Larry Beresford

Dr. Ruhlen

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.

Comanagement has been proposed as a solution to improve both patient care and professional satisfaction. But its promise can be eroded if the arrangement isn’t well planned and executed, experts say. Comanagement requires clearly defined roles, collaborative professional relationships, and some sense of equal standing with the surgeons or other specialists who call on hospitalists to care for their hospitalized patients’ medical needs.

“The growing formalization of comanagement agreements stems from prior tendency by some to view hospitalists as glorified house staff,” says Christopher Whinney, MD, FACP, FHM, director of comanagement at The Cleveland Clinic. “Hospitalists feel this is inappropriate, based on our skill set and scope of practice. There is also a concern that if a hospitalist group jumps in to do this without a clear service agreement in writing, that is where dumping can become a problem.”

Dr. Whinney is one of two expert mentors for hospitalists under a new SHM demonstration project called the Hospitalist Orthopedic Patient Service Comanagement Program, which is gathering data to evaluate its effectiveness on clinical and other outcomes. He has been working with five of the 10 participating HM groups, helping them define what it means to institutionalize formal comanagement relationships.

“Whatever your personal feelings about the comanagement relationship, pro or con, comanagement is going to be part of most hospital medicine groups’ repertoire of services,” says Hugo Quinny Cheng, MD, director of the comanagement with neurosurgery service at the University of California at San Francisco (UCSF) Medical Center. “You can try to avoid it, but if the medical center and the surgeons want it, there’s going to be pressure on your group to do it—or else they’ll look for another hospitalist group to do it.”

Dr. Cheng advises hospitalist group leaders make themselves aware of the trend and position themselves in a way to take advantage of it—or, at the very least, not be blindsided by it.

According to SHM data, 85% of hospitalist groups have done some kind of comanagement.¹ It’s not explicitly listed by SHM as one of The Core Competencies in Hospital Medicine, but it might as well be, says Leslie Flores, MHA, SHM senior advisor, practice management, because aspects of comanagement are addressed throughout.²

Defined, Distinguished, Delineated

Comanagement is different from traditional medical consultations performed by hospitalists upon request, and also differs from cases in which the hospitalist is the admitting physician of record with sole management responsibilities while the patient is in the hospital. According to an SHM white paper, A Guide to Hospitalist/Orthopedic Surgery Comanagement, the concept involves shared responsibility, authority, and accountability for the care of hospitalized patients, typically with orthopedic surgeons or other specialties, and with the hospitalist managing the patient’s medical concerns, such as diabetes, congestive heart failure, or DVT.³ (SHM’s website is full of comanagement resources, including sample service agreements; visit www.hospitalmedicine.org/publications and click on the “comanagement” button.)

But just as HM programs can be diverse in their organization, structure, and leadership, there is no single definition of comanagement, says Sylvia McKean, MD, SFHM, senior hospitalist at Brigham and Women’s Hospital in Boston. “You can have a very formal relationship where there’s a contract and where people are paid by whatever group is initiating the comanagement. There may be clear definitions in terms of their roles,” says Dr. McKean, an SHM board member who chaired the advisory panel that developed the comanagement white paper. “At the other extreme may be an informal relationship where you have a group of people in a community hospital who are available to manage medical problems when requested by specialists on a subset of patients.

“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.”

Eric Siegal, MD, SFHM, an intensivist with Aurora Medical Group in Wisconsin and an SHM board member, recommended developing comanagement services “carefully and methodically, paying close attention to consequences, intended and unintended”1 in a 2008 Journal of Hospital Medicine article. He tries to avoid broad generalizations about comanagement because “it’s applied variably across the industry. You’re going to find hospitalist programs that comanage very well and others that do it poorly.”

Dr. Siegal says he doesn’t think anyone in the field is “categorically anti-comanagement.”

However, he says it should be done thoughtfully, with clear goals in mind, and clearly defined roles and responsibilities. “Just showing up to see the specialists’ patients and calling it comanagement doesn’t necessarily mean you’re doing anything to make those patients’ care better,” he says.

Expert-Recommended

Demographic trends driving the spread of comanagement include an aging population of hospitalized patients with multiple comorbidities receiving surgical or other procedures that might not have been offered to them in the past. It fits with broader healthcare reform trends toward enhanced coordination and greater efficiency, illustrated by accountable-care organizations (ACOs).

Comanagement can be a growth and expansion opportunity for hospitalist groups, one that offers a defined niche and cements a group’s value to a hospital that wants improved relationships with surgeons. It also addresses the need for standardization and improved patient care in response to quality and safety concerns, and is associated with higher reported rates of satisfaction for surgeons and other staff and for patients.

“There are compelling reasons to do this, related to the limitations placed on resident work hours, which have affected neurosurgery and other surgical specialties profoundly, and the need to provide on-the-floor physician coverage more often and more consistently,” says UCSF hospitalist Andrew Auerbach, MD, MPH.

Comanagement has emerged as a solution to the challenge of caring for fragile patients with multiple medical comorbidities. ... Because busy surgeons cannot be in two places at once, comanagement allows for immediate availability of physicians with expertise in postoperative medical complications.—Sylvia McKean, MD, SFHM, senior hospitalist at Brigham and Women’s Hospital in Boston, SHM board member

Dr. Auerbach is the lead author of a recently published study of the neurosurgery comanagement service at UCSF, which found that the program did not result in changes in patient mortality, readmission rates, or lengths of stay (LOS), although it was associated with reduced costs and perceptions of higher quality by professionals.5 Previous research has identified similar results with regard to increased professional satisfaction but without improvements in hard clinical outcomes.6

“Our paper supports the idea that clinical benefits to patients are not there yet,” Dr. Auerbach says. “Maybe we haven’t comanaged the right kinds of patients. Is there something else we have to think about? Maybe the real action is to be found post-hospitalization.”

Comanagement Caveats

In his landmark 2008 JHM article, Dr. Siegal pointed to potential drawbacks associated with comanagement. For example, surgeons, other specialists, and residents can become disengaged from the medical care of their hospitalized patients. He also noted the exacerbation of hospitalist and generalist manpower shortages, as well as the theoretical risk of fragmentation of care that is provided by multiple physician managers. If hospitalists are asked to do things that are outside of their skill set, that can be a problem, too. But the biggest concerns seem to center on the potential negative impact on job satisfaction.

“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.”

Whatever your personal feelings about the comanagement relationship, pro or con, comanagement is going to be part of most hospital medicine groups’ repertoire of services.—Hugo Quinny Cheng, MD, director, comanagement with neurosurgery service, University of California at San Francisco Medical Center

Hospitalist dissatisfaction with comanagement is a problem with imperfect solutions, Dr. Cheng explains. “From my view, the biggest risk of comanagement is the inequality in relationships. Not every hospitalist has the temperament to do comanagement. If there is a perception that the partnership is unequal—favoring the surgeon—and if you feel like the junior partner in the relationship, it can be disheartening,” he says. “If the patient is not that sick, or if you feel you don’t have much to add professionally, it might feel like doing grunt work.”

Dr. Cheng also points to a theoretical increase in medical legal risk that the individual hospitalist faces. “With comanagement, you are taking responsibility not just for recommending care but for ensuring that the care is appropriately carried out, monitoring responses to treatment and dealing with delays,” he says. “When I talk to hospitalists, this fear of medical legal exposure comes up regularly.”

Rules of Engagement

SHM’s white paper offers a checklist of important issues to address when developing a comanagement service agreement. Issues include identifying champions from both sides of the collaboration, as well as from the hospital’s administration—which is an essential third party.

“Rules of engagement,” which should be spelled out in a written service agreement, include clarifying a shared vision, mutual goals and expectations, and the identified value proposition for both sides from the arrangement. Appropriate patients should be defined, along with what happens at night and on weekends, lines of authority and communication channels, and how conflicts will be addressed.

For Dr. McKean, the process really starts with “reflecting on your own core values.” Have a clear sense of the group’s goals, current staffing levels and pressures, and ability to add staff for a growing caseload, she says. “That’s where the rubber meets the road,” she adds. “You may want to hire people with a special interest in comanagement, and don’t try to have everyone in the group do everything.”

Jeanne Huddleston, MD, FACP, FHM, clinical scholar at the Mayo Clinic in Rochester, Minn., and past president of SHM, recommends dipping into the hospital’s database to get a better sense of the patient population targeted by a planned comanagement agreement—numbers, demographics, severity of illness, level of symptoms, length of stay, costs, and the like. Hospitalists also need to clearly understand the goals and needs of their comanagement partners—surgeons and other specialists—and of hospital administrators, who are an essential third party to the arrangement (see “What Hospitalists’ Comanagement Partners Are Saying,” above).

For Dr. Auerbach, the fundamental question is: “What are we specifically being asked to fix, and are we the right resource to fix the problem? Are we qualified to do it? Are we staffed to do it? Are we being given appropriate resources and authority to do it? And fundamentally, how are we going to know if we’ve made an improvement?” Quality metrics for comanagement—which should be gathered from the outset to provide a baseline—include in-hospital morbidity and mortality rates, 30-day mortality, hospital readmissions, length of hospital stay, costs of care, and overall return on investment for the hospital, as well as improved patient and professional satisfaction.

Experts agree that comanagement arrangements are unlikely to be self-sustaining from billing revenues alone, and thus will need some kind of support. In some cases, specialist groups can contribute the needed support, but more likely it is up to the hospital’s administration, based on its commitment to keeping its surgeons happy and busy in the operating suite, and on outcomes documenting financial and other benefits.

Medicare currently pays surgeons a global fee to manage their patient’s care associated with the surgery. Hospitalist comanagers typically bill under different codes for managing the patient’s medical conditions. But in an era of heightened regulatory scrutiny, health reform, and increased bundling of payments, this approach could be in for some revision, says Michael Ruhlen, MD, MHCM, FACHE, SFHM, chief medical officer of Carolinas Medical Centers in Charlotte, N.C.

ACOs will receive a global fee and apportion it among all the providers involved in a given episode of care, perhaps returning to capitation as a method to accomplish the apportionment, Dr. Ruhlen says. Hospitalists now developing comanagement agreements with surgeons should be aware that such changes are on the horizon, requiring all of the parties involved to rethink how their agreements are structured. In such cases, clearly demonstrating the value of both parties’ contributions to comanagement will be essential, he says.

Professional Impact

For The Cleveland Clinic’s Dr. Whinney, having a service agreement in place will help when physician reimbursement changes. “The thing you develop through these relationships is a sense of collegiality with your surgical colleagues, which is not something we’ve often seen before,” he says. “Particularly in large hospitals, where physicians don’t necessarily know each other, comanagement develops a true sense of collegiality.”

Felix Aguirre, MD, vice president of medical affairs for North Hollywood, Calif.-based IPC: The Hospitalist Company, says that a significant majority of hospitalized patients can benefit from an HM physician on the case.

“At IPC, we started with relationships [with the specialists], but as you go longer, you eventually move to more formal relationships, better defining what you are trying to do,” he says. “We’re still developing comanagement programs, and we’re trying to envision how they might relate to the readmission problem and to optimizing lengths of stay.”

Other industry leaders also ask how comanagement might contribute to the problem of hospital readmissions, perhaps with the hospitalist’s comanagement role continuing after the patient leaves the hospital. Others are exploring perioperative programs, broadly defined, with the hospitalist performing pre-operative assessments on an outpatient basis and helping to standardize processes and optimize the patient for surgery, thus reducing last-minute cancellations.

Ultimately, Dr. Huddleston says, these relationships should be built around putting the patient and the patient’s needs first, and patients don’t fit into neat boxes.

