Comanagement Works Best With Clear Boundaries

SAN DIEGO — As a hospitalist, the best approach to the comanagement of patients is to define your boundaries from the start and revisit those boundaries frequently.

Ask other members of the care team specific questions, such as: What parts of this patient's care are your responsibility? What parts of the care are mine? How are we going to decide who does what?

“If you don't know what you're doing when you're seeing the patients, if you don't have a coherent and mutually agreed upon vision for how you're going to make the care better, I'm not sure that you're actually doing anything other than showing up,” Dr. Eric M. Siegal said at the annual meeting of the Society of Hospital Medicine.

Comanagement relationships can be fraught with ambiguity, so he offered the following “existential questions” to ask in an effort to achieve clarity:

▸Why are we being asked to comanage this patient's care?

▸What are the “rules of engagement”? Do I make suggestions or decisions?

▸What responsibilities are mine vs. yours?

▸Where do our responsibilities overlap, and how do we manage those overlaps?

▸What happens if we disagree?

▸Who makes the final call?

“If you haven't at least thought these through and talked these over with the people with whom you're working, you're setting yourself up for a problem, a conflict at some point down the road,” Dr. Siegal warned.

In terms of protocol, “you absolutely have to insist on uniformity,” said Dr. Siegal, a hospitalist who is regional medical director of Cogent Healthcare, Nashville, Tenn. “You can't have orthopedist A doing it his way and orthopedist B doing it her way and hospitalist C doing it a third way. If this is how we're going to do it, then this is how everybody does it.” This applies to hospitalists as well, who need to be vigilant that they are all practicing consistently. Because board certification in hospital medicine is not yet available, hospitalists often have significantly different skill sets.

For example, if all of the members of your hospitalist program are adept at managing mechanical respiratory ventilation, that's great. But if only one member of your program can manage mechanical respiratory ventilation, “then you either have to pull that person out of the rotation to cover the vents, or nobody can manage the vents,” he said. Don't have a two-tiered system “because nothing drives specialists and nurses more crazy than to see one hospitalist come in and do one thing and then see the next hospitalist either unable to do it or do it radically differently.”

If you need help defining a reasonable role for a hospitalist, Dr. Siegal recommended reviewing the core competencies published in the January/February 2006 supplement of the Journal of Hospital Medicine (www3.interscience.wiley.com/journal/112396185/issue

Dr. Siegal recommends negotiating your expectations with other members of the comanagement team and developing guidelines when ambiguity exists. When he was director of the hospitalist program at Meriter Hospital, an affiliate of the University of Wisconsin, Madison, he sat down with cardiologists at the hospital and devised cardiology admission guidelines so everyone would be on the same page. They agreed that the cardiologist would admit patients with specific conditions that included ST-segment elevation, myocardial infarction, and advanced heart block requiring or potentially requiring emergency temporary pacing, while the hospitalist would admit patients with a different set of conditions that included chest pain of uncertain etiology and atrial arrhythmias.

“Does this cover every possible permutation? No,” Dr. Siegal said. “But the point was, we agreed on a basic set of rules up front. We disseminated them, put them in the emergency department, and it lowered the number of confusing calls and decreased the amount of angst. It's worked really nicely. As much as you can, cookbook this stuff up front so you know what the rules are.”

Revisiting the comanagement relationship after the first few months is a good idea, he noted, “because perspectives change, sometimes for the better, and sometimes for the worse.” As a case in point he described a surgeon he worked with who was initially skeptical of hospitalists. One day Dr. Siegal was called to stabilize one of the surgeon's patients who was crashing in the postanesthesia care unit. The surgeon was busy with a case at another hospital when this occurred.

“I took care of that patient and the next thing I knew, I could do no wrong,” Dr. Siegal recalled. “I'm not sure how I went from being marginally competent to very competent based on one case, but from his perspective I was and that was good enough. The point is, relationships change, but they may not always change for the better. One screw-up can radically change the relationship for the worse as well.”