In the health care system, the provision of patient care, treatment, and management involves collaboration among a number of different providers. These health care providers, including physicians, nurses, therapists, and others, coordinate care and perform tasks appropriate to their level of education, skill, qualification, and licensure. Though they vary in terms of their education, skills, and licensure, the profession of health care delivery is evolving, and their roles, challenges, and demand continue to grow. The landscape of health care delivery is complex. Individual and team-based roles across specialties suggest a wide range of perspectives on health care delivery. The purpose of one’s role and the implications of those responsibilities warrant a closer look, as they have the potential to greatly affect patient outcomes.
The roles and responsibilities of the various members of the health care team can be challenging to understand, specifically since many health care systems are in the midst of innovations that are introducing new providers. The purpose of this paper is to inform readers about the rapidly changing health care provider landscape and to explore the roles, responsibilities, and high-level collaborative relationships of the health care providers on multidisciplinary health care teams. The policies and programs detailed include laws, pilot programs, growth frameworks for medical specialties, and resources that define the responsibilities and qualifications of various health care providers.
Evolution of Health Care Providers
Human societies have been practicing medicine for many thousands of years, but the health care providers we have today are quite different from those early healers. The aim of this chapter is to provide an overview of the objective and the contents of the book, and to orient the reader to the material. We start by discussing some of the earliest medical practices, during the period in which written records of them survive. From about 4000 years ago, ancient Greek and Chinese healers began keeping records. These records show that a wide range of individuals fulfilled roles in health care, including family members, priests, slaves, academics, and individuals used as prisoners of war. It was to these early practices that the words ‘hospital’ and ‘nurse’ refer. The practice of medicine has been subject to significant changes, driven by alterations in social structure, economy, and technology, among other factors. These changes have been part of clinical medicine since its earliest practitioners; it gathers one hundred of the most important milestones in the evolution of the health care professional.
The book looks at the shifting roles and responsibilities attributed to a variety of medical practitioners, and their contributions to continually expanding the health care landscape, greatly influencing modern trends. Understanding the historical practices of medicine can allow for the development of fresh ideas in relation to contemporary health care dilemmas, and, in some cases, remind the present-day physician or patient that the more things change, the more they have stayed the same. The aim of this introduction to the book is to provide relevant historical, etymological, and theoretical context by which to set the stage and overview the contents of this volume before moving into the individual sections. A historical exploration of the changing professional makeup of the healthcare system has never been assembled in one resource and compiled in this unique book.
Historical Context
Modern-day health care providers practice within the rich historical context of ancient health care practices. Over 3,000 years ago, Hindu healers performed surgery, internal medicine, and obstetrics. The ancient Babylonians built great temples with elaborate health care facilities that housed physicians who were responsible for providing physical, mental, and spiritual health care services to fellow citizens. In Africa, remnants of the ancient Egyptian health care system remain one of the earliest influences on the ancient Greek and modern Western systems of medicine. The belief and social structure of the early cultures that physicians and healers were vehicles for divine intervention and channelers of healing attributed unique roles and responsibilities to health care providers. Health care providers are deeply affected by continual changes in health care practices directly related to the societal and cultural beliefs of the time. Historically, professional roles in health care have been highly influenced by cultural philosophies and worldviews. The Chinese yin, yang, and qi provided a framework or guiding principles for Chinese medical students and physicians in their everyday health care decision-making and practice. Health care practice often co-evolved with societal change in order to address the current health problems of the time. The natural philosophers and the ancient Greeks, as well as medieval Muslims and Nativists in the U.S., laid the foundation for contemporary holistic health care practices that build on the determining factors of a patient’s social, environmental, and genetic determinants of health when intervening in disease processes. The Greek “Fathers of Medicine,” Hippocrates and Galen, are known for their descriptions of the ‘Four Humors’ as just one part of their therapeutic spectrum of practice, which included discussion of social determinants of health. As society modernized and people began to think more progressively, society became increasingly dissatisfied with the lack of standards, professionalism, and the educational qualifications of the early health care providers. Bibliographical evidence indicates key influences on this time period as individualism, scientific pursuits, and a pseudo-religious enthusiasm for “the truth.” This was the point in history when modern medicine began to emerge from the ineffective or harmful precepts of ancient authorities. This new approach to medicine also staged a rebellion by rejecting the past of medicine, or their fathers of medicine. Massive reforms and changes were rapidly scaled up to strengthen the role of the medical doctor, benefit the training, and improve the standards for service delivery. The evolution of the role of health care professionals and those assuming the role has fulfilled the dictates of cultural change and reform. Ongoing discussions in academia and the general public determine that the integration of traditional health care providers within a plural health care system continues into the “health” industry. Given this evolution from ancient to modern health care practices, the universe of potential health care provider roles is easily illustrated.