“Sometimes it’s comanagement, sometimes it’s just consultation. Each situation is discussed at the patient level,” she says. “As programs mature, all of these approaches can coexist. That’s where the service agreements become absolutely crucial, and they have to evolve as practice evolves. If you’re really basing it on patient need, you’ll probably end up with a hybrid of models.” TH

Larry Beresford is a freelance writer based in Oakland, Calif.

References

1. Hospitalist co-management with surgeons and specialists. SHM website. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/HTMLDisplay.cfm&ContentID=25894. Accessed March 11, 2011.
2. The core competencies in hospital medicine. ShM website. Available at: www.hospitalmedicine.org/Content/NavigationMenu/Education/CoreCurriculum/Core_Competencies.htm. Accessed March 11, 2011.
3. SHM Co-Management Advisory Panel. A white paper on a guide to hospitalist/orthopedic surgery co-management, SHM website. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=25864.Accessed March 11, 2011.
4. Siegal EM. Just because you can, doesn’t mean that you should: A call for the rational application of hospitalist comanagement. J Hosp Med. 2008;3(5):398-402.
5. Auerbach AD, Wachter RM, Cheng HQ, Maselli J, McDermott M, Vittinghoff E, Burger MS. Comanagement of surgical patients between neurosurgeons and hospitalists. Arch Intern Med. 2010;170(22):2004-2010.
6. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty: A randomized, controlled trial. Ann Intern Med. 2004;141(1):28-38.
7. Pinzur MS, Gurza E, Kristopaitis T, et al. Hospitalist-orthopedic comanagement of high-risk patients undergoing lower extremity reconstruction surgery. Orthopedics. 2009; 32(7):495.

What Hospitalists’ Comanagement Partners Are Saying

Dr. Ruhlen

Depending on local setting, culture, and HM group, hospital administrators often are very supportive of comanagement relationships, particularly if they improve satisfaction for surgeons practicing at the hospital, says Michael Ruhlen, MD, MHCM, FACHE, SFHM, chief medical officer of Carolinas Medical Centers in Charlotte, N.C. But that support is not a blank check.

“Administrators want to know that comanagement creates positive effects on quality, efficiency, and throughput. In this day and age, facilities are under the gun from many directions to demonstrate such improvements. We’re also responsible for ensuring patient satisfaction,” says Dr. Ruhlen, who was a member of SHM’s comanagement advisory group.

Dr. Pinzur

Michael Pinzur, MD, an orthopedic surgeon at Loyola University Medical Center in Chicago who was an advisory panel member, says the model for the comanagement agreement varies greatly from one facility to another. “There are some places where orthopedists want the hospitalists to do their scut work,” he says. “For us, we wanted to work together.

“When we developed our comanagement program for hip fracture patients, at the urging of the hospital’s administrators, we had an idea that this was a marriage both of us would benefit from,” he says.7 “As our hospitalists learned the unique needs of our patient population, we learned from their experience and then changed some of our treatment algorhythms. And they learned from us. We see this as real comanagement. Somebody from our group meets with one of the hospitalists every day, and periodically we sit down together and talk about our care processes. … They’re so in tune with issues of the orthopedic surgeon, they do very little unwanted testing.”

Dr. Boynton

For Melbourne Boynton, MD, clinical director of Vermont Orthopedic Clinic in Rutland and a member of the Board of Councilors of the American Association of Orthopaedic Surgeons, what’s most important is what matters to the patient.

“Optimal comanagement is a team approach,” he says, and it has worked well at Rutland Regional Medical Center.

However, it is more informal, rather than under a specific service agreement, because variable situations arise with elderly patients.

“There isn’t much that can’t get fixed with communication, and with focusing on what you’d want for your own mother in this situation,” he says. Which service is primary depends on how active a role each has in the patient’s care. “The quality of care is what matters, not whose service the patient is on.”—LB

Dr. Ruhlen

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.

Comanagement has been proposed as a solution to improve both patient care and professional satisfaction. But its promise can be eroded if the arrangement isn’t well planned and executed, experts say. Comanagement requires clearly defined roles, collaborative professional relationships, and some sense of equal standing with the surgeons or other specialists who call on hospitalists to care for their hospitalized patients’ medical needs.

“The growing formalization of comanagement agreements stems from prior tendency by some to view hospitalists as glorified house staff,” says Christopher Whinney, MD, FACP, FHM, director of comanagement at The Cleveland Clinic. “Hospitalists feel this is inappropriate, based on our skill set and scope of practice. There is also a concern that if a hospitalist group jumps in to do this without a clear service agreement in writing, that is where dumping can become a problem.”

Dr. Whinney is one of two expert mentors for hospitalists under a new SHM demonstration project called the Hospitalist Orthopedic Patient Service Comanagement Program, which is gathering data to evaluate its effectiveness on clinical and other outcomes. He has been working with five of the 10 participating HM groups, helping them define what it means to institutionalize formal comanagement relationships.

“Whatever your personal feelings about the comanagement relationship, pro or con, comanagement is going to be part of most hospital medicine groups’ repertoire of services,” says Hugo Quinny Cheng, MD, director of the comanagement with neurosurgery service at the University of California at San Francisco (UCSF) Medical Center. “You can try to avoid it, but if the medical center and the surgeons want it, there’s going to be pressure on your group to do it—or else they’ll look for another hospitalist group to do it.”

Dr. Cheng advises hospitalist group leaders make themselves aware of the trend and position themselves in a way to take advantage of it—or, at the very least, not be blindsided by it.

According to SHM data, 85% of hospitalist groups have done some kind of comanagement.¹ It’s not explicitly listed by SHM as one of The Core Competencies in Hospital Medicine, but it might as well be, says Leslie Flores, MHA, SHM senior advisor, practice management, because aspects of comanagement are addressed throughout.²

Defined, Distinguished, Delineated

Comanagement is different from traditional medical consultations performed by hospitalists upon request, and also differs from cases in which the hospitalist is the admitting physician of record with sole management responsibilities while the patient is in the hospital. According to an SHM white paper, A Guide to Hospitalist/Orthopedic Surgery Comanagement, the concept involves shared responsibility, authority, and accountability for the care of hospitalized patients, typically with orthopedic surgeons or other specialties, and with the hospitalist managing the patient’s medical concerns, such as diabetes, congestive heart failure, or DVT.³ (SHM’s website is full of comanagement resources, including sample service agreements; visit www.hospitalmedicine.org/publications and click on the “comanagement” button.)

But just as HM programs can be diverse in their organization, structure, and leadership, there is no single definition of comanagement, says Sylvia McKean, MD, SFHM, senior hospitalist at Brigham and Women’s Hospital in Boston. “You can have a very formal relationship where there’s a contract and where people are paid by whatever group is initiating the comanagement. There may be clear definitions in terms of their roles,” says Dr. McKean, an SHM board member who chaired the advisory panel that developed the comanagement white paper. “At the other extreme may be an informal relationship where you have a group of people in a community hospital who are available to manage medical problems when requested by specialists on a subset of patients.

“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.”

Eric Siegal, MD, SFHM, an intensivist with Aurora Medical Group in Wisconsin and an SHM board member, recommended developing comanagement services “carefully and methodically, paying close attention to consequences, intended and unintended”1 in a 2008 Journal of Hospital Medicine article. He tries to avoid broad generalizations about comanagement because “it’s applied variably across the industry. You’re going to find hospitalist programs that comanage very well and others that do it poorly.”

Dr. Siegal says he doesn’t think anyone in the field is “categorically anti-comanagement.”

However, he says it should be done thoughtfully, with clear goals in mind, and clearly defined roles and responsibilities. “Just showing up to see the specialists’ patients and calling it comanagement doesn’t necessarily mean you’re doing anything to make those patients’ care better,” he says.

Expert-Recommended

Demographic trends driving the spread of comanagement include an aging population of hospitalized patients with multiple comorbidities receiving surgical or other procedures that might not have been offered to them in the past. It fits with broader healthcare reform trends toward enhanced coordination and greater efficiency, illustrated by accountable-care organizations (ACOs).

Comanagement can be a growth and expansion opportunity for hospitalist groups, one that offers a defined niche and cements a group’s value to a hospital that wants improved relationships with surgeons. It also addresses the need for standardization and improved patient care in response to quality and safety concerns, and is associated with higher reported rates of satisfaction for surgeons and other staff and for patients.

“There are compelling reasons to do this, related to the limitations placed on resident work hours, which have affected neurosurgery and other surgical specialties profoundly, and the need to provide on-the-floor physician coverage more often and more consistently,” says UCSF hospitalist Andrew Auerbach, MD, MPH.

Comanagement has emerged as a solution to the challenge of caring for fragile patients with multiple medical comorbidities. ... Because busy surgeons cannot be in two places at once, comanagement allows for immediate availability of physicians with expertise in postoperative medical complications.—Sylvia McKean, MD, SFHM, senior hospitalist at Brigham and Women’s Hospital in Boston, SHM board member

Dr. Auerbach is the lead author of a recently published study of the neurosurgery comanagement service at UCSF, which found that the program did not result in changes in patient mortality, readmission rates, or lengths of stay (LOS), although it was associated with reduced costs and perceptions of higher quality by professionals.5 Previous research has identified similar results with regard to increased professional satisfaction but without improvements in hard clinical outcomes.6

“Our paper supports the idea that clinical benefits to patients are not there yet,” Dr. Auerbach says. “Maybe we haven’t comanaged the right kinds of patients. Is there something else we have to think about? Maybe the real action is to be found post-hospitalization.”

Comanagement Caveats

In his landmark 2008 JHM article, Dr. Siegal pointed to potential drawbacks associated with comanagement. For example, surgeons, other specialists, and residents can become disengaged from the medical care of their hospitalized patients. He also noted the exacerbation of hospitalist and generalist manpower shortages, as well as the theoretical risk of fragmentation of care that is provided by multiple physician managers. If hospitalists are asked to do things that are outside of their skill set, that can be a problem, too. But the biggest concerns seem to center on the potential negative impact on job satisfaction.

“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.”

Whatever your personal feelings about the comanagement relationship, pro or con, comanagement is going to be part of most hospital medicine groups’ repertoire of services.—Hugo Quinny Cheng, MD, director, comanagement with neurosurgery service, University of California at San Francisco Medical Center

Hospitalist dissatisfaction with comanagement is a problem with imperfect solutions, Dr. Cheng explains. “From my view, the biggest risk of comanagement is the inequality in relationships. Not every hospitalist has the temperament to do comanagement. If there is a perception that the partnership is unequal—favoring the surgeon—and if you feel like the junior partner in the relationship, it can be disheartening,” he says. “If the patient is not that sick, or if you feel you don’t have much to add professionally, it might feel like doing grunt work.”

Dr. Cheng also points to a theoretical increase in medical legal risk that the individual hospitalist faces. “With comanagement, you are taking responsibility not just for recommending care but for ensuring that the care is appropriately carried out, monitoring responses to treatment and dealing with delays,” he says. “When I talk to hospitalists, this fear of medical legal exposure comes up regularly.”

Rules of Engagement

SHM’s white paper offers a checklist of important issues to address when developing a comanagement service agreement. Issues include identifying champions from both sides of the collaboration, as well as from the hospital’s administration—which is an essential third party.

“Rules of engagement,” which should be spelled out in a written service agreement, include clarifying a shared vision, mutual goals and expectations, and the identified value proposition for both sides from the arrangement. Appropriate patients should be defined, along with what happens at night and on weekends, lines of authority and communication channels, and how conflicts will be addressed.

For Dr. McKean, the process really starts with “reflecting on your own core values.” Have a clear sense of the group’s goals, current staffing levels and pressures, and ability to add staff for a growing caseload, she says. “That’s where the rubber meets the road,” she adds. “You may want to hire people with a special interest in comanagement, and don’t try to have everyone in the group do everything.”

