EXECUTIVE SUMMARY

In a recent study of 270 patients encounters, hospitalists encountered 133 ethical issues in 77 patients but obtained only five formal ethics consultations. Some implications for ethics:

  • Hospitalists must establish a doctor/patient relationship quickly under challenging circumstances.
  • Many hospitalists provide professional and clinical education without formal training in clinical ethics.
  • Ethicists can provide specialty-specific ethics education to hospitalists.

When Matthew McCarthy, MD, first became an attending physician at Weill Cornell Medicine in New York City, he was surprised at how many ethical issues came up on daily rounds. Few led to a formal ethics consultation.

“This meant that we made most of the decisions on our own. As a young doctor, that was a terrifying proposition,” says McCarthy, an assistant professor of medicine at Weill Cornell and a hospitalist at New York-Presbyterian Hospital, where he serves on the ethics committee.

Some healthcare proxies appeared to be making poor decisions on the patient’s behalf. In rare situations, “decisionally incapacitated surrogates” lost their proxy status, but most cases were not as extreme. “It’s hard to know what to do, especially if you don’t think the patient would’ve made those same decisions,” McCarthy explains.

As a new attending physician, McCarthy also saw doctors unsure if expensive antibiotics should be given to patients with a urinary tract infection and only days to live. The question raised ethical issues of futility and allocation of resources, which were not explored fully. “These are things that would never merit a full ethics consultation and are largely handled by doctors alone at the bedside,” McCarthy says.

McCarthy approached Joseph J. Fins, MD, MACP, FRCP, about his concerns. They decided to study the epidemiology of ethical issues facing hospital medicine. “Our study was the first prospective look at the ethical issues facing hospitalists,” says McCarthy, the study’s lead author.

Hospital medicine is the fastest growing specialty in medicine. Yet little was known about the ethical issues they face. “This is a brand-new massive subspecialty area and we needed to begin to understand: What are the ethics issues that they confront?” asks Fins, chief of the division of medical ethics and the E. William Davis, Jr., MD, professor of medical ethics at Weill Cornell Medical College. Fins also is director of medical ethics and chair of the ethics committee at New York-Presbyterian Hospital/Weill Cornell Medical Center.

To answer this important question, two attending hospitalists embedded themselves on hospitalist morning rounds and collected data on 270 patients from September 2017 through May 2018.1 A total of 270 patients were evaluated, and 113 ethical issues were identified in 77 of those patients. However, only five formal consults were brought to the facility’s ethics committee for these 270 patients.

The findings suggest that ethical issues raised during formal consultations are only “the tip of the iceberg,” Fins says. “In fact, there are ethical issues everywhere.”

Of the five formal ethics consults requested, “those involved treatment refusals, goals of care, decision-making capacity, and issues pertaining to medical futility,” McCarthy notes.

Certainly, not every ethical issue necessitates an ethics consult. However, it is unclear whether the hospitalists knew it was an ethical issue and determined a consult was not necessary, or whether the ethical issue simply went unrecognized. In the context of research, the investigators did not try to ascertain this. “We tried to be invisible,” says Fins, the study’s senior author. “We were not there to weigh in. We were there just to note what was happening.”

In one case, hospitalists discussed which antibiotic to give a patient with a Clostridioides difficile infection. “Certain choices may go beyond the pharmacological question. It might be a sociological question or ethical question,” Fins offers.

In deciding between two antibiotics, the hospitalist pointed out that one of the drugs was less toxic but was considerably more expensive. “That’s a distributive justice issue,” Fins notes. It was unclear whether the hospitalists considered this when choosing the less expensive antibiotic. It also is possible the patient’s insurance status was a factor, another potential ethical issue.

“These are issues that, when you refract them in the context of an ethical prism, they may take on a different hue and lend themselves to a meaningful analysis,” Fins adds.

Currently, there are more than 50,000 hospitalists working in the United States. Most have received no formal training in clinical ethics. “We wanted to know what hospitals are seeing so we can direct educational efforts to meet those issues head-on,” Fins says.

In 2018, 75% of hospital patients were cared for by hospitalists.2 “More importantly, perhaps, is that most of the professional and clinical education in the hospital setting is being done by hospitalists,” Fins notes. The researchers intend to develop an educational program to help hospitalists become better teachers and role models. “If they are going to be teaching medical students and residents about professionalism and medical ethics, maybe we can do a better job of preparing them,” Fins offers.

An ethics handbook specific to hospitals is planned, along with a conference on ethics and hospitalists. “We ultimately would like to begin to collect national data on the sorts of ethical issues hospitalists are seeing around the country,” Fins says.

Many hospitalists are young physicians at the beginning of their careers. “Technically, they are superb,” Fins says. “But they may not have as much interpersonal experience. And they don’t have the advantage of knowing their patients.”

The extent of hospitalists’ ethical obligation to communicate with outpatient physicians whose patients are hospitalized, or to ensure continuity of care after discharge, is somewhat unclear. “What’s your responsibility? Is it more than just getting a medication list?” Fins asks.

Hospitalists also face obstacles in establishing a doctor/patient relationship. “You are literally meeting a stranger at the bedside, and that person has to develop a relationship that is meaningful, and do so quickly during the stress of hospitalization,” Fins says. The hospitalist is assigned to a patient, in contrast to the traditional model of a patient choosing an outpatient doctor. Upon admission, that same doctor followed the patient throughout the hospitalization and provided follow-up care. “A lot of physicians bewail the demise of the traditional patient/physician encounter,” Fins notes.

A good doctor/patient relationship still is possible with hospitalists, Fins says. Patients actually may spend more time with a hospitalist in a week than they spend with their outpatient doctor in years. The care also is more intense, with a lot of weighty decisions made.

“That relationship might be more meaningful and life-altering than a longitudinal relationship over a period of general wellness,” says Fins, noting not all patients have access to outpatient physicians to begin with. “The notion that we are losing something is only true for those who had it in the first place.”

There is growing awareness of the unique ethical needs of various clinical specialties. “This is going to be the era of subspecialty clinical ethics,” Fins predicts.

The rise of hospitalists presents an important opportunity for the field, according to the authors of a recent paper.3 “Today, the real frontier is really at the interface of hospital medicine and clinical ethics. It is, really, an unexplored activity,” Fins says. Hospitalists are “so front and center and in the thick of medical education and patient care,” Fins says. While some hospitalists focus on family practice or pediatrics, the vast majority specialize in general internal medicine.

“People maybe think that the traditional ethical reflections done by internists are translatable to hospitalists,” Fins offers. “A lot of it is. But some of it is particular to their domain of practice.”

While certain essential ethics elements (fiduciary responsibility, allocation of resources, and futility) are relevant to all physicians, “the details may get played out a little differently based on the realities of the hospitalist context of care,” Fins says.

Clinical ethics evolved out of end-of-life care in the ICU. Yet ENTs and neurosurgeons encounter somewhat different end-of-life issues. “We need to move out of the origins of the field of clinical ethics to speaking intelligently with our colleagues in subspecialties,” Fins says.

REFERENCES

  1. McCarthy MW, de Asua DR, Gabbay E, et al. Frequency of ethical issues on a hospitalist teaching service at an urban, tertiary care center. J Hosp Med 2019;14:E1-E4.
  2. Society of Hospital Medicine. 2018 State of Hospital Medicine Report. Available at: http://bit.ly/2MzC6Nk. Accessed June 10, 2019.
  3. McCarthy MW, Real de Asua D, Fins JJ. The rise of hospitalists: An opportunity for clinical ethics. J Clin Ethics 2017;28:325-332.