Code of Professional Conduct
I. Qualifications of the Responsible Surgeon
B. Commitment to scientific knowledge and research
C. Commitment to maintain fitness
D. Eligibility to perform surgical procedures
E. Educational requirements
F. Confining practice to within a specialty
G. Surgical assistants
II. Relation of the Surgeon to the Patient
A. Informed consent
B. Scope of surgical care
C. Preoperative diagnosis and care
D. The operation—Intraoperative responsibility of the primary surgeon
E. Postoperative care
F. Continuity of care
G. Freedom of choice
H. Confidentiality of medical records
I. Conflict of interest
J. Unnecessary operations
K. Quality assurance
L. Surgical fees
III. Interprofessional Relations
A. Surgeons and colleagues
B. Discrimination or harassment
E. Relationships to nonphysicians
IV. Medical Education
A. Continuous medical education and professional development
V. Surgeons and Society
A. Surgical research
B. Scientific publications
C. Public relations
E. Expert testimony
F. Impaired physicians
G. Incompetent surgeons
H. Maintenance of Fellowship
(These statements were collated, approved by the Board of Regents, and initially published in 1974. They were revised in March 2004 and updated again in April 2016.)
Founded to provide opportunities for the continuing education of surgeons, the American College of Surgeons has had a deep and effective concern for the improvement of patient care and for the ethical practice of medicine. The ethical practice of medicine establishes and ensures an environment in which all individuals are treated with respect and tolerance. Discrimination or harassment on the basis of age, sexual preference, gender, race, disease, disability, or religion, are proscribed as being inconsistent with the ideals and principles of the American College of Surgeons.
Applicants for Fellowship are evaluated for professional conduct, established reputation, and ethical standing. At the organizational meeting of the College in 1913, the assemblage strongly endorsed a resolution that Fellows of the College must practice in strict honesty and must avoid any and all forms of fee splitting. Since then, applicants have been denied Fellowship because of unacceptable financial practices or other unethical behavior. Furthermore, Fellows have been disciplined or expelled for violation of the Fellowship Pledge and the Bylaws of the College.
Recognizing that the American College of Surgeons seeks to exemplify and develop the highest traditions of our ancient profession, I hereby pledge myself, as a condition of Fellowship in the College, to live in strict accordance with the College’s principles and regulations.
I pledge to pursue the practice of surgery with honesty and to place the welfare and the rights of my patient above all else. I promise to deal with each patient as I would wish to be dealt with if I was in the patient’s position, and I will respect the patient’s autonomy and individuality.
I further pledge to affirm and support the social contract of the surgical profession with my community and society.
I will take no part in any arrangement or improper financial dealings that induce referral, treatment, or withholding of treatment for reasons other than the patient’s welfare.
Upon my honor, I declare that I will advance my knowledge and skills, will respect my colleagues, and will seek their counsel when in doubt about my own abilities. In turn, I will willingly help my colleagues when requested.
I recognize the interdependency of all health care professionals and will treat each with respect and consideration.
Finally, by my Fellowship in the American College of Surgeons, I solemnly pledge to abide by the Code of Professional Conduct and to cooperate in advancing the art and science of surgery.
Code of Professional Conduct
(Approved by Board of Regents June 2003)
As Fellows of the American College of Surgeons, we treasure the trust that our patients have placed in us because trust is integral to the practice of surgery. During the continuum of pre-, intra-, and postoperative care, we accept the following responsibilities:
- Serve as effective advocates of our patients’ needs
- Disclose therapeutic options, including their risks and benefits
- Disclose and resolve any conflict of interest that might influence decisions regarding care
- Be sensitive and respectful of patients, understanding their vulnerability during the perioperative period
- Fully disclose adverse events and medical errors
- Acknowledge patients’ psychological, social, cultural, and spiritual needs
- Encompass within our surgical care the special needs of terminally ill patients
- Acknowledge and support the needs of patients’ families
- Respect the knowledge, dignity, and perspective of other health care professionals
Our profession also is accountable to our communities and to society. In return for their trust, as Fellows of the American College of Surgeons, we accept the following responsibilities:
- Provide the highest quality surgical care
- Abide by the values of honesty, confidentiality, and altruism
- Participate in lifelong learning
- Maintain competence throughout our surgical careers
- