Transcript Interrelationships in Healthcare - DR

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
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voluntary associations
AMA or AOA recognized boards
residency training or grandfathering
not part of licensure
Historical Specialization
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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
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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
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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
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THE basic relationship in healthcare
between two people
requires consent of both parties to establish
one party may terminate it
Establishing the Relationship
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sign a contract
hang out a shingle
make an appointment
accept payment
Duties to Treat
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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
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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
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radiology, pathology, emergency
group contracts create the relationship
all the rules apply
cannot pick and choose patients
being on insurance plans
Hospital Consultants
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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
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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
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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
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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
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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
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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