Who’s Who in Healthcare <ul><li>Katharine C. Rathbun, MD, MPH </li></ul><ul><li>Strategic Management of Health Care Organi...
Physician-Patient Relationship <ul><li>the basic relationship in healthcare </li></ul><ul><li>between two people </li></ul...
Establishing the Relationship <ul><li>sign a contract </li></ul><ul><li>hang out a shingle </li></ul><ul><li>make an appoi...
Group Practice <ul><li>May create multiple relationships without prior interaction with a given physician </li></ul><ul><l...
Hospital Practice <ul><li>contracts can create a physician-patient relationship </li></ul><ul><li>all the rules apply </li...
Emergency Room Coverage <ul><li>staff privileges specify the duty to take ER call and provide care for patients in specifi...
Mandatory Consultation <ul><li>Cardiologists reading all EKGs </li></ul><ul><li>Pathologist supervising lab </li></ul><ul>...
Hospital Practice <ul><li>hospitalist groups becoming common </li></ul><ul><li>contracts between doctors as well as the ot...
Medical Specialties <ul><li>voluntary associations </li></ul><ul><li>AMA or AOA recognized boards </li></ul><ul><li>reside...
Historical Specialization <ul><li>most boards were set up in the 1940’s </li></ul><ul><li>all doctors did GP training  </l...
Current Specialization <ul><li>everyone does at least 1 year of residency </li></ul><ul><li>this is specialty training </l...
Legal Status of Specialization <ul><li>many states now accept a board exam in lieu of a repeat licensing exam </li></ul><u...
Certified vs Eligible <ul><li>most boards will not recognize a status of “board eligible”  </li></ul><ul><li>you have pass...
Schools of Practice <ul><li>Allopath - what most think of as a real doctor </li></ul><ul><li>Osteopath - also real doctors...
Osteopathy vs Allopathy <ul><li>Historically had separate hospitals and practice groups  </li></ul><ul><li>Osteopaths were...
Physician Extenders <ul><li>many doctors use physician extenders </li></ul><ul><li>state specific rules </li></ul><ul><li>...
Rules About Supervision  <ul><li>how many can you have </li></ul><ul><li>how close do they have to be </li></ul><ul><li>ho...
Extenders in Hospitals <ul><li>these extenders should be credentialed individually </li></ul><ul><li>staff bylaws should d...
Students <ul><li>don’t call them doctor or nurse </li></ul><ul><li>they are there to learn not serve </li></ul><ul><li>the...
Residents <ul><li>doctors in training </li></ul><ul><li>may or may not be licensed </li></ul><ul><li>working on an institu...
Team Care <ul><li>doctor - captain of the ship  </li></ul><ul><li>modern practice is more complicated </li></ul><ul><li>ho...
Lesser Levels of Training <ul><li>basic rule is you cannot hand off care or responsibility to someone less qualified than ...
Nurses <ul><li>Registered Nurses - real nurses </li></ul><ul><li>LPN - licensed practical nurses </li></ul><ul><li>Nurse P...
Nurse-Patient Relationship <ul><li>Nurses are independently licensed </li></ul><ul><li>Nurses have an independent duty to ...
Nurse-Physician Relationship <ul><li>Mostly nurses are absolutely subservient to doctors </li></ul><ul><li>If they do not ...
Independent Nurse Practice <ul><li>Nurses may open an office and do wound care and nutrition advise </li></ul><ul><li>Nurs...
Nurses in Institutions <ul><li>Nurses in hospitals and clinics are generally employees of the institution </li></ul><ul><l...
Other Providers <ul><li>There are many other licensed or certified health care professionals </li></ul><ul><ul><li>x-ray, ...
Nurse Extenders <ul><li>lower level care providers - certified </li></ul><ul><li>medical assistants, OR technicians, lab t...
Nurse Extenders in Institutions <ul><li>need to be carefully screened </li></ul><ul><li>need to be carefully supervised </...
Licenses <ul><li>the license belongs to an individual </li></ul><ul><li>it is a privilege to get a license </li></ul><ul><...
Other Licensees <ul><li>many other licensed professions in medical practice </li></ul><ul><li>may have separate licensing ...
Unlicensed Practitioners <ul><li>unlicensed physicians </li></ul><ul><li>faith healers </li></ul><ul><li>alternative medic...
Administrators <ul><li>great responsibility - little authority when it comes to patient care </li></ul><ul><li>laws forbid...
Duties to Treat <ul><li>statutory - cord blood serologies </li></ul><ul><li>contractual - orthopedist in the ER </li></ul>...
Abandonment <ul><li>stopping care to a patient without providing sufficient notice and opportunity for the patient to find...
