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Policies,Administrative,UWMF,UWMF-wide,Human Resources

Guidelines for Professional Conduct of Physician Faculty in the Clinical Setting (108.009)

Guidelines for Professional Conduct of Physician Faculty in the Clinical Setting (108.009) - Policies, Administrative, UWMF, UWMF-wide, Human Resources

108.009

1


UW MEDICAL FOUNDATION POLICIES AND PROCEDURES
Human Resources
Guideline for Professional Conduct of Physician Faculty in the Clinical Setting


Effective Date: 07/01/2008
Supersedes Guideline Date: 09/08/2005


University of Wisconsin School of Medicine and Public Health (UWSMPH) and
University of Wisconsin Medical Foundation (UWMF) – Statement of Principles and
Ideals of Medical Professionalism.

I. UWSMPH and UWMF strive to achieve the highest standards of
performance and integrity in the fulfillment of all of our missions. In
doing so, we rely heavily upon the impeccable professional conduct of
our physician faculty members. Individually and in the aggregate, faculty
members are responsible for creating our internal environment as well
as the external image we project. As physician faculty members of the
University of Wisconsin-Madison, we are guided by the Faculty and
Academic Staff Policies and Procedures of the University. In addition, we
also recognize the obligation of our faculty members who provide care,
who teach, and who pursue research in the clinical setting, to fulfill the
unique set of expectations associated with the health care professions.
Some of these expectations are set forth in statute or regulation, but our
integrity and reputation as organizations rise above compliance and are
exhibited in the ways we treat our patients, students, staff, and each
other. This statement expresses our dedication to professionalism and
the assumption of shared accountability for our professional behavior.

Professionalism encompasses the set of knowledge, skills, values,
attitudes, and behaviors that are fundamental to our work. In order to
meet fully our responsibilities to our patients, we must teach, learn and
cultivate professionalism among our faculty, students, trainees and staff.
Our attitudes and behaviors are as critical to our success in patient care
as is our knowledge and technical competence. Professionalism
requires us to place the interests of patients above self-interest, to
embrace the qualities of altruism, honesty, integrity, respect for others,
and excellence, and to protect the confidentiality of our patients and their
healthcare information. Confidentiality, always a professional
responsibility, is now also a statutory obligation.

As faculty physicians, we are obligated and honored to establish and
maintain a rich environment for the training and education of physicians
and other health care professionals. Professional ethical and collegial
behaviors are core attributes of an excellent learning environment and
must be evident in all our thinking and actions. The optimal learning

2
environment should include respect for diversity of the student body and
assurance that harassment and discrimination are eliminated. We
commit ourselves to diversity in the student/trainees bodies as a high
priority. Mutual respect between teacher and student helps instill these
professional attitudes in students and enriches the learning experience.
The intensity of medical education and training, as well as the practice of
medicine, create numerous challenges to professionalism – long working
hours, heavy work loads, stress, fatigue, health risks, family obligations
and tensions with patients, colleagues and students, among others. We
cannot eliminate all such challenges, but our awareness, tolerance and
proper reactions can mitigate the potential for the damage they can
cause.

This document includes a set of principles that should inform our
professional interactions and accountabilities. It is intended to be a
guide to assist us in the fulfillment of our responsibilities and the conduct
of our relationships with patients, colleagues, students, and others. The
diversity of many participants in the clinical care, learning, and clinical
research processes, and, the sensitive matters with which we deal,
requires each of us to be aware of the nuances of our interpersonal
actions and how they may be perceived by others. In addition to
providing guidelines for professional behavior, this document outlines a
process for reporting concerns about transgressions of the guidelines
and an informal process to respond to reports that is consistent with the
processes of the University, UWSMPH and our hospital partners. This
document and the process it outlines combined with the 2004 “Policy for
Professional Conduct in the Learning Environment” 1 are intended to
meet the Liaison Committee on Medical Education (LCME) Standard
MS-32, which requires that, “Each School of Medicine and Public Health
must define and publicize the standards of conduct for the teacher-
learner relationship, and develop written policies for addressing
violations of these standards.”

In addition to the several elements of medical professionalism noted
above, we also strive to cultivate and maintain collegial relationships in
personal interactions, avoid physical or mental self-impairment, take
initiative in identification and rehabilitation of impaired colleagues,
students, trainees, and to appropriately report serious breaches of
professional conduct. As members of the clinical faculty, we each take
responsibility to contribute to our organizations in creating a culture and
environment that promotes every aspect of medical professionalism. We
must model professional behavior in all our activities, fulfilling the special
responsibilities to patients that are set forth in federal and state laws and
regulations, and in University, UWMF, UWSMPH, University of
Wisconsin Hospitals and Clinics (UWHC) and other affiliated hospital,
clinical policies and procedures, guidelines and Medical Staff bylaws.


1
See Exhibit 1 to this document.


3
We also assume special responsibilities to UWMF as a charitable, non-
profit organization, to obey its articles and bylaws, to refrain from any
activity that would jeopardize its tax-exempt status, or attempt to use
UWMF assets or earnings for personal gain rather than for purposes that
are exclusively charitable, scientific or educational in nature. Finally, the
elements of medical professionalism include ethical and legal business
practices in billing, coding and documenting, handling medical records
according to regulations and institutional policies, reporting questionable
billing practices, and avoiding conflicts of interest pursuant to Board of
Regents, University, faculty and academic staff policies, or policies of
UWHC and UWMF. These practices include not accepting personal gifts
of any value from vendors, payers, competitors or any other third parties
doing business (or seeking to do business) with the University, UWHC or
UWMF.2


II. Guidelines for Professional Behavior of Medical School Physician
Faculty in the Clinical Setting.

With the above statement of principles and ideals as the context for
spurring thought and reflection on our actions, influencing our behaviors,
and reminding us of our higher purposes as physicians and as faculty,
we set forth the following guidelines for professional behavior of
faculty/staff at UWSMPH who are employed by both UWSMPH and
UWMF (hereafter “physician faculty”). The elements of these Guidelines
are derived from a number of sources, including medical professional
associations, but similar professional principles and codes for other
disciplines, such as dentists or psychologists, should be consulted when
relevant.

