Hospitalists -- physicians who manage inpatient care -- should work closely with patients' primary care physicians (PCPs) particularly when sensitive issues arise using the hospitalist model of care, according to UC San Francisco researchers.
In an article published in the July 14 issue of the Journal of American Medical Association (JAMA), UCSF researchers explore ethical issues that arise when using the hospitalist model of care and suggest ways to ensure ethical protections for patients, such as confidentiality, shared medical decision making, and patient autonomy.
The hospitalist is a departure from the way doctors have traditionally functioned in hospitals. In the past, patients' PCPs would manage their inpatient care, however, with the hospitalist, the PCP no longer provides care for hospitalized patients.
"Not only should hospitalists work with PCPs but they also need to develop relationships of trust with patients to lessen ethical concerns," according to Steve Pantilat, MD, UCSF assistant clinical professor of medicine, UCSF hospitalist at UCSF Stanford Health Care, and faculty member in the UCSF program in medical ethics.
The emergence of hospitalists is based on the idea that inpatient care specialists will improve the quality of care, increase the efficiency of care, and be more available to hospitalized patients than primary care physicians, said Pantilat.
Currently there are 3,000-4,000 hospitalists, and in the future there will be as many as 20,000, which means a majority of Americans may be cared for by hospitalists, said Pantilat.
One downside to using hospitalists, according to Pantilat, is that patients experience discontinuity of care. Patients are suddenly cared for by doctors they don't know at a time when they are most sick.
This discontinuity or disruption in care, he added, raises several ethical concerns.
The promise of confidentiality between a patient and primary care physician may be compromised once the patient is hospitalized. The hospitalist may not honor promises made between patient and PCP, for example, the promise not to reveal certain information to a patient's partner or family members.
Another issue that arises is informed consent. Patients generally do not receive information about the use of hospitalists until they are admitted to the hospital and do not give informed consent to be seen by the hospitalist, Pantilat said.
Hospitalists may also face situations in which they must interpret patients' preferences for end of life care. Hospitalists may not know whether a patient wants to be resuscitated or receive aggressive treatments -- details patients often discuss with their primary care physician, according to the researchers. Although there are ethical concerns that arise using this model of care, hospitalists have the potential to create solutions to these issues, said Pantilat.
For issues of confidentiality, hospitalists should establish relationships of trust with patients as well as work with patients' PCPs to achieve compromises that protect the patients' best interests.
Regarding informed consent, Pantilat and researchers propose that patients have the option of choosing whether or not they want to be cared for by hospitalists when they enroll in a health care plan. Patients should also have the option of choosing a specific hospitalist group if they choose this form of inpatient care.
Finally, for end of life care issues, hospitalists offer the potential to improve this care significantly, said Pantilat. They should discuss these issues with patients' PCPs and develop skills in talking to patients about end of life care. Hospitalists should routinely address patients' preferences for end of life care when patients are first admitted to the hospital and should become skilled in providing high quality end of life care.
Co-authors of the study include Ann Alpers, JD, UCSF assistant professor of medicine, faculty member in the UCSF program of medical ethics and Robert Wachter, MD, UCSF associate professor of medicine and associate chair of the department of medicine at UCSF.
The study was funded by the Soros Foundation, Project Death in America and the Mayday Foundation.