Jeanne Huddleston, MD, FACP, FHM, clinical scholar at the Mayo Clinic in Rochester, Minn., and past president of SHM, recommends dipping into the hospital’s database to get a better sense of the patient population targeted by a planned comanagement agreement—numbers, demographics, severity of illness, level of symptoms, length of stay, costs, and the like. Hospitalists also need to clearly understand the goals and needs of their comanagement partners—surgeons and other specialists—and of hospital administrators, who are an essential third party to the arrangement (see “What Hospitalists’ Comanagement Partners Are Saying,” above).

For Dr. Auerbach, the fundamental question is: “What are we specifically being asked to fix, and are we the right resource to fix the problem? Are we qualified to do it? Are we staffed to do it? Are we being given appropriate resources and authority to do it? And fundamentally, how are we going to know if we’ve made an improvement?” Quality metrics for comanagement—which should be gathered from the outset to provide a baseline—include in-hospital morbidity and mortality rates, 30-day mortality, hospital readmissions, length of hospital stay, costs of care, and overall return on investment for the hospital, as well as improved patient and professional satisfaction.

Experts agree that comanagement arrangements are unlikely to be self-sustaining from billing revenues alone, and thus will need some kind of support. In some cases, specialist groups can contribute the needed support, but more likely it is up to the hospital’s administration, based on its commitment to keeping its surgeons happy and busy in the operating suite, and on outcomes documenting financial and other benefits.

Medicare currently pays surgeons a global fee to manage their patient’s care associated with the surgery. Hospitalist comanagers typically bill under different codes for managing the patient’s medical conditions. But in an era of heightened regulatory scrutiny, health reform, and increased bundling of payments, this approach could be in for some revision, says Michael Ruhlen, MD, MHCM, FACHE, SFHM, chief medical officer of Carolinas Medical Centers in Charlotte, N.C.

ACOs will receive a global fee and apportion it among all the providers involved in a given episode of care, perhaps returning to capitation as a method to accomplish the apportionment, Dr. Ruhlen says. Hospitalists now developing comanagement agreements with surgeons should be aware that such changes are on the horizon, requiring all of the parties involved to rethink how their agreements are structured. In such cases, clearly demonstrating the value of both parties’ contributions to comanagement will be essential, he says.

Professional Impact

For The Cleveland Clinic’s Dr. Whinney, having a service agreement in place will help when physician reimbursement changes. “The thing you develop through these relationships is a sense of collegiality with your surgical colleagues, which is not something we’ve often seen before,” he says. “Particularly in large hospitals, where physicians don’t necessarily know each other, comanagement develops a true sense of collegiality.”

Felix Aguirre, MD, vice president of medical affairs for North Hollywood, Calif.-based IPC: The Hospitalist Company, says that a significant majority of hospitalized patients can benefit from an HM physician on the case.

“At IPC, we started with relationships [with the specialists], but as you go longer, you eventually move to more formal relationships, better defining what you are trying to do,” he says. “We’re still developing comanagement programs, and we’re trying to envision how they might relate to the readmission problem and to optimizing lengths of stay.”

Other industry leaders also ask how comanagement might contribute to the problem of hospital readmissions, perhaps with the hospitalist’s comanagement role continuing after the patient leaves the hospital. Others are exploring perioperative programs, broadly defined, with the hospitalist performing pre-operative assessments on an outpatient basis and helping to standardize processes and optimize the patient for surgery, thus reducing last-minute cancellations.

Ultimately, Dr. Huddleston says, these relationships should be built around putting the patient and the patient’s needs first, and patients don’t fit into neat boxes.

“Sometimes it’s comanagement, sometimes it’s just consultation. Each situation is discussed at the patient level,” she says. “As programs mature, all of these approaches can coexist. That’s where the service agreements become absolutely crucial, and they have to evolve as practice evolves. If you’re really basing it on patient need, you’ll probably end up with a hybrid of models.” TH

Larry Beresford is a freelance writer based in Oakland, Calif.

References

1. Hospitalist co-management with surgeons and specialists. SHM website. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/HTMLDisplay.cfm&ContentID=25894. Accessed March 11, 2011.
2. The core competencies in hospital medicine. ShM website. Available at: www.hospitalmedicine.org/Content/NavigationMenu/Education/CoreCurriculum/Core_Competencies.htm. Accessed March 11, 2011.
3. SHM Co-Management Advisory Panel. A white paper on a guide to hospitalist/orthopedic surgery co-management, SHM website. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=25864.Accessed March 11, 2011.
4. Siegal EM. Just because you can, doesn’t mean that you should: A call for the rational application of hospitalist comanagement. J Hosp Med. 2008;3(5):398-402.
5. Auerbach AD, Wachter RM, Cheng HQ, Maselli J, McDermott M, Vittinghoff E, Burger MS. Comanagement of surgical patients between neurosurgeons and hospitalists. Arch Intern Med. 2010;170(22):2004-2010.
6. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty: A randomized, controlled trial. Ann Intern Med. 2004;141(1):28-38.
7. Pinzur MS, Gurza E, Kristopaitis T, et al. Hospitalist-orthopedic comanagement of high-risk patients undergoing lower extremity reconstruction surgery. Orthopedics. 2009; 32(7):495.

What Hospitalists’ Comanagement Partners Are Saying

Dr. Ruhlen

Depending on local setting, culture, and HM group, hospital administrators often are very supportive of comanagement relationships, particularly if they improve satisfaction for surgeons practicing at the hospital, says Michael Ruhlen, MD, MHCM, FACHE, SFHM, chief medical officer of Carolinas Medical Centers in Charlotte, N.C. But that support is not a blank check.

“Administrators want to know that comanagement creates positive effects on quality, efficiency, and throughput. In this day and age, facilities are under the gun from many directions to demonstrate such improvements. We’re also responsible for ensuring patient satisfaction,” says Dr. Ruhlen, who was a member of SHM’s comanagement advisory group.

Dr. Pinzur

Michael Pinzur, MD, an orthopedic surgeon at Loyola University Medical Center in Chicago who was an advisory panel member, says the model for the comanagement agreement varies greatly from one facility to another. “There are some places where orthopedists want the hospitalists to do their scut work,” he says. “For us, we wanted to work together.

“When we developed our comanagement program for hip fracture patients, at the urging of the hospital’s administrators, we had an idea that this was a marriage both of us would benefit from,” he says.7 “As our hospitalists learned the unique needs of our patient population, we learned from their experience and then changed some of our treatment algorhythms. And they learned from us. We see this as real comanagement. Somebody from our group meets with one of the hospitalists every day, and periodically we sit down together and talk about our care processes. … They’re so in tune with issues of the orthopedic surgeon, they do very little unwanted testing.”

Dr. Boynton

For Melbourne Boynton, MD, clinical director of Vermont Orthopedic Clinic in Rutland and a member of the Board of Councilors of the American Association of Orthopaedic Surgeons, what’s most important is what matters to the patient.

“Optimal comanagement is a team approach,” he says, and it has worked well at Rutland Regional Medical Center.

However, it is more informal, rather than under a specific service agreement, because variable situations arise with elderly patients.

“There isn’t much that can’t get fixed with communication, and with focusing on what you’d want for your own mother in this situation,” he says. Which service is primary depends on how active a role each has in the patient’s care. “The quality of care is what matters, not whose service the patient is on.”—LB

Dr. Ruhlen

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.

Comanagement has been proposed as a solution to improve both patient care and professional satisfaction. But its promise can be eroded if the arrangement isn’t well planned and executed, experts say. Comanagement requires clearly defined roles, collaborative professional relationships, and some sense of equal standing with the surgeons or other specialists who call on hospitalists to care for their hospitalized patients’ medical needs.

“The growing formalization of comanagement agreements stems from prior tendency by some to view hospitalists as glorified house staff,” says Christopher Whinney, MD, FACP, FHM, director of comanagement at The Cleveland Clinic. “Hospitalists feel this is inappropriate, based on our skill set and scope of practice. There is also a concern that if a hospitalist group jumps in to do this without a clear service agreement in writing, that is where dumping can become a problem.”

Dr. Whinney is one of two expert mentors for hospitalists under a new SHM demonstration project called the Hospitalist Orthopedic Patient Service Comanagement Program, which is gathering data to evaluate its effectiveness on clinical and other outcomes. He has been working with five of the 10 participating HM groups, helping them define what it means to institutionalize formal comanagement relationships.

“Whatever your personal feelings about the comanagement relationship, pro or con, comanagement is going to be part of most hospital medicine groups’ repertoire of services,” says Hugo Quinny Cheng, MD, director of the comanagement with neurosurgery service at the University of California at San Francisco (UCSF) Medical Center. “You can try to avoid it, but if the medical center and the surgeons want it, there’s going to be pressure on your group to do it—or else they’ll look for another hospitalist group to do it.”

Dr. Cheng advises hospitalist group leaders make themselves aware of the trend and position themselves in a way to take advantage of it—or, at the very least, not be blindsided by it.

According to SHM data, 85% of hospitalist groups have done some kind of comanagement.¹ It’s not explicitly listed by SHM as one of The Core Competencies in Hospital Medicine, but it might as well be, says Leslie Flores, MHA, SHM senior advisor, practice management, because aspects of comanagement are addressed throughout.²

Defined, Distinguished, Delineated

Comanagement is different from traditional medical consultations performed by hospitalists upon request, and also differs from cases in which the hospitalist is the admitting physician of record with sole management responsibilities while the patient is in the hospital. According to an SHM white paper, A Guide to Hospitalist/Orthopedic Surgery Comanagement, the concept involves shared responsibility, authority, and accountability for the care of hospitalized patients, typically with orthopedic surgeons or other specialties, and with the hospitalist managing the patient’s medical concerns, such as diabetes, congestive heart failure, or DVT.³ (SHM’s website is full of comanagement resources, including sample service agreements; visit www.hospitalmedicine.org/publications and click on the “comanagement” button.)

But just as HM programs can be diverse in their organization, structure, and leadership, there is no single definition of comanagement, says Sylvia McKean, MD, SFHM, senior hospitalist at Brigham and Women’s Hospital in Boston. “You can have a very formal relationship where there’s a contract and where people are paid by whatever group is initiating the comanagement. There may be clear definitions in terms of their roles,” says Dr. McKean, an SHM board member who chaired the advisory panel that developed the comanagement white paper. “At the other extreme may be an informal relationship where you have a group of people in a community hospital who are available to manage medical problems when requested by specialists on a subset of patients.

“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.”

Eric Siegal, MD, SFHM, an intensivist with Aurora Medical Group in Wisconsin and an SHM board member, recommended developing comanagement services “carefully and methodically, paying close attention to consequences, intended and unintended”1 in a 2008 Journal of Hospital Medicine article. He tries to avoid broad generalizations about comanagement because “it’s applied variably across the industry. You’re going to find hospitalist programs that comanage very well and others that do it poorly.”

Dr. Siegal says he doesn’t think anyone in the field is “categorically anti-comanagement.”

However, he says it should be done thoughtfully, with clear goals in mind, and clearly defined roles and responsibilities. “Just showing up to see the specialists’ patients and calling it comanagement doesn’t necessarily mean you’re doing anything to make those patients’ care better,” he says.

Expert-Recommended

Demographic trends driving the spread of comanagement include an aging population of hospitalized patients with multiple comorbidities receiving surgical or other procedures that might not have been offered to them in the past. It fits with broader healthcare reform trends toward enhanced coordination and greater efficiency, illustrated by accountable-care organizations (ACOs).

Comanagement can be a growth and expansion opportunity for hospitalist groups, one that offers a defined niche and cements a group’s value to a hospital that wants improved relationships with surgeons. It also addresses the need for standardization and improved patient care in response to quality and safety concerns, and is associated with higher reported rates of satisfaction for surgeons and other staff and for patients.

