Who’s Who in Healthcare Katharine C. Rathbun, MD, MPH Strategic Management of Health Care...
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Transcript of Who’s Who in Healthcare Katharine C. Rathbun, MD, MPH Strategic Management of Health Care...
Who’s Who in Healthcare
• Katharine C. Rathbun, MD, MPH
• Strategic Management of Health Care Organizations
• Spring 2005
• LSU MPA Program
• Course Page:– http://biotech.law.lsu.edu/Courses/mpa/index.htm
Physician-Patient Relationship
• the basic relationship in healthcare
• between two people
• requires consent of both parties to establish
• unilateral termination
Establishing the Relationship
• sign a contract
• hang out a shingle
• make an appointment
• accept payment
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
Hospital Practice
• contracts can create a physician-patient relationship
• all the rules apply
• cannot pick and choose patients
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
Mandatory Consultation
• Cardiologists reading all EKGs
• Pathologist supervising lab
• this is a physician-patient relationship
Hospital Practice
• hospitalist groups becoming common
• contracts between doctors as well as the other relationships
• hospital administration may be involved as well
Medical Specialties
• voluntary associations
• AMA or AOA recognized boards
• residency training or grandfathering
• medical licenses are general not specific
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
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
• federal programs require certification for certain systems
• insurers require certification for payment
Certified vs Eligible
• most boards will not recognize a status of “board eligible”
• you have passed the exam or you haven’t
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
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
Physician Extenders
• many doctors use physician extenders
• state specific rules
• physician is responsible for what they do
Rules About Supervision
• how many can you have
• how close do they have to be
• how do you authorize care
Extenders in Hospitals
• these extenders should be credentialed individually
• staff bylaws should deal with extenders specifically
Students
• don’t call them doctor or nurse
• they are there to learn not serve
• they take time to supervise
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
Team Care
• doctor - captain of the ship
• modern practice is more complicated
• hospital has responsibility and liability
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
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 their patients
• Nurses exercise independent judgement
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
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
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.
Other Providers
• There are many other licensed or certified health care professionals– x-ray, laboratory, pharmacy
• Legally and administratively these are similar to nurses
Nurse Extenders
• lower level care providers - certified
• medical assistants, OR technicians, lab technicians
• on the job training vs certification
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
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
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
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
Duties to Treat
• statutory - cord blood serologies
• contractual - orthopedist in the ER
• ethical - patient is there
• continuing care
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
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.
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
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
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
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
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
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
Informed Consent
• more detailed than simple consent
• many states have statutes on this
• this is about not loosing a law suit