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

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 - 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

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

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

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

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

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

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

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

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

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

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

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

Unlicensed Practitioners unlicensed physicians faith healers alternative medicine

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

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.

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

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

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