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