There is no question that patient co-management has lead to explosive growth in hospitalist medicine. What is up for debate is whether co-management is always good for our profession, particularly when we serve as the attending of record.
Early on in my career, I felt strongly that we should admit only “medicine” patients. Although I still sometimes struggle with the question of who we should admit and who should go to our subspecialist friends, I now find myself more in the camp of those who think we should be prepared to admit almost any patient.
I began my career being very sensitive to the issue of subspecialists’ “dumping” patients on our service. I did not want to become an H&P machine who offered subspecialists an easy way out of doing paperwork, and little else. I was convinced that I should never admit an acute abdomen, for instance, particularly in the absence of any co-morbid conditions.
Back then, there was less push for us to even fill that admitting role. Older surgeons assumed they could do it all, and they certainly did not need a “pill pusher” like me to tell them how to manage diabetes or teach them about DVT prophylaxis.
How quickly times change. Over the eight years that I have been practicing, we have seen a 180-degree turnaround in surgeons’ philosophy. We rarely even see a surgeon with a stethoscope, and most surgeons could not be happier about leaving the medicine to us.
My attitude has also changed. Now, I tell my new group that there is no such thing as a patient who could not benefit from having hospitalist care, and that it is perfectly reasonable to admit a 25-year-old with no co-morbids for an appendectomy. What do we add? Especially in a 24/7 group, we are always available to the patient, which is a tremendous “add.” And under any scheduling model, we can manage pain and treat unexpected post-op complications.
Some argue that this adds too many costs to the health care system, and I am in no position to provide data to counter that argument. But I don’t believe that this is the case. I have seen many cases managed by hospitalists where an otherwise healthy patient with a specific surgical problem derived unexpected value from being admitted to our service. And, as part of our value-added mantra, I know that we streamline the admission-to-discharge process, even if we do not provide significant medical acumen to a patient in our role as attending.
Then there is this concern: Is there a point where we are doing scut work and nothing more? I suppose that can be the case, but I think the perception of scut often is the by-product of practicing passive hospital medicine.
By that, I mean that if we have the attitude that there is nothing we can add to a patient’s care, then scut is about all we’ll be doing. However, if we take ownership of a case, we may find ourselves providing a valuable service–discussing smoking cessation or reminding a patient about routine screening such as colonoscopy–even if such care is unrelated to the reason why the patient was admitted. (Not to mention the fact that we add a billable diagnosis to the group’s bottom line.)
Throughout the co-management process, particularly when hospitalists serve as the attending, it is critically important to maintain good dialogue with the subspecialist.
I always make sure that my surgical friends understand that, if I am admitting a patient for primarily a subspecialty or surgical reason, I expect them to be immediately available when issues arise that are outside my scope of practice. If they agree to those terms, and I have found that subspecialists always do, then I think it is time for us to consider admitting virtually every patient.