“There are compelling reasons to do this, related to the limitations placed on resident work hours, which have affected neurosurgery and other surgical specialties profoundly, and the need to provide on-the-floor physician coverage more often and more consistently,” says UCSF hospitalist Andrew Auerbach, MD, MPH.

Comanagement has emerged as a solution to the challenge of caring for fragile patients with multiple medical comorbidities. ... Because busy surgeons cannot be in two places at once, comanagement allows for immediate availability of physicians with expertise in postoperative medical complications.—Sylvia McKean, MD, SFHM, senior hospitalist at Brigham and Women’s Hospital in Boston, SHM board member

Dr. Auerbach is the lead author of a recently published study of the neurosurgery comanagement service at UCSF, which found that the program did not result in changes in patient mortality, readmission rates, or lengths of stay (LOS), although it was associated with reduced costs and perceptions of higher quality by professionals.5 Previous research has identified similar results with regard to increased professional satisfaction but without improvements in hard clinical outcomes.6

“Our paper supports the idea that clinical benefits to patients are not there yet,” Dr. Auerbach says. “Maybe we haven’t comanaged the right kinds of patients. Is there something else we have to think about? Maybe the real action is to be found post-hospitalization.”

Comanagement Caveats

In his landmark 2008 JHM article, Dr. Siegal pointed to potential drawbacks associated with comanagement. For example, surgeons, other specialists, and residents can become disengaged from the medical care of their hospitalized patients. He also noted the exacerbation of hospitalist and generalist manpower shortages, as well as the theoretical risk of fragmentation of care that is provided by multiple physician managers. If hospitalists are asked to do things that are outside of their skill set, that can be a problem, too. But the biggest concerns seem to center on the potential negative impact on job satisfaction.

“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.”

Whatever your personal feelings about the comanagement relationship, pro or con, comanagement is going to be part of most hospital medicine groups’ repertoire of services.—Hugo Quinny Cheng, MD, director, comanagement with neurosurgery service, University of California at San Francisco Medical Center

Hospitalist dissatisfaction with comanagement is a problem with imperfect solutions, Dr. Cheng explains. “From my view, the biggest risk of comanagement is the inequality in relationships. Not every hospitalist has the temperament to do comanagement. If there is a perception that the partnership is unequal—favoring the surgeon—and if you feel like the junior partner in the relationship, it can be disheartening,” he says. “If the patient is not that sick, or if you feel you don’t have much to add professionally, it might feel like doing grunt work.”

Dr. Cheng also points to a theoretical increase in medical legal risk that the individual hospitalist faces. “With comanagement, you are taking responsibility not just for recommending care but for ensuring that the care is appropriately carried out, monitoring responses to treatment and dealing with delays,” he says. “When I talk to hospitalists, this fear of medical legal exposure comes up regularly.”

Rules of Engagement

SHM’s white paper offers a checklist of important issues to address when developing a comanagement service agreement. Issues include identifying champions from both sides of the collaboration, as well as from the hospital’s administration—which is an essential third party.

“Rules of engagement,” which should be spelled out in a written service agreement, include clarifying a shared vision, mutual goals and expectations, and the identified value proposition for both sides from the arrangement. Appropriate patients should be defined, along with what happens at night and on weekends, lines of authority and communication channels, and how conflicts will be addressed.

For Dr. McKean, the process really starts with “reflecting on your own core values.” Have a clear sense of the group’s goals, current staffing levels and pressures, and ability to add staff for a growing caseload, she says. “That’s where the rubber meets the road,” she adds. “You may want to hire people with a special interest in comanagement, and don’t try to have everyone in the group do everything.”

Jeanne Huddleston, MD, FACP, FHM, clinical scholar at the Mayo Clinic in Rochester, Minn., and past president of SHM, recommends dipping into the hospital’s database to get a better sense of the patient population targeted by a planned comanagement agreement—numbers, demographics, severity of illness, level of symptoms, length of stay, costs, and the like. Hospitalists also need to clearly understand the goals and needs of their comanagement partners—surgeons and other specialists—and of hospital administrators, who are an essential third party to the arrangement (see “What Hospitalists’ Comanagement Partners Are Saying,” above).

For Dr. Auerbach, the fundamental question is: “What are we specifically being asked to fix, and are we the right resource to fix the problem? Are we qualified to do it? Are we staffed to do it? Are we being given appropriate resources and authority to do it? And fundamentally, how are we going to know if we’ve made an improvement?” Quality metrics for comanagement—which should be gathered from the outset to provide a baseline—include in-hospital morbidity and mortality rates, 30-day mortality, hospital readmissions, length of hospital stay, costs of care, and overall return on investment for the hospital, as well as improved patient and professional satisfaction.

Experts agree that comanagement arrangements are unlikely to be self-sustaining from billing revenues alone, and thus will need some kind of support. In some cases, specialist groups can contribute the needed support, but more likely it is up to the hospital’s administration, based on its commitment to keeping its surgeons happy and busy in the operating suite, and on outcomes documenting financial and other benefits.

Medicare currently pays surgeons a global fee to manage their patient’s care associated with the surgery. Hospitalist comanagers typically bill under different codes for managing the patient’s medical conditions. But in an era of heightened regulatory scrutiny, health reform, and increased bundling of payments, this approach could be in for some revision, says Michael Ruhlen, MD, MHCM, FACHE, SFHM, chief medical officer of Carolinas Medical Centers in Charlotte, N.C.

ACOs will receive a global fee and apportion it among all the providers involved in a given episode of care, perhaps returning to capitation as a method to accomplish the apportionment, Dr. Ruhlen says. Hospitalists now developing comanagement agreements with surgeons should be aware that such changes are on the horizon, requiring all of the parties involved to rethink how their agreements are structured. In such cases, clearly demonstrating the value of both parties’ contributions to comanagement will be essential, he says.

Professional Impact

For The Cleveland Clinic’s Dr. Whinney, having a service agreement in place will help when physician reimbursement changes. “The thing you develop through these relationships is a sense of collegiality with your surgical colleagues, which is not something we’ve often seen before,” he says. “Particularly in large hospitals, where physicians don’t necessarily know each other, comanagement develops a true sense of collegiality.”

Felix Aguirre, MD, vice president of medical affairs for North Hollywood, Calif.-based IPC: The Hospitalist Company, says that a significant majority of hospitalized patients can benefit from an HM physician on the case.

“At IPC, we started with relationships [with the specialists], but as you go longer, you eventually move to more formal relationships, better defining what you are trying to do,” he says. “We’re still developing comanagement programs, and we’re trying to envision how they might relate to the readmission problem and to optimizing lengths of stay.”

Other industry leaders also ask how comanagement might contribute to the problem of hospital readmissions, perhaps with the hospitalist’s comanagement role continuing after the patient leaves the hospital. Others are exploring perioperative programs, broadly defined, with the hospitalist performing pre-operative assessments on an outpatient basis and helping to standardize processes and optimize the patient for surgery, thus reducing last-minute cancellations.

Ultimately, Dr. Huddleston says, these relationships should be built around putting the patient and the patient’s needs first, and patients don’t fit into neat boxes.

“Sometimes it’s comanagement, sometimes it’s just consultation. Each situation is discussed at the patient level,” she says. “As programs mature, all of these approaches can coexist. That’s where the service agreements become absolutely crucial, and they have to evolve as practice evolves. If you’re really basing it on patient need, you’ll probably end up with a hybrid of models.” TH

Larry Beresford is a freelance writer based in Oakland, Calif.

References

1. Hospitalist co-management with surgeons and specialists. SHM website. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/HTMLDisplay.cfm&ContentID=25894. Accessed March 11, 2011.
2. The core competencies in hospital medicine. ShM website. Available at: www.hospitalmedicine.org/Content/NavigationMenu/Education/CoreCurriculum/Core_Competencies.htm. Accessed March 11, 2011.
3. SHM Co-Management Advisory Panel. A white paper on a guide to hospitalist/orthopedic surgery co-management, SHM website. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=25864.Accessed March 11, 2011.
4. Siegal EM. Just because you can, doesn’t mean that you should: A call for the rational application of hospitalist comanagement. J Hosp Med. 2008;3(5):398-402.
5. Auerbach AD, Wachter RM, Cheng HQ, Maselli J, McDermott M, Vittinghoff E, Burger MS. Comanagement of surgical patients between neurosurgeons and hospitalists. Arch Intern Med. 2010;170(22):2004-2010.
6. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty: A randomized, controlled trial. Ann Intern Med. 2004;141(1):28-38.
7. Pinzur MS, Gurza E, Kristopaitis T, et al. Hospitalist-orthopedic comanagement of high-risk patients undergoing lower extremity reconstruction surgery. Orthopedics. 2009; 32(7):495.

What Hospitalists’ Comanagement Partners Are Saying

Dr. Ruhlen

Depending on local setting, culture, and HM group, hospital administrators often are very supportive of comanagement relationships, particularly if they improve satisfaction for surgeons practicing at the hospital, says Michael Ruhlen, MD, MHCM, FACHE, SFHM, chief medical officer of Carolinas Medical Centers in Charlotte, N.C. But that support is not a blank check.

“Administrators want to know that comanagement creates positive effects on quality, efficiency, and throughput. In this day and age, facilities are under the gun from many directions to demonstrate such improvements. We’re also responsible for ensuring patient satisfaction,” says Dr. Ruhlen, who was a member of SHM’s comanagement advisory group.

Dr. Pinzur

Michael Pinzur, MD, an orthopedic surgeon at Loyola University Medical Center in Chicago who was an advisory panel member, says the model for the comanagement agreement varies greatly from one facility to another. “There are some places where orthopedists want the hospitalists to do their scut work,” he says. “For us, we wanted to work together.

“When we developed our comanagement program for hip fracture patients, at the urging of the hospital’s administrators, we had an idea that this was a marriage both of us would benefit from,” he says.7 “As our hospitalists learned the unique needs of our patient population, we learned from their experience and then changed some of our treatment algorhythms. And they learned from us. We see this as real comanagement. Somebody from our group meets with one of the hospitalists every day, and periodically we sit down together and talk about our care processes. … They’re so in tune with issues of the orthopedic surgeon, they do very little unwanted testing.”

Dr. Boynton

For Melbourne Boynton, MD, clinical director of Vermont Orthopedic Clinic in Rutland and a member of the Board of Councilors of the American Association of Orthopaedic Surgeons, what’s most important is what matters to the patient.

“Optimal comanagement is a team approach,” he says, and it has worked well at Rutland Regional Medical Center.

However, it is more informal, rather than under a specific service agreement, because variable situations arise with elderly patients.

“There isn’t much that can’t get fixed with communication, and with focusing on what you’d want for your own mother in this situation,” he says. Which service is primary depends on how active a role each has in the patient’s care. “The quality of care is what matters, not whose service the patient is on.”—LB

Click here to listen to Dr. McKean

Click here to listen to Dr. Wachter

Click here to listen to Dr. Siegal

Click here to listen to Dr. Cheng

Click here to listen to Dr. Auerbach

Click here to listen to Dr. McKean

Click here to listen to Dr. Wachter

Click here to listen to Dr. Siegal

Click here to listen to Dr. Cheng

Click here to listen to Dr. Auerbach

Click here to listen to Dr. McKean

Click here to listen to Dr. Wachter

Click here to listen to Dr. Siegal

Click here to listen to Dr. Cheng

Click here to listen to Dr. Auerbach

One of the emerging trends in comanagement by hospitalists (see “The Comanagement Conundrum,” p. 1, April 2011) is an expanded role in the perioperative care of surgical patients—extending from before the operation into rehabilitation. To be successful, hospitalists should think more broadly than the usual focus on medical needs immediately post-surgery, says Burke Kealey, MD, director of perioperative comanagement at Regions Hospital in St. Paul, Minn.

