Frequency of Ethical Issues on a Hospitalist Teaching Service at an Urban, Tertiary Care Center
Little is known about the daily ethical conflicts encountered by hospitalists that do not prompt a formal clinical ethics consultation. We describe the frequencies of ethical issues identified during daily rounds on hospitalist teaching services at a metropolitan, tertiary-care, teaching hospital. Data were collected from September 2017 through May 2018 by two attending hospitalists from the ethics committee who were embedded on rounds. A total of 270 patients were evaluated and 113 ethical issues were identified in 77 of those patients. These issues most frequently involved discussions about goals of care, treatment refusals, decision-making capacity, discharge planning, cardiopulmonary resuscitation status, and pain management. Only five formal consults were brought to the Hospital Ethics Committee for these 270 patients. Our data are the first prospective description of ethical issues arising on academic hospitalist teaching services and are an important step in the development of a targeted ethics curriculum for hospitalists.
© 2019 Society of Hospital Medicine
Much has been written about the sources of the hidden curriculum in clerkships and postgraduate medical education.1-3 However, these descriptions do not adequately account for the critical role that hospitalists play in the development of trainees when they encounter ethical challenges on teaching services.4 As a role model, teacher, and the attending of record, a hospitalist’s response to ethical issues in practice can have a pivotal influence on the life and work of trainees, either instilling positive virtues or perpetuating the negative impact of the hidden curriculum.5-8 Understanding the epidemiology of ethical issues arising on academic hospitalist services has important implications for medical education, clinical ethics, and professionalism, as well as for patient care.
METHODS
Study Setting and Design
We conducted a mixed-method observational study at NewYork–Presbyterian–Weill Cornell Medical Center, an 862-bed, tertiary-care, academic institution located in New York, New York. We performed a prospective description of the frequency of all consecutively identified ethical and contextual issues pertinent to clinical decision-making by observing morning rounds with housestaff hospitalist services. Ethical issues were categorized using a comprehensive standardized instrument previously developed and published by the Division of Medical Ethics.9
The Division of Hospital Medicine employs 79 physicians, 30 of whom are dedicated full-time to daytime care on house-staff (or teaching) or physician assistant services. Of these 30 physicians, two (7%) were coinvestigators in this project and were excluded from participation to avoid bias. Between September 2017 and May 2018, the attending physicians of record of all available housestaff services were invited to participate with their teams in our research study on a weekly basis. We observed 10 different Hospital Medicine attending physicians (10/28, 36% of the available physician sample) over 19 sessions. Before rounds, a brief introduction to the nature of the study was provided to each team. It was explicitly stated that the observers were present to identify and document possible ethical issues that may arise while discussing the patients on rounds, and that the purpose of the study was neither an evaluation of the team members or their decisions nor a critique or quality improvement exercise. Observing researchers were not allowed to participate in the discussion of any case.
To avoid potential case duplication, we allowed for a minimum two-week interval before rounding twice on any particular team. To control for interobserver variability, we observed in pairs during these sessions. Discrepancies between observers were resolved by post hoc discussion and application of the definitions of the standardized instrument used to identify and catalog ethical and contextual issues.