A. Respect for Persons.

1. Treat patients, patient family members, colleagues, other health
professionals, trainees and students with the same respect and
dignity you would want them to show you.i As faculty members,
we strive to serve as role models for our students and trainees.

2. Treat patients with kindness and respect their privacy and
modesty.ii

3. Cooperate with members of the health care team, including
students and trainees, to assure high quality patient care.iii
Recognize that today’s practice of medicine requires collaboration
and teamwork and that physicians have a special obligation to
foster teamwork.

2
Section I of these Guidelines is taken from Jeffrey E. Grossman, M.D., “Commitment to Medical
Professionalism,” June 2004, a document written for UWMS/UWMF.


4
4. Do not use offensive language, verbally or in writing, when
referring to patients or their illnesses.iv

5. Do not harass others, physically, verbally, psychologically or
sexually.v

6. Do not discriminate against others on the basis of sex, religion,
race, color, national origin, ancestry, disability, age, marital status,
or sexual orientation.vi


B. Honesty and integrity

1. Protect proper clinical decisions made in the interest of the
patient, regardless of payment arrangements for care or physician
compensation plans.vii

2. Be truthful in verbal and written communications and do not
knowingly mislead others.viii

3. Acknowledge unexpected outcomes and errors to colleagues and
patients and follow institutional policies on such outcomes.ix

4. Do not cheat, plagiarize, or otherwise act dishonestly.x

5. Do not abuse special privileges, for example, making personal or
unauthorized long-distance telephone calls on institutional lines.xi

6. Honestly and fairly evaluate colleagues, students, and trainees.xii

C. Respect for Patient Confidentiality

1. Protect patient medical and personal details and patient records
and do not share them with anyone, except health care
professionals involved in the care of the patient or otherwise as
outlined in UW, UWMF, UWHC or other applicable institutional
policies.xiii

2. Avoid discussion of patients or their illnesses in public places.xiv

3. Do not publicly identify patients, verbally or in writing, without
permission or other adequate justification.xv

4. Do not invite or permit unauthorized persons into patient
examining rooms, other areas where patients are being cared for,
or designated restricted areas in the hospital or clinic.xvi

5. Do not share your confidential computer passwords except as
permitted by written institutional policies.xvii

5

6. Do not look up confidential data on patients without a professional
“need to know.” xviii

7. Protect patient confidentiality in the use of electronic mail and in
the storage of patient information.xix

D. Responsibility for Patient Care

1. Obtain the patient’s informed consent for diagnostic tests and
therapies.xx

2. For the attending physician, assume 24-hour responsibility for the
patients under your care and when off duty or on vacation, assure
that your patients are adequately attended by another
practitioner.xxi

3. Follow up on ordered diagnostic tests and complete patient record
documentation conscientiously and in a timely manner.xxii

4. Coordinate with the health care team the timing of information
sharing with patients and their families to present a coherent and
consistent treatment plan.xxiii

5. Charge patients or their insurers only for clinical services provided
or supervised and accurately document the services performed
according to accrediting body and federal/state regulatory and
other payer requirements.xxiv

6. Do not delete or change any previous entry in a medical record;
follow institutional policies and procedures for amending a
medical record.xxv

7. Avoid abandonment of a patient, and if you are unwilling or unable
to continue care, assist the patient in making a referral to another
competent practitioner able to care for the patient.xxvi

8. Recognize that generally you should not treat yourself or provide
medical care to your own family members and loved ones.xxvii

E. Awareness of Limitations and Acting on Such Knowledge

1. Be aware of your personal limitations and deficiencies in
knowledge/abilities and know when and whom to ask for
supervision, assistance or consultation.xxviii

2. Know when and for whom to provide appropriate supervision.xxix


6
3. Follow all institutional policies for countersignature of student and
trainee workups and orders.xxx

4. Do not abuse alcohol or drugs that could diminish the quality of
patient care or academic performance.xxxi

5. Avoid patient involvement when you are ill, distracted, or feel
overwhelmed with personal problems that may diminish the
quality of care you can provide.xxxii

6. Do not engage in romantic or sexual relationships with patients;
and if such a relationship appears to be developing, seek
guidance or terminate the professional relationship.xxxiii

7. Avoid engaging in unsupervised involvement in areas or situations
where you are not adequately trained.xxxiv

F. Avoiding Conflicts of Interest

1. Resolve all clinical conflicts of interest using good clinical
judgment in the best interest of the patient.xxxv

2. Do not accept non-educational gifts of value from drug companies
or medical equipment vendors or suppliers or any third parties
who do business or seek to do business with the organizations
known as “UW Health” or with other organizations affiliated with
the University, UWSMPH, UWMF or UWHC.xxxvi

3. Do not participate in incentive programs offered by
pharmaceutical, device, and equipment companies, especially
when participation involves prescribing company products for the
patient.xxxvii

4. Do not refer patients to laboratories or other agencies in which
you have a financial stake.xxxviii

5. Do not accept a “kickback” (that is, a benefit) for any patient
referral.xxxix

G. Personal Professional Behavior

1. Identify yourself and your professional level to patients and staff;
and, if you are the patient’s attending physician, so identify
yourself to the patient; introduce medical students and other
members of the team by their proper title, not as “doctor.” xl