Modern Trends
Interdisciplinary teams that support the patient’s care efficiency. Specialists and generalists work together on a patient plan of care, where specialists are consulted when the generalist has additional healthcare problems identified during a patient visit. In today’s healthcare environment, integrated provider care teams are being prioritized for patient care because they have not only shown leadership among the providers, but they have also demonstrated a more efficient utilization of care for the patient by not having to see multiple providers across different settings that are often separately fragmented among systems.
A new trend in healthcare is a patient-centered medical home that coordinates all care needs. A PCMH uses interdisciplinary team members with patient involvement that is partnered with the patient’s primary care health home team. The focus is on the patient, health, and family working with the patient’s guided goals for wellness, with a long-term outcome of a market share, which equates to a healthier community. The terms “clinical” and “clinical healthcare provider” are now being used to describe a protected title in provider services that are licensed and approved to provide specialty care services outside of the generalist provider. They are also being used to recognize the distinction between clinical expertise, e.g., clinical pharmacist provider versus a medication prescribing provider who can also include nurses that draw blood versus a phlebotomist who draws blood for the physician from a licensed practical nurse described in the U.S. and internationally. Hence, today’s field continues to adapt.
Types of Health Care Providers
Health care providers as navigators of care
Section 3: Navigating the landscape of health care providers
3.2. Types of health care providers
Physician. Physicians often act as primary care providers, diagnosing and treating a variety of medical conditions, diseases, and patients of all ages and populations. They are responsible for establishing care plans and referring patients to specialists or for diagnostic procedures as needed.
Nurses. Nurses work directly with patients and often serve as the primary conduits between patients and the health care delivery system. Nurses are responsible for giving patients direct care and emotional support. A key component of nursing is individuals’ ability to advocate for the patient in hospital settings or the broader health care system.
Allied health professionals. Allied health encompasses numerous professional roles of varied training, certification, and practice regimes, from physical therapists to audiologists to social workers. Allied health practitioners are professionals whose services are directly integrated with those of physicians as members of the health care team, concerned with the identification, diagnostic evaluation, and treatment of acute and chronic diseases and disabilities; management of health care for both patients and normal individuals through preventive health care in activities such as providing for the safe and healthful condition of the workers, enhancement of physical ability of employees on the job, and customers through occupational medicine. The commonality that ties these professions is that allied health extends the reach of health care to non-hospital and health care facilities and to both inpatient and outpatient care, addressing a wide array of patients in multiple capacities.
Physicians
Physicians are the medical professionals who are trained to diagnose and treat diseases, illnesses, and injuries. They play a key leadership role in planning and coordinating care with the rest of the patient care team. Their expertise in diagnosing and treatment planning is defined in a specific area of medicine. Their treatment plans may include writing prescriptions for medications, ordering tests, administering vaccines, referring to specialists, or suggesting lifestyle changes, depending on your needs. There are many types of physicians, also called specialists. There are hundreds of specialties, but some of the most common include family practice, internal medicine, pediatric medicine, obstetrics and gynecology, and psychiatry.
