Hospitalist Co-Management Of Neurosurgery Patients: The Inside Story Of A Winning Intervention

In this month’s Archives of Internal Medicine, my colleagues and I report the results of our early experience with hospitalist co-management of neurosurgery patients. We found stratospheric satisfaction among neurosurgeons and nurses, as well as impressive cost reductions ($1400/admission). At the same time, there was no impact on quality or safety, at least as judged by hard end-points such as mortality and readmission rates.

While these results might seem like a mixed bag, I believe that the overall impact of this service has been fantastic, for patients, surgeons, and our own hospitalists. Let me explain, beginning with a brief history of hospitalist co-management, folding in the history of our neurosurgery co-management effort (which we call the “Co-Management with Neurosurgery Service”, or CNS), and ending with some of the more subtle outcomes that lead me to feel that this is one of the most important things our hospitalist program has done since its inception in 1995.

A Brief History of Co-Management
When the hospitalist field took off in the mid-1990s, we projected that its growth would largely reflect the degree to which hospitalists assumed the care of inpatient internal medicine (and later, pediatrics) patients: those with pneumonia, heart failure, sepsis, GI bleed, and the like. Sure, I recognized that there would be increased opportunities for traditional medical consultation – we come when you call us – but I completely underestimated the siren call of co-management.

It turns out that once there are hospitalists in the house, the notion of having them actively co-manage surgical patients is hard to resist, for several reasons. First, many of the problems such patients experience before and after surgery are really medical, not surgical. Secondly, just as a hospitalist can provide on-site availability that the primary care physician can’t match for medical patients, he or she can do the same for surgical patients. (In this case, it’s not that the primary care doc is stuck in the office, but rather the surgeon is stuck in the OR.) Third, in an era of more widespread quality measurement and reporting, it seems likely that a hospitalist will improve quality measures such as DVT prophylaxis and evidence-based management of CHF more than a surgeon, flying solo, would be able to.

Finally, there are the economics. If, in helping to manage the post-operative care of a surgical patient, a hospitalist frees up the surgeon to do another case in the operating room, the economics for both the surgeon (payment for one more case) and the hospital (ditto) are highly favorable. If the surgeon earns $450,000/year and the hospitalist $200,000, it’s clearly more lucrative to have the latter take over some of the medical management if that frees up the former to scrub in for one more hip replacement or craniotomy.

But the economics are not simple. Precisely because hospitalists don’t perform procedures, their pro fee collections generally don’t come close to covering their salaries and benefits. In the case of medical patients, there’s no ambiguity regarding where to seek additional dollars to augment these collections: in more than 90% of hospitalist programs, it is the hospital that pays the difference between the collections and the costs, to the tune of about $100,000 per clinical FTE. The fact that the hospitalist field is the fastest-growing medical specialty in modern history tells you all you need to know about hospitals’ collective thinking about the wisdom of this investment.

But surgeons are generally paid a case-rate (a fixed payment per surgical case), which bundles in the compensation not just for the surgery but also the pre- and post-operative management. This raises a sticky question: if hospitalists require a support payment for co-management, shouldn’t some of the dollars come out of the surgeon’s pot o’cash? This very question held up our co-management efforts, and those at hundreds of hospitals around the country, for several years; more on this later.

In the late 1990s, several institutions began experimenting with hospitalist-surgical co-management. I collaborated with one of the most prominent: the Hospitalist-Orthopedics Team (HOT) at the Mayo Clinic. The Mayo folks demonstrated that the HOT resulted in patients being ready for discharge sooner, with a small decrease in minor complications, but no major improvements in hard end-points. Not exactly the Salk vaccine.

Despite these less-than-jawdropping results, interest in co-management grew – mostly, I suspect, because of the economic issues I described earlier rather than any ironclad evidence that this model improved quality or efficiency. This growth curve tilted upwards in 2003, occasioned by the ACGME’s first duty-hours limitations, which instantly removed tens of thousands of hours of surgical resident bandwidth from the system. If surgical housestaff previously worked 110 hours/week and now could only work 80 – and if surgical residents both want and need to scrub into as many cases as possible – something has to give, and that something is the amount of time residents are available on the wards to manage patients before and after surgery. Who could pick up the slack? Sure, some of the work could be assumed by NPs or PAs, but, for the more complex patient populations, hospitalist co-management seemed the best solution.

