Leaving the "scutwork" to the hospitalist does not meet the eyeball test of fairness.

{ 17 comments… read them below or add one }

jb April 21, 2011 at 12:40 pm

 
Sorry, I’m still misunderstanding the role of the hospitalist.
Hospitalists are a subset of (usually) internists.  They are distinct from the more traditional internist due to their practice location and hours- i.e., only in the hospital and responsible only for what occurs on their watches.  To the extent that they have a unique body of knowledge or practice with respect to the wider internist community, it derives from that unique location.  Hospitalists are physically located in the building for their entire professional lives, and therefore are in an ideal position to learn how best to use the hospital and its resources for the welfare of their patients.  In any hospital setting, getting something done, or at least started, now is better than waiting for another physician to finish in the OR or office.  A physician who works on every shift with discharge planners, social workers, and similar resource staff will be ideally suited.  You can look at such service as admitology, or R-7, or whatever you choose, but to other specialties it is a part of your job, just like debriding bedsores is part of my job as a surgeon.  Yes, your training is ideal for evaluating complex patient problems, as mine is for complex surgery, but that is why it’s called a job.  We all have to do our share of non-fulfilling work, just to get the patients taken care of.  I don’t get a thrill out of the debridement, or starting a central line, or evaluating the depressed woman whose chief complaint is breast pain since 1982, but when patients care requires me to do something, it gets done.  A recurring theme seems to be your self image- the reference to R-7 (?), or having other specialties “swooping in.”  I do most of my H&Ps and DC summaries, and I don’t feel like less of a physician when I do them. I don’t look at E&M work as scutwork (your term)- it’s vital and important to patient care.  Is there something I’m missing?

rcentor April 21, 2011 at 1:28 pm

Hospitalists only object to doing H&P and discharge summaries when they are not really caring for the patient. Surgeons do not ask hospitalists to do this. Other specialists sometimes do. Hospitalists are physicians; know who to care for patients; and do all the things you mention on their patients. When an orthopedic surgeon wants the hospitalist to do the admission and discharge, and the patient is only there for a broken hip, then I believe things have gone wrong. The key here is the primary problem and who should care for that problem.

The fact that you have this misunderstanding underscores my concern about the field.

Mt Doc April 21, 2011 at 1:42 pm

Come on, JB. You know when you are asking for a hospitalists's input because you want help in managing a medical aspect of the case, and when you consult the hospitalists because you don't want to be bothered doing the H&P and discharge summary but don't need or want his/her input otherwise. So do we.

oskie94 April 21, 2011 at 3:21 pm

Co-management promotes efficiencies and is "scalable." Hospitalists are readily available inside the hospital while many proceduralists split time betwen the hospital and outpatient site of service venues. The hospital wards/floor is their domain. It's really no different than the ED where the ED physician runs the show, or the psych unit where the psychiatrist is in charge, or the inpatient rehabilitation unit where the physiatrist coordinates care.
In the modern ACO, there are different venues where different "attendings" are running the show. A patient may fall, break a hip, arrive via EMS to the ED (see the ED MD), get an ortho consult (ortho MD) have ortho surgery (ortho MD), be admitted to the hospital service (hospitalist MD), go to rehab (PM&R MD), then be discharged to an assisted living center (PCP MD). As the paitent moves through different phases of care, different MD's are running the show. Why should hospitalists resent their role? They are part of the continuum of care for the patient. The real trick is simply making doctors communicate better.

amidoc April 21, 2011 at 3:33 pm

No orthopedician is reading this engaging discussion as they are either minting money in the OR or playing golf on their off days. Life goes on…

