However, as individuals, physicians are generally free to choose whom they treat (within some limitations, such as the requirement to honor agreed-upon contracts, not abandoning patients with whom there is an existing therapeutic relationship and not refusing to care for patients based on race or other forms of discrimination).2
How do these ethical principles and obligations apply to populations and to hospital coverage? The hospital is an institution that serves a population. Is the physician responsible for remaining available to any individual in the treated population at the discretion of the hospital? Is the physician bound to accept the contractual obligations of the hospital staff agreements in order to serve the population?
This dilemma brings to light the ethical concept of distributive justice, a fair distribution of healthcare resources within a society and the individual physician’s role in achieving it.
Indeed, hospital administration holds significant responsibility in these questions. The ethical implications of hospital administrative control over physician staff can be profound.3 Efforts that hospitals might take to ease the burdens posed by inpatient consultative care include increasing reimbursement for consultations (e.g., paying a flat fee in addition to allowing the billing of insurance), lobbying for additional liability protections for inpatient care and lobbying for state-level subsidies.
Back to the Case
This case highlights the difficulties rheumatologists face in providing services to populations while balancing the needs of the individual physician and practice. For rheumatologists, who are often in short supply outside of major metropolitan medical centers, deciding to withdraw from hospital staff may leave a hospital, and consequently a population, without consultative coverage. However, continuing to provide inpatient consultative services may become a burden that threatens practice viability, physician satisfaction and competitiveness in recruiting additional physicians.
There is no single right answer to this dilemma. Each practice and each physician will have to decide on the best balance between the needs of the practice (and its physicians) and the community. But understanding where the conflicts lie can be helpful in arriving at a well-reasoned decision.
Questions for the Reader
Have you had an experience in which your needs as a physician or the needs of your practice were in conflict with those of a larger organization, such as a hospital where you have clinical privileges?
Have you decided to stop providing consulting care at a particular hospital? What issues were most important in your decision? Do you think you made the right decision? Let us know.
