I HUMAN RESOURCES ^10 ^32 ^s2 ^117

The successful delivery of women’s health care depends on the people directly and indirectly involved with providing that care. For this reason, issues of human resources management must be addressed at all levels of health care delivery, including health systems, hospitals, surgical centers, and offices.

Human resources encompasses practical matters of hiring, manag­ing, and evaluating, and—when necessary—terminating employment of staff. Equally important, however, is an understanding of the principles that drive these personnel management decisions and an understanding of what constitutes professional and unprofessional behavior. Human resources issues vary depending on the type of institution, scope of prac­tice, union regulations, and staff needs.

Personnel

Regardless of the setting, certain elements constitute effective personnel management in the delivery of health care services. Written job descrip­tions should exist for each staff position, and these descriptions should be reviewed periodically to ensure that staff members function at an appropriate level and do not perform tasks beyond those they are licensed and trained to do. Written policies that indicate specific responsibilities of personnel should be prepared, approved by the medical staff, and reviewed periodically. Previous employment references should be checked for all new employees. Current licensure verification is mandatory for all licensed personnel. A system for credentialing of personnel should be in place and reviewed at least every 2 years (see also the “Evaluating Credentials and Granting Privileges” section earlier in Part 1).

The human resources operations in health care institutions are governed by the policies and procedures of that institution. The leadership of the women’s health component should have extensive knowledge of and a collegial working relationship with the institutional human resources unit.

At the office practice level, human resource needs also must be addressed. An office-based medical practice or clinic should have an office manager or other key staff member assigned to personnel management. A personnel manual should be created for the entire office staff. Issues of preemployment screening, benefits, employee assistance programs, and performance reviews should be considered for inclusion in the manual.

Professional Behavior

It is vitally important in providing health care services that all staff be aware of what constitutes professional and unprofessional behavior. Such behavior can be outlined in codes of ethics, such as the codes developed by the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (the College) (see Bibliography, Resources, and Appendix A). The behavior that institutions expect of staff may be summarized in a personnel manual or similar guide. Certain situa­tions in the practice of women’s health care merit special attention from an ethical perspective and are addressed here. Institutional ethics committees, ethics consultants, and ethics consultation services are valuable resources in determining the appropriate resolution of these situations and others (see also the “Ethical Issues” section later in Part 1).

Academic institutions, professional corporations, hospitals, and other health care organizations should have policies and procedures by which alleged violations of professional behavior can be reported and investi­gated. Also, it is necessary for these institutions to adopt policies on legal representation and indemnification for their employees or others acting in an official capacity who, in discharging their obligations relative to unethi­cal or illegal behavior of individuals, are exposed to potentially costly legal actions. The College agrees with the position of the American Association of University Professors that institutions should “ensure effective legal and other necessary representation and full indemnification in the first instance for any faculty member named or included in lawsuits or other extra-institutional legal proceedings arising from an act or omission in the discharge of institutional or related professional duties or in the defense of academic freedom at the institution.”

Code of Professional Ethics of the American College of Obstetricians and Gynecologists

Obstetrician-gynecologists (and other clinicians caring for women) have ethical responsibilities to patients, society, and other health care providers.

This code of ethics describes the ethical foundations for professional activities in women’s health care and summarizes the rules of ethical con­duct built on these foundations. Noncompliance with this code may affect an individual’s initial or continuing Fellowship in the College. The code is an excellent guide for other individuals or organizations to evaluate the ethical appropriateness of an individual’s practice, behavior, or both. The Iundamental code of ethics is supported by Committee Opinions issued by the College’s Committee on Ethics, which comment upon other timely ethical issues relevant to the practice of obstetrics and gynecology. Some, but not all, of the ethics Committee Opinions are referenced in the code of ethics.

Confidentiality

Clinicians who provide women’s health care should respect the rights of patients, colleagues, and others and safeguard patient information and confidences within the limits of the law. Maintaining confidentiality is intrinsic to respect for patient autonomy and promotes the free exchange of information between patient and physician relevant to medical decision making (see also the “Ethical Issues” section later in Part 1). Additionally, in certain situations, maintaining confidentiality is critical to ensure a woman’s safety from retaliatory actions by an abusive family member or partner.