At a minimum, physicians go to four years of medical school and three years of residency training in an area of medicine. Some physicians complete additional training by doing a fellowship. This adds one to three years of education and experience in a more specialized area of medicine. After their education and training, physicians must pass an exam to become a licensed doctor. Additionally, physicians are required to take continuing medical education courses and renew their license regularly to stay up to date on new developments in medicine. Physicians are also required to pass a national exam to obtain certification in their chosen specialty. Each professional area also will have specific certification requirements depending on their field. Physicians are the most educated professionals on the health care team. To practice medicine in the United States, physicians are required to have a medical degree and a license to practice medicine. You may not have direct interactions with these professionals the same way you will with other members of their care team. Given their length and breadth of education, physicians are likely to be key innovators. The role of physician innovators is changing rapidly. It no longer involves a lone provider toiling away in a laboratory, developing treatments or devices in isolation. Instead, the role of a physician innovator now involves collaborating in new ways within a new era of medical technology and medical practice. Moreover, following the passage of health reform legislation, physicians became entrepreneurial collaborators tasked with rapidly developing and testing solutions to improve the efficiency and reduce the individual and population risk of healthcare. Improvements to their care modes and delivery should make it patient-centered, more collaborative among providers, and more convenient and responsive to access and preferences over time.
Nurses
As the largest group of health care providers in the United States, nurses work in a variety of roles and care settings. From newly graduated to specialized experts, nurses spend more time with patients than any other care provider, usually coordinating patient care from the time of admission until the patient goes home. Nurses are expected to provide direct patient care, contribute to the intricacies of patient care, assess health care services to ensure they are safe, effective, and efficient, advocate for patient safety and rights, and educate the public about health care and the work of nurses. The depth, flexibility, and ubiquity of nursing training suggest that professional nurses trained at the baccalaureate level can work in a variety of settings and practice in a multitude of roles throughout a lifetime. In addition, there are recommendations for adopting and implementing policies that promote practice longevity and ongoing professional development to increase the effectiveness of nurses.
The scope and location of a nurse’s training affect the complexity of work they can do and the knowledge, skills, and creativity used to work within their scope of practice. Many nurses working in hospitals have excellent training in clinical practice and health care knowledge and experience. Their education and training afford them the necessary skills to participate in clinical decision-making and transfer to the public and patients evidence-based information to make health care decisions and guide patient-centered education. Nurses working in the community have excellent skills in out-of-hospital care. They provide care for patient populations with complex health care needs to prevent hospital admissions, hospital readmissions, and unnecessary use of medical services. This demands robust communication and collaboration abilities with patients and multiple health care entities. Staffing ratios in acute care hospitals and the difficulties of working in understaffed conditions are serious challenges facing the profession today. Burnout not only leads to nursing shortages but directly affects the health care workforce’s ability to provide safe, unbiased, patient-centered care. Efforts are underway to develop innovative nursing practice models and expand scopes of practice, particularly in acute care settings, to address workforce challenges and better meet patient health care needs. However, changes in the overall health care landscape and reimbursement strategies that have traditionally supported hospital-based care have made innovative care delivery models challenging. Innovations in nursing practice include the spread of telehealth nursing roles in outpatient care settings, wherein the team-based approach is required and nurses collaborate with and consult other nursing staff, medical staff, etc. Nurses’ expertise lies in the knowledge, skills, and abilities necessary to expand their professional practice and improve the overall patient experience, outcomes, and effectiveness of care provided as part of an interdisciplinary team. Thus, the team’s and other members’ legal, clinical, and ethical expectations are described to the team in this section. Moreover, it outlines the nurse’s role as an essential collaborator, particularly within their interdisciplinary practice.
Allied Health Professionals
Allied health is a diverse group of professionals who perform a range of functions that may be assigned according to their specific specialties. The range of responsibilities they have within a health system is extremely wide and includes vocations such as art and music therapists, diagnostic medical sonographers, dietitians, medical laboratory technologists, radiographers, physical therapists, pharmacists, podiatrists, and many others. Radiographers and ultrasonographers are diagnostic services that collect images and other diagnostics. Physical therapists are specialists trained in the assessment and management of medical conditions that cause pain, limit mobility, affect muscle strength, joint and tissue function, and performance. Pharmacists optimize treatment outcomes based on a patient’s clinical and pharmaceutical needs. Trainees must go to school for four years and then must train for six years or longer. In a hospital system, professionals may be seen as one link in the chain of services that diagnose, treat, or monitor disease. They may be responsible for patient care from the time a patient is referred for assistance to the time a decision is made on treatment. That can include working with multidisciplinary teams to develop a care plan. They might also work with a patient throughout their journey in the healthcare system, helping with diagnosis, treatment, and management in an individual or group setting. Recently, determination and improvement of nursing functions was one of the healthcare reform movements, and to fulfill the basic right to health, the various roles and the importance of the pharmaceutical profession were suggested. The pharmacist is a professional who is in charge of drug-related areas such as making, registering, storing, procuring, compounding, distributing, selling, and consulting. The pharmacist is the only professional in the area of medicine who has a general ability to experience all of the processes and can also combine various data.
