Principles of Practice
SECTION 1 PRINCIPLES OF PRACTICE
SECTION 2 ETHICS AND THE BUSINESS OF ORTHOPAEDICS
III. Referrals and Ownership of Medical Services
IV. Relationship with Industry
section 1 Principles of Practice
A Orthopaedic practice involves managing relationships among the following:
1. Medical ethics of patient care
2. Business realities of medical practice
3. Legal environment that involves complex and changing laws
B Conflicts of interest among ethical medical care, business goals, and legal considerations can arise. Wherever a conflict of interest arises, it must be resolved in the best interest of the patient.
C The physician-patient relationship is the central focus of all ethical concerns.
D Documents have been developed by the American Academy of Orthopaedic Surgeons (AAOS) with the help of other organizations to outline ethical principles of medicine and orthopaedic surgery (http://www.aaos.org/about/papers/ethics.asp):
1. Medical Professionalism in the New Millennium: A Physician Charter (2002)
2. Principles of Medical Ethics and Professionalism in Orthopaedic Surgery (2002)
3. AAOS Standards of Professionalism (http://www3.aaos.org/member/profcomp/sop.cfm)
4. Guide to Professionalism and Ethics in the Practice of Orthopaedic Surgery (2011)
5. Code of Ethics and Professionalism for Orthopaedic Surgeons (2009)
E Most documents are aspirational.
F AAOS Standards of Professionalism are unique in that they represent the minimal level of acceptable conduct.
G Nonadherence to these principles can result in the loss of membership.
II PRINCIPLES OF ETHICS AND PROFESSIONALISM
A Ethics is the discipline dealing with the principles or moral values that govern relationships between and among individuals and defines what the orthopaedic surgeon ought to do.
B Key elements of the AAOS Code of Ethics and Professionalism for Orthopaedic Surgeons (2009):
1. The physician-patient relationship is the “central focus of all ethical concerns.”
2. Conduct of the orthopaedic surgeon must have the following goals:
Emphasize the patient’s best interests
Provide “competent and compassionate care”
Obey the law and maintain professional dignity and discipline
3. Conflicts of interest are common
4. The other sections of the code address additional important issues.
C Medical Professionalism in the New Millennium: A Physician Charter (2002)
1. The AAOS adopted the charter crafted by physicians throughout the industrialized world who were concerned about changes in health care delivery systems that threaten the values of professionalism.
Three fundamental principles of professionalism define the basis of the contract between the field of medicine and society:
2. The charter also defines a set of 10 professional responsibilities that apply to physicians.
D Standards of professionalism represent the mandatory minimum levels of acceptable conduct for orthopaedic surgeons (http://www3.aaos.org/member/profcomp/sop.cfm).
1. Providing musculoskeletal services to patients (2008):
Responsibility to the patient is paramount.
Provide needed and appropriate care or refer to a qualified alternative provider.
Present pertinent medical facts and obtain informed consent.
Advocate for the patient and provide the most appropriate care.
Safeguard patient confidentiality and privacy.
Maintain appropriate relations with patients.
Respect a patient’s request for additional opinions.
Pursue lifelong scientific and medical learning.
If impaired by substance abuse, seek professional care and limit or cease practice as directed.
Disclose to the patient any conflict of interest, financial or otherwise, that may influence care.
2. Professional relationships (2005)
Responsibility to the patient is paramount.
Maintain fairness, respect, and confidentiality with colleagues and other professionals.
Act in a professional manner with colleagues and other professionals.
Work collaboratively to reduce medical errors, increase patient safety, and improve outcomes.
3. Orthopaedic expert witness testimony (2010)
Provide fair and impartial opinions.
Evaluate care by standards of time, place, and context as delivered.
Do not condemn standard care or condone substandard care.
Explain the basis for any opinion that varies from standard.
Seek and review all pertinent records.
Have knowledge and experience, and respond accurately to questions.
Have current valid, unrestricted license to practice medicine.
Have an active practice or familiarity with current practices to warrant expert designation.
Accurately represent credentials, qualifications, experience, or background.
Fees should not be contingent on outcome.
Expect reasonable compensation that is based on expertise, time, and effort needed to address issue.
4. Research and academic responsibilities (2006)
Responsibility to patient is paramount.
Seek peer review, and follow regulations.
Be truthful with patients and colleagues.
Report fraudulent or deceptive research.
Claim credit only if substantial contributions made.
Give credit when presenting other’s ideas, language, data, graphics, or scientific protocols.
Make significant contributions when publishing manuscripts.
Disclose existence of duplicate publications.
Include and credit or acknowledge all substantial contributors.
5. Advertising by Orthopaedic Surgeons (2007)
Advertising must not suggest any of the following:
Do not use false or misleading statements.
Use no misleading representation about ability to provide medical treatment.
Use no false or misleading images or photographs.
Provide no false or misleading certification levels.
Provide no false or misleading statements regarding development or study of surgical procedures.
6. Orthopaedist-Industry Conflicts of Interest (2007)
Surgeons shall regard their responsibility to the patient as paramount
Surgeons shall refuse any direct financial inducement to use a particular implant, device, or drug.