Stalwart Hospitalist April 21, 2011 at 4:29 pm

@jb – "R7" and "scut work" are not my terms; they were terms in other comments to which I was responding. 
@oskie94 — With regard to the hospitalist role, the discipline has never stated collectively (nor intends to, I don't think) that its "domain" is the entirety of the hospital wards in terms of participating directly in the care of every patient therein.  It has been defined — by us — as basically the following two subdomains:
1.  Care of inpatient internal medicine patients, whether as the primary service or the consulting service.  As Mt Doc points out, the latter instance necessitates an active question on management of patient issues, not merely the existence of chronic medical disease at baseline stability.
2.  Evaluation, investigation, and improvement of inpatient hospital systems and workflows.  This work is done away from direct patient care, but often has implications for how inpatient physicians — of all disciplines — provide care for their hospitalized patients over time.
It does not logically follow from either #1 or #2 that my role as a hospitalist includes completing an H&P on a surgical patient because the operating surgeon is in the OR.  I wholeheartedly agree that having some other provider available to "get things started" in these situations; physician assistants and nurse practitioners have filled this need in many instances in recent years.

Stalwart Hospitalist April 21, 2011 at 4:34 pm

An additional point — I think that jb's has the perception issue down pat:  "You can look at such service as admitology, or R-7, or whatever you choose, but to other specialties it is a part of your job, just like debriding bedsores is part of my job as a surgeon."  Other specialties may hold this view quite confidently.  However, confidence does not substitute for correctness, and this view is incorrect.

Ernie G April 21, 2011 at 4:35 pm

I again relate to JB's comments.  In my previous comment on another thread, my questions asking who will be the R7, do the "scut work", and deal with "social issues", etc, were answered by the stalwart hospitalist in the manner I would expect- there is no "scut" work, "R7" work has to be done.  Like JB says, it is all stuff that needs to be done.  Like oskie94 and JB state, I think the hospitalist should "own" hospital work.  I don't think JB is misunderstanding DB. I agree with the recurring theme of "self image" problems when hospitalist DB describes "abuse" of hospitalists.

Stalwart Hospitalist April 21, 2011 at 4:38 pm

@oskie94 — I couldn't agree more that co-management, done correctly, can generate huge efficiencies.  (Scalability may end up being more of a function of how reimbursement mechanisms evolve in the coming years.)  I admit elderly hip fracture patients all the time, because delirium, fluid shifts, diabetes management, and anticoagulation management are well served by my training and experience, and staying closely involved with the patient's care helps to anticipate and hopefully avoid problems in these arenas.  When I have something to bring to the table clinically, you will always find me right there at the table.

Stalwart Hospitalist April 21, 2011 at 4:56 pm

@Ernie G — This is what is really comes down to:  what non-hospitalists think the role of the hospitalist should be, as opposed to what hospitalists think the role of the hospitalist should be.  And on this point, I suspect that we will remain at an impasse.
It seems to me that the key sticking point is the following:  hospital medicine views the hospital as containing a subset of patients that fall within its domain; some other specialties or physicians view every patient in the hospital as having some subset of work that should be the hospitalist's domain.
We'll have to agree to disagree, but I find it interesting that some physicians think it is reasonable for them to define for hospital medicine what its domain is.  I do not believe that many surgeons would be all that open to hearing what I think their job ought to be. 

Stalwart Hospitalist April 21, 2011 at 4:58 pm

Last point –
"Admitologist" is so clunky.  I like "throughput jockey."

Mt Doc April 21, 2011 at 6:20 pm

I understand the  term "scut work" to refer to work which, although necessary, is foisted off on one individual when it actually should be performed by someone else, for convenience or economics. In medical training I hand carried blood work to the lab and transported patients to and from the radiology department, work which was critically necessary but which contributed nothing to my training, did not require a person in postgraduate training to do, and should have been done by a transporter or phlebotomist – ergo, "scut".
If a surgeon admits a patient for an operation, that surgeon should do an H&P, personally document it, and do a discharge summary when the patient goes home.  I guess you can get a PA to do the dictation and cosign it if you want. Admitting the surgical patient to a medical service for the SOLE purpose of getting another person to do  the paperwork (and I absolutely agree the H&P and discharge summary are critical parts of patient care) is by this definition scut work for the medical person who has to do it.
I think the difference here is that hospitalists regard themselves as medical consultants. They manage medical admissions and serve as internal medicine consultants to surgeons who have complicated patients. It seems that some surgeons regard them as a service provided by the hospital to do the paperwork, field the nurses' phone questions, etc. To them, it seems that the outpatient internists and FP's are using them in this capacity, so why shouldn't they? It is possible they are right, but the difference is that hospitalists are MANAGING the patients admitted for pneumonia, cva's or whatever, whereas the surgeons are managing the care of the uncomplicated surgery patients – they do not need nor do they want the input of the hospitalist other than to do the paperwork, and the hospitalist does not regard this as his/her role. The distinction is clear to hopitalists but apparently not to some others. At least this is how I see it.
Paperwork which is absolutely useless, as is some of the redundant garbage filling a lot of medical charts, doesn't come up to the level of scut.

