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Emergence of Hospitalist Comanagement

Limitations of Traditional Medical Consultation

While the traditional model for medical consultation still exists in many hospitals, particularly at academic medical centers, many surgeons and hospitalists have expressed concerns about its limitations. Traditional consultation requires the referring physician to recognize when a patient requires a consultant's input. However, a surgeon may not recognize when a patient is at high risk for medical complications, and thus fails to seek a consultation in a timely manner. Similarly, a hospitalist may identify important medical problems beyond the initial reason for consultation. The traditional consultation model, which limits the consultant to leaving recommendations, may also be inefficient if their implementation by the referring physician is delayed. To overcome these limitations, many hospitalists have taken on a more active role in caring for patients admitted for surgical or other specialty care. This new model has been termed comanagement.

Growth of Comanagement

A 2005 survey by the Society of Hospital Medicine (SHM) found that 85% of Hospital Medicine groups performed comanagement. Several factors are driving the growth of comanagement. Demographic changes in the surgical population have been a major impetus for surgeons' demand for comanagement. As surgical volumes increase, surgeons must spend greater amounts of time in the operating room and have become less available to care for their patients on the floor. The availability of surgical house staff at teaching hospitals has also become increasingly limited due to tighter restrictions on resident duty hours. Simultaneously, surgical patients are older and sicker, and thus at greater risk for medical complications. Not surprisingly, many surgeons now feel that the traditional consultation model is too limiting. A study in 2007 found that only 41% of surgeons felt that consultants should limit their input to the initial consultation question, and only 37% believed that consultants should avoid writing orders without prior approval from the primary team. The majority of surgeons in this study desired a comanagement relationship with their consultant.

Medical centers have also pushed Hospital Medicine groups to adopt a comanagement role. Much of this impetus may arise from the desire to recruit and retain surgeons who demand medical comanagement. However, in some cases, hospital administrators have advocated for comanagement as a way to improve quality, safety, and cost efficiency in surgical patients, the same way that hospitalists have demonstrated these benefits in their own patients. Hospitals may also desire comanagement in response to nursing staff concerns about the limited availability of surgeons and specialists to respond to questions or address problems in their patients.

While not all hospitalists have been eager to pursue comanagement, many hospital medicine groups view it as a way to expand their role and demonstrate their value. Comanagement has also been seen as a potential source of revenue to hospitalist groups, both through increased professional fee collection as well as strategic support ...

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