Roles and Responsibilities of Health Care Providers
In the United States, professionals who sit at the center of health care are often referred to as health care providers. From public health practitioners and pharmacists to nurse practitioners and physicians, patient care is provided through traditional and alternative approaches almost anywhere in the community. Health care providers are responsible for much of the direct care patients seek. Direct care is what is often reflected in the media and consists of health services that require hands-on treatment and contact between patients and providers. From relieving symptoms to making diagnoses, providing treatment, and creating caring and healing touch, many services contribute to patient wellness and survival.
However, the provision of direct care is just one aspect of what health care providers are responsible for. Health care providers are individuals who serve as the interface between patients and the system of care available in the community. This involves activities like asking about drug use, recalling necessary changes to medication, and ensuring that a specialist made a necessary referral. All of these activities are referred to as care coordination. Health care providers with these responsibilities help individuals seek to guide patients seamlessly through the web of all available services. In the review of case laws and the ethical requirements of doctors, respect for patients and the field of health care are key tenets in patient care. It is important to recognize the shared territory that providers from across sectors must navigate to produce vital and satisfying products and services for their patients being served by crossing their professional boundaries for maximum effect. Any evolving process that changes with professional responsibilities and the development of new technologies changes with society. Finally, everyone understands what is being accomplished when professionals and patients face their roles and obligations every day.
Direct Patient Care
3.1 Direct Patient Care Direct patient care, defined as face-to-face interactions with the patient, makes up a large portion of the health care landscape. Primary care physicians, clinical specialists, and surgeons all have direct involvement with their patients for the time they are receiving care. The range of practice in direct care extends from broad generalists, such as primary care physicians and nurse practitioners, who are responsible for a variety of patient concerns, to specialists with a niche practice filled with very unique patient needs, such as rural urologists. Many technology-driven competencies have been integrated into patient care today, such as EMR use, secure and encrypted email communications, telehealth, telemedicine, or web-based provider portals. Direct patient care involves the development of provider and provider team skills and actions that are associated with excellence in the patient experience. A best practice, for example, is to incorporate compassion and empathy into patient encounters. Patients experience interactions of trust at all healthcare touchpoints because of the wisdom and skill projected by their providers. Sometimes, that wisdom is related to how the provider communicates with the patient, the care values conveyed, and the understanding of the patient’s world that is acknowledged. This optimal practice holds providers true to have feelings to provide care, compassion, and understanding when delivering care. Perhaps competency management and a greater focus on emotional intelligence and patient empathy in clinical training will assist in training a stronger care value in orienting providers to always acknowledge patient social needs and policies specific to different patient populations, but all clinic demographics are diverse. All clinicians need to know about inpatient care. Care management and/or until health care is provided by robots and artificial general intelligence, you can bet that direct patient care will remain an integral part of health care and an important fixture in future clinical training for its use in patient management and improving their clinical outcomes. Continue improving methods to reduce administrative burdens for clinicians to increase the time we can spend with our patients providing care.
Care Coordination and Communication
In any health care setting, care coordination is a crucial part of delivering efficient and high-quality care. Care coordination and communication among all members of a patient’s care team are key areas in which collaboration among providers improves patient outcomes. In hospital care, clear communication around patient treatment plans and care needs between nurses and attending physicians creates a continuum of care that helps patient progress and outcomes. Two critical areas of care coordination within both acute hospital care, outpatient care, and beyond include managing patients as they transition between care settings and between different care providers. On the inpatient side, a care coordinator might be a staff member who makes follow-up appointments or educates patients in medication management post-discharge. Managing patient transitions within communities faced with provider shortages requires, in part, a good understanding of a patient’s history, especially in medications and potential side effects.