2. As a medical professional and role model for students and
trainees, strive to maintain a professional composure even though

7
you may be stressed by fatigue, professional pressures or
personal problems.xli

3. Do not write offensive or judgmental comments about anyone in
patient charts.xlii

4. Do not criticize or belittle the medical decisions of colleagues or
trainees or the performance of medical students in the presence
of patients.xliii

H. Responsibility for Peer Behavior

1. You are encouraged to take initiative to identify and help
rehabilitate impaired students, physicians, nurses, and other
employees with the help of appropriate UWSMPH, University,
UWMF or UWHC offices and/or committees.xliv

2. You are urged to report conduct by a physician faculty member
that disregards these Guidelines to the UWMF Professional
Conduct Committee.xlv

3. You may discuss your observations about his/her conduct with the
physician faculty member, who is transgressing these
Guidelines.xlvi

I. Respect for Personal Ethics

1. As a professional, you are not required to perform procedures,
such as an elective abortion or termination of medical treatment,
which you believe to be unethical, illegal, or detrimental to the
patient; but you recognize your personal beliefs should not
interfere with patient choice.xlvii

2. In a situation as described in (1), there is an obligation to assure
that patients and their families are informed of available treatment
options that are consistent with acceptable standards of medical
and nursing care and given reasonable assistance in making
alternative arrangements for care.xlviii

J. Ethical Guidelines for Use of Institutional Property and Resources and for
Institutional Business Dealings

1. Use facilities and lands owned by the University, UWMF, UWHC
or any affiliated health care institution only for purposes and
activities related to institutional missions and not for personal
gain.xlix

2. Use assets such as personnel, time, equipment, and supplies of
the University, UWSMPH, UWMF, UWHC or other affiliated health

8
care institutions only for purposes related to the institutional
missions and activities and not for personal gain.l

3. Be responsible and accountable to the University, UWSMPH,
UWMF, UWHC, and other institutions for the property and
resources with which you are entrusted as employees and staff.li

4. Use University, UWSMPH, UWMF, UWHC, and other affiliated
institutional computer and telecommunication networks only for
purposes and activities related to institutional missions and avoid
anything beyond incidental personal use, following all ethical
standards and policies relating to confidentiality, using personal
logins, and not sharing them with others, and protecting
proprietary and confidential information contained in the network.lii

5. Encourage fair competition in provision of health care services
and products based on factors such as quality, skill, experience,
and conveniences offered to patients, so that patients have an
opportunity to choose freely; avoid actions that fix prices, divide
geographic markets or that may artificially raise prices for our
services or otherwise impede competition.liii

6. Do not use, directly or indirectly, inside information of the
University, UWSMPH, UWMF, UWHC or any affiliated health care
institution for personal gain or the gain of others.liv

K. Special Ethical Responsibilities to UWMFlv

1. Follow UWMF’s contract with the UW System Board of Regents
and UWMF’s Articles and Bylaws; use its assets or earnings only
for purposes that are charitable, scientific or educational; refrain
from any activity that would jeopardize UWMF’s status as a
charitable tax-exempt organization.lvi

2. Do not use UWMF’s personnel, property, or equipment for
personal gain.lvii

3. Do not solicit or accept contributions or gifts or bequests that
would jeopardize UWMF’s charitable tax-exempt status.lviii

4. Do not use the name or auspices of UWMF, directly or indirectly,
to intervene in a political campaign and do not attempt to
influence legislation, in the name of or with the backing of
UWMF.lix

L. Integrity in Research

1. Human subject’s research must meet high ethical standards.lx


9
2. Report research results honestly in scientific and scholarly
presentations and publications.lxi

3. When publishing and presenting reports, give proper credit and
responsibility to colleagues and others who participated the
research.lxii

4. Report research findings to the public and the press honestly and
without embellishment.lxiii

5. Avoid potential conflicts of interest in research; disclose all funding
sources and forms of ownership.lxiv

6. Adhere to federal and institutional policies and rules that govern
research involving human subjects and animals.lxv


III. Reporting Concerns about Transgressions of the Guidelines

A. Initial Discussions with the Faculty Member Colleague Whose Conduct
is of Concern.

Before making a report to the UWMF Professional Conduct Committee,
you are encouraged, but not required, to discuss the issue informally
with the faculty member colleague whose conduct appears to transgress
the Guidelines. If you are uncomfortable discussing the concern with the
faculty member, you are encouraged to discuss the matter with your
department chair or section head. You may seek information from
UWSMPH Dean for Human Resources, UWSMPH Ombudsperson,
University Legal Services or the UWMF Vice President for Legal
Services. The Conduct Committee may seek legal counsel’s advice at
any point during the process.

B. Reporting Procedures and Initial Intake

An initial report should be to the physician chair of the UWMF
Professional Conduct Committee (Conduct Committee) and should be in
writing. If the initial report is verbal, the Committee chair will request the
report in writing. The Committee chair will decide in consultation with
other Committee members and/or staff whether the matter should be
reviewed by this Committee or whether another committee at UWHC, at
another affiliated clinical site or at the UWSMPH or University should
review the report.

