As healthcare professionals, we have a responsibility to promote patient autonomy and self-advocacy. Modern healthcare has shifted to prioritize a culture that is increasingly patient-centered, with a focus on shared decision making and therapeutic alliance.1
Most medical professionals and patients would presumably agree that this is a positive change. Still, the patient-clinician relationship is complicated, particularly in the hospital setting, where patients do not feel well physically and are simultaneously managing the disruptive consequences—practical, emotional, and financial—of an unplanned hospitalization. Compounding these challenges is the physically and mentally demanding nature of inpatient medicine, with long hours and high stakes that often place clinicians under large amounts of stress, at times leading them to feel rushed, fatigued, and indifferent during their interactions with patients.2
When these factors accumulate, they can lead to conflict and patient dissatisfaction. A patient may fire the current hospitalist and request a new clinician to take over their care, in the hope that this will improve their inpatient experience. Outside of extreme situations involving allegations of abuse or discrimination, or in which the standard of medical care is not being met, the decision whether or not to grant such requests is controversial. In this installment of The Flipside, we present opposing viewpoints on the topic of patients’ right to fire their hospitalists.
Firing the hospitalist should not be tolerated (Dr. Marcantonio)
When a dissatisfied patient chooses to fire the hospitalist, it’s important first to understand the reasons for the mismatch in therapeutic alliance. A patient may cite a variety of concerns about the clinician, including inadequate communication skills, lack of trust in the individual, unaddressed symptoms, unhappiness with the outcome of medical decision making, or simply the desire for a second opinion.
Whether or not a new hospitalist is likely to meet the patient’s expectations and improve satisfaction is an important consideration, especially if the standard of medical care is already being met. Some may argue that simply allowing the option to switch may be validating to patients and can help preserve their sense of autonomy. However, this pauses the plan of care, potentially leading to care delays and longer length of stay—all without guarantee that the new hospitalist and patient will be a good match. Rather, hospitalist clinicians should use alternative methods of empowering patients and promoting their autonomy.
When medically appropriate, patients can and should help inform the aspects of their care that may be flexible; for example, the choice between two medications with similar efficacy but differing side effect profiles, timing of morning lab draws, or whether to first wean the dose or frequency of pain medications.1 Simply asking a patient’s opinion or suggestions related to the proposed plan of care can go a long way toward building trust and promoting patient autonomy. Often, lack of control leads to feelings of frustration and helplessness, and when we give control back in small doses—ideally from the beginning of the hospital stay—patients are less likely to reach a breaking point.
When they do express dissatisfaction with care and request to switch their hospitalist, encouraging them to maintain the existing partnership challenges both parties to find common ground and also helps create boundaries, which are inarguably essential to any professional or personal relationship. Equally important is the hospitalist’s sincere efforts to reflect on prior interactions, seek opportunities to improve their care delivery and bedside manner, and validate the patient’s negative experiences during a difficult time.
It is also important to note that in most hospital systems, the patient-clinician relationship is a temporary one, and if the patient remains admitted to the hospital, then another individual will eventually take over care. Thus, when patients with unmet medical or personal needs continue to require hospitalization, the system will ultimately allow for exposure to fresh eyes, additional opinions, and differing skill sets and communication styles among clinicians.
When circumstances arise such that the patient’s request for a new hospitalist is time-sensitive (i.e., before an upcoming procedure or in disagreements over discharge timing), other resources should be used to offer the patient support and ensure that the standard of care is being met. Such resources may include specialty consultant input, patient advocacy teams, and hospital ethics committees.3 If feasible within a particular setting, a second opinion might be offered via consultation from a different hospitalist, an alternate hospitalist group practicing in the system, or hospital medicine leadership.
Some may raise the additional concern that being fired is demoralizing and leads to physician burnout, which certainly carries important implications for the sustainability and longevity of a career in hospital medicine. We must also consider the potential consequences this situation creates for patients. Patients who fire their hospitalist often unknowingly place themselves in a vulnerable position, that is, susceptible to bias and stigmatization from subsequent clinicians, nursing staff, and other members of the healthcare team. In handing off or receiving these patients, team members often label them as “difficult.” Even with the best intentions, the individual assuming care will most likely maintain some form of bias toward the patient.3 Similarly to patients who leave against medical advice, a history of firing physicians is likely to be written in the discharge summary, preserved in the medical record, and potentially disseminated in future documentation.