Our Early Experience With Co-Management
At UCSF, our hospitalist program dabbled in co-management with our orthopedic service about six years ago, and our experience demonstrated that these services could fail if both logistics and culture weren’t right. The rules of engagement were vague, the hospitalists felt that their time on the service was undercompensated, and our medical residents, who were helping the faculty co-manage the ortho patients, hated it (they felt they were substituting for the orthopedics housestaff, which, to a degree, was correct). For a variety of reasons, the sense of collegiality and mutual understanding vital to this kind of collaborative care was lacking: when there was a bad outcome on orthopedics, we felt that there was finger pointing (“where was the hospitalist?”) rather than an honest effort to learn from experience. After a fairly unpleasant year, we pulled the plug on the service, convinced that this was not the right time, right place or right people, and that, while co-management could work, both the logistics and the culture had to be just so.

Around this time – 2004, as I recall – my hospital’s Chief Medical Officer, Ernie Ring, approached me regarding the possibility of co-managing neurosurgery patients. The need was pretty obvious. This is one of the busiest and highest-profile services in the hospital. Ranked as one of the top five neurosurgery services in the nation, it receives referrals from all over the world and carries an average daily patient census of 50-60. When we analyzed the service, we realized that this large volume of patients, many of whom were quite ill, was being managed by one hapless second-year surgery resident who had drawn the short straw; the rest of the surgeons spent the day in the OR. It was not hard to find cases of poor outcomes because patients’ deterioration was not recognized quickly enough or addressed appropriately.

But we had this money problem: staffing the service with one hospitalist a day, 365 days a year, was a half-million-dollar proposition. For a couple of years, three-way meetings that included me, the CMO, and the neurosurgery department leadership ended with a philosophical agreement to begin co-management, but a snag over the source of the dollars. From the medical center’s perspective, the surgical department needed to ante up some of its own professional fee revenues to support co-management. The surgeons, like those everywhere, felt the hospital should be the source. Nobody blinked, and so the CNS remained a drawing board proposition.

Finally, in 2007, after 3 years of negotiation, the medical center leadership realized that it would have to bankroll the service if co-management was to become a reality. After a couple of bad outcomes that might have been prevented had there been a hospitalist on the service, the hospital agreed to provide all the necessary funding. The CNS was born.

The Co-Management With Neurosurgery Service: The Inside Story
Now that the funding was secure, we needed to sort out how the service
would actually function. I asked Quinny Cheng, the wonderful director of our med consult service, to lead the CNS. Quinny and I met with the chair of neurosurgery, Mitch Berger, a world-class surgeon and former high school football academic all-American. (Wooed to Alabama by Bear Bryant and Wake Forest by Arnold Palmer, he chose Harvard because “there’s life after football,” demonstrating uncommon maturity for an 18-year-old kid.) Mitch is a Just-Do-It kind of guy: larger than life, passionate about patient care, and a bit impatient. His initial view was that the co-managing hospitalist should round on every patient, every day. “Mitch, in a 12 hour shift, that’s about 10 minutes per patient,” we said. Instead, we advocated for having us actively co-manage the sickest 13-16 patients on the service (as determined by a triage rule described in the paper), being available to the nurses, physicians, and families to check in on the other 35-40 as needed.

Before we launched we were also determined to agree on clear rules of engagement; failure to achieve such an agreement, I was convinced, had been responsible for dooming our orthopedics co-management experiment. We would manage the medical problems, largely independently. The surgeons would retain ownership of the surgical issues (“We don’t do burr holes,” was our cheeky motto). Decisions around anticoagulation, so potentially hazardous in these patients, would be made jointly.

There was one other thing that needed to be hammered out, and I didn’t mince words. “If one of the surgeons yells at one of my hospitalists, we’ll give you three months notice and then leave the service.” Although the iconic image of the scalpel-throwing surgeon is somewhat hyperbolic, it does exist in nature, as does a physician hierarchy that has surgeons on top and general internists near the bottom. I needed to be clear that, at least as far as the hospitalists went, anything but a respectful partnership wouldn’t be tolerated.

The Outcomes of the CNS: Hard and Not-So-Hard
While the Archives paper describes the hard outcomes in our first 18 months of the service, it was some of the softer ones that convinced me that this was an extraordinarily positive experiment. For example, after having at least one or two cases each year of truly awful patient outcomes that could be pegged to insufficient floor oversight, I haven’t heard about such a case since we began co-management three years ago.