C. Inter-institutional Communications to Insure Appropriate Institutional
Management of Reports and Avoidance of Duplication

A number of the Guidelines recorded above are stated (or substantially
stated) in University rules and/or policies, as well as in professional

10
society ethical standards. In addition, there are certain topic areas, such
as integrity in research, discrimination against employees or students,
and violation of HIPAA rules involving University protected health
information, where the University has well developed processes for
addressing issues raised in a report against a physician faculty member.
In those cases, UWMF Professional Conduct Committee may not be the
appropriate venue to manage the report. Therefore, it will be important,
as well as fair to the faculty member involved, for the Conduct
Committee chair to contact the department chair and the UWSMPH
Assistant Dean for Human Resources in each case where a report is
filed with the Conduct Committee. The Conduct Committee chair will
make confidential contact(s) and seek information as to whether the
UWSMPH wishes to proceed on the report. In those cases where the
UWSMPH decides to proceed, the UWMF Conduct Committee will defer
to the University or UWSMPH process.

D. Guidelines for When to Report

As noted above in the Guidelines, Section II. H., “Responsibility for Peer
Behavior,” there is an ethical duty on the part of physician faculty
members to help identify and rehabilitate impaired students, physicians,
trainees, and other employees with the help of appropriate institutional
offices and committees. Situations where the Guidelines have been
transgressed by behavior of a physician faculty member should be
reported. Such reporting should be viewed as a responsibility and as
positive action.

E. Who May Make a Report to the UWMF Conduct Committee

Any UWSMPH faculty member, other University, UWHC or UWMF
employee, a University medical or other health professions student, or a
health professional trainee in a University, UWHC, or affiliated program,
may report a concern about a physician faculty member to the
Committee.

F. Confidentiality of the Report and Review

A reporter may ask that certain people do not learn of the report and
review, and the Conduct Committee and staff will seek to meet the
request. The report and review are protected by sec. 146.38, Wisconsin
Statutes.

G. Prohibition against Retaliation

In most cases retaliation against a person making a report is a separate
act of misconduct, regardless of the validity of the concern reported.
Acts of retaliation, including threats, should be referred for investigation
for disciplinary action. In many situations, the University, UWHC, and/or

11
UWMF may be subject to governmental sanctions if there is retaliation
against a reporter or others cooperating with the process.


IV. Informal Procedures for Improving or Preventing Future Behavior not
Meeting the Medical Professional Guidelines

A. Rationale for the Informal Process

Physician faculty often face the stresses of multiple responsibilities in the
clinical setting and some may not see the effect their unprofessional
behavior has on colleagues, students, trainees and/or other health care
professionals. Such behavior may have a serious detrimental effect on
the performance of others in the health care setting and usually makes
teamwork impossible. It is in the interest of the physician faculty
member involved for one or more colleagues on the Conduct Committee
to talk informally with him or her about the perceived adverse conduct.
They can provide collegial advice and attempt to find ways to remedy the
situation that are acceptable to the faculty member and the department
chair. This process provides opportunities to address concerns before
the conduct begins seriously to affect others’ performance. The Liaison
Committee for Medical Education has determined that the UWSMPH has
insufficient procedures for addressing harassment and discrimination
against its medical students. It is anticipated that instances of disregard
of the UWSMPH/UWHC “Policy for Professional Conduct in the Learning
Environment” (2004) by physician faculty members (but not such
disregard by students, trainees, or other employees of the University,
UWHC, or UWMF) will be addressed through these procedures. This
informal process does not replace any other institutional process dealing
with, or established to deal with, a medical professionalism concern.

B. UWMF Professional Conduct Committee

The Committee shall be nominated by the Executive Committee of
UWMF, with approval of the Dean of UWSMPH and the UWMF Board of
Directors. The Conduct Committee, as a UWMF committee, shall consist
of five physician faculty members, who are leaders in advancing medical
professionalism. The Conduct Committee is authorized to handle
informally any report of transgression of the Guidelines unless and until
UWSMPH or the University indicates they wish to handle the matter
based on the process in Section III.C., outlined above. Any
recommendation for referral for discipline, or investigation of a physician
faculty member as an employee under FPP or ASPP, must be made to
UWSMPH Health for management by the appropriate University
process.





12
C. Initial Committee Phase

The initial phase is identification and remediation with a primary goal of
significant improvement or correction of the behavior by the involved
physician faculty member. After a written report is received, the
Committee chair makes an initial decision, following the procedures
outlined in III.C. above, as to whether the report should be referred to the
appropriate UWSMPH or University official. If the decision is not to refer
to the UWSMPH, the Committee will review the report and decide
whether further review is warranted. In making this decision, the
Committee may consult principles and policies articulated by the
professional association or specialty society of the involved physician
faculty member. If it is decided that further review is warranted, the
physician faculty member will be offered a chance to meet with one or
more Committee members to discuss the matter and provide
information. If it appears to the Committee that a transgression of the
guidelines has occurred, the Committee may recommend and
encourage educational programs, counseling and or other programs for
remediation. The recommendation will be forwarded to the department
chair and that chair asked to report back to the Committee within two
months on what remediation occurred and whether improvement has
been seen. Educational programs and use of other resources within the
institutions referred to as “UW Health,” will be strongly encouraged.

D. Second Phase of the Committee Process

The second phase is for Committee focus on repeated transgressions of
professional conduct not corrected or improved in Phase I, or for focus
on conduct that warrants more intense review. The Committee may
place a particular report directly into the Second Phase if, after review in
the Initial Phase, the decision of the department chair and the
Committee is that the conduct appears egregious and/or the Initial
Phase is not appropriate. At the Second Phase, the involved physician
faculty member meets together with the department chair and the full
Committee to present information and discuss the situation. After such
meeting, the Committee and the department chair may advise the
physician faculty member as to further expected improvements with a
timeline and potential future consequences if the conduct does not end.
Or, after such meeting, the Committee and the department chair may
discuss the matter and decide to refer the matter for formal University or
other institutional process.