They include documentation of an actual need for the service.
They include proof that the service was provided.
They are not based on the volume or value of business that the physician generates.
Surgeons shall accept no financial support to attend social functions with no educational element.
III CHILD, ELDER, AND SPOUSAL ABUSE
1. Each year, intentional violence claims 20,000 lives, is responsible for more than 300,000 hospitalizations, and causes millions of injuries.
2. It is estimated that 1.4 million children in the United States suffer some form of maltreatment each year. As many as 2000 children die each year from abuse.
1. The U.S. Child Abuse Prevention and Treatment Act of 1974 requires orthopaedic surgeons to report all suspected cases of child abuse to local authorities.
2. Failure to report suspected child abuse might result in state disciplinary actions.
1. Elder abuse has been estimated to affect 2 million older Americans each year.
2. A 1989 Congressional study indicated that 1 of every 25 Americans older than 65 years suffers some serious form of abuse, neglect, or exploitation.
3. Many states have provided legislation to protect from liability the physicians who report elder abuse.
4. Risk factors for elder abuse include increasing age, functional disability, cognitive impairment, and higher rates of child abuse within the regional population. Gender is not a risk factor.
1. One in four women experience domestic violence. Women account for 85% of the victims of intimate partner violence (men only about 15%).
2. The reporting of suspected spousal abuse is not required, and there is a corresponding absence of legal protection for physicians.
3. A physician may encourage a patient to seek self-protection. If the physician believes that an individual is truly incapable of self-protection, a court order may be obtained to permit reporting.
4. Risk factors for spousal abuse include pregnancy, women’s age of 19 to 29 years in households earning less than $10,000/year, and African-American race with low socioeconomic status.
A Importance of diversity: The understanding of the value of diversity in race, gender, creed, and sexual orientation is increasing in all areas of life.
1. It is essential to be sensitive to diversity issues with regard to colleagues in orthopaedic surgery and medicine, professionals in fields of allied medicine, and patients.
2. Other important aspects of diversity and nondiscrimination include obesity, psychiatric disease, income class, physical disability, and the status of human immunodeficiency virus (HIV) infection.
B Treatment decisions should not be made on any basis that would constitute illegal discrimination.
1. To include but not limited to race, color, gender, sexual orientation, religion, or national origin (AAOS Standards of Professionalism)
C Sensitivity to diversity issues is an increasingly important aspect of professionalism.
1. Each practitioner must examine the attitudes, preconceptions, and emotions in this dimension that are exhibited in the workplace.
2. Practitioners must be aware of how speech and behaviors might be perceived by other people of different backgrounds.
3. It is possible for the actions of someone with good intentions to be interpreted as threatening or derogatory by other people of different backgrounds.
1. Avoiding sexual misconduct is an important aspect of professionalism in relationships with patients, coworkers, staff, and colleagues.
2. Sexual relationships, even if consensual, between individuals in a professional supervisor-trainee relationship create the potential for sexual exploitation and the loss of objectivity.
B Sexual harassment in employment
1. Quid pro quo: Harassment is directly linked to employment or advancement.
2. Hostile environment harassment: Actual sexual advances are not necessary to create a hostile work environment.
Verbal or physical conduct (e.g., gestures, innuendo, humor, pictures) of a sexual nature may be interpreted as harassment.
3. “Reasonable woman” test is the adopted standard for offensive behavior. If a “reasonable woman” would have found the behavior objectionable, then harassment may have occurred.
4. Individuals in medical training programs are considered employees of the school that is training them. This status allows them to pursue harassment claims under the Civil Rights Act.
C Sexual misconduct in the patient care setting
1. Sexual misconduct with patients is a form of exploitation.
2. Such misconduct is unethical and may represent malpractice or even criminal acts of assault. Courts have maintained that a patient is unable to give meaningful consent to sexual or romantic advances by a physician. Physicians are encouraged to report instances of sexual misconduct by their colleagues.
3. Many states have laws prohibiting physicians from pursuing relationships with current or former patients.
4. The physician-patient relationship must be terminated before any romantic interest can be pursued between the two persons involved.
4. Even then, it may still be unethical if the physician exploits certain confidences, trust, or emotions learned while serving as the patient’s physician.
“Impairment” can include chemical impairment, dependence, misconduct, or incompetence.
A A surgeon (resident, fellow, or attending physician) who discovers impairment in a colleague or supervisor has the responsibility to ensure that the problem is identified and treated.
B Mechanisms exist for the proper identification and treatment of the impaired physician. Misconduct can be reported to state and local agencies.
C When reporting such incidences, the practitioner must be sure to act in good faith with reasonable evidence.
D When a patient is at risk for immediate harm, the practitioner should assert authority to relieve the impaired physician of the patient’s care and address the problem with the senior hospital staff as soon as possible.
1. Patient care skills—including the provision of “compassionate, appropriate, and effective” care—should be mastered.
2. Medical knowledge (biomedical, clinical, and cognate sciences) must be assimilated and applied to patient care.
3. Practice-based learning includes improving patient care with investigation and the appraisal of scientific evidence.
