Background: The purpose of this study was to observe the roles played by six hospice medical directors from two hospice programs during interdisciplinary team case reviews. Methods: The study analyzed videotapes of case reviews in two hospice agencies over a two year period. The results indicate that the roles and levels of participation vary. Medical Directors were observed reviewing and assisting with care plans, acting as a liaison with primary physicians, educating staff, consulting with attending physicians, participating in quality assurance activities, and dealing with budget issues. Results: Medical Directors did not make home visits or assume the role of attending physician during the observation period. Conclusions: The study demonstrates variance in roles among medical directors and raises new questions for future research.