E. Third Phase

The third phase is referral of the involved physician faculty member for
formal action, including investigation and potential discipline at the
appropriate institution. If the breach of conduct is sufficiently egregious
or has continued after attempts at remediation in the first two phases,
the Committee, after consultation with the department chair, may decide

13
to refer the matter to the appropriate University officer, if the conduct
appears to violate University regulations or policies. Alternatively, the
Committee may refer the matter to another appropriate institution, where
the physician faculty member practices, such as UWHC. The faculty
member may also be advised that the conduct appears to violate state or
federal laws or regulations. If disciplinary action (or “corrective action”
under the UWHC Bylaws) is initiated at a hospital institutional site, then
after such disciplinary process starts, any subsequent determination or
decision to restrict or remove staff privileges or membership must be
reported by that institution to the National Practitioner Data Bank and the
Wisconsin Medical Examining Board.

F. Cooperation by the Physician Faculty Member in Informal Procedures

Once a decision has been made for the Conduct Committee to review a
reported concern, or to triage the matter to a UWHC or University
Committee, the faculty member in question will receive written and
verbal notification either from the Chair of the Conduct Committee or the
Chair of their department. We expect all physician faculty members to
cooperate with the informal procedures outlined above, including
providing to the Conduct Committee truthful and accurate information.
See AMA Principles, sec. II, V; UWHC Medical Staff Bylaws, Article III,
sec. 3 d.

G. Confidentiality of Conduct Committee Proceedings

All informal procedures by the Conduct Committee under the Initial and
Second Phases will be confidential pursuant to sec. 146.38, Wisconsin
Statutes, and no information about the report or the process will be
released to anyone except pursuant to law. Committee members, the
department chair and any others involved in the procedures will maintain
confidentiality of the information gained in the informal procedures
pursuant to law. If the concerns about the involved physician faculty
member are remedied after the informal process, then no release of
information beyond those involved in the Committee proceedings will be
made, except as required by law. If the concerns after such process are
not remedied, then referral and disclosure of the matter to the
appropriate body or institution may be necessary.

H. Prohibition Against Retaliation See Section III. G. above


Acknowledgement. UWSMPH and UWMF wish to thank the Dartmouth-Hitchcock
Medical Center for permission to use liberally its Code of Professional Conduct (1999),
in preparation of these Guidelines.





14
Approved by:
UWMF Executive Committee
UWMF Council of Chairs and Council of Faculty
UWMF Board of Directors
UWSMPH Academic Planning Council
UWSMPH Faculty

ENDNOTES


i
AMA Principles of Medical Ethics (hereafter AMA Principles), sec. I, IV (2001).
These Principles are a requirement for membership on the UWHC Medical Staff and
are reproduced at the end of the 2004-05 UWHC Medical Staff Bylaws. UWHC
Medical Staff Bylaws (hereafter UWHC Bylaws), Article III, sec. 2 (2004-05); AMA
Current Opinions E-9.123 “Disrespect and Derogatory Conduct in the Patient-
Physician Relationship” (12/03) and E-10.01 “Fundamental Elements of the Patient-
Physician Relationship” (1993) www.ama-assn.org/ama/pub/category/2498html ; UW
School of Medicine and Public Health/University Hospital and Clinics POLICY FOR
PROFESSIONAL CONDUCT IN THE LEARNING ENVIRONMENT (appr. 5/19/04
UWMS Academic Planning Council) (hereafter Learning Environment Policy), which is
Exhibit 1 to these UWMS/UWMF Guidelines; LIAISON COMMITTEE ON MEDICAL
EDUCATION (LCME) Standard MS-32 (9/03); LCME letter to UW System President
Lyall, February 23, 2003; Am. Board of Internal Medicine, Project Professionalism,
“Professionalism in Medicine: Issues and Opportunities in the Educational
Environment,” Introduction, p. 5 (1995); see Am. J. of Medicine 97 (6): i-iii (Dec 1994);
Am. College of Surgeons, Statements on Principles, Pledge, Code of Professional
Conduct (2004) (hereafter FACS Principles) www.facs.org/fellows_info/statements .

ii
AMA Principles, sec. I, IV supra at n. i; see AMA Current Opinions E-5.059 “Privacy
in the Context of Health Care”(6/02), E-5.045 “Filming Patients in Health Care
Settings” (12/01), E-5.046 “Filming Patients for the Education of Health Professionals”
(12/03) supra at n. i.

iii
UWHC Bylaws, Art. III, sec. 1.a (2004-05); AMA Principles, sec. IV, V; FACS
Principles, Pledge; all cited supra at n. i.

iv
See AMA Principles, sec. I supra at n. i.

v
See UW-Madison Faculty Legislation (Fac. Leg.) II-303-306 (1981-1 Mar 1999)
www.secfac.wisc.edu/governance>; Learning Environment Policy, 3d para., Ex. 1 to
these Guidelines; Title IX of the Education Amendments of 1972, 20 U.S.C. s. 1681;
62 Fed. Reg. 12034 (3/13/97); 34 CFR s. 106; 42 U.S.C. s. 1983 and extensive
federal case law; UWHC Bylaws, Art. III, sec. 3 c., which states a requirement to abide
by applicable laws; Wisconsin Medical Examining Board rules for physicians which
state that is it unprofessional conduct to violate any law, administrative rule or
regulation, the circumstances of which substantially relate to the practice of medicine.
WIS. ADM. CODE, (hereafter WIS Code) Chap. Med 10.02(2)(z); LCME, supra at n. i;
see UW-Madison website .


