A new doctor in the house - Ethical issues in hospitalist systems

The traditional patient-primary care physician (PCP) relationship provides many ethical protections for patients, including confidentiality, shared medical decision making, and respect for patient autonomy. Hospitalist models, which introduce a purposeful discontinuity of care, threaten these protections and raise certain ethical concerns. We analyze 2 cases that explore ethical issues arising in hospitalist systems and suggest ways to ensure ethical protection for patients. The first case examines how hospitalization can disrupt the patient-PCP relationship and raise ethical issues regarding confidentiality. In the second case, we discuss decision making when the patient's goals and preferences for care change as a result of hospitalization. Effective hospitalist systems provide a model for a trusting patient-physician relationship. Although the hospitalist must take responsibility for inpatient management, the PCP has a key role in addressing important issues in the hospital and providing care after discharge. As hospitalists assume control of inpatient care, they must also provide ethical protections to patients to supplement those currently vested in the patient-PCP relationship. An approach that keeps the patient's best interests foremost, defines a clear role for the PCP, and takes advantage of the expertise and availability of hospitalists will best serve patients and physicians.