Principles of Professional Conduct

Adopted July 2006
Revised February 2013

Introduction
These guidelines for ethical behavior address the demands of contemporary foot and ankle surgical practice. The American College of Foot and Ankle Surgeons (College) developed the Principles of Professional Conduct for the benefit of our patients as well as to serve as a guide to conduct in the physician-patient relationship. The Principles provides standards of conduct that define the essentials of expected behavior for the foot and ankle surgeon. The mission of the College is to advance the competency of foot and ankle surgeons and the care of their patients by providing continuing education, publishing research and serving as a source of information to the public. Foot and ankle surgeons should recognize that they are role models for residents, surgeons-in-training and other health care professionals and should by their deeds and actions comply with the College’s Principles of Professional Conduct.

1. The Physician-Patient Relationship
   
2. Personal Conduct
   
3. Conflicts of Interest 
   
4. Maintenance of Competence 
   
5. Relationships with Foot and Ankle Surgeons and Health Professionals 
   
6. Relationship to the Public
7. Advertising and Solicitation 
   
8. Principles of Care 
   
9. Research and Academic Responsibilities 
   
10. Community Responsibility 
    

I. The Physician-Patient Relationship

1. The foot and ankle surgical profession exists for the primary purpose of caring for the patient. The physician-patient relationship is the central focus of all ethical concerns.
2. The physician-patient relationship has a contractual basis and is based on confidentiality, trust and honesty. Both the patient and the surgeon are free to enter or discontinue the relationship within any existing contractual constraints. A foot and ankle surgeon has an obligation to render care only for those conditions that he or she is competent to treat. In the absence of a pre-existing physician-patient relationship, the foot and ankle surgeon is under no ethical obligation to care for a person unless no other provider is available. A foot and ankle surgeon is morally bound to provide care in emergency situations and to arrange proper follow-up. Foot and ankle surgeons should keep in mind that contracts with health insurance plans might define a legal obligation to provide care to certain patients.
3. Foot and ankle surgeons should not discriminate against classes or categories of patients in the delivery of needed health care. Such classes and categories include gender, color, creed, race, religion, age, ethnic or national origin, political beliefs, and nature of illness, disability, socioeconomic status or sexual orientation.
4. A foot and ankle surgeon should render services to the best of his or her ability. Having undertaken the care of a patient, the foot and ankle surgeon may not neglect that person. Unless discharged by the patient, and if further surgical service is needed, the surgeon may discontinue service only after giving adequate notice to the patient so that the patient can secure alternative care. The foot and ankle surgeon should transfer records, if requested. Managed care agreements may contain provisions which alter the method by which patients are discharged. If the enrollment of a physician or patient is discontinued in a managed care plan, the physician will have an ethical responsibility to assist the patient in obtaining follow-up care.
5. Foot and ankle surgeons have a duty to protect and foster an individual patient’s informed choices. The doctrine of informed consent means that surgeons provide adequate information that is comprehensible to a competent patient or patient surrogate. At a minimum, this should include the nature of the medical condition, the objectives of the proposed treatment, treatment options, possible outcomes and the risks involved. Foot and ankle surgeons should be committed to the concept of shared decision making, which involves assisting patients in making decisions that account for medical, situational and personal factors.
6. Foot and ankle surgeons should maintain confidentiality. Because written, electronic and verbal information may be intercepted or overheard, surgeons should always be aware of anyone who might be monitoring communication about a patient. Foot and ankle surgeons need to abide by all laws pertaining to privacy and confidentiality and should choose methods of storage and transmission of patient information that minimize the likelihood of data becoming available to unauthorized persons or organizations, including social media. Foot and ankle surgeons have an obligation to keep information in the patient’s medical record confidential. Information should be released only with the written permission of the patient or the patient’s legally authorized representative. Specific exceptions to this general rule may exist (e.g., workers compensation, communicable disease, HIV, knife/gunshot wounds, abuse, and substance abuse). It is important that a foot and ankle surgeon be familiar with and understands the laws and regulations in his or her jurisdiction that relate to the release of information. Both ethically and legally, a patient has certain rights to know the information contained in his or her medical record. While the chart is legally the property of the practice or the institution, the information in the chart is accessible by the patient.
   

