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  • “Hospital admission frequently occasions sensitive and highly charged decisions about issues such as code status, aggressiveness of interventions, and end-of-life care, to name a few, at a time when patients are sickest, most vulnerable, and least able to look after their own interests.”1

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. Hospital Medicine does not constitute a novel relationship but one founded 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. How ethical principles are applied depends on the context of care. The ethical disputes that may be encountered are not unique to Hospital Medicine, but have 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. Dedication to ethical practice preserves stability in a “crisis” and promotes a culture of trust necessary for advocacy and a sound doctor-patient relationship. Especially 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, the doctor-patient relationship may be in jeopardy. The ethics, expertise, and availability of the hospitalist balance patient-centered obligations with the need to maximize efficiencies within temporal constraints. The old adage “the secret of caring for the patient is caring for the patient” is aided when hospitalists do not make assumptions about their patients' priorities at the outset and evaluate each patient with a fresh perspective. Communication with the patient's outpatient doctor, familiarization with the medical record and meetings with patients and their intimates who may have essential information to share during the patient's illness is not only good clinical care but congruent with ethical practice.

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Practice Point
  • Having a longitudinal perspective from an outpatient colleague can help mitigate against diagnostic and prognostic errors that may occur when the object of one's practice is hospitalized patients. Consultation with an outpatient physician is also critical to build a trusting hospitalist-patient relationship. ...

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