Medical professionalism and codes of conduct

Health care providers are required to follow laws and codes of conduct and to perform their duties with professionalism. Most health professions are subject to a combination of self-regulation (e.g., through licensing boards) and regional laws that aim to ensure adherence to ethical and legal standards. Regulatory domains for clinicians include medical malpractice, professional misconduct, physician impairment, conflicts of interest, and referral of patients. Other rules guide engagement with the public, such as clinician-patient romantic relationships and clinician use of social media. Professional codes of conduct and laws governing, e.g., medical malpractice and physician impairment vary by jurisdiction and over time. Clinicians must adhere to the regulatory requirements that apply to their practice.

See also “Principles of medical law and ethics.”

Medical malpractice

For more information about different types of errors leading to negligence, see “Medical error” in “Patient safety.”

• Definition: Negligent conduct on the part of a health care provider or performance of a medical task with unreasonable lack of skill. ^[1]
• Elements of malpractice
  • The clinician-patient relationship has been established.
  • This obligation to provide care has been neglected.
  • There is damage to the patient.
  • The medical negligence is directly responsible for the damage to the patient.
• Reporting malpractice ^[2]
  • Clinicians are ethically obliged to report any violations resulting from their colleagues' incompetence, negligence, and/or unethical conduct.
  • Contact the hospital authorities at the first instance; if the consequences of the malpractice pose a threat to patients' health, contact the state licensing board.
• Defensive medicine: testing and treatment that is not medically necessary but is performed by the clinician to avoid legal liability ^[3]
  • Is unethical and should be avoided because it increases risk of patient harm and does not add significant benefits (e.g., an unnecessary CT scan causes radiation exposure)
  • Clinicians should openly communicate with patients about the risks and benefits of tests or treatments that they believe are not medically necessary.

The 4 D's of malpractice: Duty (obligation to deliver proper medical care to the patient), Dereliction of duty, Damage to the patient, Direct cause of damage.

Professional misconduct

• Professional misconduct is any clinician behavior that goes against the ethical principles of medical practice. ^[4]
• Clinician misconduct can occur outside the established clinician-patient relationships and thus does not always constitute malpractice.
• Examples of misconduct ^[4]
  • Bullying
  • Inappropriate comments towards colleagues or patients
  • Sexual harassment of colleagues or patients
  • Billing fraud
  • Inadequate record keeping (e.g., intentional falsification of medical records)
  • Accepting expensive gifts from patients or industry
• Colleagues who suspect a clinician of misconduct should report their concerns to the state medical board and, if the misconduct implies any legal liability, to the proper federal authorities. ^[5]

Physician impairment

• Definition: the inability of a clinician to provide adequate medical care due to mental health disorder, substance-related disorder, or physical condition that limits the use of motor, cognitive, or perceptive skills ^[6]
• Potential signs of impairment ^[7]
  • Disruptive behavior (e.g., increased conflicts with colleagues or patients, irritability, anxiety, aggression)
  • Physical signs of substance use disorder (e.g., needle marks, alcohol smell)
  • Nonadherence with working schedule (e.g., being late or absent at work for no reason) or sudden changes in schedule (e.g., unusually early or late appointments)
  • Decreased quality of care (e.g., increased rate of medical errors, incorrect charting)
  • Personal life problems (e.g., divorce, withdrawal from family, debts)
• Physician Health Program: a program that is supervised by a state medical board and is aimed to prevent, detect, and manage disorders that cause impairment in clinicians ^[8]
  • Colleagues of a clinician should contact the PHP if they suspect impairment.
  • The PHP performs a thorough assessment of the potentially impaired clinician and arranges management if impairment is confirmed.
  • If an impaired clinician accepts the treatment voluntarily, the PHP is not obliged to notify the state medical board about the clinician's condition.
  • If the clinician refuses treatment, the PHP will report the clinician's condition to the state medical board, which may lead to an involuntary referral for treatment and disciplinary actions.
  • After treatment, the PHP monitors the clinician with regular assessments and/or laboratory tests for 1–5 years depending on the condition underlying the impairment.

Clinician-patient romantic relationships ^[9]

• Romantic relationships with current patients are always unethical and inappropriate.
  • A romantic clinician-patient relationship compromises the objectivity of the clinician's decisions in regard to the care of that patient.
  • Such relationships make patients more vulnerable to exploitation.
• Romantic relationships with former patients are also inappropriate if:
  • Less than one year has passed since the end of the patient-clinician relationship.
  • The clinician has a position of influence or influence from their previous experience with the former patient (e.g., knowledge of trauma expressed during therapy).
  • The former relationship was a patient-psychiatrist relationship
• Should a clinician feel that their actions may be perceived as sexual and/or lead to a romantic relationship with a current patient, the clinician should take active measures to avoid unnecessary contact with the patient.
  • Use direct, close-ended questions.
  • Conduct interviews with a chaperone present.
• Romantic relationships with patient-accompanying third parties (e.g., their children, friends, surrogates) may also be inappropriate in case the third party plays a considerable role in clinician-patient interaction and may be emotionally dependent on the clinician. ^[10]