ErnieG April 21, 2011 at 7:13 pm

@ Stalwart Hospitalist
 
My questions on an earlier thread about who will be the R7, who will do the scut, and who will write an H&P were essentially answered correctly- they are all necessary work that needs to be done. They are all the inglorious part of being a physician.
But how is it that hospitalists get involved in “the evaluation, investigation, and improvement of inpatient hospital systems and workflows” which “often has implications for how inpatient physicians — of all disciplines — provide care for their hospitalized patients over time” YET step away from the idea that “its ‘domain’ is the entirety of the hospital wards in terms of participating directly in the care of every patient therein?” It seems the hospitalist is desperate to show that it can give the hospital something important, but want to be “medical consultants” only to IM patients.  They want to tell the hospital and other docs how to use an “effective bowel regimen medication ordering” when they don’t even manage post-operative patients on PCAs. Unlike the ED physician, who takes his or her domain as the ED, the hospitalist are afraid of taking the hospital as their domain but want to think they can make the hospital better.  They start to look like IM’s who want to deal only with inpatient IM, but don’t want to deal with the trouble of taking care of the chronic outpatient IM problems. They look like IM residents who don’t know how to transition into outpatient medicine, but think is it their right to be “attendings” who don’t get their hands dirty. In order to make “inpatient hospital systems and workflows” better, the hospitalist will need to grab inpatient medicine, both “medical” and “surgical”. If hospitalist really seem like they are above this task, it really does seem (as JB suggested) that hospitalists suffer from low self-esteem.  The idea that hospitalists can define itself is odd.  By making the hospital the only place of practice and as an employee of the hospital, the hospitalist has in essence stated that it is providing a service to the hospital. 
I think that if the hospitalist finally swallows the idea that the hospital is its domain, the specialty will win out by 1) showing that the care of the hospitalized patient is better off, 2) it can make care more efficient, 3) sit at the table with the hospital to demand better compensation 4) stop looking like whining IM post-residents
 
 @DB
 
I think that most patients admitted with hip fractures can benefit from IM or hospitalist care. Rarely does a hip fracture patient not have any other medical problems, and rarely is hip fracture recognized as osteoporosis that should treated medically or that it is a sign of other medical problem (i.e. dysrhythmia, sycope, vertigo, etc).  Is your beef really with orthopedic surgeons?
My overall problem with DB’s definition of the hospitalist is that it wants to define itself as a “place specialty”- hospital patients.  Only the ED physician defines himself as such. Yet unlike the ED physician, it does not want to take over that domain. It wants to be only IM/consulting- but wants to improve the hospital.  There is no “hospitalist” residency nor board certification.  I understand it is a work in progress. I really do think hospitalist can bring a lot to the table, but only by immersing themselves in the hospital can it be more than post IM residents admitting outpatient IM physicians patients waiting to get them out the door.  Otherwise hospitalist have no business getting involved in hospital wide system workflows.

Stalwart Hospitalist April 21, 2011 at 9:43 pm

This is how hospitalists affect patient care in the hospital:
 
http://onlinelibrary.wiley.com/doi/10.1002/jhm.562/abstract
 
86% reduction in hospital-acquired VTE by standardizing a process?  I guarantee you that hospitalists did not clinically care for all those patients who would have gotten a DVT but didn't, but they significantly reduced morbidity nonetheless.
 