Institutions should have policies in place to safeguard patient informa­tion from inadvertent or inappropriate breaches of confidentiality. Federal regulations detailed in the Health Insurance Portability and Accountability Act (HIPAA) also set rules for what information may be shared with other practitioners and agencies with and without an individual’s permission (see also the “Compliance With Government Regulations” section earlier in Part 1).

There has been substantial growth in the variety of methods of com­munication. Patient information may be stored not only on a paper record but also electronically. Patient information may be transmitted over the telephone (including wireless cellular telephones), facsimile machines, and e-mail. By whatever means a patient’s health information is stored or exchanged, the same ethical principles of confidentiality apply. Health information technology systems should be compatible with the require­ments of HIPAA and flexible enough to accommodate state privacy laws, a particular concern for adolescent care, assisted reproductive technology, and genetic testing. Health information technology systems must integrate these various rules.

Moreover, in 2003 and in subsequent amendments, the U.S. Department of Health and Human Services implemented compulsory privacy rules under HIPAA that sought to create assurances that all patient account handling, billing, and medical records protect the confidentiality and pri­vacy of patient information. These rules apply to health care plans, health care clearinghouses, and practitioners, including hospitals and physicians, and they carry substantial penalties for violations. These laws enforce the patient’s right to confidential and private medical information in all set­tings.

Tests that may have multiple medical or psychosocial ramifications require nondirective counseling and comprehensive explanation of the process, goals, and implications. The patient should be informed of per­tinent policies regarding the use of information resulting from tests and the legal requirements that relate to the release of information before she grants her consent.

Situations may arise in which a clinician has competing obligations: on the one hand to protect the patient’s confidentiality and on the other hand to disclose test results to prevent harm to a third party. In these situations, the clinician first should explore every avenue of communication in discus­sions with the patient about rights and responsibilities. Consultation with an institutional ethics committee or a medical ethics specialist may help the clinician decide whether to disclose the information. In some rare situ­ations, it may be appropriate to disclose confidential information, though it may be prudent to seek legal advice before doing so.

Practitioners and patients consistently cite confidentiality as a major obstacle to the delivery of health care to minors. Although ensuring confi­dentiality is relatively simple when providing services to adults, providing the same degree of confidentiality to minors can be less straightforward. The legal status of a minor, requirements for parental consent or notifica­tion before the provision of medical services, and economic considerations often encumber the patient-physician relationship. The AMA has reaf­firmed a policy that supports confidential care of adolescents as critical to their health care and encourages practitioners to allow emancipated and mature minors to give informed consent for medical, surgical, and psychiatric procedures within state and federal law. Clinicians should be familiar with current state statutes on the rights of minors to consent to health care services and the laws that affect confidentiality. All states require consent for the treatment of a minor from a person legally entitled to authorize such care.

Chaperones

Local practices and expectations differ with regard to the use of chaperones, but the presence of another staff member in the room during the physical examination can confer benefits for the patient and the clinician, regard­less of the sex of the clinician. Chaperones can provide reassurance to the patient about the professional context and content of the examination and the intention of the clinician, and they can offer witness to the actual events taking place should there be any misunderstanding. The request by either a patient or a health care provider to have a chaperone present during a physical examination should be accommodated regardless of the health care practitioner’s sex. In addition to any staff chaperone, patients may find it helpful to have a family member present.

The presence of a third party in the room, however, may cause some embarrassment to the patient and limit her willingness to talk openly with the clinician. If a chaperone is present during the examination, the clini­cian may need to provide a separate opportunity for private conversation. If the chaperone is an employee of the practice, the clinician must estab­lish clear rules about respect for privacy and confidentiality. In addition, some patients (especially, but not limited to, adolescents) may consider the presence of a family member as an intrusion. Family members should not be used as chaperones unless specifically requested by the patient, and then only in the presence of an additional chaperone who is not a family member.