Moreover, I find the survey results compelling. We surveyed the non-nurse caregivers (mostly neurosurgeons with a smattering of NPs and pharmacists on the service). Their response to the statement: “Patients’ medical problems are promptly recognized and appropriately addressed” was 2.7 (on a 1-5 scale, where 5 is complete agreement) before the CNS began, and 4.4 afterwards, a highly significant uptick. Six months after the service began, this group’s response to the statement, “The presence of a hospitalist improves care for neurosurgery patients,” was 4.9 out of 5, representing near-uniform agreement.

Perhaps more impressively, 34 neurosurgery nurses answered the post-implementation survey. The average nurse had worked at UCSF for 11 years – they’d seen it all, including lots of failed quality improvement strategies implemented with great hype. Their score on the statement, “The presence of a hospitalist improves care for neurosurgery patients,” was 5.0, meaning all 34 gave it the highest rating. I have to believe that perceptions like these reflect real improvements in care.

Then there’s the cost data: $1,400 lower costs per surgical case, translating into a savings of more $1.5 million during the first 18 months of the program. This yields a return-on-investment of 2:1, independent of any revenue enhancements via greater surgeon availability to do cases, or any impacts on quality, malpractice liability, or nurse satisfaction and retention.

So, while the study does not prove that lives were saved, I find the evidence of benefit, and of the positive return-on-investment, to be pretty compelling.

Our Archives article was accompanied by an editorial written by Patrick O’Malley of the Uniformed Services University of the Health Sciences in Bethesda. In the editorial, subtitled, “Can We Afford to Do This?” the author states, “this well-performed study stops short of providing definitive evidence to support co-management or refute its value, from any perspective.” He then goes on to attack the economics of the co-management model:

I would argue that even the economic rationale for co-management is poor because it really involves shifting work to lower-paid workers (internists), allowing surgeons to spend more time in the operating room, where they get paid more by a dysfunctional reimbursement system that disproportionally rewards procedural care over more cognitive services.

Well, duh. As it happens, this is also the rationale for having NPs or nutritionists perform many primary care tasks in the Patient-Centered Medical Home, and for using Turbo Tax instead of an accountant for your taxes. In other words, this is what systems look like as they seek higher value: they shunt work down the income scale, allowing more highly paid specialists to focus on what they can uniquely do, and assigning some of their prior tasks to lower paid, less specialized individuals who can do the work well at lower unit costs. I’m still scratching my head trying to figure out why Dr. O’Malley finds this offensive, or demeaning. Sure, it is unfair that some surgeons make four times what a primary care internist makes. It’s also unfair that Alex Rodriguez makes $43,000 every time he gets up to bat. Tilting at this particular set of windmills doesn’t change the facts on the ground – particularly since, in this case, patients likely benefit from the new arrangement.

Perhaps Dr. O’Malley will be pleased to know that hospitalists benefit too, in ways that I could never have predicted.

Our negotiated agreement pays significantly more for a day’s work on neurosurgery than for a day on the medicine wards. (Note to my fellow hospitalist directors: I wouldn’t have agreed to co-management without this premium.) This has helped ease the job of recruiting our faculty to rotate on the CNS, as 6-8 of them do each year. And many of our faculty have really taken to the work. While hospitalists clearly add value on the medicine wards, the effect is attenuated by our army of very smart medicine housestaff who can function quite well without us. On CNS, our hospitalists have the gratifying feeling that the patients are getting far better care directly because of our presence.

My concern about the relationship between the surgeons and hospitalists has also proven to be a non-issue – quite the opposite, actually. In three years, I can recall only one incident in which a surgeon lost his temper with a hospitalist. One. Instead, the relationship has been characterized by tremendous mutual respect: we know that we couldn’t do what they do (extraordinarily well), and I am confident that they feel the same way about us. It feels like a real partnership.

This partnership has other value as well. When the medical center makes a bad decision that affects all services (cutting the availability of pharmacists, for example), it is no longer just our medical service advocating in isolation. We sit down with our neurosurgical colleagues and make our case together. And our collective voice is loud. Having a surgeon on your side – particularly a 6 foot, 4 inch former defensive tackle – is like having that big kid in class looking out for you in grade school.

