Who’s Who in Healthcare

• Katharine C. Rathbun, MD, MPH

• Strategic Management of Healthcare Organizations

• Spring 2009

Physicians

• Many different types of people hold themselves out as physicians

• Difference is science vs faith healing

• Schools of Practice vs Specialties

Schools of Practice

• Allopath - a real doctor

• Osteopath - also real doctors - scientific training with physical therapy added

• Scientific medical practice

• Share the same licenses

Osteopathy vs Allopathy

• Historically– Separate hospitals and practice groups– Osteopaths were the less respected

• Becoming integrated

• Share allopathic residencies

• Many osteopaths take AMA boards

Medical Specialties

• voluntary associations

• AMA or AOA recognized boards

• residency training or grandfathering

• not part of licensure

Historical Specialization

• most boards were set up in the 1940’s

• 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

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

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

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

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

Unlicensed Practitioners

• unlicensed physicians

• faith healers

• alternative medicine

Physician-Patient Relationship

• THE basic relationship in healthcare

• between two people

• requires consent of both parties to establish

• one party may terminate it

Establishing the Relationship

• sign a contract

• hang out a shingle

• make an appointment

• accept payment

Duties to Treat

• statutory - cord blood serologies

• contractual - orthopedist in the ER

• ethical - patient is there

• continuing care

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

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

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.

Group Practice

• may create multiple relationships

• less personal

• system may assign patients

• difficult to “fire” a patient from one doctor

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

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

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

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 both physicians and hospitals

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

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

Physicians in Hospitals

• Specialties that support the hospital

• Consultants in the hospital

• Hospitalists

Hospital Specialties

• radiology, pathology, emergency

• group contracts create the relationship

• all the rules apply

• cannot pick and choose patients

• being on insurance plans

Hospital Consultants

• cardiologists reading all EKGs

• intensivists running the ICU

• there is a physician-patient relationship

• patient care is direct or indirect

• must work with the attending physician

Hospital Practice

• hospitalist groups becoming common

• doctor-doctor relationship as well as doctor-patient relationship

• hospital administration may or may not be involved

Team Care

• Doctor - captain of the ship

• Modern practice is more complicated

• Hospital services, teaching programs, group practices

• Shared responsibility and liability

Residents

• doctors in advanced training

• may or may not be licensed

• working on an institutional license

• there to learn

• they may give some service

• DON’T charge for their services

Students

• don’t call them doctor or nurse

• they are there to learn not serve

• they take time to supervise

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

Rules About Supervision

• how many can you have

• how close do they have to be

• how do you authorize care

• how do you supervise

Extenders in Hospitals

• extenders should be credentialed

• staff bylaws should have specific provisions for extenders

Nurses

• Registered Nurses - real nurses

• LPN - licensed practical nurses

• Nurse Practitioners

• non-licensed caregivers

Nurse-Patient Relationship

• Nurses are independently licensed

• Nurses have an independent duty to patients

• Nurses exercise independent judgment

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

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

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

Nurse Extenders

• lower level care providers

• medical assistants, surgery technicians, lab technicians

• on the job training vs certification

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

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

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