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  1. 1. Who’s Who in Healthcare • Katharine C. Rathbun, MD, MPH • Strategic Management of Healthcare Organizations • Spring 2009
  2. 2. Physicians • Many different types of people hold themselves out as physicians • Difference is science vs faith healing • Schools of Practice vs Specialties
  3. 3. Schools of Practice • Allopath - a real doctor • Osteopath - also real doctors - scientific training with physical therapy added • Scientific medical practice • Share the same licenses
  4. 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. 5. Medical Specialties • voluntary associations • AMA or AOA recognized boards • residency training or grandfathering • not part of licensure
  6. 6. 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
  7. 7. 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
  8. 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. 9. 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
  10. 10. 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
  11. 11. Unlicensed Practitioners • unlicensed physicians • faith healers • alternative medicine
  12. 12. Physician-Patient Relationship • THE basic relationship in healthcare • between two people • requires consent of both parties to establish • one party may terminate it
  13. 13. Establishing the Relationship • sign a contract • hang out a shingle • make an appointment • accept payment
  14. 14. Duties to Treat • statutory - cord blood serologies • contractual - orthopedist in the ER • ethical - patient is there • continuing care
  15. 15. 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
  16. 16. 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
  17. 17. 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.
  18. 18. Group Practice • may create multiple relationships • less personal • system may assign patients • difficult to “fire” a patient from one doctor
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. Physicians in Hospitals • Specialties that support the hospital • Consultants in the hospital • Hospitalists
  26. 26. Hospital Specialties • radiology, pathology, emergency • group contracts create the relationship • all the rules apply • cannot pick and choose patients • being on insurance plans
  27. 27. 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
  28. 28. Hospital Practice • hospitalist groups becoming common • doctor-doctor relationship as well as doctor-patient relationship • hospital administration may or may not be involved
  29. 29. Team Care • Doctor - captain of the ship • Modern practice is more complicated • Hospital services, teaching programs, group practices • Shared responsibility and liability
  30. 30. 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
  31. 31. Students • don’t call them doctor or nurse • they are there to learn not serve • they take time to supervise
  32. 32. 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
  33. 33. Rules About Supervision • how many can you have • how close do they have to be • how do you authorize care • how do you supervise
  34. 34. Extenders in Hospitals • extenders should be credentialed • staff bylaws should have specific provisions for extenders
  35. 35. Nurses • Registered Nurses - real nurses • LPN - licensed practical nurses • Nurse Practitioners • non-licensed caregivers
  36. 36. Nurse-Patient Relationship • Nurses are independently licensed • Nurses have an independent duty to patients • Nurses exercise independent judgment
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. Nurse Extenders • lower level care providers • medical assistants, surgery technicians, lab technicians • on the job training vs certification
  41. 41. 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
  42. 42. 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
  43. 43. 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