Who’s Who in Healthcare

1. Who’s Who in Healthcare • Katharine C. Rathbun, MD, MPH • Strategic Management of Health Care Organizations • Spring 2006 • LSU MPA Program

2. Physicians • Many different types of people hold themselves out as physicians • Difference is science vs faith healing • Schools of Practice vs Specialties

3. Schools of Practice • Allopath - what most think of as a real doctor • Osteopath - also real doctors - scientific training with some physical therapy added • These are the only two schools of scientific medical practice • Share the same licenses

4. Osteopathy vs Allopathy • Historically had separate hospitals and practice groups • Osteopaths were the less respected - still some stigma • Becoming integrated • Often share residencies • Many osteopaths take AMA boards

5. Medical Specialties • voluntary associations • AMA or AOA recognized boards • residency training or grandfathering • medical licenses are general not specific

6. Historical Specialization • most boards were set up in the 1940’s • all doctors did GP training • some went on to residencies to specialize • some would just start doing a specialty practice • most boards accepted both residency and experience • board certification was for a lifetime

7. Current Specialization • everyone does at least 1 year of residency • this is specialty training • specialists are no longer GP’s first • most boards have closed to grandfathering • most boards now require recertification

8. Legal Status of Specialization • many states now accept a board exam in lieu of a repeat licensing exam • hospitals require certification for privileges • federal programs require certification for certain systems • insurers require certification for payment

9. Physician-Patient Relationship • the basic relationship in healthcare • between two people • requires consent of both parties to establish • unilateral termination

10. Establishing the Relationship • sign a contract • hang out a shingle • make an appointment • accept payment

11. Group Practice • May create multiple relationships without prior interaction with a given physician • System may assign patients • difficult to “fire” a patient from one doctor

12. Hospital Practice • contracts can create a physician-patient relationship • all the rules apply • cannot pick and choose patients

13. Hospital Practice • hospitalist groups becoming common • contracts between doctors as well as the other relationships • hospital administration may be involved as well

14. Emergency Room Coverage • staff privileges specify the duty to take ER call and provide care for patients in specific situations • privileges at multiple hospitals can cause problems • “I’m not on call” isn’t the right answer

15. Mandatory Consultation • Cardiologists reading all EKGs • Pathologist supervising lab • this is a physician-patient relationship

16. Referral/Consultation • REFERRAL shifts the care of a patient to another provider and is an acceptable way to terminate a relationship • CONSULTATION brings another provider into the relationship but does not terminate the original relationship • either may be done by both physicians or hospitals

17. Referrals • usually done because the physician or hospital is not able to provide the necessary services • may be done for religious or ethical reasons • may be done for personality reasons • may not be done for prohibited reasons • protected classes of people • emergency wallet biopsies

18. Consultations • Bringing in the expert or the specialist • hospitals often require these for certain services • ICU admissions, obstetrics, reading EKGs • in-house second opinions • curb-side consults - illegal under HIPPA

19. Team Care • doctor - captain of the ship • modern practice is more complicated • hospital has responsibility and liability

20. Physician Extenders • many doctors use physician extenders • state specific rules • physician is responsible for what they do • the military is different

21. Rules About Supervision • how many can you have • how close do they have to be • how do you authorize care

22. Extenders in Hospitals • these extenders should be credentialed individually • staff bylaws should deal with extenders specifically

23. Students • don’t call them doctor or nurse • they are there to learn not serve • they take time to supervise

24. Residents • doctors in training • may or may not be licensed • working on an institutional license • there to learn although they may give some service • DON’T charge for their services

25. Nurses • Registered Nurses - real nurses • LPN - licensed practical nurses • Nurse Practitioners • non-licensed caregivers • certified vs licensed

26. Nurse-Patient Relationship • Nurses are independently licensed • Nurses have an independent duty to their patients • Nurses exercise independent judgement

27. Nurse-Physician Relationship • Mostly nurses are absolutely subservient to doctors • If they do not agree with physician orders, they can refuse to participate but they cannot change orders. • They may be protected by the practice acts or the rules of the hospital

28. Independent Nurse Practice • Nurses may open an office and do wound care and nutrition advise • Nurses may not open an office and practice medicine even if they are nurse practitioners • Nurses may not be hired by a hospital and set up a medical practice either

29. Nurses in Institutions • Nurses in hospitals and clinics are generally employees of the institution • The institution is generally liable for what they do. • If the physician hires them, they are generally functioning as a physician extender.

30. Other Providers • There are many other licensed or certified health care professionals • x-ray, laboratory, pharmacy • Legally and administratively these are similar to nurses

31. Nurse Extenders • lower level care providers - certified • medical assistants, OR technicians, lab technicians • on the job training vs certification

32. Nurse Extenders in Institutions • need to be carefully screened • need to be carefully supervised • cannot rely on the license or certification • institution has all the responsibility

33. Licenses • the license belongs to an individual • it is a privilege to get a license • you have a right to keep it • general not specialty license

34. Other Licensees • many other licensed professions in medical practice • may have separate licensing boards or be under the board of medical examiners • often work in hospitals or other institutions

35. Registration/Certification • License • can only be granted by the state • qualifications set by the state • Registration • an official roster • may be public or private • Certification • usually private recognition

36. Unlicensed Practitioners • unlicensed physicians • faith healers • alternative medicine

37. Administrators • great responsibility - little authority when it comes to patient care • laws forbid corporate practice of medicine • need good contracts and institutional rules to allow them to control what goes on • Some states license or register administrators

38. Duties to Treat • statutory - cord blood serologies • contractual - orthopedist in the ER • ethical - patient is there • continuing care

39. Abandonment • stopping care to a patient without providing sufficient notice and opportunity for the patient to find substitute care • illegal • unethical • hospitals may be the perpetrators or the victims

40. Fiduciary Duty • a physician is a fiduciary • the fiduciary has a duty to put the interests of the client above their own interests and do what is best for the client • this does not mean break the law, violate ethics or work for free

41. Terminating the Relationship - Patients • patients may terminate the provider-patient relationship at will as long as they are legally able to consent • patients don’t always do what is good for them • patients can’t force a physician or hospital to provide certain types of care - their legal choice is shut up or go away

42. Terminating the Relationship - Providers • The physician-patient relationship is 24/7. • It must be formally terminated by the physician. • The physician must provide alternatives to the patient or a lot of time during which they continue to provide care. • Alternative care must be realistically available.

43. Lesser Levels of Training • basic rule is you cannot hand off care or responsibility to someone less qualified than yourself • you also cannot supervise someone doing something you don’t know how to do • both these rules are violated all the time • side of the road • in the clinic/hospital

44. Consent to Care • you have to have permission from a consenting adult to do anything to them • violating this is battery • the patient may pick and choose with some exceptions • the patient may terminate the relationship by refusing consent

45. Substitute Consent • not everyone is a consenting adult • know who has the authority to consent and talk only to them • parents have limited authority over the care of their children • spouses have no authority over each other

46. Questions of Ability to Consent • you either have someone with the legal ability to consent or you don’t • questionable situations have to be addressed by a judge • big city hospitals often have the judge’s phone number posted in the ER

47. Informed Consent • more detailed than simple consent • many states have statutes on this • this is about not loosing a law suit

48. Exceptions to Consent • emergency exception • expectation that anyone would want preservation of life and limb • may apply if the patient is medically or legally incompetent • statutory exceptions • public health law • mental health law • court ordered care