Innovative, next-generation tools and practices promise enhanced communication among care partners or even with patients specific to their care. These tools will incorporate principles of health literacy and personalized care and will put patients as central actors in their care management. Challenges to implement innovative communication tools are significant and include breaking down information and data silos among and between provider staff and within patient communities. As a result, care coordination is an interdisciplinary endeavor, one that extends the scope of what is traditionally considered delivery system or public health provision, encompassing a range of participants, such as patients themselves and their families, and institutions including community organizations, payers, suppliers, and governmental agencies. Successful care coordination thus results from efficient collaboration across a wide array of actors, which engenders the high-value patient care experiences increasingly emphasized as a common goal in health care delivery endeavors.
Innovations in Patient Care
Innovations in patient care are transforming the way healthcare is delivered and, in many ways, the traditional patient-provider interaction. Remote monitoring technologies such as wearable digital health devices and sensors represent a substantial shift from conventional brick-and-mortar health services. In addition to value for patients, telemedicine can increase the volume and efficiencies of services provided to a health system’s population. Communication methods can facilitate appropriate responses to patient needs without necessitating a trip to the ER or physician’s office, which is particularly important given the limited human resources and intensive care beds. Guided by patient-reported symptoms and algorithms, these tools can be leveraged for health assessment and provide guidelines for patient isolation and acute care triage.
While remote medicine provides proven value, it also presents unique challenges and a reevaluation of common standards. Technology, particularly through the progression in machine learning, has been a focal point in reshaping precision medicine, drug development, and clinical care. In medicine, AI is being used to develop individualized disease diagnostics and treatments based on patient molecular profiles. For example, AI can be used to create and monitor a cancer treatment plan that adapts to the unique genomic makeup of tumor cells and their surrounding environment. Ethical implications of healthcare innovations are substantial and lie within data privacy, confidentiality, and informed consent rights. The multiple facets of societal and clinical impact require healthcare provider teams to shape the verbal and non-verbal behavior of technologies. The exponential rate of innovations in patient care has the remarkable capacity to improve patient outcomes, patient care, and drive transformations of health service delivery.
Telemedicine and Remote Monitoring
As a groundbreaking innovation in the delivery of health care, telemedicine has the potential to revolutionize how patients navigate the increasingly complex landscape of health care providers. By offering telemedicine consultations that allow providers in urban medical centers to examine, diagnose, and prescribe treatments for patients hundreds of miles away, underserved patients in rural and frontier areas—communities charged with historical and cultural isolation and high rates of health issues—could receive care once thought impossible in their regions. Connected through conferencing technology, providers and patients can converse in real time while viewing the same x-rays, tests, and physical symptoms, minimizing distance and time constraints paramount to consulting with specialists in urban areas. The expanding capabilities of telemedicine will assist these patients further. As cutting-edge innovation enters health care in the form of remote monitoring, many patients may never have to leave their homes to manage their chronic health conditions.
For patients who may face major logistical challenges in gaining access to doctors, telemedicine, usually in the form of video consultations and remote monitoring, has the potential to transform the practices of health care delivery. It is vital to note, however, that access to telecommunications infrastructure and the devices necessary for video conferencing covaries negatively with income and positively with education. Therefore, it is likely that, in their current iteration, remote monitoring and telemedicine programs cater mostly to the middle and upper classes. For all it serves, telemedicine provides convenient access to health care. Those in the know herald the benefits of video consultations, often themselves practiced in offices and hospitals. Patients can administer tests, manage chronic disease, and obtain help for illnesses in their homes or workplaces without ever stepping foot in the doctor’s office. On-call 24 hours a day, these teleproviders are just a webcam away. Placing many health care inquiries at the provider’s fingertips, these video consultations can enhance autonomy and increase patient involvement in disease management, which, due to the convenience telemedicine provides, may likely yield consistent monitoring and follow-through with treatment strategies.
Artificial Intelligence in Health Care
Artificial intelligence (AI) is often positioned as a technology poised to revolutionize medicine. Indeed, AI shows promise in augmenting human expertise in several capacities in health care. In a diagnostic capacity, AI could act in place of a health care provider, reading scans, exams, or lab values for subtle patterns that a human expert or a less sophisticated computer program might overlook. This role is perhaps the most discussed, with flashy headlines of algorithms that outperform top doctors and robots that could act as our specialists. Technologies that assist administrative processes, such as scheduling or intake, to reduce burden have also seen some implementation, particularly patient-facing.
