Twenty-two years after the term hospitalist was coined, the specialty of hospital medicine continues to evolve, both within the vast domains of internal medicine and pediatrics and to specialties such as obstetrics and gynecology, neurology, and psychiatry, to name a few.1, 2 The hospitalist model of care has shown benefits in terms of reductions in cost, mortality, and length of stay, and improvement in quality and safety measures.3 This is evident both where hospitalists are the primary attending and in the comanagement model of care. In the comanagement model, the hospitalist works in partnership as an active consultant, writing orders in the patient’s chart, rounding with the primary team, and communicating with the staff, patient and family, and outpatient providers, thereby providing cohesive coordination of care.4 Orthopedic surgery, neurosurgery, and vascular surgery represent some of the surgical specialties that have adopted the comanagement model where the same hospitalists may be dedicated to these surgical services year round. This affords the surgeon (primary attending) more uninterrupted time in the operating room while the hospitalist actively comanages the medical care of the patients.4, 5
The biggest benefit of introducing a comanagement model is effective prevention and early diagnosis and management of medical complications. With progressive knowledge of the patients, procedures, and providers of the service the hospitalist may be comanaging, the comanagement hospitalists in each specialty develop a unique skill set over time. A comanagement hospitalist would be able to anticipate diagnoses that were not established on prior encounters; catch early decompensation; manage complex anticoagulation questions in the perioperative period; carefully manage fluids in patients with heart or renal failure; or individualize pain management for patients at high risk of delirium (instead of providing the standard protocolized care). The experiential and evidence-based knowledge required to effectively manage these patients continues to grow, as comanagement hospitalists are exposed to newer specialties, and the medical complexity of patients is on the rise.
Given the benefits of the comanagement model across multiple surgical fields,4, 5, 6, 7 should internal medicine-trained hospitalists be incorporated into the medical subspecialties of cardiology, gastroenterology, oncology, and hematology, where outpatient care remains a significant component of these specialties’ patient volumes? Based on the surgical comanagement benefits, one may postulate that such a model may continue to drive successful quality and safety results, allow the primary attending in these specialties to have more time for procedures or clinic, and ultimately foster a higher level of efficiency for the specialist in both the inpatient and outpatient settings.
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-Nidhi Rohatgi, MD, MS, Kevin Schulman, MD, MBA, Neera Ahuja, MD