Overview ^[11]

• Definition: A conflict of interest (COI) occurs when a clinician's objectivity regarding their primary interest (i.e., patient welfare) is potentially affected by a secondary interest (e.g., personal financial gain).
• Minimizing COIs ^[12][13]
  • Clinicians should always disclose COIs to patients, employing institutions, and when presenting medical results (e.g., at a medical conference or in a peer-reviewed journal).
  • Gifts of significant value from the medical industry should be declined.
    • Gifts may only be accepted if they directly benefit patients and do not have substantial monetary value (e.g., pens, notepads, medical textbooks).
    • Cash should never be accepted.
    • Gifts that have “strings attached” should not be accepted (e.g., a gift that affects the clinicians's prescribing practices).
  • Clinicians should not allow pharmaceutical industry-funded advertisements in their practice.
  • Industry subsidies for clinician travel, lodging, or personal expenses should be declined.
• Acceptable gifts and donations ^[12]
  • Gifts from patients that are small and do not have substantial monetary value (e.g., home-cooked meals, flowers, knitted quilts) ; ^[14]
    • The gift should not influence the patient's care.
    • Gifts that may represent a financial sacrifice for the patient should be declined.
    • No amount of direct cash exchange (e.g., checks, deposits) is acceptable.
    • The clinician may suggest that the patient donate to a charitable organization in lieu of a personal gift.
    • When declining gifts, clinicians should stress that the clinician-patient relationship remains intact.
  • Medical industry honoraria to attend medical education conferences
  • Industry-funded simple meals or social events
  • Remuneration for medical consultation for a pharmaceutical or medical device company
  • Industry-funded scholarships for travel to academic conferences by medical students or residents.

The clinician must disclose all COIs to all affected parties and, in the event of a COI, refer patients to an unbiased colleague whenever possible.

Conscientious refusal

• Definition: Conscientious refusal is the denial of indicated medical care because it poses a conflict with the personal, religious, or moral beliefs of the provider (e.g., abortion, birth control).
• Health care provider responsibilities
  • Timely referral to a different provider who offers the required care
  • In case of emergency, when a referral is not possible, or if the patient's physical or mental health is at risk, provision of necessary care regardless of moral conflict
  • Provide patients with accurate and unbiased information and resources to facilitate informed decision-making.
  • Notify patients about moral conflicts related to the provision of standard care (e.g., abortion, contraceptives, sterilization).
• Abortion services and reproductive medicine
  • Individuals should be referred within an appropriate time frame to a provider who offers the required medical care.
  • Resource-poor areas
    • Denying safe and legal access to reproductive services in low-income communities promotes inequality
    • Providers who object to providing care on moral grounds should only practice in areas where other providers are available and/or where referrals can be made.
• Key considerations
  • Patient well-being and access to ethical medical care are the foremost priorities.
  • Conditions in which conscientious refusal is unethical:
    • When it imposes religious or moral beliefs on patients
    • When it has a negative effect on patient well-being
    • When it is based on scientific misinformation
    • When it reinforces racial or socioeconomic inequalities

• The physician may refer a patient to another physician or diagnostic or therapeutic service if they consider the referral beneficial to the patient. ^[15]
  • The referral may involve nonphysician health care providers.
  • It is never ethical to refer a patient to illegal medical treatment.
  • Referrals to complementary and alternative medicine providers may be ethical if the use of such practices is grounded in scientific knowledge (e.g., chiropractic interventions or acupuncture for lower back pain). ^[15][16][17]
• Stark law prohibits the physician from self-referrals (i.e., referring patients to entities with which the physician or one of their immediate family members has a financial relationship). ^[18]
• Physicians who perform self-referrals should ensure that the referral is indeed required, disclose all the potential COIs to the patient, and provide them with information about alternative care providers. ^[19]

Clinicians increasingly use social media and other internet resources for learning, networking, interacting with patients, and disseminating health care related knowledge. The following considerations can help ensure that their online presence aligns with professional ethics. ^[20]

• Identifiable patient information should not be posted online (unless documented consent has been obtained from the patient).
• Appropriate boundaries should be maintained when communicating with patients online.
• Proper personal conduct should be maintained (e.g., in comments on social media posts), even in the context unrelated to medicine.
• If a colleague posts professionally inappropriate content online, the colleague should be alerted to the fact that their behavior is inappropriate and be encouraged to remove the content and avoid inappropriate posts in the future. If personal communication fails to resolve the issue, appropriate authorities (e.g., state licensing board) should be notified.
• Clinicians should follow cybersecurity measures to ensure that their personal information is safeguarded.