The perioperative service at Regions includes staffing of a pre-operative clinic, a partnership with the hospital’s anesthesia department, and use of a pre-operative patient checklist. Many primary-care physicians (PCPs) want to retain a role in the pre-operative assessments of their patients, so the Regions service has tried to partner with physicians in the community to work on standardizing the process.

Dr. Kealey, an SHM board member, was hired by Regions’ orthopedic department right out of residency in 1995 to do medical comanagement of its patients. His service later was absorbed into an emerging HM department. It has experimented with models including the use of nurse practitioners and physician assistants.

Today, Regions dedicates three of its 16 full-time hospitalist teams to comanagement services, largely on the orthopedics floor, but also for cardiovascular surgery and urology. “As hospitalists, we can help to facilitate using the best, up-to-date medical knowledge” both before and after surgery, he says.

At the University of Rochester School of Medicine in New York, a group of fellowship-trained geriatric hospitalists has taken on comanagement of hip fracture patients at the Geriatric Fracture Center, leading to improved processes and patient outcomes.¹ According to hospitalist Susan M. Friedman, MD, MPH, the program began as a collaboration between a geriatrician and an orthopedic surgeon. They found that their patients’ outcomes seemed to be better when they worked together on a case, so they sat down to talk about what they were doing and how to standardize it.

“From the start, they set the tone for how this is supposed work, and when it doesn’t, they find out why and address it,” Dr. Friedman says. The program does not use a formal service agreement, but there is a strong emphasis on co-ownership, mutual respect, and communication. “One thing that has helped us a lot is data-gathering,” she adds. The hip fracture comanagement has cut lengths of stay and readmissions by half and complications by one-third for the mostly elderly patients.

Larry Beresford is a freelance writer based in Oakland, Calif.

Reference

1. Friedman SM, Mendelson DA, Bingham KW, Kates SL. Impact of co-managed geriatric fracture center on short-term hip fracture outcomes. Arch Intern Med. 2009;169(18):1712-1717.

One of the emerging trends in comanagement by hospitalists (see “The Comanagement Conundrum,” p. 1, April 2011) is an expanded role in the perioperative care of surgical patients—extending from before the operation into rehabilitation. To be successful, hospitalists should think more broadly than the usual focus on medical needs immediately post-surgery, says Burke Kealey, MD, director of perioperative comanagement at Regions Hospital in St. Paul, Minn.

The perioperative service at Regions includes staffing of a pre-operative clinic, a partnership with the hospital’s anesthesia department, and use of a pre-operative patient checklist. Many primary-care physicians (PCPs) want to retain a role in the pre-operative assessments of their patients, so the Regions service has tried to partner with physicians in the community to work on standardizing the process.

Dr. Kealey, an SHM board member, was hired by Regions’ orthopedic department right out of residency in 1995 to do medical comanagement of its patients. His service later was absorbed into an emerging HM department. It has experimented with models including the use of nurse practitioners and physician assistants.

Today, Regions dedicates three of its 16 full-time hospitalist teams to comanagement services, largely on the orthopedics floor, but also for cardiovascular surgery and urology. “As hospitalists, we can help to facilitate using the best, up-to-date medical knowledge” both before and after surgery, he says.

At the University of Rochester School of Medicine in New York, a group of fellowship-trained geriatric hospitalists has taken on comanagement of hip fracture patients at the Geriatric Fracture Center, leading to improved processes and patient outcomes.¹ According to hospitalist Susan M. Friedman, MD, MPH, the program began as a collaboration between a geriatrician and an orthopedic surgeon. They found that their patients’ outcomes seemed to be better when they worked together on a case, so they sat down to talk about what they were doing and how to standardize it.

“From the start, they set the tone for how this is supposed work, and when it doesn’t, they find out why and address it,” Dr. Friedman says. The program does not use a formal service agreement, but there is a strong emphasis on co-ownership, mutual respect, and communication. “One thing that has helped us a lot is data-gathering,” she adds. The hip fracture comanagement has cut lengths of stay and readmissions by half and complications by one-third for the mostly elderly patients.

Larry Beresford is a freelance writer based in Oakland, Calif.

Reference

1. Friedman SM, Mendelson DA, Bingham KW, Kates SL. Impact of co-managed geriatric fracture center on short-term hip fracture outcomes. Arch Intern Med. 2009;169(18):1712-1717.

One of the emerging trends in comanagement by hospitalists (see “The Comanagement Conundrum,” p. 1, April 2011) is an expanded role in the perioperative care of surgical patients—extending from before the operation into rehabilitation. To be successful, hospitalists should think more broadly than the usual focus on medical needs immediately post-surgery, says Burke Kealey, MD, director of perioperative comanagement at Regions Hospital in St. Paul, Minn.

The perioperative service at Regions includes staffing of a pre-operative clinic, a partnership with the hospital’s anesthesia department, and use of a pre-operative patient checklist. Many primary-care physicians (PCPs) want to retain a role in the pre-operative assessments of their patients, so the Regions service has tried to partner with physicians in the community to work on standardizing the process.

Dr. Kealey, an SHM board member, was hired by Regions’ orthopedic department right out of residency in 1995 to do medical comanagement of its patients. His service later was absorbed into an emerging HM department. It has experimented with models including the use of nurse practitioners and physician assistants.

Today, Regions dedicates three of its 16 full-time hospitalist teams to comanagement services, largely on the orthopedics floor, but also for cardiovascular surgery and urology. “As hospitalists, we can help to facilitate using the best, up-to-date medical knowledge” both before and after surgery, he says.

At the University of Rochester School of Medicine in New York, a group of fellowship-trained geriatric hospitalists has taken on comanagement of hip fracture patients at the Geriatric Fracture Center, leading to improved processes and patient outcomes.¹ According to hospitalist Susan M. Friedman, MD, MPH, the program began as a collaboration between a geriatrician and an orthopedic surgeon. They found that their patients’ outcomes seemed to be better when they worked together on a case, so they sat down to talk about what they were doing and how to standardize it.

“From the start, they set the tone for how this is supposed work, and when it doesn’t, they find out why and address it,” Dr. Friedman says. The program does not use a formal service agreement, but there is a strong emphasis on co-ownership, mutual respect, and communication. “One thing that has helped us a lot is data-gathering,” she adds. The hip fracture comanagement has cut lengths of stay and readmissions by half and complications by one-third for the mostly elderly patients.

Larry Beresford is a freelance writer based in Oakland, Calif.

Reference

1. Friedman SM, Mendelson DA, Bingham KW, Kates SL. Impact of co-managed geriatric fracture center on short-term hip fracture outcomes. Arch Intern Med. 2009;169(18):1712-1717.

An article in the upcoming May issue of Archives of Pediatrics and Adolescent Medicine tracks the growing incidence of Clostridium difficile bacterial infections in hospitalized children.

Cade M. Nylund, MD, assistant professor of pediatrics at the Uniformed Services University of the Health Sciences in Bethesda, Md., and colleagues analyzed a national database of children discharged from hospitals in 1997, 2000, 2003, and 2006. Of 10.5 million total cases, only 0.2% had C. diff infections, but the number of cases increased by about 15% per year.

Incidence, severity, and deaths from C. diff in adults have also been increasing. Unlike adults, however, the authors did not observe an increase in severity of the disease for children over this time period. Infection, however, was associated with increased risk of death, higher colectomy rates, longer hospital stays, and higher costs.

Dr. Nylund says it is difficult to explain why is increasing in hospitalized children, but it might reflect antibiotic treatment practices, since prior antibiotic exposure is considered a risk factor. It also could be due to a more virulent strain of C. diff commonly found in hospitals, or the fact that healthcare providers are more aware of the need to test symptomatic patients for this infection.

According to Dr. Nylund, pediatric hospitalists should be aware of the significant impact of C. diff. "These children are more likely to stay in the hospital or die," he says. He suggests paying attention to such risk factors as antibiotic use, immune system suppression, and persistent diarrhea, as well as the need for a differential diagnosis. Appropriate and early isolation is important, as is hand-washing with soap and water, not using just alcohol-based hand gels, he adds.

"A lot of antibiotics are used to treat C. diff, some of them off-label," Dr. Nylund says. "I get phone consults, typically for difficult, recurring, and chronic cases. It seems like I'm receiving those calls more frequently."

For more information on treatment of C. diff, check out the Key Clinical Question in the March 2009 issue of The Hospitalist.

An article in the upcoming May issue of Archives of Pediatrics and Adolescent Medicine tracks the growing incidence of Clostridium difficile bacterial infections in hospitalized children.

Cade M. Nylund, MD, assistant professor of pediatrics at the Uniformed Services University of the Health Sciences in Bethesda, Md., and colleagues analyzed a national database of children discharged from hospitals in 1997, 2000, 2003, and 2006. Of 10.5 million total cases, only 0.2% had C. diff infections, but the number of cases increased by about 15% per year.

Incidence, severity, and deaths from C. diff in adults have also been increasing. Unlike adults, however, the authors did not observe an increase in severity of the disease for children over this time period. Infection, however, was associated with increased risk of death, higher colectomy rates, longer hospital stays, and higher costs.

Dr. Nylund says it is difficult to explain why is increasing in hospitalized children, but it might reflect antibiotic treatment practices, since prior antibiotic exposure is considered a risk factor. It also could be due to a more virulent strain of C. diff commonly found in hospitals, or the fact that healthcare providers are more aware of the need to test symptomatic patients for this infection.

According to Dr. Nylund, pediatric hospitalists should be aware of the significant impact of C. diff. "These children are more likely to stay in the hospital or die," he says. He suggests paying attention to such risk factors as antibiotic use, immune system suppression, and persistent diarrhea, as well as the need for a differential diagnosis. Appropriate and early isolation is important, as is hand-washing with soap and water, not using just alcohol-based hand gels, he adds.

"A lot of antibiotics are used to treat C. diff, some of them off-label," Dr. Nylund says. "I get phone consults, typically for difficult, recurring, and chronic cases. It seems like I'm receiving those calls more frequently."

For more information on treatment of C. diff, check out the Key Clinical Question in the March 2009 issue of The Hospitalist.

An article in the upcoming May issue of Archives of Pediatrics and Adolescent Medicine tracks the growing incidence of Clostridium difficile bacterial infections in hospitalized children.

Cade M. Nylund, MD, assistant professor of pediatrics at the Uniformed Services University of the Health Sciences in Bethesda, Md., and colleagues analyzed a national database of children discharged from hospitals in 1997, 2000, 2003, and 2006. Of 10.5 million total cases, only 0.2% had C. diff infections, but the number of cases increased by about 15% per year.

Incidence, severity, and deaths from C. diff in adults have also been increasing. Unlike adults, however, the authors did not observe an increase in severity of the disease for children over this time period. Infection, however, was associated with increased risk of death, higher colectomy rates, longer hospital stays, and higher costs.

Dr. Nylund says it is difficult to explain why is increasing in hospitalized children, but it might reflect antibiotic treatment practices, since prior antibiotic exposure is considered a risk factor. It also could be due to a more virulent strain of C. diff commonly found in hospitals, or the fact that healthcare providers are more aware of the need to test symptomatic patients for this infection.

According to Dr. Nylund, pediatric hospitalists should be aware of the significant impact of C. diff. "These children are more likely to stay in the hospital or die," he says. He suggests paying attention to such risk factors as antibiotic use, immune system suppression, and persistent diarrhea, as well as the need for a differential diagnosis. Appropriate and early isolation is important, as is hand-washing with soap and water, not using just alcohol-based hand gels, he adds.

"A lot of antibiotics are used to treat C. diff, some of them off-label," Dr. Nylund says. "I get phone consults, typically for difficult, recurring, and chronic cases. It seems like I'm receiving those calls more frequently."