However, the most immediate and practical application of AI in health care may be its ability to process big data. Massive data sets, such as genomics and electronic health records, are increasingly becoming available to health care providers. However, integrating it into care is difficult and resource-intensive. In this regard, AI’s biggest strength is its ability to quickly compute through cross-referenced information and identify trends and insights not readily visible to human providers. Perhaps the most patient-facing example is in treatment plans. AI can take vast databases of treatment and outcome information and suggest the optimal protocol for an individualized patient. In particular, AI shines when dealing with numerous factors that might affect a proposed treatment plan, such as comorbidities, interactions, genetics, and more. Recent research suggests this system could contribute to better patient outcomes and reduced health disparities. Some of these algorithms have been implemented commercially. We’ve reached a place where AI systems are part of the health care field, and while they are not a futuristic doctor replacement, they can provide additional insights or supporting information for professionals. One well-known example of this is a constantly evolving prediction system that allows hospitals to predict who will become critically ill. In the development of these applications, issues of bias and ethical development began to emerge. AI developers must be attentive to the biases and assumptions built into their algorithms and data sets, consider governance and selectivity for their algorithms, and be ready to take accountability for errors. These algorithms are not perfect and will further evolve, but they are providing a model for how AI will serve in the health care field: as adjuncts to, not a replacement for, human judgment.
It is imperative for anyone interacting with health care systems—be they patients, a family member or friend of a patient, a provider, hospital leadership, or a state or federal regulator—to have an understanding of primary providers and the roles they fill, as well as how these roles have changed over time. There are significant opportunities for improved communication and quality of care across a variety of providers. Coordination between these groups, many of whom are experts with different areas of focus, can significantly reduce redundancy, streamline efforts, eliminate unnecessary and often dangerous duplication of tests, and help ensure that all aspects of a patient’s full, well-rounded health are given proper attention. By engaging with diversely trained professionals, a patient is likely to save time, health care dollars, and anxiety while receiving attainment of high quality care from a physician with whom they have already established not only a professional but also a personal relationship. The roles of various providers have evolved. For example, the majority of the practice of psychiatry was outside of hospitals in the United States by the 1970s. As technologies affect the care delivery system in the 21st century, expect the roles of care providers to change correspondingly. The health of populations is greatly impacted by the social determinants of health. Innovations such as those in eHealth, medical sub-specialization, and home delivery of meals and medications; and Tele-Health, or technology providing care at a distance, have the potential to improve the health of many population groups, social determinants and regional disparities, though—similar to every care delivery innovation—they are not without concern. While some professionals educate patients about e-health, there are some that contribute time, money, or other resources directly to closing the digital divide. Larger health systems, managed care organizations, and the federal and state governments use different technologies to communicate with patients as well as health care providers. Of note, many health care providers use tele- or e-health for electronic referrals, business meetings and patient conferences. Such technology, in theory, helps in coordination of services, value-based health care, and patient-centered collaboration. Because the technology and EMR/Practice Management Software are constantly evolving, this collaborative venture is currently in a process of transformation. It involves both centralized and decentralized technologies, operating under the specter of large fiduciary and efficiency gains, but the titled and affiliated health systems in a state help broker and monitor for-profit companies within the larger telehealth network. Residents of many rural areas are now able to access specialists due to these technologies. The use of non-physician health care professionals’ technology and informatics are continuing to grow daily. Many providers such as dentists, denturists, speech therapists, and audiologists in Eastern Oregon use technology to educate, perform remote triage, and/or refer clients to primary care professionals. It is hard to know at the moment how many providers and others align with locally provided, evidence-based health care. Currently discussions are being held among large study clubs, house and senate members, and communities to decide if innovation Compacts can be made that mirror regional best practice guidelines. In conclusion, the number of professionals a patient seeks care from and the roles that those professionals can play in patient care are numerous. Thankfully, patients do not typically seek care for a particular disease process from all of the professionals that can influence said disease process. Efficiencies in the energy expended by all parties can be had by understanding the roles of the various professionals that patients are likely to seek care from—thereby accenting areas of opinion that do not overlap—and that is the purpose for this text. It is through this continuous dialog that the larger health care systems can revisit the roles played by those professional groups within the health care system.
