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INTRODUCTION

Nearly 2500 years ago, the Hippocratic writers decreed in the Epidemics, Bk. I, Sect. XI, “Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things—to help, or at least to do no harm.” The basic tenets of ethics apply to all medical specialties. The hospitalist-patient relationship depends upon a long-standing tradition of practices and manifestations of professionalism in which the physician places the interests of the patient above his or her own, and practices with competence, integrity, and beneficence. The context of care determines the application of ethical principles; however the ethical issues encountered in Hospital Medicine share with other forms of medical practice a rich history in bioethics, social movements, and landmark court cases.

The nature of the doctor-patient relationship and the new dichotomy of the inpatient and outpatient settings continue to evolve as specialized care becomes more localized to geographic areas such as the emergency room, intensive care unit, most recently, general medical units, and in the future, the medical home. This fragmentation of the clinical encounter into a unit of hospitalization represents a departure from the time-honored, and almost mythic, longitudinal doctor-patient relationship of general practice and primary care.

Unlike the classic doctor-patient relationship, decision making in the hospital is generally more harried and of a more critical nature. This may jeopardize the doctor-patient relationship if patients do not understand the role of hospitalists, perceive that their primary care physicians have abandoned them, or have questions of trust due to cultural differences or other factors. Dedication to ethical practice preserves stability in a “crisis” and promotes a culture of trust necessary for advocacy and a sound doctor-patient relationship.

Ethics, expertise, and availability of the hospitalist may help balance patient-centered obligations with the need to efficiently manage interventions. Hospitalists should not make initial assumptions about their patients’ priorities without first evaluating each patient with a fresh perspective. Communication with the patient’s outpatient provider, familiarization with the medical record, and meetings with patients and their family or friends who may have essential information to share during the patient’s illness are both good clinical care and congruent with ethical practice.

PRACTICE POINT

  • Having a longitudinal perspective from an outpatient colleague may mitigate diagnostic and prognostic errors that may occur when the object of one’s practice is hospitalized patients. Consultation with an outpatient physician builds a trusting hospitalist-patient relationship. Patients may suspect potential conflicts of interest or dual agency between hospitalists and the patient needs.

The ethical mandate to optimize cooperation, or comanagement, between doctors and other members of the health care team is an essential element of the hospitalist model. In hospitals different professional specialties have traditionally functioned, often in isolation. Hampered care coordination—and the splitting of the clinical team—potentially compromises the therapeutic relationship. However, the hospitalist’s appropriate use of consultants, awareness of one’s sphere of ...

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