Referral

Relationships with other health care providers should reflect fairness, honesty, integrity, mutual respect, and concern for the patient. Clinicians may best fulfill their obligations to patients through referral to other pro­fessionals who have the appropriate skills and expertise to address the situation. Therefore, clinicians should consult, refer to, or cooperate with other professionals and institutions to the extent necessary to serve the patients’ best interests. In cases of conscientious objection, in which a clini­cian declines to provide requested care to a patient for moral or religious reasons, transfer of primary clinical responsibility to another clinician is in the patient’s best interest.

With respect to referrals, the role of the referring clinician is to iden­tify the most appropriate resources and qualified consultants. Physicians should be aware of potential conflicts of interest and be sure that referrals cannot be construed as inappropriate or otherwise prohibited by state or federal law.

In the current health care climate, however, clinicians may find barri­ers to making appropriate referrals. Managed care plans or other systems may limit referrals or stipulate referral to a defined panel of specialists. Physicians who believe that a patient’s health is jeopardized by these policies should consider appealing to the plan or medical director (see “Conflict of Interest” later in this section).

It is in the best interest of everyone—primary care physicians, consul­tants, patients, and health care plans—that consultation criteria are mutu­ally agreed upon in clearly stated policies. At times a consultant may be called on unexpectedly, inconveniently, and sometimes inappropriately to be involved in or to assume the care of a patient. In these situations, a physician is only ethically obligated to provide consultation or assume the care of the patient if there is a contractual agreement or a preexisting patient-physician relationship or if there is a severe medical emergency in which there is no reasonably available alternative caregiver. Whether the specialist assumes ongoing care of the patient or functions as a consultant should be established clearly by mutual agreement of the consultant, the referring practitioner, and the patient.

Expert Witnesses

Clinicians have a continuing responsibility to society as a whole and should support and participate in activities that enhance the community. As professionals and members of medical or nursing societies, they are required to uphold the dignity and honor of their professions. One way health care providers can do so is through serving as expert witnesses on behalf of defendants, the government, or plaintiffs.

The moral and legal duty of health care providers who testify before a court of law is to do so in accordance with their expertise. This duty implies adherence to the strictest code of personal and professional eth­ics. Truthfulness is essential. Misrepresentation of one’s personal clinical opinion as the only right or wrong treatment option for the patient may be harmful to individual parties and to the profession at large. Health care providers who serve as expert witnesses should have experience and knowl­edge in the areas of clinical medicine that enable them to testify about the standards of care that applied and the scientific evidence that existed at the time of the occurrence that is the subject of the legal action. Their review of the facts should be thorough, fair, and impartial and should not exclude any relevant information. It should not be biased in favor of the defendant, the plaintiff, or the government. The role of an expert witness should be to provide testimony that is complete, objective, and helpful to a just resolu­tion of the proceeding.

Testimony should evaluate performance in light of generally accepted standards, neither condemning performance that falls within generally accepted standards nor endorsing or condoning performance that falls below these standards. The expert witness should distinguish clearly between medical malpractice and medical maloccurrence and should make every effort to assess the relationship of the alleged substandard practice to the outcome. Deviation from a practice standard is not always substan­dard care or causally related to a bad outcome. Expert witnesses should be prepared to have the testimony they have given in any judicial proceeding subjected to peer review by an institution or professional organization to which they belong.

Fees for testifying should not be greatly disproportionate to fees cus­tomary for professional services. It is clearly unethical for health care providers to accept compensation that is contingent on the outcome of litigation.

Impaired Clinicians

Impairment in providers of patient care is common; the lifetime prevalence of alcohol or drug dependence is reported to be 8-15% among physicians. This fact carries responsibility for impaired clinicians and their colleagues. As noted in the “Code of Professional Ethics of the American College of Obstetricians and Gynecologists” (see also Appendix A):

• The obstetrician-gynecologist should not practice medicine while impaired by alcohol, drugs, or physical or mental disability. The obstetrician-gynecologist who experiences substance abuse prob­lems or who is physically or emotionally impaired should seek appropriate assistance to address these problems and must limit his or her practice until the impairment no longer affects the quality of patient care.

• The obstetrician-gynecologist should strive to address through the appropriate procedures the status of those physicians who demon­strate questionable competence, impairment, or unethical or illegal behavior. In addition, the obstetrician-gynecologist should cooper­ate with appropriate authorities to prevent the continuation of such behavior.