For more information on treatment of C. diff, check out the Key Clinical Question in the March 2009 issue of The Hospitalist.

A new study of patients with ischemic stroke (JAMA. 2011;305:373-380) found that those admitted to hospitals certified as primary stroke centers had a modestly lower risk of death and serious disability.

Ying Xian, MD, PhD, of the Duke Clinical Research Institute in Durham, N.C., and colleagues compared mortality rates for 30,000 stroke patients in a New York state database, half of them admitted to certified stroke centers and the rest to nondesignated hospitals. Overall 30-day, all-cause mortality was 10.1% for the former group, 12.5% for the latter.

But this modestly lower death rate is still important, says Mark J. Alberts, MD, director of the stroke program at Northwestern University Feinberg School of Medicine in Chicago. "There aren't that many interventions we do in modern medical care that actually prevent death."

In an editorial accompanying the JAMA stroke study, Dr. Alberts portrays an emerging, multitiered system of stroke care, "with the comprehensive stroke center at the top of the pyramid, the primary stroke center in the middle, and the acute stroke-ready hospital at the base." He compares this emerging system to trauma care, which has Level 1 trauma centers at the top of its pyramid.

Not every hospital within a region might be able to pursue stroke center certification, or even become more stroke-ready, he says. But hospitals could work collaboratively to create regional stroke referral networks based on the distribution of patients and resources. Hospitalists can help promote such networks (see The Hospitalist, December 2009). "I would start by knowing your patient population, how many stroke patients present at your hospital each year," he explains.

"The overriding concept is to get stroke patients as efficiently and safely as possible to the hospital that can provide them with the most appropriate level of care," Dr. Alberts says.

More than 800 U.S. hospitals are certified as primary stroke centers by the Joint Commission. While there are not yet formal standards or requirements for an acute-stroke-ready hospital, the term suggests mobilizing resources, capabilities and expertise to receive stroke patients, stabilize them, and send them to the most appropriate facilities based on their medical needs.

A new study of patients with ischemic stroke (JAMA. 2011;305:373-380) found that those admitted to hospitals certified as primary stroke centers had a modestly lower risk of death and serious disability.

Ying Xian, MD, PhD, of the Duke Clinical Research Institute in Durham, N.C., and colleagues compared mortality rates for 30,000 stroke patients in a New York state database, half of them admitted to certified stroke centers and the rest to nondesignated hospitals. Overall 30-day, all-cause mortality was 10.1% for the former group, 12.5% for the latter.

But this modestly lower death rate is still important, says Mark J. Alberts, MD, director of the stroke program at Northwestern University Feinberg School of Medicine in Chicago. "There aren't that many interventions we do in modern medical care that actually prevent death."

In an editorial accompanying the JAMA stroke study, Dr. Alberts portrays an emerging, multitiered system of stroke care, "with the comprehensive stroke center at the top of the pyramid, the primary stroke center in the middle, and the acute stroke-ready hospital at the base." He compares this emerging system to trauma care, which has Level 1 trauma centers at the top of its pyramid.

Not every hospital within a region might be able to pursue stroke center certification, or even become more stroke-ready, he says. But hospitals could work collaboratively to create regional stroke referral networks based on the distribution of patients and resources. Hospitalists can help promote such networks (see The Hospitalist, December 2009). "I would start by knowing your patient population, how many stroke patients present at your hospital each year," he explains.

"The overriding concept is to get stroke patients as efficiently and safely as possible to the hospital that can provide them with the most appropriate level of care," Dr. Alberts says.

More than 800 U.S. hospitals are certified as primary stroke centers by the Joint Commission. While there are not yet formal standards or requirements for an acute-stroke-ready hospital, the term suggests mobilizing resources, capabilities and expertise to receive stroke patients, stabilize them, and send them to the most appropriate facilities based on their medical needs.

A new study of patients with ischemic stroke (JAMA. 2011;305:373-380) found that those admitted to hospitals certified as primary stroke centers had a modestly lower risk of death and serious disability.

Ying Xian, MD, PhD, of the Duke Clinical Research Institute in Durham, N.C., and colleagues compared mortality rates for 30,000 stroke patients in a New York state database, half of them admitted to certified stroke centers and the rest to nondesignated hospitals. Overall 30-day, all-cause mortality was 10.1% for the former group, 12.5% for the latter.

But this modestly lower death rate is still important, says Mark J. Alberts, MD, director of the stroke program at Northwestern University Feinberg School of Medicine in Chicago. "There aren't that many interventions we do in modern medical care that actually prevent death."

In an editorial accompanying the JAMA stroke study, Dr. Alberts portrays an emerging, multitiered system of stroke care, "with the comprehensive stroke center at the top of the pyramid, the primary stroke center in the middle, and the acute stroke-ready hospital at the base." He compares this emerging system to trauma care, which has Level 1 trauma centers at the top of its pyramid.

Not every hospital within a region might be able to pursue stroke center certification, or even become more stroke-ready, he says. But hospitals could work collaboratively to create regional stroke referral networks based on the distribution of patients and resources. Hospitalists can help promote such networks (see The Hospitalist, December 2009). "I would start by knowing your patient population, how many stroke patients present at your hospital each year," he explains.

"The overriding concept is to get stroke patients as efficiently and safely as possible to the hospital that can provide them with the most appropriate level of care," Dr. Alberts says.

More than 800 U.S. hospitals are certified as primary stroke centers by the Joint Commission. While there are not yet formal standards or requirements for an acute-stroke-ready hospital, the term suggests mobilizing resources, capabilities and expertise to receive stroke patients, stabilize them, and send them to the most appropriate facilities based on their medical needs.

David Meltzer, MD, PhD, a hospitalist and medical researcher at the University of Chicago, is one of 15 appointees who were named in January to the Methodology Committee of the Patient-Centered Outcomes Research Institute (PCORI), which was created by last year's Accountable Care Act to advise the federal government on clinical-effectiveness research (CER).

Dr. Meltzer, chief of UC's Division of Hospital Medicine and director of the Center for Health and Social Sciences in Chicago, has been active in a number of areas of advanced medical research, including technology assessment, CER, value-of-information research, and prioritization of the research agenda. One of his research topics has been whether hospitalists reduce length of stay and costs.

"Healthcare is a very complicated issue, for a bunch of reasons," he says. "It costs a lot of money, and it matters to a lot of people."

Last year's health-reform debate demonstrated how complicated it can be, with CER itself the target of some controversy. The challenge for PCORI is “to increase the information available to make the best choices regarding the application of medical treatments," he explains.

According to Dr. Meltzer, who also sits on the Congressional Budget Office's panel of health advisors, the reality is that physicians use medical evidence to guide treatment decisions every day. "But there are major holes in what we know and don't know. I would hope that PCORI will help to fill in those major holes more quickly," he adds.

If CER is done effectively, Dr. Meltzer says, hospitalists and other clinicians could find themselves and their patients more frequently involved in research and data generation, making it increasingly important to explain to patients why this sort of research is important.

"He has not only been a leader in hospital medicine, but also a noted health economist and researcher," says Margaret Fang, MD, a hospitalist at the University of California at San Francisco. "All of these skills will be vitally important when addressing issues in comparative-effectiveness research."

David Meltzer, MD, PhD, a hospitalist and medical researcher at the University of Chicago, is one of 15 appointees who were named in January to the Methodology Committee of the Patient-Centered Outcomes Research Institute (PCORI), which was created by last year's Accountable Care Act to advise the federal government on clinical-effectiveness research (CER).

Dr. Meltzer, chief of UC's Division of Hospital Medicine and director of the Center for Health and Social Sciences in Chicago, has been active in a number of areas of advanced medical research, including technology assessment, CER, value-of-information research, and prioritization of the research agenda. One of his research topics has been whether hospitalists reduce length of stay and costs.

"Healthcare is a very complicated issue, for a bunch of reasons," he says. "It costs a lot of money, and it matters to a lot of people."

Last year's health-reform debate demonstrated how complicated it can be, with CER itself the target of some controversy. The challenge for PCORI is “to increase the information available to make the best choices regarding the application of medical treatments," he explains.

According to Dr. Meltzer, who also sits on the Congressional Budget Office's panel of health advisors, the reality is that physicians use medical evidence to guide treatment decisions every day. "But there are major holes in what we know and don't know. I would hope that PCORI will help to fill in those major holes more quickly," he adds.

If CER is done effectively, Dr. Meltzer says, hospitalists and other clinicians could find themselves and their patients more frequently involved in research and data generation, making it increasingly important to explain to patients why this sort of research is important.

"He has not only been a leader in hospital medicine, but also a noted health economist and researcher," says Margaret Fang, MD, a hospitalist at the University of California at San Francisco. "All of these skills will be vitally important when addressing issues in comparative-effectiveness research."

David Meltzer, MD, PhD, a hospitalist and medical researcher at the University of Chicago, is one of 15 appointees who were named in January to the Methodology Committee of the Patient-Centered Outcomes Research Institute (PCORI), which was created by last year's Accountable Care Act to advise the federal government on clinical-effectiveness research (CER).

Dr. Meltzer, chief of UC's Division of Hospital Medicine and director of the Center for Health and Social Sciences in Chicago, has been active in a number of areas of advanced medical research, including technology assessment, CER, value-of-information research, and prioritization of the research agenda. One of his research topics has been whether hospitalists reduce length of stay and costs.

"Healthcare is a very complicated issue, for a bunch of reasons," he says. "It costs a lot of money, and it matters to a lot of people."

Last year's health-reform debate demonstrated how complicated it can be, with CER itself the target of some controversy. The challenge for PCORI is “to increase the information available to make the best choices regarding the application of medical treatments," he explains.

According to Dr. Meltzer, who also sits on the Congressional Budget Office's panel of health advisors, the reality is that physicians use medical evidence to guide treatment decisions every day. "But there are major holes in what we know and don't know. I would hope that PCORI will help to fill in those major holes more quickly," he adds.

If CER is done effectively, Dr. Meltzer says, hospitalists and other clinicians could find themselves and their patients more frequently involved in research and data generation, making it increasingly important to explain to patients why this sort of research is important.

"He has not only been a leader in hospital medicine, but also a noted health economist and researcher," says Margaret Fang, MD, a hospitalist at the University of California at San Francisco. "All of these skills will be vitally important when addressing issues in comparative-effectiveness research."

Bradley Flansbaum, DO, MPH, SFHM, director of the hospitalist program at Lenox Hill Hospital in New York City, recently posted "A Hospitalist's Lament," on the SHM-sponsored The Hospitalist Leader blog about the nuances of palliative care and advanced-care-planning discussions for patients nearing the end of life.

Dr. Flansbaum writes that, when asked to name a medical specialty other than HM that he might have enjoyed pursuing, he replies: "pain and palliative care." As he explains, "I didn’t discover that this was an area of interest for me until my career was much advanced," too late to pursue new opportunities for advanced training in palliative-care fellowships.

Yet he views eliciting the needs and wishes of terminally ill hospitalized patients as an art worth mastering. Hospitalists inevitably deal with end-of-life issues as a routine part of their jobs. "It's in our bailiwick. It's what we do, and it behooves us to get better at it," he says.

In his post, Dr. Flansbaum examines the recent medical literature (Sudore RL, Fried TR. Ann Int Med 2010;153:256; Perkins HS. Ann Int Med 2007;147:51-57; Sulmasy DP, Snyder L. JAMA 2010;304:1946-1947) questioning the benefits of advanced-care planning and advance-directive documents, such as living wills, in shaping the care patients want and need at the end of their lives. While these documents are not wasted effort, he says, "too often they're not very useful. We're learning that it's an incredibly dynamic process, contingent on cultural factors, and changing over time. One piece of paper with a static declaration isn't going to cover the bases. I've come to realize that it is about a talking, ongoing process."

