Who

1
Whos Who in Healthcare

• Katharine C. Rathbun, MD, MPH
• Strategic Management of Health Care Organizations
• Spring 2008

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 - a real doctor
• Osteopath - also real doctors - scientific
  training with physical therapy added
• Two schools of scientific medical practice
• Share the same licenses

4
Osteopathy vs Allopathy

• Historically
• separate hospitals and practice groups
• Osteopaths were the less respected
• Becoming integrated
• Share allopathic residencies
• Many osteopaths take AMA boards

5
Medical Specialties

• voluntary associations
• AMA or AOA recognized boards
• residency training or grandfathering
• not part of licensure

6
Historical Specialization

• most boards were set up in the 1940s
• all doctors did GP training
• some went to specialty residencies
• some just did a specialty practice
• boards accepted residency or 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 GPs 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
• government requires certification for certain
  programs
• insurers require certification for payment

9
Physician-Patient Relationship

• THE basic relationship in healthcare
• between two people
• requires consent of both parties to establish
• one party may terminate

10
Establishing the Relationship

• sign a contract
• hang out a shingle
• make an appointment
• accept payment

11
Group Practice

• may create multiple relationships
• less personal
• system may assign patients
• difficult to fire a patient from one doctor

12
Hospital Specialties

• radiology, pathology, emergency
• group contracts create the relationship
• all the rules apply
• cannot pick and choose patients

13
Hospital Consultants

• cardiologists reading all EKGs
• intensivists running the ICU
• there is a physician-patient relationship
• patient care is direct or indirect

14
Hospital Practice

• hospitalist groups becoming common
• doctor-doctor relationship as well as
  doctor-patient relationship
• hospital administration may or may not be involved

15
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
• Both are done by physicians and hospitals

16
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
• wallet biopsies EMTALA

17
Consultations

• Bringing in the expert or the specialist
• Hospitals often require consultations
• ICU admissions, obstetrics, reading tests
• Form of second opinion
• Curb-side consults - illegal under HIPPA

18
Team Care

• Doctor - captain of the ship
• Modern practice is more complicated
• Hospital services, teaching programs, group
  practices
• Shared responsibility and liability

19
Residents

• doctors in advanced training
• may or may not be licensed
• working on an institutional license
• there to learn
• they may give some service
• DONT charge for their services

20
Students

• dont call them doctor or nurse
• they are there to learn not serve
• they take time to supervise

21
Physician Extenders

• many doctors use physician extenders
• many extenders hate the term
• there are state specific rules
• supervising physician is responsible
• the military is different

22
Rules About Supervision

• how many can you have
• how close do they have to be
• how do you authorize care
• how do you supervise

23
Extenders in Hospitals

• extenders should be credentialed
• staff bylaws should have specific provisions for
  extenders

24
Nurses

• Registered Nurses - real nurses
• LPN - licensed practical nurses
• Nurse Practitioners
• non-licensed caregivers

25
Nurse-Patient Relationship

• Nurses are independently licensed
• Nurses have an independent duty to patients
• Nurses exercise independent judgment

26
Nurse-Physician Relationship

• In most settings, nurses are absolutely
  subservient to doctors
• A nurse may refuse an order but may not change an
  order
• Nurses may be protected from bad orders by the
  practice acts or the rules of the hospital

27
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 to set up a
  medical practice

28
Nurses in Institutions

• Nurses in hospitals and clinics are generally
  employees of the institution
• The institution is generally responsible and
  liable for what they do.
• If a physician hires a nurse, the physician takes
  on these responsibilities

29
Nurse Extenders

• lower level care providers
• medical assistants, surgery technicians, lab
  technicians
• on the job training vs certification

30
Nurse Extenders in Institutions

• need to be carefully screened
• need to be carefully supervised
• institution has all the responsibility
• cannot rely on the license or certification

31
Other Providers

• Many other health care professionals
• Doctors
• physicians, psychologists, dentists
• independent some with limitations
• Technicians
• x-ray, laboratory, pharmacy
• legally and administratively similar to nurses

32
Administrators

• great responsibility - little authority when it
  comes to patient care
• laws forbid corporate practice of medicine
• need good contracts and institutional rules so
  they can control what goes on
• some states license or register administrators

33
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

34
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

35
Unlicensed Practitioners

• unlicensed physicians
• faith healers
• alternative medicine

36
Duties to Treat

• statutory - cord blood serologies
• contractual - orthopedist in the ER
• ethical - patient is there
• continuing care

37
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

38
Terminating the Relationship Patients

• patients may terminate the provider-patient
  relationship at will as long as they are legally
  able to consent
• patients dont always do what is good for them
• patients cant force a physician or hospital to
  provide certain types of care - their legal
  choice is shut up or go away

39
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.

40
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

41
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
• Im not on call isnt the right answer

42
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 dont know how to do
• both these rules are violated all the time
• side of the road
• in the clinic/hospital