Fiduciary Duty <ul><li>a physician is a fiduciary </li></ul><ul><li>the fiduciary has a duty to put the interests of the c...
Terminating the Relationship - Patients <ul><li>patients may terminate the provider-patient relationship at will as long a...
Terminating the Relationship - Providers <ul><li>The physician-patient relationship is 24/7. </li></ul><ul><li>It must be ...
Referral/Consultation <ul><li>REFERRAL shifts the care of a patient to another provider and is an acceptable way to termin...
Referrals <ul><li>usually done because the physician or hospital is not able to provide the necessary services </li></ul><...
Consultations <ul><li>Bringing in the expert or the specialist </li></ul><ul><li>hospitals often require these for certain...
Consent to Care <ul><li>you have to have permission from a consenting adult to do anything to them </li></ul><ul><li>viola...
Substitute Consent <ul><li>not everyone is a consenting adult </li></ul><ul><li>know who has the authority to consent and ...
Questions of Ability to Consent <ul><li>you either have someone with the legal ability to consent or you don’t </li></ul><...
Informed Consent <ul><li>more detailed than simple consent </li></ul><ul><li>many states have statutes on this </li></ul><...
Exceptions to Consent <ul><li>emergency exception  </li></ul><ul><ul><li>expectation that anyone would want preservation o...
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  1. 1. Who’s Who in Healthcare <ul><li>Katharine C. Rathbun, MD, MPH </li></ul><ul><li>Strategic Management of Health Care Organizations </li></ul><ul><li>Spring 2005 </li></ul><ul><li>LSU MPA Program </li></ul><ul><li>Course Page: </li></ul><ul><ul><li>http://biotech.law.lsu.edu/Courses/mpa/index.htm </li></ul></ul>
  2. 2. Physician-Patient Relationship <ul><li>the basic relationship in healthcare </li></ul><ul><li>between two people </li></ul><ul><li>requires consent of both parties to establish </li></ul><ul><li>unilateral termination </li></ul>
  3. 3. Establishing the Relationship <ul><li>sign a contract </li></ul><ul><li>hang out a shingle </li></ul><ul><li>make an appointment </li></ul><ul><li>accept payment </li></ul>
  4. 4. Group Practice <ul><li>May create multiple relationships without prior interaction with a given physician </li></ul><ul><li>System may assign patients </li></ul><ul><li>difficult to “fire” a patient from one doctor </li></ul>
  5. 5. Hospital Practice <ul><li>contracts can create a physician-patient relationship </li></ul><ul><li>all the rules apply </li></ul><ul><li>cannot pick and choose patients </li></ul>
  6. 6. Emergency Room Coverage <ul><li>staff privileges specify the duty to take ER call and provide care for patients in specific situations </li></ul><ul><li>privileges at multiple hospitals can cause problems </li></ul><ul><li>“I’m not on call” isn’t the right answer </li></ul>
  7. 7. Mandatory Consultation <ul><li>Cardiologists reading all EKGs </li></ul><ul><li>Pathologist supervising lab </li></ul><ul><li>this is a physician-patient relationship </li></ul>
  8. 8. Hospital Practice <ul><li>hospitalist groups becoming common </li></ul><ul><li>contracts between doctors as well as the other relationships </li></ul><ul><li>hospital administration may be involved as well </li></ul>
  9. 9. Medical Specialties <ul><li>voluntary associations </li></ul><ul><li>AMA or AOA recognized boards </li></ul><ul><li>residency training or grandfathering </li></ul><ul><li>medical licenses are general not specific </li></ul>
  10. 10. Historical Specialization <ul><li>most boards were set up in the 1940’s </li></ul><ul><li>all doctors did GP training </li></ul><ul><li>some went on to residencies to specialize </li></ul><ul><li>some would just start doing a specialty practice </li></ul><ul><li>most boards accepted both residency and experience </li></ul><ul><li>board certification was for a lifetime </li></ul>
  11. 11. Current Specialization <ul><li>everyone does at least 1 year of residency </li></ul><ul><li>this is specialty training </li></ul><ul><li>specialists are no longer GP’s first </li></ul><ul><li>most boards have closed to grandfathering </li></ul><ul><li>most boards now require recertification </li></ul>
  12. 12. Legal Status of Specialization <ul><li>many states now accept a board exam in lieu of a repeat licensing exam </li></ul><ul><li>hospitals require certification for privileges </li></ul><ul><li>federal programs require certification for certain systems </li></ul><ul><li>insurers require certification for payment </li></ul>
  13. 13. Certified vs Eligible <ul><li>most boards will not recognize a status of “board eligible” </li></ul><ul><li>you have passed the exam or you haven’t </li></ul>
