Who’s 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

Physician-Patient Relationship

• the basic relationship in healthcare

• between two people

• requires consent of both parties to establish

• unilateral termination

Establishing the Relationship

• sign a contract

• hang out a shingle

• make an appointment

• accept payment

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

Hospital Practice

• contracts can create a physician-patient relationship

• all the rules apply

• cannot pick and choose patients

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

Mandatory Consultation

• Cardiologists reading all EKGs

• Pathologist supervising lab

• this is a physician-patient relationship

Hospital Practice

• hospitalist groups becoming common

• contracts between doctors as well as the other relationships

• hospital administration may be involved as well

Medical Specialties

• voluntary associations

• AMA or AOA recognized boards

• residency training or grandfathering

• medical licenses are general not specific

Historical Specialization

• most boards were set up in the 1940’s

• 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

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

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

Certified vs Eligible

• most boards will not recognize a status of “board eligible”

• you have passed the exam or you haven’t

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

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

Physician Extenders

• many doctors use physician extenders

• state specific rules

• physician is responsible for what they do

Rules About Supervision

• how many can you have

• how close do they have to be

• how do you authorize care

Extenders in Hospitals

• these extenders should be credentialed individually

• staff bylaws should deal with extenders specifically

Students

• don’t call them doctor or nurse

• they are there to learn not serve

• they take time to supervise

Residents

• doctors in training

• may or may not be licensed

• working on an institutional license

• there to learn although they may give some service

• DON’T charge for their services

Team Care

• doctor - captain of the ship

• modern practice is more complicated

• hospital has responsibility and liability

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

Nurses

• 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 their patients

• Nurses exercise independent judgement

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

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

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.

Other Providers

• There are many other licensed or certified health care professionals– x-ray, laboratory, pharmacy

• Legally and administratively these are similar to nurses

Nurse Extenders

• lower level care providers - certified

• medical assistants, OR technicians, lab technicians

• on the job training vs certification

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

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

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

Unlicensed Practitioners

• unlicensed physicians

• faith healers

• alternative medicine

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

Duties to Treat

• statutory - cord blood serologies

• contractual - orthopedist in the ER

• ethical - patient is there

• continuing care

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

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.

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

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

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

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

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

Questions of Ability to Consent

• you either have someone with the legal ability to consent or you don’t

• questionable situations have to be addressed by a judge

• big city hospitals often have the judge’s phone number posted in the ER

Informed Consent

• more detailed than simple consent

• many states have statutes on this

• this is about not loosing a law suit

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