Who

1
Whos Who in Healthcare

• Katharine C. Rathbun, MD, MPH
• Strategic Management of Health Care Organizations
• Spring 2005
• LSU MPA Program
• Course Page
• http//biotech.law.lsu.edu/Courses/mpa/index.htm

2
Physician-Patient Relationship

• the basic relationship in healthcare
• between two people
• requires consent of both parties to establish
• unilateral termination

3
Establishing the Relationship

• sign a contract
• hang out a shingle
• make an appointment
• accept payment

4
Group Practice

• May create multiple relationships without prior
  interaction with a given physician
• System may assign patients
• difficult to fire a patient from one doctor

5
Hospital Practice

• contracts can create a physician-patient
  relationship
• all the rules apply
• cannot pick and choose patients

6
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

7
Mandatory Consultation

• Cardiologists reading all EKGs
• Pathologist supervising lab
• this is a physician-patient relationship

8
Hospital Practice

• hospitalist groups becoming common
• contracts between doctors as well as the other
  relationships
• hospital administration may be involved as well

9
Medical Specialties

• voluntary associations
• AMA or AOA recognized boards
• residency training or grandfathering
• medical licenses are general not specific

10
Historical Specialization

• most boards were set up in the 1940s
• all doctors did GP training
• some went on to residencies to specialize
• some would just start doing a specialty practice
• most boards accepted both residency and
  experience
• board certification was for a lifetime

11
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

12
Legal Status of Specialization

• many states now accept a board exam in lieu of a
  repeat licensing exam
• hospitals require certification for privileges
• federal programs require certification for
  certain systems
• insurers require certification for payment

13
Certified vs Eligible

• most boards will not recognize a status of board
  eligible
• you have passed the exam or you havent

14
Schools of Practice

• Allopath - what most think of as a real doctor
• Osteopath - also real doctors - scientific
  training with some physical therapy added
• These are the only two schools of scientific
  medical practice
• Share the same licenses

15
Osteopathy vs Allopathy

• Historically had separate hospitals and practice
  groups
• Osteopaths were the less respected - still some
  stigma
• Becoming integrated
• Often share residencies
• Many osteopaths take AMA boards

16
Physician Extenders

• many doctors use physician extenders
• state specific rules
• physician is responsible for what they do

17
Rules About Supervision

• how many can you have
• how close do they have to be
• how do you authorize care

18
Extenders in Hospitals

• these extenders should be credentialed
  individually
• staff bylaws should deal with extenders
  specifically

19
Students

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

20
Residents

• doctors in training
• may or may not be licensed
• working on an institutional license
• there to learn although they may give some
  service
• DONT charge for their services

21
Team Care

• doctor - captain of the ship
• modern practice is more complicated
• hospital has responsibility and liability

22
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

23
Nurses

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

24
Nurse-Patient Relationship

• Nurses are independently licensed
• Nurses have an independent duty to their patients
• Nurses exercise independent judgement

25
Nurse-Physician Relationship

• Mostly nurses are absolutely subservient to
  doctors
• If they do not agree with physician orders, they
  can refuse to participate but they cannot change
  orders.
• They may be protected by the practice acts or the
  rules of the hospital

26
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 and set up
  a medical practice either

27
Nurses in Institutions

• Nurses in hospitals and clinics are generally
  employees of the institution
• The institution is generally liable for what they
  do.
• If the physician hires them, they are generally
  functioning as a physician extender.

28
Other Providers

• There are many other licensed or certified health
  care professionals
• x-ray, laboratory, pharmacy
• Legally and administratively these are similar to
  nurses

29
Nurse Extenders

• lower level care providers - certified
• medical assistants, OR technicians, lab
  technicians
• on the job training vs certification

30
Nurse Extenders in Institutions

• need to be carefully screened
• need to be carefully supervised
• cannot rely on the license or certification
• institution has all the responsibility

31
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

32
Other Licensees

• many other licensed professions in medical
  practice
• may have separate licensing boards or be under
  the board of medical examiners
• often work in hospitals or other institutions

33
Unlicensed Practitioners

• unlicensed physicians
• faith healers
• alternative medicine

34
Administrators

• great responsibility - little authority when it
  comes to patient care
• laws forbid corporate practice of medicine
• need good contracts and institutional rules to
  allow them to control what goes on

35
Duties to Treat

• statutory - cord blood serologies
• contractual - orthopedist in the ER
• ethical - patient is there
• continuing care

36
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

37
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

38
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

39
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.

40
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
• either may be done by both physicians or hospitals

41
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
• emergency wallet biopsies

42
Consultations

• Bringing in the expert or the specialist
• hospitals often require these for certain
  services
• ICU admissions, obstetrics, reading EKGs
• in-house second opinions
• curb-side consults - illegal under HIPPA

43
Consent to Care

• you have to have permission from a consenting
  adult to do anything to them
• violating this is battery
• the patient may pick and choose with some
  exceptions
• the patient may terminate the relationship by
  refusing consent

44
Substitute Consent

• not everyone is a consenting adult
• know who has the authority to consent and talk
  only to them
• parents have limited authority over the care of
  their children
• spouses have no authority over each other

45
Questions of Ability to Consent

• you either have someone with the legal ability to
  consent or you dont
• questionable situations have to be addressed by a
  judge
• big city hospitals often have the judges phone
  number posted in the ER

46
Informed Consent

• more detailed than simple consent
• many states have statutes on this
• this is about not loosing a law suit

47
Exceptions to Consent

• emergency exception
• expectation that anyone would want preservation
  of life and limb
• may apply if the patient is medically or legally
  incompetent
• statutory exceptions
• public health law
• mental health law
• court ordered care