II. Personal Conduct

1. The foot and ankle surgeon should maintain a reputation for truth and honesty. In all professional conduct, the foot and ankle surgeon is expected to provide competent and compassionate patient care, exercise appropriate respect for other health care professionals and maintain the patient’s best interests as paramount. Foot and ankle surgeons should not misrepresent directly or indirectly, their skills, training, professional credentials, board certification status or identity. Foot and ankle surgeons should uphold the dignity of the profession and accept its ethical values.
2. The foot and ankle surgeon should respect the law, uphold the dignity and honor of the profession and accept the profession’s self-imposed discipline. Within legal and other constraints, if the foot and ankle surgeon has a reasonable basis for believing that a physician or other health care provider has been involved in any unethical or illegal activity, he or she should attempt to prevent the continuation of this activity by communicating with that person and/or identifying that person to a duly-constituted peer review authority or the appropriate regulatory agency. In addition, the foot and ankle surgeon should cooperate with peer review and other authorities in their professional and legal efforts to prevent the continuation of unethical or illegal conduct.
3. Foot and ankle surgeons have an ethical responsibility to protect patients and the public by identifying and assisting impaired colleagues. “Impaired” means being unable to practice medicine with reasonable skill and safety because of physical or mental illness, loss of motor skills or excessive use or abuse of drugs and alcohol. Foot and ankle surgeons should be able to recognize impairment in physician partners and other health care providers and should seek assistance from appropriate resources to encourage these individuals to obtain treatment. It is ethical for a surgeon to take actions to encourage colleagues who are chemically dependent to seek rehabilitation.
4. When using the Internet for social networking, either personal or professionally, foot and ankle surgeons should use privacy settings to safeguard personal content or information, with the understanding that privacy settings have limited effectiveness and once content is posted it is often times irretrievable. Foot and ankle surgeons should self-monitor their online presence to ensure information on their own sites, and to the extent possible, content posted about them by others, is accurate and appropriate.  To maintain appropriate professional boundaries, foot and ankle surgeons should separate personal and professional online access and content. Foot and ankle surgeons (including students, residents, and fellows) should recognize that online actions and content may negatively affect their reputations, careers, and public trust in the podiatric profession.
   

III. Conflicts of Interest 

1. The practice of medicine inherently presents potential conflicts of interest. Foot and ankle surgeons should place service to patients before personal material gain and should avoid undue influence on their clinical judgment. When a conflict of interest arises, it must be resolved in the best interest of the patient. The foot and ankle surgeon should explore reasonable alternatives to ensure that the most appropriate care is provided to the patient. If the conflict of interest cannot be resolved, the foot and ankle surgeon should notify the patient of the conflict and offer to withdraw from the relationship.
2. If the foot and ankle surgeon has a financial or ownership interest in a durable medical goods provider, imaging center, surgery center or other health care facility where the surgeon’s financial interest is not immediately obvious, the foot and ankle surgeon must disclose this interest to the patient. The foot and ankle surgeon has an obligation to know the applicable laws regarding physician ownership, compensation and control of these services and facilities.
3. When a foot and ankle surgeon receives anything of significant value from industry, an actual or potential conflict exists which should be disclosed to the patient. When a foot and ankle surgeon receives inventor royalties from industry, the surgeon should disclose this fact to the patient if such royalties relate to the patient’s treatment. It is unethical for a foot and ankle surgeon to receive monetary compensation from industry for using a particular device or medication. Reimbursement for reasonable administrative costs in conducting or participating in a scientifically sound research clinical trial is acceptable. Acceptance of gifts, trips, hospitality or other items is discouraged.
4. A foot and ankle surgeon reporting on clinical research or experience with a given procedure or device must disclose any financial interest in that procedure or device if the surgeon or any institution with which that surgeon is connected has received anything of value from its inventor or manufacturer.
5. Except when inconsistent with applicable law, foot and ankle surgeons have a right to dispense medication, assistive devices, orthopedic appliances and similar related patient-care items, and to provide facilities and render services as long as their doing so provides a convenience or an accommodation to the patient without taking financial advantage of the patient. Ultimately, the patient must have the choice of accepting the dispensed medication or patient-care items or obtaining them outside the office.
   