Lastly, and arguably the most practically relevant point, is that the infrastructure of hospital medicine is currently not built to sustain the practice of switching hospitalists if it were to be universally accepted. In smaller, more resource-limited hospitals, only one individual might be working at any given time. In larger hospital systems with multiple hospitalists working simultaneously, the transition of patients from one clinician to another can be time-consuming, inefficient, burdensome to the accepting provider (who may feel scrutinized and under pressure to satisfy an already dissatisfied patient), and inequitable from a census standpoint.
More widespread acceptance of requests to switch hospitalists will inevitably lead to increased frequency of requests, further compounding the logistical challenges of reassigning patients. Similarly, the patient who fires a clinician but remains unhappy with the replacement may feel compelled to make another request to switch. Most hospital medicine systems will be unable to meet these demands. Certainly, extreme circumstances exist in which we may need to honor a patient’s request to change practitioners; however, these individualized decisions should be made thoughtfully and truly be considered necessary exceptions. Otherwise, we run the risk of perpetuating a system that is marked by inequity and bias.
Firing the hospitalist clinician should be allowed (Dr. Hoyle)
Many hospitalists are opposed to the practice of allowing patients to fire their inpatient clinicians and experience a strong, immediate, and instinctive aversion to the idea. This may have its roots in how clinicians view themselves—as compassionate healers, and reasonable and fair-minded people. They imagine being fired by a patient and consider how that would sting, how it would seem unfair and unreasonable. They cannot imagine the situation where being removed and replaced by a colleague would truly benefit the patient. And it would certainly come with a cost or psychological toll. It would feel like failure at best, or public humiliation at worst. Colleagues would probably understand, but they also might wonder. Medical professionals already often experience stress, moral injury, and burnout in the modern healthcare environment, so assuming limited benefits to the patient and significant negative effects on the hospitalist, it makes perfect sense not to allow firing.2,4 Case closed.
However, hospitalist switching may not need to be a burden for the clinician, and the potential benefits for the patient could be greater than initially perceived. Many hospitalized patients experience disempowerment and a lack of autonomy.5,6 Establishing a strong therapeutic alliance with a patient can be difficult, especially in situations of recurrent hospitalization, severe debility, and dependence on external caregivers, which may further erode patient autonomy and self-determination.
Patients often make choices that may be considered irrational, such as declining medications or procedures, or even self-directing discharge. A patient’s decision to fire the hospitalist certainly could fit this pattern of behavior—grasping to expand one’s severely restricted autonomy—but with one key distinction: it’s much less dangerous. Since the practice of hospitalist firing is not well documented or researched, there is no data to demonstrate its effectiveness at restoring patient autonomy or improving the physician-patient relationship afterward. However, it seems likely that such benefits do exist even if only as a placebo effect.
The clinician who chooses to step humbly aside might create the golden opportunity a patient needs to reclaim autonomy and forge a therapeutic alliance with a different healthcare professional. The concern for negative psychological impact on the clinician could be alleviated by normalizing hospitalist switching within the culture of medicine such that stepping down from a patient’s care is not viewed as a failure, but a beneficial exercise of humility, wisdom, and emotional maturity. In fact, permitting both parties to proactively address relationship tensions by attempting to find a better therapeutic match might alleviate distress on the part of the hospitalist as well. Culture change at a systems level has been identified as a promising avenue for the promotion of patient-centered care, and the issue of firing in hospital medicine presents a perfect opportunity to advance such work.1
One major consideration is practicality, or “cost of implementation” in a systems-based practice framework. Is it truly practical to allow patients to dictate switching their hospitalists? Clearly, there should be some constraints on clinician firing in order to avoid creating substantial systems inefficiencies, but the specific limitations will depend heavily on one’s particular setting. Regardless, drawing a clear distinction between “not practical” and “not acceptable” is essential. A system might exist in which firing is not allowed in settings where it is not logistically feasible, but permitted in other situations where it is. As with many policy decisions in healthcare, this may be best addressed not by overarching policy but at the ground level, taking into account the specific circumstances of the request.