In like fashion, I don't tell everyone how to do their job in terms of an effective bowel regimen, but I lead a task group of internists, surgeons, and nurses to decide on a best practice standard for our hospital, which then will reduce variability and reduce time to first bowel movement in post-op surgical patients (even on those patients the hospitalists don't personally get involved in).
 
I disagree with the assertion that trying to affect patient care indirectly at a systems level makes me "afraid" to take the hospital as my domain.  Actually, trying to accomplish the same degree of change via direct clinical care alone would likely be unsuccessful.
 
Perhaps the hospitalists in your hospital take a different approach, and are as you say you've observed.  The demand for hospitalists has certainly grown faster than the supply of systems-trained and quality-improvement trained hospitalists to fill those roles.  However, to generalize your comments to the larger hospitalist community is an uninformed approach.  I am also sorry that you felt it necessary to resort to an ad hominem attack at the conclusion of your response to me; that is unfortunate.
 
I have tried to lay out an argument for what hospital medicine thinks that — as a specialty — it can bring to the table in terms of value, and for why the skills we bring to the table should be seen as valuable.  Many are not yet unconvinced, and some will always remain so.  However, I am quite secure in what I personally bring to the table in terms of value to my own hospital, both in terms of direct patient care, and in improving hospital processes in general.

Stalwart Hospitalist April 21, 2011 at 9:47 pm

It is evident that ErnieG will be holding fast to his opinion, and I will not spill further electrons trying to sway him.  I am quite confident and secure in the skills and value that I bring to the table for my inpatients, primary and consultative, and to the hospital at large in the non-clinical ways I've described.
 
There is a place that the hospital medicine community wants to get to, and it is still on that road.  I suspect that some physicians will not agree with what hospital medicine wants to define as its role in health care, and that discussions like these will continue.

Cory April 21, 2011 at 9:50 pm

The problem we had with post-op care later in my career was that the internists did it better than the surgeons (the older surgeons did it great but when they retired the newer guys preferred the OR). Everyone agreed on that (which wasn't true earlier in my career).
But the problem became that because the internists did it better, there became less and less incentive for the surgeons to do even the simplest post-op stuff. And as time went on, less incentive to do any pre op stuff.
Gradually the internists were doing scut as well as serious consultations. No one knew how to stop the cycle. The surgeons became, what an earlier generation of surgeons took umbrage at, mere technicians. 
Better for patients? in some cases yes, in other cases no.

Mt Doc April 21, 2011 at 11:25 pm

Ernie G, I'm not "afraid" to do postop care. In the cases I'm referring to the surgeon doesn't WANT me to do postop care, only to  do the paperwork. He/She wants to manage to the postop fluids, diet, antibiotics etc but God forbid he should dictated the discharge summary detailing what's been done. Maybe he thinks that's that's "beneath" him (You know the old saw, and I'm trying to joke here – you look at a surgeon and think, "there but for the grace of God, goes God") but if he's managing the case I think it's his job.
I agree somewhat with Cory. Maybe today's surgeons regard their role as purely to operate. Historically the surgeon's job included preop and postop care and the fees were designed to reflect this. Much of a surgeon's training (almost all of medical school and much of the residency) dealt with these aspects of care. If all a surgeon is going to do is operate, and delegate all the other aspects of care to other people, why spend the time and money to train surgeons in the arts of physical diagnosis, pharmacology, physiology, interpretation of lab data, and years of developing surgical "wisdom" (which is what distinguishes an invaluable surgeon from a technician)? You could train technicians, PA's or nurses to do the bulk of the procedures, supervised by a few highly trained people in case complications occurred during the procedure, kind of like anesthesia is handled today. There would be no justification then for high procedural fees and things could get a lot cheaper real quick. On the flip side, why should a good surgeon ask a hospitalist to see a patient when it's not needed – that just jacks the cost of care up also.
Personally I expect more from a surgeon than that, but I freely admit that I'm an aging curmudgeon.

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