15

vi
Wis. Stats. s. 111.31-111.395; Wis. Stats. s.106.52 (nondiscrimination in places of
public accommodation including hospitals and clinics on the basis of sex, race, color,
creed, disability, national origin, ancestry or sexual orientation); Learning Environment
Policy, 3d para., supra at n. i; see federal nondiscrimination law and regulations in
education: Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d; Sec. 504 of the
Rehabilitation Act of 1973 as amended, 29 U.S.C. s.794; Age Discrimination Act of
1975, 42 U.S.C. s. 6101; 34 CFR Pts. 100-106, 110; AMA Principles, sec. III and IV;
LCME, supra at n. i; FACS Code, Principles, “Interprofessional Relations” III. B. supra
at n. i; UWHC Bylaws, Art. XVI, sec. l. d; UWHC Administrative Policies (hereafter
UWHC Adm. Pol.) #4.34 II.B.l.

vii
AMA Principles, sec. VIII supra at n. i; UWHC Bylaws, Art. XVI, Sec. 2. a; FACS
Principles, Pledge, supra at n. i.

viii
AMA Principles, sec. II supra at n.i; WIS. Code Chap. UWS 8.01 (Board of
Regents);
WIS. Code Chap. Med 10.02(2)(m), which states that it is unprofessional conduct to
knowingly make any false statement in practicing under any license with fraudulent
intent; FACS Principles, Code, supra at n. i; see AMA Current Opinions E-9.132
“Health Care Fraud and Abuse” (1998) supra at n. i.

ix
AMA Principles, sec. II supra at n.i; AMA Current Opinions E-8.12 “Patient
Information” (6/94), E-8.121 “Ethical Responsibility to Study and Prevent Error and
Harm” (12/03) supra at n. i; FACS Principles, Code, supra at n. i; see UWHC Adm.
Pol. # 4.45, “Disclosure of Unanticipated Outcomes to Patient/Family.”

x
AMA Principles, sec. II supra at n. i; FACS Principles, Pledge, supra at n. i ; WIS.
Code Chap. UWS 8.01(1).

xi
WIS. Code Chap. UWS 8.03(1)(a); see “Use of University Telephones” Chancellor’s
Office Policy (Jan. 1993).

xii
WIS. Code Chap. UWS 8.01(1); see Section II, A. and B. in the text of these
Guidelines.

xiii
WIS Code Chap. Med 10.02(2)(n); AMA Principles, sec. IV supra at n. i; AMA
Current Opinions E-5.05 “Confidentiality” (6/94), E-5.07 “Confidentiality: Computers”
(6/98) supra at n. i; 45 CFR Pts. 160 and 164; UW-Madison policies implementing
HIPAA rules www.wisc.edu/hipaa/privacy “Health Information Privacy Manual” # 3.2,
3.8 III; UWHC Adm. Pol. #4.13- 4.16, 4.29, 4.34, 4.38, 6.21; UWHC Bylaws, Art. XVI,
sec. 7; UWMF HIPAA Policies and Guidelines www.uwmf.wisc.edu/policies; see UW-
Madison HIPAA Training for Clinicians www.wisc.edu/hipaa .

xiv
Id.

xv
Id.

xvi
AMA Current Opinions E-5.059 “Privacy in the Context of Health Care” (6/02) supra
at n. i; see UWHC Adm. Pol. #1.15 “Restricted Areas”.


16

xvii
UW-Madison Best Practices Guidelines www.son.wisc.edu/hipaa_security; UWMF
Information Services and Policy Manual, “Acceptable Use Policy” B. 4, 6
www.uwmf.wisc.edu/policies; UWHC Adm. Pol.# 1.01, 1.02, 4.39.

xviii
Id.

xix
UW-Madison “Health Information Policy Manual” –“Provider-Patient Email” #8.6
supra at n. xiii; UWMF HIPAA Policies, “E-Mail of PHI from Health Care Provider to
Patient”, Privacy #013 ; UWHC Adm. Pol. #6.32.
.

xx
NOTE that in Wisconsin, the professional and legal obligation to obtain legally
effective informed consent rests with the physician performing the therapy or
procedure. This professional and legal obligation cannot be delegated even though
the physician may assign or ask someone else on the team to talk to the patient or
obtain a signed consent form. WIS. Code Chap.Med 10.02(2)(u); Wis. Stats, sec.
448.30; UWHC Bylaws, Art. XVI, Sec. 2. c supra at n. i; Meriter Hospital Medical Staff
Rules and Regulations (hereafter Meriter Rules), sec. 20 (2/04); AMA Principles, sec.
IV (respect for the rights of patients) supra at n. i; FACS Principles, Code,
“Relationship of the Surgeon to the Patient” II. A. supra at n. i; see UWHC Adm. Pol.
#4.17, 4.34 II. B.9.

xxi
UWHC Bylaws, Art. III, Sec. 3. b, Art. XVI, sec. 1. a, 2. a; Meriter Rules, sec. 4, 14
(2/04) supra at n. xx.

xxii
UWHC Bylaws, Art. XVI, sec. 1. a, 2. a, b, sec. 7; UWHC Adm. Policy #8.07, 6.15;
Meriter Rules, sec. 4, 6, 8, 25, 26 (2/04) supra at n. xx; see AMA Principles, sec. V (“A
physician shall …make relevant information available to patients, colleagues…”) supra
at n. i; see AMA Current Opinions E-8.095 “Reporting Clinical Test Results” (6/98)
supra at n. i.

xxiii
See UWHC Bylaws, Article III, sec. 1. a. supra at n. i; UWHC Adm. Pol. # 4.34 II,
B. 9; see AMA Principles, sec. I, IV, VIII supra at n. i; see FACS Code, Principles,
“Qualifications of the Responsible Surgeon” I. A, “Relationship of the Surgeon to the
Patient” II. A, “Interprofessional Relations” III. A. supra at n. i.