  14. 14. Schools of Practice <ul><li>Allopath - what most think of as a real doctor </li></ul><ul><li>Osteopath - also real doctors - scientific training with some physical therapy added </li></ul><ul><li>These are the only two schools of scientific medical practice </li></ul><ul><li>Share the same licenses </li></ul>
  15. 15. Osteopathy vs Allopathy <ul><li>Historically had separate hospitals and practice groups </li></ul><ul><li>Osteopaths were the less respected - still some stigma </li></ul><ul><li>Becoming integrated </li></ul><ul><li>Often share residencies </li></ul><ul><li>Many osteopaths take AMA boards </li></ul>
  16. 16. Physician Extenders <ul><li>many doctors use physician extenders </li></ul><ul><li>state specific rules </li></ul><ul><li>physician is responsible for what they do </li></ul>
  17. 17. Rules About Supervision <ul><li>how many can you have </li></ul><ul><li>how close do they have to be </li></ul><ul><li>how do you authorize care </li></ul>
  18. 18. Extenders in Hospitals <ul><li>these extenders should be credentialed individually </li></ul><ul><li>staff bylaws should deal with extenders specifically </li></ul>
  19. 19. Students <ul><li>don’t call them doctor or nurse </li></ul><ul><li>they are there to learn not serve </li></ul><ul><li>they take time to supervise </li></ul>
  20. 20. Residents <ul><li>doctors in training </li></ul><ul><li>may or may not be licensed </li></ul><ul><li>working on an institutional license </li></ul><ul><li>there to learn although they may give some service </li></ul><ul><li>DON’T charge for their services </li></ul>
  21. 21. Team Care <ul><li>doctor - captain of the ship </li></ul><ul><li>modern practice is more complicated </li></ul><ul><li>hospital has responsibility and liability </li></ul>
  22. 22. Lesser Levels of Training <ul><li>basic rule is you cannot hand off care or responsibility to someone less qualified than yourself </li></ul><ul><li>you also cannot supervise someone doing something you don’t know how to do </li></ul><ul><li>both these rules are violated all the time </li></ul><ul><ul><li>side of the road </li></ul></ul><ul><ul><li>in the clinic/hospital </li></ul></ul>
  23. 23. Nurses <ul><li>Registered Nurses - real nurses </li></ul><ul><li>LPN - licensed practical nurses </li></ul><ul><li>Nurse Practitioners </li></ul><ul><li>non-licensed caregivers </li></ul>
  24. 24. Nurse-Patient Relationship <ul><li>Nurses are independently licensed </li></ul><ul><li>Nurses have an independent duty to their patients </li></ul><ul><li>Nurses exercise independent judgement </li></ul>
  25. 25. Nurse-Physician Relationship <ul><li>Mostly nurses are absolutely subservient to doctors </li></ul><ul><li>If they do not agree with physician orders, they can refuse to participate but they cannot change orders. </li></ul><ul><li>They may be protected by the practice acts or the rules of the hospital </li></ul>
  26. 26. Independent Nurse Practice <ul><li>Nurses may open an office and do wound care and nutrition advise </li></ul><ul><li>Nurses may not open an office and practice medicine even if they are nurse practitioners </li></ul><ul><li>Nurses may not be hired by a hospital and set up a medical practice either </li></ul>
  27. 27. Nurses in Institutions <ul><li>Nurses in hospitals and clinics are generally employees of the institution </li></ul><ul><li>The institution is generally liable for what they do. </li></ul><ul><li>If the physician hires them, they are generally functioning as a physician extender. </li></ul>
  28. 28. Other Providers <ul><li>There are many other licensed or certified health care professionals </li></ul><ul><ul><li>x-ray, laboratory, pharmacy </li></ul></ul><ul><li>Legally and administratively these are similar to nurses </li></ul>
  29. 29. Nurse Extenders <ul><li>lower level care providers - certified </li></ul><ul><li>medical assistants, OR technicians, lab technicians </li></ul><ul><li>on the job training vs certification </li></ul>
  30. 30. Nurse Extenders in Institutions <ul><li>need to be carefully screened </li></ul><ul><li>need to be carefully supervised </li></ul><ul><li>cannot rely on the license or certification </li></ul><ul><li>institution has all the responsibility </li></ul>
  31. 31. Licenses <ul><li>the license belongs to an individual </li></ul><ul><li>it is a privilege to get a license </li></ul><ul><li>you have a right to keep it </li></ul><ul><li>general not specialty license </li></ul>
  32. 32. Other Licensees <ul><li>many other licensed professions in medical practice </li></ul><ul><li>may have separate licensing boards or be under the board of medical examiners </li></ul><ul><li>often work in hospitals or other institutions </li></ul>