Physicians and other clinicians are considered impaired when their ability to practice is limited or altered by mental illness, a physical illness or condition, or misuse of alcohol or other drugs and medications. An impaired health care provider should be obligated to enter a treatment pro­gram, with the specific type of program dependent on state legal require­ments, the requirements of the state licensure board, and the preferences of the impaired practitioner. Obviously, there is considerable advantage to the impaired practitioner, the practitioner’s family, the department, the medical staff, the institution, and the public when a colleague’s suspicion leads to early identification and successful rehabilitation.

In many states, it is mandatory to report a physician or advanced- practice health care clinician who is reasonably believed to be impaired. Conditions that are reportable include, but are not limited to, impairment by alcohol, drugs, physical disability, or mental instability; practice mis­conduct; practicing medicine fraudulently; gross incompetence; or gross negligence. The failure of a colleague to take action or any action taken to shield the impaired clinician from disclosure, although understandable, can result in serious consequences for individuals who should have recog­nized the situation.

Practitioners who have developed a degree of chemical dependency or inappropriate behavior that causes stress within their families and in their personal lives but that has not impaired their medical practice should not be ignored and may still require intervention. A colleague’s ability to iden­tify a health care provider in this state carries with it the responsibility to make an effort to personally help the individual or to guide the individual to competent help. This helps the troubled colleague and prevents his or her problems from having a detrimental effect on patients in the future. Ignoring the issue is a disservice to the affected practitioner.

Other personal, medical, or family problems may negatively affect a practitioner’s professional functioning. Such problems ordinarily are not included under the term impaired practitioner, but they should not be ignored. The department head or other responsible person should be informed and should consult personally with the health care provider involved. In an emergency situation, physicians should know whom they should ask to address a problem related to an impaired colleague. The chief medical officer and on-call administrator often are the designated authori­ties, but staff members should know who the appropriate on-call contact person is for all types of health care providers at an institution. (Practical guidance regarding the management of impaired and disruptive clinicians can be found in the “Evaluating Credentials and Granting Privileges” sec­tion earlier in Part 1.)

Infectious Disease Prevention

Another factor that may impair a health care provider’s ability to practice is the presence of an infectious disease. The welfare of the patient is central to all considerations in the patient-provider relationship. For this reason, health care institutions and health care providers share a responsibility to avoid causing harm to patients by taking reasonable steps to reduce the risk of transmission of vaccine-preventable or other infectious diseases. The Centers for Disease Control and Prevention (CDC) recommends that health care facilities and organizations have vaccine programs in place, review health care provider vaccination and immunity status at the time of hire and on a regular basis (ie, at least annually), and offer needed vaccines in conjunction with routine annual disease-prevention measures (eg, seasonal influenza vaccination or tuberculin testing). In addition, it is recommended that health care providers follow standard precautions for patient care to prevent transmission of a vaccine-preventable or other infectious disease.

Vaccinations

Health care providers are obligated to serve their patients’ best interests by following authoritative guidance on vaccination for patients and clinicians, where medically appropriate and based on the best evidence. To avoid their own contribution to the spread of disease, College Fellows have an ethical obligation to be vaccinated themselves and to follow recommen­dations and other safety policies put into place by their local or national public health authorities, such as the CDC and the College. Any perceived burdens or potential risks to clinicians from vaccination do not supersede their responsibility to limit the spread of potentially harmful infectious disease.

Despite the evidence pointing to the benefit of vaccination, compliance with voluntary vaccination programs for health care providers has been disappointing. Mandatory vaccination of health care providers may be an ethically justified strategy in cases in which the harm to patients and the general population is believed to outweigh the autonomy of individual physicians. Mandates should be put in place only if supported by valid data about the efficacy and safety of the vaccine. In addition, public health plans that include mandatory vaccination will be most beneficial if they are developed in cooperation with key stakeholders and consider the needs of individual practitioners, institutions, and communities. Any vaccine man­dates should include recognized exceptions for medical contraindications as well as an active opt-out mechanism for those physicians who profess conscientious objections to vaccination. Practitioners should be reminded that there is a high standard applied to the qualification of conscientious objections.