xxiv
WIS. Code Chap. Med 10.02(2)(m); AMA Current Opinions E-6.05 “Fees for
Medical Services” (6/94) supra at n. i; FACS Principles “Relation of Surgeon to
Patient” II. L. (Surgical Fees) supra at n. i; see UWMF “Patient Business Services
Policies and Procedures, “Charging,” “Prepayments (Self Pay)”
; see UWHC Adm. Pol. # 2.12, 2.13; JCAHO Manual
2005, IM. 6.10 and IM.6.20 www.hosp.wisc.edu/jcaho ; also
extensive Medicare/Medicaid regulations and payer requirements.

xxv
UWHC Bylaws, Art. XVI, sec. 7 supra at n. i; Meriter Rules sec. 30 supra at n. xx;
UWHC Adm. Pol. #6.14; UWMF Health Information Services, “General Documentation
Guidelines” (see Sandra Schumacher at UWMF HIS).

xxvi
UWMF Clinical Policy, “No Further Service Policy” (1/1/05)
; see AMA Principles, sec. I, IV, VIII supra at n. i; AMA

17

Current Opinions E-8.115 “Termination of Physician-Patient Relationship” (6/96) supra
at n. i; see UWHC Bylaws, Art. III, Sec. 3. b; Meriter Rules, sec. 33 supra at n. xx.

xxvii
AMA Current Opinion E-8.19 “Self Treatment or Treatment of Immediate Family
Members” (6/93) supra at n. i.

xxviii
WIS. Code Chap. Med 10.02(2)(h)(i); AMA Principles, sec. V (“A physician shall
continue to study, apply and advance scientific knowledge, maintain a commitment to
medical education…, obtain consultation, and use the talents of other health
professionals when indicated.”) supra at n. i; FACS Principles, Pledge, Code, and
“Qualifications of the Responsible Surgeon” I. C. “Commitment to Maintain Fitness”
supra at n. i; see UWHC Bylaws, Art. III, Sec. 1. b.; Meriter Rules, sec. 13 supra at n.
xx.

xxix
UWHC Bylaws, Art. XVI, Sec. 2. a., 2. e., 5, 8. a.; Meriter Rules, sec. 12 (2/04)
supra at n. xx; see AMA Current Opinions E-3.03 “Allied Health Professionals” (12/97)
supra at n. i .

xxx
See for example UWHC Adm. Pol. # 6.15, p.3, 5 and #8.16; Meriter Rules, sec. 16
supra at n. xx.

xxxi
WIS. Code Chap. Med 10.02(2)(h)(i); AMA Current Opinions E-8.15 “Substance
Abuse” (12/86) supra at n. i; see UWHC Bylaws, Art. III, sec. 1. b.

xxxii
Id; FACS Principles, “Qualifications of the Responsible Surgeon” I. C.
“Commitment to Maintain Fitness” supra at n. i; AMA Current Opinions E-9.0305
“Physician Health and Wellness” (6/04) supra at n. i

xxxiii
WIS. Code Chap. 10.02(2)(zd); Wis. Stats, sec. 895.70, which makes sexual
exploitation by a therapist a crime and defining a therapist as including a physician
who performs or purports to perform psychotherapy; AMA Current Opinions E-8.14
“Sexual Misconduct in the Practice of Medicine” (3/92) and E-8.145 “Sexual or
Romantic Relations Between Physicians and Key Third Parties” (12/98) supra at n. i

xxxiv
WIS. Code Chap. Med 10.02(2)(h)(i)(j); see UWHC Bylaws, Art. III, Sec. 3. a, Art.
VIII, Sec. 1. b; see AMA Principles, sec. I, V supra at n. i; see FACS Principles, Code,
and “Qualifications of the Responsible Surgeon” I. A, E, F supra at n. i

xxxv
AMA Principles, sec. VIII supra at n. i; AMA Current Opinions E-8.03 “Conflicts of
Interest: Guidelines” (6/94); see also, AMA Current Opinions E-8.031-8.035 (conflicts
in other areas: bio-medical research, clinical trials, facility ownership, home health)
supra at n. i; FACS Principles, Pledge, Code and “Relationship of the Surgeon to the
Patient” II. I. “Conflict of Interest” supra at n. i

xxxvi
See WIS. Code Chap. UWS 8.03(1)(b); UWHC Adm. Pol. #11.19 II. F, G, H.

xxxvii
See AMA Principles sec. VIII supra at n. i; see AMA Current Opinions E-8.06
“Prescribing and Dispensing Drugs and Devices” sec. (2) (6/02) supra at n. i; see
UWHC Bylaws, Art. III, sec. 2.


18

xxxviii
Federal Stark Law, 42 U.S.C. s. 1395nn; Phase II Regulations, 69 F.R.16054;
Federal Antikickback Law, 42 U.S.C. s. 1320a- 7 b(b); Antikickback Regulations, 42
CFR 1001.951; see AMA Current Opinions E-8.032 “Conflicts of Interest: Facility
Ownership by Physicians”(6/94) supra at n. i.

xxxix
Id.; see UWHC Bylaws, Art. III, sec. 2.

xl
See WIS. Code Chap. Med 10.02(2)(t); AMA Current Opinions E-8.087 “Medical
Student Involvement in Patient Care” (6/01) supra at n. i; see UWHC Adm. Pol. #1.30;
4.34 II. B. 5.

xli
See Section II, E. “Awareness of Limitations” in text of these Guidelines and its
citations.

xlii
AMA Principles, sec. I, IV supra at n. i; see Section II, A. 3. “Respect for Persons”
above in text of the Guidelines - cooperate with members of the health care team;
FACS Principles, Pledge (2d and 6th para.), Code (9th bullet) supra at n. i.