Over the past two years, the fruits of this partnership have truly begun to flower. Quinny Cheng, the hospitalist who runs the CNS service, won a departmental teaching award last year… from the Department of Neurosurgery! And, several months ago, Mitch Berger called me for a meeting. “We want to be the leading neurosurgery department in the country in quality and safety,” he said. I was thrilled; I’ve been pushing this agenda for years throughout UCSF Medical Center. “I want to hire a physician to lead our efforts.” But where would he find a neurosurgeon with the skills, interests, and time to run a world-class quality and safety program, I wondered aloud. But Mitch was thinking differently. “I’d like to hire one of your hospitalists to run it.”

So, while not all co-management experiments will succeed, I’m convinced that our partnership with neurosurgery has not only improved quality, safety, and efficiency, but also resulted in exciting collaborations in education, research, and quality improvement. If you’re in the position to consider such a relationship, go in with your eyes open, make sure the conditions are right, and sweat the culture along with the logistics and the dollars. But if these stars align, I’d recommend you do it.

In healthcare, we talk a lot about unanticipated consequences, and when we do it’s usually not a happy tale. This is that rare case in which the unanticipated consequences have been uniformly positive. Thanks to all my colleagues – particularly Quinny Cheng, the other hospitalists who rotate on CNS, Andy Auerbach for taking the lead on the Archives paper, the medical center leaders who support the service, and our friends in neurosurgery, especially Mitch Berger – for making it so.

14 Responses to “Hospitalist Co-Management Of Neurosurgery Patients: The Inside Story Of A Winning Intervention”

  1. Brad F December 23, 2010 at 6:01 pm #

    Bob
    Your service is unique. Its prestige, huge size, outsized personalities, financial support, and most importantly, vision, make it almost an n=1 propopostion. On the latter point, you had posted some time back re: Berwick and reproducibility of success given inability to clone proven stars. A complement to you and your team, you must look in the mirror. :)

    As I read your post, I almost anticipated the defense against the not so agreeable commentary–saw it coming (motivation to put pen to paper?). I must say though, I see both sides.

    You have done some fine work, but I am still not convinced cogmgt is the best way to spend what will be dwindling hospital dollars (especially in a bundled world when cognitive services will fight for a bigger slice of the pie). When the alchemy is right at a place like UCSF, it is a no brainer. For many other hospitals though, I am less sanguine.

    In fairness, you point this out to a great degree, but again, this approach to care, for me at least, is not ready for full prime time roll out. It will be a local phenomena; right for some, wrong for others–but not a “home run, one size fits all, check list, Gawande, Pronovost,” endeavour.

    Brad

  2. Brian Clay, MD December 24, 2010 at 3:31 pm #

    Brad makes a good point, but Bob did point out that the “decision on the dollars” was a three-year undertaking — by no means a no-brainer for their institution.

    Bob — I would be curious as to whether the upcoming ACGME resident work environment rule changes that come online in July 2011 will affect this arrangment; specifically, will there be any medicine residency schedule re-organization for next year that requires more hospital medicine FTEs on the medicine services, and, if so, are those FTEs being newly recruited or drawn from elsewhere within the division (such as the CNS)?

  3. Bob Wachter December 24, 2010 at 4:14 pm #

    Thanks to both Brad and Brian for your comments. I agree with Brad – there is lots of local baseball involved in these arrangements. I told our particular story in the hopes that our experiences – both positive and negative – would help others considering co-management programs. But, cliched as it is, this is one of those “if you’ve seen one co-management program, you’ve seen one…” situations.

    One of the key factors, which I didn’t touch on but Brian correctly raises, is the availability of qualified hospitalists to staff these services. To staff a daytime service 365 days a year takes about 2.5 FTEs of personnel. So if you’re having trouble recruiting enough good people to staff your existing services, that would certainly go in the negative column in your deliberations about co-management.

    For us, our decision to staff CNS in 2007 meant that we didn’t pursue nocturnist (overnight) coverage for a few years. We finally added overnight coverage this year, partly in preparation for the new ACGME regulations. We are likely to require one might nighttime person for 2011-2012; we’re still working out the details of our response to the new intern hour limits, but it is probably going to require two in-house faculty overnight.

    There is a little apples and oranges here, though, in that we tap into very different recruiting pools for different jobs. The hospitalists who co-manage patients on neurosurgery are full-time academic hospitalists who also attend on our teaching services several months a year, and do other academic work such as research or QI. In other words, they are career academic hospitalists – so in committing 2.5 FTEs to the CNS service, I had to feel that this arrangement would help us hire such people, or at least not be a drag on our recruitment and retention efforts.

