1. Whos Who in Healthcare Katharine C. Rathbun, MD, MPH Strategic Management of Healthcare Organizations Spring 2009

2. Physicians Many different types of people hold themselves out as physicians Difference is science vs faith healing Schools of Practice vs Specialties

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. 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. Medical Specialties voluntary associations AMA or AOA recognized boards residency training or grandfathering not part of licensure

6. Historical Specialization most boards were set up in the 1940s 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. Current Specialization everyone does at least 1 year of residency this is specialty training specialists are no longer GPs first most boards have closed to grandfathering most boards now require recertification

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. 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. 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. Unlicensed Practitioners unlicensed physicians faith healers alternative medicine

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. Establishing the Relationship sign a contract hang out a shingle make an appointment accept payment

14. Duties to Treat statutory - cord blood serologies contractual - orthopedist in the ER ethical - patient is there continuing care

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. Terminating the Relationship PATIENTS patients may terminate the provider-patient relationship at will as long as they are legally able to consent patients dont always do what is good for them patients cant force a physician or hospital to provide certain types of care - their legal choice is shut up or go away

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. Group Practice may create multiple relationships less personal system may assign patients difficult to fire a patient from one doctor

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. 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 Im not on call isnt the right answer

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 dont know how to do both these rules are violated all the time –side of the road –in the clinic/hospital

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. 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. 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. Physicians in Hospitals Specialties that support the hospital Consultants in the hospital Hospitalists

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. 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. Hospital Practice hospitalist groups becoming common doctor-doctor relationship as well as doctor-patient relationship hospital administration may or may not be involved

29. Team Care Doctor - captain of the ship Modern practice is more complicated Hospital services, teaching programs, group practices Shared responsibility and liability

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 DONT charge for their services

31. Students dont call them doctor or nurse they are there to learn not serve they take time to supervise

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. 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. Extenders in Hospitals extenders should be credentialed staff bylaws should have specific provisions for extenders

35. Nurses Registered Nurses - real nurses LPN - licensed practical nurses Nurse Practitioners non-licensed caregivers

36. Nurse-Patient Relationship Nurses are independently licensed Nurses have an independent duty to patients Nurses exercise independent judgment

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. 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. 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. Nurse Extenders lower level care providers medical assistants, surgery technicians, lab technicians on the job training vs certification

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. 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. 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