xliii
See Section II, A. “Respect for Persons” above in text of these Guidelines and its
citations; Learning Environment Policy, 3d para. supra at n. i.

xliv
See AMA Principles, sec. II supra at n. i; AMA Current Opinions E-9.031 “Reporting
Impaired, Incompetent or Unethical Colleagues” (6/04) supra at n. i; FACS Principles,
“Surgeons and Society” V. F-H supra at n. i.

xlv
Id.; AMA Current Opinions E-9.04 “Discipline and Medicine” (6/94) supra at n. i; see
Section III. C in the text of these Guidelines.

xlvi
FACS Principles, “Surgeons and Society” V. F. (Impaired Physicians) supra at n. i;
AMA Current Opinions E-9.0305 “Physician Health and Wellness” (last para.)(6/04)
supra at n. i.

xlvii
AMA Principles, sec. VI supra at n. i; see for example, WIS. Code Chap. Med
11.03; AMA Current Opinions E-10.01 “Fundamental Elements of the Patient-
Physician Relationship” (5) (1993) and E-10.015 “The Patient-Physician Relationship”
(12/01) supra at n. i; see UWHC Adm. Pol. #4.34 II.B. 9, 21.

xlviii
Id., n. xlvii (see AMA Current Opinions E-10.01); see AMA Principles sec. I, IV, VIII
supra at n. i; FACS Principles, “Relation of the Surgeon to the Patient” II. G. supra at
n. i.

xlix
WIS. Code Chap. UWS 8.03(1)(a) “Unclassified Staff Code of Ethics”; UW-Madison
Faculty Policy and Procedures, FPP 8.05, 8.06 www.secfac.wisc.edu/goverance/FPP

l
Id.

li
FPP 8.05 C supra at n. xlix.


19

lii
WIS. Code Chap. UWS 8.03(1)(a), 8.03(1)(c); FPP 8.06 D supra at n. xlix; see
Section II, C. in text of these Guidelines; AMA Current Opinions E-5.07
“Confidentiality: Computers” (6/98) supra at n. i.

liii
See AMA Current Opinions E-6.11 “Competition” (7/83) supra at n. i; extensive
federal and state laws, regulations and case law on antitrust.

liv
See WIS. Code Chap. UWS 8.03(1)(a), 8.03(1)(c).

lv
UWMF was created as a medical education and research foundation “existing
exclusively for charitable, educational and scientific purposes for the benefit of the
UWSMPH and UW-Madison.” Specifically it was “established to support provision of
high quality medical care, education and research” at UWSMPH. In 1995 it was
formed as a Wisconsin corporation with agreement of the UW System Board of
Regents. Key to its continuing existence and function as a support to the UWSMPH is
its charitable tax-exempt status. In order to maintain that status, federal laws and
regulations must be observed. For example, neither UWMF nor any clinical
department, can operate as a business corporation or general practice corporation
formed by physicians in private practice, which is permitted to exist to provide financial
benefit (profit) to its stockholders or members. Therefore, special ethical
responsibilities exist with the physician faculty employees of UWMF, including those
who sit on the UWMF Board of Directors and the various committees of UWMF or who
are department chairs, section heads or other leaders. Any physician faculty member
who has a question about the appropriateness of any individual faculty or
departmental activity should seek advice from the appropriate senior UWMF official
before proceeding. The special responsibilities are listed in Section II. K. in the text.
See UWMF Articles and Bylaws and n. lvi.

lvi
UW System Board of Regents Agreement with UWMF, e.g. para. 2, 3, 15-17ff (May
8, 1995); UWMF Articles of Incorporation, Art. IX (1995); UWMF Bylaws (see Art. II,
sec. 2.1; Art. III, sec. 3.1; Art. XII, sec. 12.4; Art. XV, sec. 15.1: Ex. H) (6/29/01); 26
U.S.C. sec. 501©(3) –“no part of the net earnings (of the corporation may inure) to the
benefit of any private shareholder or individual”; 26 U.S.C. sec. 4958-63 (1996); 26
CFR sec. 53.4958-1 to 53.4958-8 (2002).

lvii
Id.; WIS. Code Chap. UWS 8.03(1)(a)

lviii
Id at n. lv. and n. lvi.

lix
Id at n. lvi.; see UWMF Information Services Policy and Procedures Manual,
“Acceptable Use Policy” para. 21 (2003) www@uwmf.wisc.edu/policies .

lx
The Belmont Report: Ethical Principles (1979) www.hhs.gov/ohrp ; 45 CFR Pt. 42;
FACS Principles, “Surgeons and Society” V. A. supra at n. i.

lxi
WIS. Code Chap. UWS 8.01(1); FACS Principles, “Surgeons and Society” V. B.
supra at n. i.

lxii
Id.; see AMA Principles sec. II, V supra at n. i.


20

lxiii
WIS. Code Chap. UWS 8.01(1); FACS Principles, “Surgeons and Society” V. C.
supra at n. i.

lxiv
WIS. Code Chap. UWS 8.01(1), 8.03(1)(a)(b), 8.025(2); UW-Madison Policies and
Procedures for Conflicts of Interest in Clinical Research www.wisc.edu/grad (go to
“research compliance”, then “conflict of interest.”)

lxv
45 CFR Pt. 42; 7 U.S.C. sec. 2131 ff, 9 CFR Pts. 1-4; UW-Madison policies on
human subjects protection www.wisc.edu/grad (go to “research compliance,” then
“human subjects program”), for UW health sciences boards
www.medicine.wisc.edu/hsc; UW-Madison policies on animal welfare
www.rarc.wisc.edu .