From the beginning of the hospitalist movement, hospitalists have filled a collaborative role in assuming care of primary care physicians’ patients in the hospital. Just as primary care physicians (PCPs) cannot feasibly be in two places at once (the office and the hospital), surgeons and medical subspecialists cannot simultaneously manage complex inpatients and perform procedures and other specialty services. The limited surgical availability with restricted surgical resident work hours creates added pressure on surgical residents to maximize operating room time. Likewise, medical subspecialties face similar pressures with limited fellow work hours. The active involvement of a medical comanager may make practical and economic sense if it is planned well and actively managed. In addition, co-management may improve the quality of care by having a generalist on site to anticipate and address common problems that arise during hospitalization without the delays that may occur with traditional medical consultation.
Comanagement is now a prominent practice pattern as an integrated part of hospitalist practice. Comanagement practices have now been described in collaboration with orthopedic surgery, neurosurgery, vascular surgery, otolaryngology, hepatology, and pediatrics. Thus, in all likelihood, the practice of comanagement by hospitalists will not wane, and both surgeons and medical subspecialists will call on hospitalists in this collaborative spirit. Some authors express concerns for exacerbating the workforce shortage of internists by increasing overall workload with comanagement and increasing the “silo” delineations in medicine. However, comanagement may provide value if there is a clear delineation of roles and responsibilities and the value equation is articulated for all parties—hospitalists, surgeons, patients, and hospital leadership. Based on the author’s experience with orthopedic comanagement and on other hospitalists’ successful collaborations, this chapter will suggest specific steps that can be taken to initiate a potential comanagement effort and avoid common pitfalls.
ANTICIPATE THE GROWTH OF THE SPECIALTY IN THE HOSPITAL SETTING
Musculoskeletal disorders and diseases are the leading cause of disability in the United States and account for more than one-half of all chronic conditions in people over 50 years of age in developed countries. One in two Americans has a musculoskeletal condition requiring medical attention, twice the rate of chronic heart and lung conditions. Annual direct and indirect costs for bone and joint health are $874 billion, 5.7% of the gross domestic product.
Based on these data, it is little wonder that orthopedic surgeons will have increasing volumes of patient visits and operative interventions in the coming years, especially in the setting of an aging population with increasing expectations for functional recovery and quality of life. The challenge associated with this growth will be the increasing number of medical comorbidities in these older patients and the need for systematic evaluation of these comorbidities to optimize the perioperative course. It is estimated that surgery-related costs will rise 50% and surgical complications 100% in the United States in the next two decades.
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