IV. Maintenance of Competence

The foot and ankle surgeon should continually strive to maintain and improve medical knowledge and skill and should make available to patients and colleagues the benefits of his or her professional attainments. Each foot and ankle surgeon should participate in continuing medical educational activities.

V. Relationships with Foot and Ankle Surgeons and Health Professionals 

1. Good relationship among physicians, nurses and other health care professionals are essential for quality patient care. The foot and ankle surgeon should promote the development of an expert health care team that will work together harmoniously to provide optimal patient care.
2. The professional conduct of the foot and ankle surgeon will be scrutinized by professional associations, hospital(s), managed care organization(s), peer review committees and state medical and/or licensing boards. These groups deserve the participation and cooperation of foot and ankle surgeons.
3. When foot and ankle surgeons see Internet content posted by colleagues that appears unprofessional, they have a responsibility to bring that content to the attention of the poster, so he or she can remove it or take other appropriate action.  If the behavior significantly violates professional norms and the poster does not take appropriate action to resolve the situation, the foot and ankle surgeon should report the matter to appropriate authorities.
4. Foot and ankle surgeons are frequently called upon to provide expert medical testimony in courts of law. In providing testimony, the foot and ankle surgeon should ensure that the testimony provided is non-partisan, scientifically correct and clinically accurate. The foot and ankle surgeon should not testify concerning matters about which he or she is not knowledgeable. It is unethical for a foot and ankle surgeon to accept a contingency fee based on the outcome of a case in which testimony is given or derive personal, financial or professional favor in addition to compensation. See ACFAS Expert Witness Testimony Standards.
   

VI. Relationship to the Public 

1. Professional fees should be commensurate with the services provided. Foot and ankle surgeons should submit billing codes that reflect the levels of service or complexity that were provided. It is unethical for surgeons to charge for services not rendered.
2. Foot and ankle surgeons are encouraged to devote some time and work to provide charity care for individuals who have no means of paying.
3. The foot and ankle surgeon may enter into a contractual relationship with a group, a prepaid practice plan or a hospital. The physician has an obligation to serve as the patient’s advocate and to ensure that the patient’s welfare remains the paramount concern.
4. The focus of managed care organizations on cost containment and resource allocation can present ethical challenges. Foot and ankle surgeons should actively resist managed care policies that restrict free exchange of medical information. A surgeon should not withhold information about treatment options simply because the option is not covered by a particular managed care organization. Foot and ankle surgeons should always act in the best interests of their patients and as an advocate when necessary.
5. The foot and ankle surgeon should neither accept nor offer commissions in any form or manner on fees for professional medical services, referrals, consultations, pathology services, radiology services, prescriptions or other services or article supplied to patients. Division of professional fees or acceptance of rebates from fees paid by patients to radiological, pathological, laboratory, shoe stores or other establishments is wholly inappropriate.
   