The CDC recommends that all health care providers be immunized against the following diseases: hepatitis B virus (HBV), influenza, measles, mumps, rubella, pertussis, and varicella. In addition, there are certain dis­eases, such as meningococcal disease, typhoid fever, and polio, for which vaccination of health care providers might be indicated in certain circum­stances (ie, health care providers with certain health conditions or who are at risk of work-related exposure). The CDC advises that all health care providers who perform exposure-prone procedures (eg, hysterectomy) or who are otherwise at risk of HBV infection should receive prevaccination testing for chronic HBV infection. The CDC also recommends postvacci­nation serologic HBV antibody testing 1-2 months after the final dose of HBV vaccine is administered for all health care providers who are recently vaccinated or have recently completed HBV vaccination and who are at risk of occupational blood or body fluid exposure.

Vaccinations against hepatitis C virus (HCV) and HIV are not available. Although routine HCV and HIV testing is not recommended specifically for health care workers, the CDC recommends that all individuals born from 1945 to 1965 undergo one-time HCV testing to enable early diagnosis and treatment, and the CDC and the U.S. Preventive Services Task Force recom­mend that adults be screened routinely for HIV infection.

During an influenza pandemic, disruption of critical services can pose as much of a threat to the public’s health as influenza itself, which justi­fies prioritizing key workers—such as essential health care workers—in an effort to protect critical services. To meet the ethical objectives of promot­ing public health, especially during a pandemic, strategies should be imple­mented to increase vaccination rates among clinicians and prevent contact between symptomatic clinicians and patients. In the event of a bioterror­ism attack that uses an infectious agent (such as smallpox), other immu­nizations may be recommended for the preservation of the health care workforce. Clinicians should seek accurate and timely information from appropriate sources, including the CDC (see Bibliography and Resources) and professional organizations.

Immunization policies and practices should be individually tailored for patients and clinicians, as well as the unique infectious agent. During a public health emergency, access to care and resources should be based on women’s clinical needs rather than the type of insurance, if any, that they have or their prior relationship to a clinic or other health care institution. Some infectious agents, such as influenza, affect pregnant women dispro­portionately, and clinicians should advocate for appropriate allocation of vaccines to this high-risk population. To adequately protect pregnant women, pandemic preparedness efforts should include clinical research specifically designed to address the safety and efficacy of treatment inter­ventions or prevention strategies used by pregnant women. Live vaccines should not, in general, be administered to pregnant women. Clinicians who treat pregnant patients or women with compromised immune sys­tems may wish to receive an inactivated vaccine rather than a live vac­cine to minimize the risk of unintentional transmission of the infectious agent.

Other Preventive Measures

In the absence of effective immunization against infectious agents, such as HIV and HCV, health care providers should follow standard precau­tions for patient care to minimize the risk of transmission from patient to health care provider. It appears that health care providers who follow rec­ommended infection-control procedures are at little risk of acquiring HIV while caring for HIV-infected patients. The risk of acquiring HCV appears to be lower than the risk of acquiring HBV and higher than the risk of acquiring HIV. Although routine screening for HIV and HCV is not recom­mended for health care workers, clinicians who have reason to believe that they are infected with these or other serious infectious agents that might be transmitted to patients should be tested voluntarily for the protection of their patients. Guidance on the management of health care workers exposed to blood or body fluids, such as through a needlestick, is found in the “Infection Control” section in Part 2.

Health care providers who have influenza or other acute, nonchronic infectious diseases that are easily transmitted to patients, staff, and others should refrain from working until they are no longer infectious. Clinicians infected with a bloodborne virus must make a decision as to which pro­cedures they can continue to perform safely. This decision will depend on the category of clinical activity and the circulating viral burden (see also the “Infection Control” section in Part 2).

Conflict of Interest ^101

Potential conflicts of interest are inherent to the practice of medicine. Clinicians are expected to recognize them and to maintain patient care and welfare as a priority. If there is a possible substantial conflict of interest, the clinician should attempt to resolve the issue. Consultation with colleagues or an institutional ethics committee may be sought. If a conflict of interest cannot be resolved, the clinician should disclose his or her concerns to the patient and take steps to withdraw from her care.

