Ethics Forum: Terminating Hospital Consulting Services

Case

A single-specialty rheumatology practice provides consultative services for three local hospital systems. Over time, the burden on the practice to provide these services is increasing. Each hospital employs a unique electronic medical record (EMR), each of which is distinct from that used by the practice. The time required to relearn each interface with the relative infrequency of use is substantial. Each hospital now employs hospitalists, and communication with each inpatient’s attending is challenging. The referring physician is typically off shift when the rheumatologist arrives to see the patient, and it is rare for the referring hospitalist and rheumatologist to actually meet or speak to each other. Fewer outpatient primary care physicians are providing hospital care, and hospital consultations are no longer generating outpatient referrals.

The rheumatology practice is planning to hire a new junior partner, and several candidates have expressed concern about the time required to satisfy inpatient demands while balancing an already busy outpatient clinic schedule, suggesting that the on-call schedule is a liability for physician recruitment.

Dilemma

Providing inpatient consultative services to each of the three hospital systems is no longer advantageous to the rheumatology practice. However, there are no other local rheumatologists to provide coverage to these institutions.

What is the ethical obligation for the rheumatology practice to continue to provide consultative services to hospitals within their community?

Discussion

Compared with a busy outpatient practice, inpatient consultative care presents many rheumatologists with significant challenges, especially with respect to efficiency. Several factors contribute to this, including:

1. Communication with the referring team: In many hospital settings, requests for consultation come from ancillary staff (e.g., a ward clerk calls the rheumatology office to “order” the consultation rather than physician-to-physician communication). This may obscure the reason for the consultation and require additional work in figuring out the question. Shift changes among the responsible hospitalist teams may complicate attempts to communicate with the individual who generated the consultation request, hindering requests for clarification and communication of recommendations.
2. Networking: As hospitals increasingly move to hospitalist coverage, the opportunity for a consultant to forge relationships with referring providers is reduced. When hospital patients were cared for by their internist, family practitioner or general practitioner, the inpatient rheumatology consultation offered an opportunity to strengthen clinical relationships that would continue in the outpatient setting. Such relationships don’t exist between rheumatologists and most hospitalists.
3. EMRs: Hospitals utilize a variety of EMR programs. EMRs add a significant amount of time to clinical workflow, and it is unlikely a consulting rheumatologist will use these unfamiliar EMRs frequently enough to master them. Upgrades to EMRs can accumulate between consultations, changing the interface substantially. The investment in time to gather data and enter information into each hospital’s EMR can be substantial.
4. Financial and lifestyle matters: Making ends meet in clinical medicine requires a busy clinic schedule. The low efficiency of hospital consultation results in relatively low reimbursement. A rheumatologist typically receives no compensation to be on call, and inpatient consultation is an add-on activity that must be fulfilled around the core business of the clinic schedule. The unusual and inconvenient work hours may be contradictory to a desirable work–life balance.

Physicians have long embraced their responsibility to care for those in need. Implicit in this ethos is a willingness to sacrifice individual needs for those of the patient. The ethical concept of beneficence—the physician’s professional duty to the patient’s best interests—is a reflection of this. Indeed, the patient–physician relationship is codified by specialty societies, such as the American College of Physicians, as obligating the physician to serve the patient’s interest.¹

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.

Colin C. Edgerton, MD, FACP, RhMSUS, is a practicing rheumatologist with Low Country Rheumatology in Charleston, S.C., a clinical assistant professor of medicine at the Medical College of Georgia—Georgia Regents University, and assistant professor of medicine, Uniformed Services, University of the Health Sciences.

References

1. Snyder L, American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: 6th ed. Ann Intern Med. 2012 Jan 3;156(1 Pt 2):73–104.
2. AMA Council on Ethical and Judicial Affairs. Code of Medical Ethics of the American Medical Association. 2012–2013.
3. Abbo E. Virtual Mentor. The ethics of efficiency in hospital medicine: Developing a new paradigm for the patient-physician relationship. American Medical Association Journal of Ethics. 2008 Dec;10(12):817–822.