Part of his "lament" as a hospitalist is that caring for terminally ill patients can be rife with ambiguities. Meanwhile, "everybody talks about how there's so much money wasted at the end of life, and we should be corralling our healthcare resources in a more efficient way. And yet the solutions we will need to get us to that place are damned hard," he says. (Listen to excerpts from the interview with Dr. Flansbaum [MP3 12.8MB])

Dr. Flansbaum recommends hospitalists make detailed conversations with patients confronting life-limiting illnesses a priority, which requires setting aside enough time for patients and understanding that such conversations are not singular events. He also encourages physicians to consider what their own values and priorities might be in such a situation, an exercise he recently conducted with his residents.

Bradley Flansbaum, DO, MPH, SFHM, director of the hospitalist program at Lenox Hill Hospital in New York City, recently posted "A Hospitalist's Lament," on the SHM-sponsored The Hospitalist Leader blog about the nuances of palliative care and advanced-care-planning discussions for patients nearing the end of life.

Dr. Flansbaum writes that, when asked to name a medical specialty other than HM that he might have enjoyed pursuing, he replies: "pain and palliative care." As he explains, "I didn’t discover that this was an area of interest for me until my career was much advanced," too late to pursue new opportunities for advanced training in palliative-care fellowships.

Yet he views eliciting the needs and wishes of terminally ill hospitalized patients as an art worth mastering. Hospitalists inevitably deal with end-of-life issues as a routine part of their jobs. "It's in our bailiwick. It's what we do, and it behooves us to get better at it," he says.

In his post, Dr. Flansbaum examines the recent medical literature (Sudore RL, Fried TR. Ann Int Med 2010;153:256; Perkins HS. Ann Int Med 2007;147:51-57; Sulmasy DP, Snyder L. JAMA 2010;304:1946-1947) questioning the benefits of advanced-care planning and advance-directive documents, such as living wills, in shaping the care patients want and need at the end of their lives. While these documents are not wasted effort, he says, "too often they're not very useful. We're learning that it's an incredibly dynamic process, contingent on cultural factors, and changing over time. One piece of paper with a static declaration isn't going to cover the bases. I've come to realize that it is about a talking, ongoing process."

Part of his "lament" as a hospitalist is that caring for terminally ill patients can be rife with ambiguities. Meanwhile, "everybody talks about how there's so much money wasted at the end of life, and we should be corralling our healthcare resources in a more efficient way. And yet the solutions we will need to get us to that place are damned hard," he says. (Listen to excerpts from the interview with Dr. Flansbaum [MP3 12.8MB])

Dr. Flansbaum recommends hospitalists make detailed conversations with patients confronting life-limiting illnesses a priority, which requires setting aside enough time for patients and understanding that such conversations are not singular events. He also encourages physicians to consider what their own values and priorities might be in such a situation, an exercise he recently conducted with his residents.

Bradley Flansbaum, DO, MPH, SFHM, director of the hospitalist program at Lenox Hill Hospital in New York City, recently posted "A Hospitalist's Lament," on the SHM-sponsored The Hospitalist Leader blog about the nuances of palliative care and advanced-care-planning discussions for patients nearing the end of life.

Dr. Flansbaum writes that, when asked to name a medical specialty other than HM that he might have enjoyed pursuing, he replies: "pain and palliative care." As he explains, "I didn’t discover that this was an area of interest for me until my career was much advanced," too late to pursue new opportunities for advanced training in palliative-care fellowships.

Yet he views eliciting the needs and wishes of terminally ill hospitalized patients as an art worth mastering. Hospitalists inevitably deal with end-of-life issues as a routine part of their jobs. "It's in our bailiwick. It's what we do, and it behooves us to get better at it," he says.

In his post, Dr. Flansbaum examines the recent medical literature (Sudore RL, Fried TR. Ann Int Med 2010;153:256; Perkins HS. Ann Int Med 2007;147:51-57; Sulmasy DP, Snyder L. JAMA 2010;304:1946-1947) questioning the benefits of advanced-care planning and advance-directive documents, such as living wills, in shaping the care patients want and need at the end of their lives. While these documents are not wasted effort, he says, "too often they're not very useful. We're learning that it's an incredibly dynamic process, contingent on cultural factors, and changing over time. One piece of paper with a static declaration isn't going to cover the bases. I've come to realize that it is about a talking, ongoing process."

Part of his "lament" as a hospitalist is that caring for terminally ill patients can be rife with ambiguities. Meanwhile, "everybody talks about how there's so much money wasted at the end of life, and we should be corralling our healthcare resources in a more efficient way. And yet the solutions we will need to get us to that place are damned hard," he says. (Listen to excerpts from the interview with Dr. Flansbaum [MP3 12.8MB])

Dr. Flansbaum recommends hospitalists make detailed conversations with patients confronting life-limiting illnesses a priority, which requires setting aside enough time for patients and understanding that such conversations are not singular events. He also encourages physicians to consider what their own values and priorities might be in such a situation, an exercise he recently conducted with his residents.

Sally Bullock, MD, medical director of the hospitalist program at Middle Tennessee Medical Center (MTMC) in Murfreesboro, Tenn., received the hospital’s 2011 Physician of the Year award at its annual Physician Christmas Reception in December. The award is voted on by hospital staff, and this is the first time it was given to a hospitalist.

“I’ve been here on staff for 26 years, mostly in private practice as an internist,” Dr. Bullock says. “Visiting the hospital was always a favorite part of my practice. In fact, I did not use hospitalists to care for my patients.”

However, family demands and time pressures of the practice led her to leave it for the flexibility of multiple part-time medical jobs, including HM shifts. In November of 2007, after repeated requests from Andy Brown, MD, MTMC's vice president of medical affairs, she accepted the hospitalist leadership position.

"I encouraged Dr. Bullock to take on this role because she genuinely cares about her patients. Sally is an excellent clinician and communicator who also leads by example," Dr. Brown says. "I knew that physicians would recognize these qualities and want to be part of the program."

The hospitalist program at MTMC started in 1999 with six physicians but experienced contraction in 2006. Under Dr. Bullock's leadership, it has grown to 22 physicians, with more expansion expected this year.

"I just jumped on it, and we got busy recruiting," Dr. Bullock says, adding that the award from her peers at MTMC reflects both her longevity in the medical community and appreciation for "taking the hospitalist program where it needs to be."

Currently, her position includes hospitalist shifts, both scheduled and fill-in, squeezing in administrative duties, and mentoring other physicians. "I'm sort of the program's surge protector," she says.

Sally Bullock, MD, medical director of the hospitalist program at Middle Tennessee Medical Center (MTMC) in Murfreesboro, Tenn., received the hospital’s 2011 Physician of the Year award at its annual Physician Christmas Reception in December. The award is voted on by hospital staff, and this is the first time it was given to a hospitalist.

“I’ve been here on staff for 26 years, mostly in private practice as an internist,” Dr. Bullock says. “Visiting the hospital was always a favorite part of my practice. In fact, I did not use hospitalists to care for my patients.”

However, family demands and time pressures of the practice led her to leave it for the flexibility of multiple part-time medical jobs, including HM shifts. In November of 2007, after repeated requests from Andy Brown, MD, MTMC's vice president of medical affairs, she accepted the hospitalist leadership position.

"I encouraged Dr. Bullock to take on this role because she genuinely cares about her patients. Sally is an excellent clinician and communicator who also leads by example," Dr. Brown says. "I knew that physicians would recognize these qualities and want to be part of the program."

The hospitalist program at MTMC started in 1999 with six physicians but experienced contraction in 2006. Under Dr. Bullock's leadership, it has grown to 22 physicians, with more expansion expected this year.

"I just jumped on it, and we got busy recruiting," Dr. Bullock says, adding that the award from her peers at MTMC reflects both her longevity in the medical community and appreciation for "taking the hospitalist program where it needs to be."

Currently, her position includes hospitalist shifts, both scheduled and fill-in, squeezing in administrative duties, and mentoring other physicians. "I'm sort of the program's surge protector," she says.

Sally Bullock, MD, medical director of the hospitalist program at Middle Tennessee Medical Center (MTMC) in Murfreesboro, Tenn., received the hospital’s 2011 Physician of the Year award at its annual Physician Christmas Reception in December. The award is voted on by hospital staff, and this is the first time it was given to a hospitalist.

“I’ve been here on staff for 26 years, mostly in private practice as an internist,” Dr. Bullock says. “Visiting the hospital was always a favorite part of my practice. In fact, I did not use hospitalists to care for my patients.”

However, family demands and time pressures of the practice led her to leave it for the flexibility of multiple part-time medical jobs, including HM shifts. In November of 2007, after repeated requests from Andy Brown, MD, MTMC's vice president of medical affairs, she accepted the hospitalist leadership position.

"I encouraged Dr. Bullock to take on this role because she genuinely cares about her patients. Sally is an excellent clinician and communicator who also leads by example," Dr. Brown says. "I knew that physicians would recognize these qualities and want to be part of the program."

The hospitalist program at MTMC started in 1999 with six physicians but experienced contraction in 2006. Under Dr. Bullock's leadership, it has grown to 22 physicians, with more expansion expected this year.

"I just jumped on it, and we got busy recruiting," Dr. Bullock says, adding that the award from her peers at MTMC reflects both her longevity in the medical community and appreciation for "taking the hospitalist program where it needs to be."

Currently, her position includes hospitalist shifts, both scheduled and fill-in, squeezing in administrative duties, and mentoring other physicians. "I'm sort of the program's surge protector," she says.

Dermatology is about sleuthing and putting things together that don't go together, says Lindy Fox, MD, founder of the interdisciplinary dermatology hospitalist consultation service at the University of California at San Francisco (UCSF). She recommends hospitalists learn basic descriptions of dermatological conditions, categories, and terminology. That way, when they make a phone presentation of symptoms to a consulting dermatologist, the specialist can determine whether the patient needs an in-person consultation.

Differential diagnosis of a dermatological condition considers history, duration, timing, waxing, and waning, Dr. Fox told participants in the hands-on Hospitalist Mini-College at UCSF last October.

"We worry about pain much more than about itching. We worry about medications and drug eruptions. A family history is important, and a social history, especially for patients who travel. But the most important thing is morphology," she says. "What is the primary lesion? Learn to recognize the primary lesion and the differential diagnosis will follow."

It is a concern that fewer dermatologists have any presence in the hospital, and the resulting demands on hospitalists will only increase, Dr. Fox says. At UCSF, she and two colleagues consult on patients who have skin diseases that are severe enough to require hospitalization, or who develop a cutaneous manifestation of the disease for which they were admitted or as a consequence of treatment of that disease. They closely collaborate with UCSF's hospitist service, as well as teach residents and, at the bedside, internists. This approach, however, is rare, mainly limited to academic medical centers, she says.

"There are young dermatologists out there who want to stay in the hospital and work with internists but the structure often isn't there," Dr. Fox says. "What hospitalists can do is help to facilitate these relationships for dermatologists who want to work in the hospital."

Dermatology is about sleuthing and putting things together that don't go together, says Lindy Fox, MD, founder of the interdisciplinary dermatology hospitalist consultation service at the University of California at San Francisco (UCSF). She recommends hospitalists learn basic descriptions of dermatological conditions, categories, and terminology. That way, when they make a phone presentation of symptoms to a consulting dermatologist, the specialist can determine whether the patient needs an in-person consultation.

Differential diagnosis of a dermatological condition considers history, duration, timing, waxing, and waning, Dr. Fox told participants in the hands-on Hospitalist Mini-College at UCSF last October.