VII. Advertising and Solicitation

1. The foot and ankle surgeon should not publicize himself or herself through any medium or form of public communication in an untruthful, misleading, or deceptive manner. This includes falsely advertising the status of one’s membership in the College (i.e. advertising as a Fellow when Associate status is proper). The foot and ankle surgeon has a responsibility to properly represent him or herself with regard to training, ability, board certification and scope of practice.
2. The foot and ankle surgeon, in connection with his or her name, must use the title(s), degree(s), or designation(s) authorized by individual state law. The title “doctor” or any abbreviation cannot be used in advertising without the qualification “podiatrist,” “podiatric physician,” or “Doctor of Podiatric Medicine,” or other appropriate designation. Foot and ankle surgeons are, by their nature, certified by a specialty board and may use the appropriate term in connection with his or her specialty.
3. A foot and ankle surgeon may advertise through public communications media such as professional announcements, telephone and medical directories, social media, Internet web pages and broadcast and electronic media. Types of useful information that could be included in ethical advertising include a statement as to specialty board certification; services provided under specified private or public insurance plans or health care plans; names of schools and postgraduate clinical training programs from which the surgeon has graduated together with degrees received; a listing of publications in educational journals; affiliations with hospitals or clinics; and a statement as to whether the surgeon regularly accepts installment payments of fees, credit cards and/or other available financing options. This list is illustrative and should not be interpreted as excluding other relevant information consistent with ethical guidelines.
4. A foot and ankle surgeon shall not compensate or give anything of value directly or indirectly to a representative of the press, radio, television or other communication medium in anticipation of or return for recommending services or for professional publicity. A foot and ankle surgeon may pay the reasonable cost of advertising, shall approve all advertisements before dissemination or transmission and shall retain a copy or record of all such advertisements in their entirety, including content posted online and via social media. A foot and ankle surgeon shall be held personally responsible for any violation incurred by public relations, advertising or similar firm which he or she retains, or any entity that advertises on his or her behalf.
5. A foot and ankle surgeon shall not initiate contact with a prospective patient knowing that the physical, emotional or mental state or degree of education of the person solicited is such that the person could not exercise reasonable judgment in employing a surgeon.
   F. A foot and ankle surgeon who has given unsolicited, in-person advice to a layperson that the individual should have medical or health care shall not accept employment resulting from that advice if the advice embodies or implies a statement or claim that is false, fraudulent, deceptive or misleading; involves the use by the of undue influence, coercion, duress, harassment, intimidation, unwarranted promises of benefits, over-persuasion, overreaching, or pressure for immediate response; or if the surgeon has been given notice that the individual non-patient does not want to receive said communication.
   

VIII. Principles of Care 

1. A foot and ankle surgeon should practice only within the scope of his or her personal education, training and experience. If a foot and ankle surgeon contracts to provide comprehensive lower extremity care, then he or she has the obligation to ensure that appropriate care is provided in areas outside of his or her personal expertise.
2. It is unethical to prescribe, provide, or seek compensation for unnecessary services. It is unethical to prescribe controlled substances when they are not medically indicated.
   

IX. Research and Academic Responsibilities

1. All research and academic activities must be conducted under conditions of full compliance with ethical, institutional and government guidelines. Patients participating in research programs must have given full informed consent and retain the right to withdraw from the research protocol at any time.
2. Foot and ankle surgeons should not claim as their own intellectual property that which is not theirs. Plagiarism or the use of others' work without attribution is unethical. Violating copyright law may have legal consequences. When submitting a document for publication, any previous publication of any portion of the document must be fully disclosed.
3. The principal investigator of a scientific research project or clinical research project is responsible for proposing, designing and reporting the research. The principal investigator may delegate portions of the work to other individuals, but this does not relieve the principal investigator of the responsibility for work conducted by the other individuals. The principal investigator or senior author of a scientific report is responsible for ensuring that appropriate credit is given for contributions to the research described.

X. Community Responsibility

1. The honored ideals of the medical profession state that the responsibility of the foot and ankle surgeon extends not only to the individual but also to society as a whole. Activities that have the purpose of improving the health and well-being of the patient and/or the community in a cost-effective way deserve the interest, support and participation of the foot and ankle surgeon.
2. Foot and ankle surgeons have the dual duty to respect the law and to work for the health, well-being and the best interest of both the patient and the community. In general, foot and ankle surgeons should be committed to upholding and enhancing community values, be aware of the needs of the community and use the knowledge and experience acquired as professionals to contribute to an improved community.
   

Any member charged with a violation of any ethical standard set forth herein may be subject to disciplinary measures, including censure, suspension or expulsion, as described in Article 11 of the College’s Bylaws.