    On the other hand, while our nighttime coverage is open to our full-time faculty, more than half the shifts this year were covered by two (superb) recent graduates of our program who may not be hospitalist “lifers.” Similarly, our co-management arrangements with our cardiology and bone-marrow transplant services generally involve hiring recent grads of our residency who intend to pursue fellowship training in cardiology or oncology, respectively. Finding good folks for these positions hasn’t been too hard. But we have a large and terrific residency, and we’re located in a desirable place. I recognize that none of these are universal conditions.

    The bottom line is that your most important resource is your people. If adding co-management to your portfolio either stretches you too thin or mandates hiring people just to fill the spots (ie, folks you wouldn’t otherwise hire), then this needs to be factored into your decision-making.

    – Bob

  4. Menoalittle December 25, 2010 at 3:02 am #

    Bob,

    As always, yours is a creative approach to improving care to the benefit of the patients. My recollection is draw to a busy neurosurgery service at an academic center in which 2 neurosurgery interns covered a service of about 30 patients (before the Libby Zion case), more or less. Needless to say, there were innumerable medical trainwrecks on that service.

    On the more practical end of things, is your hospitalist service billing insurances (you do not say that you are not) for consultations and E and M services on the CNS?

    Best regards,

    Menoalittle

  5. Bob Wachter December 26, 2010 at 1:19 pm #

    Thanks to Menoalittle for your comments. Where appropriate, we bill as consultants on the CNS (with the surgeons remaining physicians-of-record); this is the way most co-management arrangements work. Our triage rules for the service ensure that the patients we are seeing have several active medical problems that easily justify the need for medical consultation.

    As I noted, with our payer mix and a volume of approximately 15 complex patients per day, the professional fee collections don’t come near covering the salary and benefits of our faculty – thus the need for another source of support to make this (and most other) co-management services viable.

  6. anonymous December 26, 2010 at 4:51 pm #

    so it seems the nurses survey response was the most compelling part of the data set.  i wonder how much of that is from having someone to call and and trust to respond in a fairly predictable manner, rather than a frenzied scream from a beleaguered intern that they were too busy to come now.

    i wonder whether some of the early disasters could have been avoided with a consultation that was placed to medicine/critical care in a timely fashion rather than requiring an extensive remake of such a system?

  7. Bob Wachter December 26, 2010 at 6:38 pm #

    Re: Anonymous’s comment: I don’t think so. Before we began co-management with neurosurgery, we might get one consult from this service every couple of days. If we really pushed to lower the threshold for consultation, perhaps we’d be called to see 1-2 patients a day. But not more than that.

    But the problem goes well beyond volume. I am convinced that the trusting relationships – really, the partnership – that has characterized this service is a direct reflection of having an embedded hospitalist; someone who “lives” on the service and becomes well known to all the docs, nurses, and others on neurosurgery. This is a fundamentally different model from a “call us and we’ll be there” structure, even if you try to put that kind of model on steroids.

    Of course both models can coexist: an embedded hospitalist and an enhanced roving responder. In fact, we have a rapid response team and an ICU consult team that will come when anyone thinks the patient is rapidly deteriorating and needs help. But they really serve different needs. The RRT and ICU teams help put out fires, whereas co-management’s greatest value is in preventing the fires in the first place.

  8. Bob Wachter December 27, 2010 at 5:34 pm #

    Here’s a comment from Zac Kahler, an ER resident who blogs himself at http://www.agraphia.net. Unfortunately, we’re still having some technical problems posting some comments on the site [feel free to email me directly if you're trying to post and it isn't getting through. We're continuing to work on it but the site remains a bit glitchy]. Here’s Zac’s comment: 

    Bob -

    Fascinating comments as always. Long-time reader, first time commenter.

    Interestingly, I find myself sympathizing with Dr. O’Malley. If you are freeing up the neurosurgeons to perform more surgeries – and therefore boosting their revenue stream – I think you’re absolutely entitled to a direct cut of that revenue. Moreover if your presence on the service is saving the hospital a cool million, I think you’ve got tremendous bargaining power.

    I say this because it would be just as easy for the surgeons to hire 2.5 FTE’s worth of NP or PA coverage to cover the medical side of their service. Since that hasn’t happened, I have to assume that it is the presence of a trained hospitalist and the generation of an in-hospital medical home that makes this co-management work.