Clinicians may feel pressure from regulatory bodies and managed care organizations (which may seek to limit or otherwise direct the care that is provided) and from the health care industry (which urges the use of its procedures and products through advertising and promotions). Both situ­ations can present conflicts of interest.

Participation in managed care organizations and care directed by regu­latory bodies may create potential conflicts of interest for women’s health care providers in fulfilling their primary duty to their patient. Financial and administrative constraints may create disincentives to treatment otherwise recommended by the obstetrician-gynecologist. Clinicians should serve as the patient’s advocate and exercise all reasonable means to ensure that the most appropriate care is provided to the patient. Practitioners who believe, based on clinical evidence, that a patient’s health is jeopardized by the policies, coverage limits, or utilization restrictions of a plan should consider an appeal to the plan or medical director. Health care providers are encouraged to become actively involved with the policy-making boards of managed care or other plans in which they participate with the goal of improving patient welfare, and they should contribute to the quality improvement processes that result in plan guidelines.

Conflict of interest also may arise through patenting or restrictive licens­ing of medical procedures, diagnostic tests, or predictive tests. In addition to raising problems of efficacy and safety, the patenting of medical pro­cedures and tests may jeopardize patients’ interests by delaying the rapid transmission of new scientific knowledge and adding costs to a procedure or test that might put it out of reach of patients. Academic health care pro­viders should be aware of the powerful incentives placed on them by their universities to maximize extramural revenues and should urge that such policies not encourage patenting arrangements that restrict use by other researchers or clinicians.

Physicians also may be faced with conflicts of interest in the conduct of clinical trials in which a treating clinician is also a principal investigator of a trial. At a minimum, the principal investigator should disclose financial relationships with the trial sponsor to the patient or research participant before her enrollment in the trial. In addition, the physician-investigator should ensure that publication of results of the trial is not contingent on a positive outcome for the sponsor. Clinical investigators also should partici­pate actively in the writing of manuscripts that bear their name, not merely sign a “ghostwritten” manuscript.

The College has provided guidance for Fellows interacting with the health care industry and recommends that physicians set guidelines for themselves and their office staff for interaction with representatives. As the practice environment of medicine evolves, interactions with pharma­ceutical and device industries necessarily change. The College guidelines summarized in the following paragraphs are subject to continual review and update, and the most recent version can be accessed at www.acog.org/ Resources_And_Publications/Committee_Opinions_List.

Clinicians should choose diagnostic procedures and treatments on the basis of medical considerations and patient needs, regardless of any direct or indirect interest in the health care industry that they may have or any benefits they receive from that industry. Clinicians have an obligation to seek the most accurate, up-to-date, evidence-based, and balanced sources of information about new products that they contemplate using. They should not base decisions solely or primarily on information provided by the products’ marketers. When any product promotion leads to inappro­priate or unbalanced medical advice or recommendations to patients, an ethical problem exists.

Clinicians should understand that gifts tied to promotional informa­tion, even small gifts and meals, are designed to influence health care pro­vider behavior. The acceptance of any gift, even of nominal value, tied to promotional information is strongly discouraged. The acceptance of cash donations, trips, and services directly from industry by individual physi­cians raises clear conflicts and is not ethical.

Although the provision of pharmaceutical samples offers potential benefits to patients, particularly for those who are uninsured or for whom purchase of medications otherwise represents a burden, such samples also may influence prescribing behavior inappropriately. Physicians may choose to provide samples or vouchers but should be aware that providing samples may promote patients’ ongoing use of a particular medication, when other potential alternatives exist. When vouchers or samples are dispensed, consideration should be given to providing them preferentially to those patients with a true need and dispensing a supply sufficient for a full course of therapy.

Limitations on commercial support of continuing medical education (CME) have been published by the Accreditation Council for Continuing Medical Education, the Council of Medical Specialty Societies, and the AMA (see Resources). The gift of special funds to permit medical students, residents, and fellows to attend carefully selected educational conferences may be permissible as long as the selection of the attendees is made by the academic or training institution or by the accredited CME provider with the full concurrence of the academic or training institution. Subsidies from industry should not be accepted directly to pay for the costs of travel, lodging, or other personal expenses of clinicians who are attending the conferences, nor should subsidies be accepted to compensate for the clini- dan’s time.