  33. 33. Unlicensed Practitioners <ul><li>unlicensed physicians </li></ul><ul><li>faith healers </li></ul><ul><li>alternative medicine </li></ul>
  34. 34. Administrators <ul><li>great responsibility - little authority when it comes to patient care </li></ul><ul><li>laws forbid corporate practice of medicine </li></ul><ul><li>need good contracts and institutional rules to allow them to control what goes on </li></ul>
  35. 35. Duties to Treat <ul><li>statutory - cord blood serologies </li></ul><ul><li>contractual - orthopedist in the ER </li></ul><ul><li>ethical - patient is there </li></ul><ul><li>continuing care </li></ul>
  36. 36. Abandonment <ul><li>stopping care to a patient without providing sufficient notice and opportunity for the patient to find substitute care </li></ul><ul><li>illegal </li></ul><ul><li>unethical </li></ul><ul><li>hospitals may be the perpetrators or the victims </li></ul>
  37. 37. Fiduciary Duty <ul><li>a physician is a fiduciary </li></ul><ul><li>the fiduciary has a duty to put the interests of the client above their own interests and do what is best for the client </li></ul><ul><li>this does not mean break the law, violate ethics or work for free </li></ul>
  38. 38. Terminating the Relationship - Patients <ul><li>patients may terminate the provider-patient relationship at will as long as they are legally able to consent </li></ul><ul><li>patients don’t always do what is good for them </li></ul><ul><li>patients can’t force a physician or hospital to provide certain types of care - their legal choice is shut up or go away </li></ul>
  39. 39. Terminating the Relationship - Providers <ul><li>The physician-patient relationship is 24/7. </li></ul><ul><li>It must be formally terminated by the physician. </li></ul><ul><li>The physician must provide alternatives to the patient or a lot of time during which they continue to provide care. </li></ul><ul><li>Alternative care must be realistically available. </li></ul>
  40. 40. Referral/Consultation <ul><li>REFERRAL shifts the care of a patient to another provider and is an acceptable way to terminate a relationship </li></ul><ul><li>CONSULTATION brings another provider into the relationship but does not terminate the original relationship </li></ul><ul><li>either may be done by both physicians or hospitals </li></ul>
  41. 41. Referrals <ul><li>usually done because the physician or hospital is not able to provide the necessary services </li></ul><ul><li>may be done for religious or ethical reasons </li></ul><ul><li>may be done for personality reasons </li></ul><ul><li>may not be done for prohibited reasons </li></ul><ul><ul><li>protected classes of people </li></ul></ul><ul><ul><li>emergency wallet biopsies </li></ul></ul>
  42. 42. Consultations <ul><li>Bringing in the expert or the specialist </li></ul><ul><li>hospitals often require these for certain services </li></ul><ul><ul><li>ICU admissions, obstetrics, reading EKGs </li></ul></ul><ul><li>in-house second opinions </li></ul><ul><li>curb-side consults - illegal under HIPPA </li></ul>
  43. 43. Consent to Care <ul><li>you have to have permission from a consenting adult to do anything to them </li></ul><ul><li>violating this is battery </li></ul><ul><li>the patient may pick and choose with some exceptions </li></ul><ul><li>the patient may terminate the relationship by refusing consent </li></ul>
  44. 44. Substitute Consent <ul><li>not everyone is a consenting adult </li></ul><ul><li>know who has the authority to consent and talk only to them </li></ul><ul><li>parents have limited authority over the care of their children </li></ul><ul><li>spouses have no authority over each other </li></ul>
  45. 45. Questions of Ability to Consent <ul><li>you either have someone with the legal ability to consent or you don’t </li></ul><ul><li>questionable situations have to be addressed by a judge </li></ul><ul><li>big city hospitals often have the judge’s phone number posted in the ER </li></ul>
  46. 46. Informed Consent <ul><li>more detailed than simple consent </li></ul><ul><li>many states have statutes on this </li></ul><ul><li>this is about not loosing a law suit </li></ul>
  47. 47. Exceptions to Consent <ul><li>emergency exception </li></ul><ul><ul><li>expectation that anyone would want preservation of life and limb </li></ul></ul><ul><ul><li>may apply if the patient is medically or legally incompetent </li></ul></ul><ul><li>statutory exceptions </li></ul><ul><ul><li>public health law </li></ul></ul><ul><ul><li>mental health law </li></ul></ul><ul><li>court ordered care </li></ul>
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