    I’m fairly far removed from the equation as an ED resident, but of course during training we rotate on every service. As such I think we get a fairly unique and unbiased opinion on how patient care flows through the hospital, and I hold our hospitalists in very high regard.

    Perhaps this is an inroad to compensating hospitalists for the “cerebral” work that simply doesn’t get compensated the same as procedures? By demonstrating a cost savings to the hospital, and a revenue increase to the surgical service, you’ve indirectly displayed the true value of an internist…

  9. Daniel Ari Mendelson, MS, MD, FACP, AGSF December 30, 2010 at 5:18 pm #

    Our experience with comanagement of a geriatric fracture service has shown improvements in mortality, morbidity, 30 day readmission, and cost. Skillful comanagement has a lot to offer patients, families, providers, and systems.

    Friedman, S. M., D. A. Mendelson, et al. (2009). “Impact of a comanaged Geriatric Fracture Center on short-term hip fracture outcomes.” Arch Intern Med 169(18): 1712-1717.

    Friedman, S. M., D. A. Mendelson, et al. (2008). “Geriatric co-management of proximal femur fractures: total quality management and protocol-driven care result in better outcomes for a frail patient population.” J Am Geriatr Soc 56(7): 1349-1356.

    Kates, S., D. Mendelson, et al. (2010). “Co-managed care for fragility hip fractures (Rochester model).” Osteoporosis International 21(Suppl 4): S621-S625.

    Kates, S. L., D. Blake, et al. (2010). “Comparison of an Organized Geriatric Fracture Program to United States Government Data.” Geriatric Orthopaedic Surgery & Rehabilitation 1(1): 15-21.

    Menzies, I. B., D. A. Mendelson, et al. (2010). “Prevention and Clinical Management of Hip Fractures in Patients With Dementia.” Geriatric Orthopaedic Surgery & Rehabilitation 1(2): 63-72.

    Schnell, S., S. M. Friedman, et al. (2010). “The 1-Year Mortality of Patients Treated in a Hip Fracture Program for Elders.” Geriatric Orthopaedic Surgery & Rehabilitation 1(1): 6-14.

  10. Hospital Doctor December 31, 2010 at 4:20 pm #

    Well , duh ? Thanks for sharing the continuing financial scam hospitalists play on unexpecting patients and their insurance companies in the name of Quality. It seems that we have been paying Neurosurgeons a global fee schedule to manage the pre and post operative care for the patients they operate on. Turns out that the Neurosurgeons are not that good at the post operative piece in complex patients. We invite the hospitalist in to provide the care and bill for services. Any “good” hospitalist can find a “Billable encounter” for some problem that a well written (or copy and paste)progress note can collect on. If you are not good at the “I Progress note for Cash” business, just search the web for a National Hospitalist Company to help you.This effort frees up the Neurosurgeon to get paid for more post operative care that they don’t provide and the hospitalist to Bill for more services the patient doesn’t really need. Of Course everyone is happier. What is lost in the whole program is the Value proposition. It costs too much. We pay Neurosurgeons for work they don’t do and we pay Hospitalists for services most patients don’t need. A How to take advantage of our broken health care payment system at the local level in the name of Quality scam.Let’s hope for better in 2011.

  11. Bob Wachter December 31, 2010 at 7:37 pm #

    This comment from Chris Johnson, a pediatric intensivist who blogs at http://www.chrisjohnsonmd.com/blog/

    Bob:

    You’ve made many good points, but I think your observation about physician culture is key. Finding the money to pay for co-management is important, but if the surgical service regards the hospitalists as glorified residents, rather than colleagues, the resultant acrimony will doom it. As a 30-year PICU doc, I’ve seen that. Although it’s less common then a few decades ago, there are still surgeons out there who believe they know everything I know and can do everything I can do, plus operate.