When new medical devices are approved or cleared by the U.S. Food and Drug Administration (FDA), access to training on those devices may be tightly regulated by the FDA and may require training by the manufac­turer. The company may require physicians to travel to non-CME seminars designed to familiarize the physician with the new equipment. This pres­ents an ethical difficulty for the physician. Training in proper use of devices encountered in the practice of obstetrics and gynecology is ideally provided through professional societies with CME accreditation. When training is not available from an accredited CME provider, or industry training is mandated by the FDA, and industry offers appropriate education, the obstetrician-gynecologist may participate if the training is focused on the safe, medically relevant, and FDA-cleared or FDA-approved indications for use of the equipment or device in the shortest possible time.

Billing Fraud

Practitioners should understand billing and coding requirements thor­oughly or have staff on whom they can rely for this expertise (see also the “Practice Management” section in Part 2). Even honest mistakes have caused clinicians difficulties in this area. Dishonest billing is illegal and is an abdication of the clinician’s responsibilities to society. This statement applies even when deceptive practices are meant to benefit the patient. For example, if the annual gynecologic examination is not covered under the insurance plan, the clinician may opt to code for vaginitis or meno­pausal syndrome instead of the routine examination. However, as well intentioned as such strategies may be, they introduce dishonesty into the patient-practitioner relationship, and the insurance companies will con­sider it fraud.

Sexual Harassment

Sexual harassment is a form of sex discrimination prohibited under Title VII of the Civil Rights Act of 1964. Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitute sexual harassment. The following conditions apply to sexual harassment:

• A term or condition of an individual’s employment or academic success is predicated on submission to such conduct. These over­tures may be explicit or implicit.

• The basis for employment or academic decisions or advancement is reliant on submission to or rejection of such behavior.

• An individual’s work or academic performance is affected because of this behavior, which creates an intimidating, hostile, or offensive working environment.

Men and women can be victims of sexual harassment. Institutions and other facilities should have policies on sexual harassment, and all person­nel should be made aware of these policies. Guidance should be offered to all employees, students, residents, and supervisors who report these inci­dents. All complaints should be investigated and have follow-up.

Sexual Misconduct

The practice of obstetrics and gynecology includes interaction at times of intense emotion and vulnerability for the patient and involves sensi­tive medical and social histories, physical examinations, and diagnoses. Children and adolescents are particularly vulnerable to emotional conflict

and damage to their developing sense of identity and sexuality when roles and role boundaries with trusted adults are confused.

Sexual misconduct is not a new issue in the practice of medicine. It has been reevaluated in terms of current medical ethics to give additional consideration to respect for the rights of individuals, the unequal power relationship between a professional and a patient, and the potential for abuse of that power.

The College’s Committee on Ethics agrees with the AMA’s Council on Ethical and Judicial Affairs statement on this issue (see Bibliography). The AMA council provided the following guidelines, which the College’s Committee on Ethics first affirmed in 1994 and continues to affirm:

• Mere mutual consent is rejected as a justification for sexual relations with patients because the disparity in power, status, vulnerability, and need makes it difficult for a patient to give meaningful consent to sexual contact or sexual relations.

• Sexual contact or a romantic relationship concurrent with the patient-physician relationship is unethical.

• Sexual contact or a romantic relationship with a former patient may be unethical under certain circumstances. The relevant standard

is the potential for misuse of physician power and exploitation of patient emotions derived from the former relationship.

• Education on ethical issues involved in sexual misconduct should be included throughout all levels of medical training.

• Physicians have a responsibility to report offending colleagues to disciplinary boards.

Although the AMA and College statements were developed specifically in reference to physicians, sexual misconduct by any health care provider is an abuse of professional power and a violation of patient trust. Regardless of societal changes, rigid conformance to ethical principles in this regard is considered essential.

Bibliography

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American College of Obstetricians and Gynecologists. Coding responsibility. ACOG Committee Opinion 249. Washington, DC: ACOG; 2001.

American Medical Association. Code of medical ethics of the American Medical Association: current opinions with annotations. 2012-2013 ed. Chicago (IL): AMA; 2012.

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