Those who oppose the practice of firing the hospitalist often argue that it should be allowed only for good reason, such as when a clinician is not meeting the standard of care; however, adjudicating what qualifies as good reason or when the standard of care is not being met is fraught with difficulties. Patients may be reluctant to fully express their true reasons for pursuing a clinician change, perhaps out of courtesy, out of fear, or for various other reasons. The hospitalist in question may be the only party with the situational knowledge and the medical expertise to determine whether the patient’s stated reason is valid or whether the patient has the capacity to make the request, creating a conflict of interest. The most practical solution is simply to allow clinician-change requests when logistically feasible without attempting to judge or validate the stated reason.
Discussion
The inpatient setting presents a uniquely challenging situation in which a patient and clinician are paired without the opportunity for the patient to express preferences or ensure mutual consent. In examining the arguments surrounding hospitalist firing, there are certainly areas of consensus. Patient-centeredness is essential in the practice of hospital medicine, and this should be made a priority as soon as the relationship begins. Therefore, even in the event of conflict or moral injury on the part of the hospitalist, all requests to reassign the clinician should be met with humility and compassion, with a focus on the reason for dissatisfaction and sincere effort to resolve tensions. Whether or not a switch is made, involvement of a third party, such as a patient advocate or consulting clinician, may help ensure equity in the decision-making process, facilitate common ground, and potentially resolve the situation.
The question of whether or not to allow patient-directed hospitalist firing should come down to a case-by-case assessment of the risks and the benefits to both parties, with the understanding that this determination in itself may not be straightforward. Those who ascribe the highest importance to patient autonomy and self-determination are more likely to support the practice of switching hospitalists, while those who more strongly prioritize clinician advocacy, systems efficiency, and predictability might be opposed. The potential benefits to the patients may be difficult to predict in advance and are certainly difficult to quantify, assuming there was never any overt mistreatment or clinical negligence.
Regardless of medical and ethical concerns, logistical and practical considerations of the hospital system in question may ultimately dictate whether or not a request to change hospitalists can be granted. Further research surrounding patient autonomy and satisfaction in hospital medicine may be able to illuminate this discussion further and inform decisions, whether at the individual, hospital-wide, or policy level.
Dr. Hoyle
Dr. Marcantonio
Dr. Hoyle is a clinical instructor in the department of medicine at Duke University and an adult hospitalist at Duke Regional Hospital, both in Durham, N.C. Dr. Marcantonio is an assistant professor in the departments of medicine and pediatrics, and of family medicine and community health at Duke University, and a medicine-pediatrics hospitalist at Duke University Hospital and Duke Regional Hospital, all in Durham, N.C.
References
- Grover S, et al. Defining and implementing patient-centered care: an umbrella review. Patient Educ Couns. 2022;105(7):1679-1688. https://doi.org/10.1016/j.pec.2021.11.004.
- Warner ME, et al. The work environment and hospitalist work well-being and burnout. J Hosp Med. 2025;20(3):229-237. https://doi.org/10.1002/jhm.13506.
- West T and Torrico TJ. Terminating the therapeutic relationship. 2024. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. Available at: https://pubmed.ncbi.nlm.nih.gov/39383280/.
- Chandrabhatla T, et al. Second victim experiences and moral injury as predictors of hospitalist burnout before and during the COVID-19 pandemic. PLoS One. 2022;17(10):e0275494. https://doi.org/10.1371/journal.pone.0275494.
- Castro EM, et al. Patient empowerment, patient participation and patient-centeredness in hospital care: A concept analysis based on a literature review. Patient Educ Couns. 2016;99(12):1923-1939. https://doi.org/10.1016/j.pec.2016.07.026.
- Prato L, et al. Empowerment, environment and person-centred care: A qualitative study exploring the hospital experience for adults with cognitive impairment. Dementia (London). 2019;18(7-8):2710-2730. https://doi.org/10.1177/1471301218755878.