"We worry about pain much more than about itching. We worry about medications and drug eruptions. A family history is important, and a social history, especially for patients who travel. But the most important thing is morphology," she says. "What is the primary lesion? Learn to recognize the primary lesion and the differential diagnosis will follow."

It is a concern that fewer dermatologists have any presence in the hospital, and the resulting demands on hospitalists will only increase, Dr. Fox says. At UCSF, she and two colleagues consult on patients who have skin diseases that are severe enough to require hospitalization, or who develop a cutaneous manifestation of the disease for which they were admitted or as a consequence of treatment of that disease. They closely collaborate with UCSF's hospitist service, as well as teach residents and, at the bedside, internists. This approach, however, is rare, mainly limited to academic medical centers, she says.

"There are young dermatologists out there who want to stay in the hospital and work with internists but the structure often isn't there," Dr. Fox says. "What hospitalists can do is help to facilitate these relationships for dermatologists who want to work in the hospital."

Dermatology is about sleuthing and putting things together that don't go together, says Lindy Fox, MD, founder of the interdisciplinary dermatology hospitalist consultation service at the University of California at San Francisco (UCSF). She recommends hospitalists learn basic descriptions of dermatological conditions, categories, and terminology. That way, when they make a phone presentation of symptoms to a consulting dermatologist, the specialist can determine whether the patient needs an in-person consultation.

Differential diagnosis of a dermatological condition considers history, duration, timing, waxing, and waning, Dr. Fox told participants in the hands-on Hospitalist Mini-College at UCSF last October.

"We worry about pain much more than about itching. We worry about medications and drug eruptions. A family history is important, and a social history, especially for patients who travel. But the most important thing is morphology," she says. "What is the primary lesion? Learn to recognize the primary lesion and the differential diagnosis will follow."

It is a concern that fewer dermatologists have any presence in the hospital, and the resulting demands on hospitalists will only increase, Dr. Fox says. At UCSF, she and two colleagues consult on patients who have skin diseases that are severe enough to require hospitalization, or who develop a cutaneous manifestation of the disease for which they were admitted or as a consequence of treatment of that disease. They closely collaborate with UCSF's hospitist service, as well as teach residents and, at the bedside, internists. This approach, however, is rare, mainly limited to academic medical centers, she says.

"There are young dermatologists out there who want to stay in the hospital and work with internists but the structure often isn't there," Dr. Fox says. "What hospitalists can do is help to facilitate these relationships for dermatologists who want to work in the hospital."

Pneumonia is one of the most common diagnoses encountered by hospitalists, if not the most common, and its presentation continues to become more complicated, says Scott Flanders, MD, SFHM, professor of medicine and director of the hospitalist program at the University of Michigan Health System in Ann Arbor. Dr. Flanders has published on pneumonia (J Hosp Med. 2006;1(3):177-190), and this past fall he gave presentations on the subject at hospitalist conferences in San Francisco and Chicago—with a particular emphasis on how to prevent its recurrence in hospitalized patients at risk.

“The causative agents for community-acquired pneumonia (CAP) evolve over time,” even though the actual source of a hospitalized patient’s pneumonia may never be known, says Dr. Flanders, past president of SHM. The swine flu (H1N1) and community-acquired MRSA “are two examples of etiologic agents that were not even a consideration five years ago—and now are something hospitalists have to be aware of, understand, and recognize that they can cause pneumonia in patients who are admitted to the hospital from the community,” he says. “They need to be considered as potential etiologic agents first and foremost, because the treatments for them differ from usual empiric pneumonia treatments.

There is a subset of patients with bad reflux disease, history of GI bleeds, on anticoagulants, who have more potential benefit than harm from PPIs. Hospitalists should see if their patients fall into these categories and, if they don’t, consider discontinuing these medications.

—Scott Flanders, MD, SFHM, professor of medicine and director of the hospitalist program at the University of Michigan Health System, Ann Arbor, SHM past president

“As hospitalists, we spend a lot of time trying to think what we can do to prevent recurrent pneumonia episodes in our patients and looking for what could have caused the initial incident,” Dr. Flanders says. “Pneumococcal vaccination is not as good as we’d like it to be in preventing recurrent pneumonia. We have to look to see if there’s anything else we can do to help prevent it.”

One simple step is to review the patient’s medication list, see if proton pump inhibitors (PPI) for reducing gastric acid or antipsychotic medications are on the list, then ask whether they can be discontinued; both treatments are associated in the medical literature with higher rates of pneumonia recurrence. Patients often receive PPIs for empiric prevention of gastrointestinal bleeding in the ICU, a risk that might have ceased.

“There is a subset of patients with bad reflux disease, history of GI bleeds, on anticoagulants, who have more potential benefit than harm from PPIs,” Dr. Flanders explains. “Hospitalists should see if their patients fall into these categories and, if they don’t, consider discontinuing these medications.”

Dr. Flanders also points out hospitalists should keep an eye out for antipsychotic medications. “Many patients absolutely need these medications and are functional because they are on them,” he says. “We’d never consider stopping them for those patients. But some patients get them started for episodes of delirium in the hospital that have resolved or to enhance their sleep. I’d strongly recommend considering stopping them in that case.”

By contrast, statin use might improve outcomes associated with pneumonia.

Antibiotic selection is another big issue, and Dr. Flanders says hospitalists will be judged by how closely they stick to the recommended treatment guidelines. “They should be familiar with what the guidelines recommend, and recognize the types of variables they need to document if they are going to deviate from the recommendations,” he says. The evidence also says to stop routinely treating pneumonia with antibiotics beyond seven days, he adds.

Larry Beresford is a freelance writer based in Oakland, Calif. 

Pneumonia is one of the most common diagnoses encountered by hospitalists, if not the most common, and its presentation continues to become more complicated, says Scott Flanders, MD, SFHM, professor of medicine and director of the hospitalist program at the University of Michigan Health System in Ann Arbor. Dr. Flanders has published on pneumonia (J Hosp Med. 2006;1(3):177-190), and this past fall he gave presentations on the subject at hospitalist conferences in San Francisco and Chicago—with a particular emphasis on how to prevent its recurrence in hospitalized patients at risk.

“The causative agents for community-acquired pneumonia (CAP) evolve over time,” even though the actual source of a hospitalized patient’s pneumonia may never be known, says Dr. Flanders, past president of SHM. The swine flu (H1N1) and community-acquired MRSA “are two examples of etiologic agents that were not even a consideration five years ago—and now are something hospitalists have to be aware of, understand, and recognize that they can cause pneumonia in patients who are admitted to the hospital from the community,” he says. “They need to be considered as potential etiologic agents first and foremost, because the treatments for them differ from usual empiric pneumonia treatments.

There is a subset of patients with bad reflux disease, history of GI bleeds, on anticoagulants, who have more potential benefit than harm from PPIs. Hospitalists should see if their patients fall into these categories and, if they don’t, consider discontinuing these medications.

—Scott Flanders, MD, SFHM, professor of medicine and director of the hospitalist program at the University of Michigan Health System, Ann Arbor, SHM past president

“As hospitalists, we spend a lot of time trying to think what we can do to prevent recurrent pneumonia episodes in our patients and looking for what could have caused the initial incident,” Dr. Flanders says. “Pneumococcal vaccination is not as good as we’d like it to be in preventing recurrent pneumonia. We have to look to see if there’s anything else we can do to help prevent it.”

One simple step is to review the patient’s medication list, see if proton pump inhibitors (PPI) for reducing gastric acid or antipsychotic medications are on the list, then ask whether they can be discontinued; both treatments are associated in the medical literature with higher rates of pneumonia recurrence. Patients often receive PPIs for empiric prevention of gastrointestinal bleeding in the ICU, a risk that might have ceased.

“There is a subset of patients with bad reflux disease, history of GI bleeds, on anticoagulants, who have more potential benefit than harm from PPIs,” Dr. Flanders explains. “Hospitalists should see if their patients fall into these categories and, if they don’t, consider discontinuing these medications.”

Dr. Flanders also points out hospitalists should keep an eye out for antipsychotic medications. “Many patients absolutely need these medications and are functional because they are on them,” he says. “We’d never consider stopping them for those patients. But some patients get them started for episodes of delirium in the hospital that have resolved or to enhance their sleep. I’d strongly recommend considering stopping them in that case.”

By contrast, statin use might improve outcomes associated with pneumonia.

Antibiotic selection is another big issue, and Dr. Flanders says hospitalists will be judged by how closely they stick to the recommended treatment guidelines. “They should be familiar with what the guidelines recommend, and recognize the types of variables they need to document if they are going to deviate from the recommendations,” he says. The evidence also says to stop routinely treating pneumonia with antibiotics beyond seven days, he adds.

Larry Beresford is a freelance writer based in Oakland, Calif. 

Pneumonia is one of the most common diagnoses encountered by hospitalists, if not the most common, and its presentation continues to become more complicated, says Scott Flanders, MD, SFHM, professor of medicine and director of the hospitalist program at the University of Michigan Health System in Ann Arbor. Dr. Flanders has published on pneumonia (J Hosp Med. 2006;1(3):177-190), and this past fall he gave presentations on the subject at hospitalist conferences in San Francisco and Chicago—with a particular emphasis on how to prevent its recurrence in hospitalized patients at risk.

“The causative agents for community-acquired pneumonia (CAP) evolve over time,” even though the actual source of a hospitalized patient’s pneumonia may never be known, says Dr. Flanders, past president of SHM. The swine flu (H1N1) and community-acquired MRSA “are two examples of etiologic agents that were not even a consideration five years ago—and now are something hospitalists have to be aware of, understand, and recognize that they can cause pneumonia in patients who are admitted to the hospital from the community,” he says. “They need to be considered as potential etiologic agents first and foremost, because the treatments for them differ from usual empiric pneumonia treatments.

There is a subset of patients with bad reflux disease, history of GI bleeds, on anticoagulants, who have more potential benefit than harm from PPIs. Hospitalists should see if their patients fall into these categories and, if they don’t, consider discontinuing these medications.

—Scott Flanders, MD, SFHM, professor of medicine and director of the hospitalist program at the University of Michigan Health System, Ann Arbor, SHM past president

“As hospitalists, we spend a lot of time trying to think what we can do to prevent recurrent pneumonia episodes in our patients and looking for what could have caused the initial incident,” Dr. Flanders says. “Pneumococcal vaccination is not as good as we’d like it to be in preventing recurrent pneumonia. We have to look to see if there’s anything else we can do to help prevent it.”

One simple step is to review the patient’s medication list, see if proton pump inhibitors (PPI) for reducing gastric acid or antipsychotic medications are on the list, then ask whether they can be discontinued; both treatments are associated in the medical literature with higher rates of pneumonia recurrence. Patients often receive PPIs for empiric prevention of gastrointestinal bleeding in the ICU, a risk that might have ceased.

“There is a subset of patients with bad reflux disease, history of GI bleeds, on anticoagulants, who have more potential benefit than harm from PPIs,” Dr. Flanders explains. “Hospitalists should see if their patients fall into these categories and, if they don’t, consider discontinuing these medications.”

Dr. Flanders also points out hospitalists should keep an eye out for antipsychotic medications. “Many patients absolutely need these medications and are functional because they are on them,” he says. “We’d never consider stopping them for those patients. But some patients get them started for episodes of delirium in the hospital that have resolved or to enhance their sleep. I’d strongly recommend considering stopping them in that case.”

By contrast, statin use might improve outcomes associated with pneumonia.

Antibiotic selection is another big issue, and Dr. Flanders says hospitalists will be judged by how closely they stick to the recommended treatment guidelines. “They should be familiar with what the guidelines recommend, and recognize the types of variables they need to document if they are going to deviate from the recommendations,” he says. The evidence also says to stop routinely treating pneumonia with antibiotics beyond seven days, he adds.

Larry Beresford is a freelance writer based in Oakland, Calif.