  12. AD December 31, 2010 at 11:55 pm #

    I have been a patient on the neurosurgical service at UCSF; fortunately, I did not require the services of a hospitalist. I am also an Internist who yet cares for patients in the ambulatory care environment and the hospital.
    Dr. Wachter and his colleagues should be commended for their efforts to advance the care of the hospitalized patient. Programs at UCSF and like institutions are superior but are not representative of the community hospitalist program. To extrapolate their success in co-management of the seriously ill surgical patient to the community hospitalist is premature.
    At Moffett hospital my recovery was hastened by nurses, therapists and pharmacists whose performance was superior to their peers at community hospitals. These performances contribute to improved UCSF outcomes.
    Hospitalists at UCSF are faculty physicians, their motivations are academic and quality driven. Shoddy work would not be tolerated by their peers or their trainees.
    Community physicians have publicly described (1) negative experiences with hospitalists. These experiences are more common than published.
    The hospitalist movement must accept a measure od responsibility for recent fragmentation of care (2). One would anticipate that if they were a boon to healthcare this would not be increasingly reported as their numbers grow.
    Serious consideration should be given to Dr.O’Malley’s editorial comments.
    Hospital administrators finance, develop and countenance sub standard hospitalist programs to guarantee the loyalty of primary care providers who look to the hospitalists as a source of income enhancement allowing increased office income, further, in these environments specialists treat hospital based physicians as interns not internists, physicians available 24/7 to admit patients and call for consults and procedures (often unnecessary) (3).
    In these situations the hospitalist concept is discredited. Poor work product of these programs is often a patient safety hazard and drives up healthcare costs.
    The lengths of stay, outcomes and resource utilization in the scenarios described are dissimilar to those of UCSF and similar institutions. Kudos justifiably earned by UCSF cannot be distributed to all hospitalist programs.
    A solution would be an accreditation process to guarantee that the hospital based physicians and their organizations achieve minimal standards of quality and competence. We ask for competence and quality from the professionals with whom we interact, can we not ask for quality standards of physicians’ patients’ have thrust on them often the hour of their greatest need.
    I am certain that Dr. Wachter and Dr O’Malley will find common ground in achieving this objective.

    1) Beckman H. Three Degrees of Separation. Annals of Int Med: 2009:150.890-891.

    2) Jencks S. Defragmenting Care. Ann of Int Med: 2010: 153:757-758.

    3) Redberg R et al. Diagnostic Tests: Another Frontier for Less is More. Arch of Int Med. Published Online Dec 13.2010.

  13. Marco ( Hospital Doctor) ( please dont use my name for obvious reasons) January 9, 2011 at 6:18 pm #

    Bob,

    I appreciate the thoughtful post  on  working with the Neurosurgeons.

    But let’s be honest. Surgeons want hospitalists on the case to relieve them of the “usual and customary post op care”  so they can spend more time in the OR to generate income. Then, generating more income, they refuse to share some of it with the physicians who are doing their work. The hospital (aka “the patient”) foots the bill. Improving quality is not the driving force here and everyone knows it.

    I know this to  be true because at my institution we are required to see all ortho patients even if they have no medical issues (unlike your situation where you see only the most ill). No only that, we are forbidden from ever signing off a case even if the patient has no active medical issues. I suspect this is the direction co-managment is going and it is easy to see why surgeons love it. I dont know how long Medicare will tolerate it.

    I am not convinced this is a good idea for patient care. My experience is that the surgeon becomes even more removed from the case than before  since the hospitalist is there. Recently, I was co-managing a plastic surgery case and the patient developed post op anemia. This progressed. I suspected she was bleeding into her abdominal wound and wrote this in the chart and tried to call the surgeon who did not return several calls. His rounding nurse thought she had a GI bleed. He never saw the patient post op. Finally  after 7 units of blood transfused she stabilized and was D/C’d. I saw the surgeon 2 months later and he thanked me after opening her wound in the office and was surprised to find a massive hematoma that he evacuated.

    Similar situations have occurred, some without such a benign result.

    I believe medicine is going in the wrong direction here. It used to be that as the case got examined we brought in the most qualified person to handle it. Now it seems we get the less qualified to manage it. I enjoy challenging cases but I cannot operate to stop bleeding.

    I think your situation works because you have top notch surgeons. I dont think it has universal applicability.

    Marco

  14. Eric Siegal February 8, 2011 at 3:35 am #

    Bob,

    What is striking about your report is how much thought and effort you put into developing and evolving your comanagement service. You negotiated clear rules of engagement up front, restricted the scope of your service to patients who actually might need a hospitalist (gasp!), measured your outcomes, and presumably fine-tuned as you progressed. Your efforts were immensely aided by an amazingly progressive neurosurgery chair, a hospitalist leader (Quinny) who is nationally regarded for his expertise in comanagement, a highly mature division, and, well… you.

    My point (if not obvious already) is that you had did everything right under nearly ideal circumstances (and even then, outcomes didn’t change). In my experience, the majority of comanagement efforts fall well short of this ideal… with results to match.

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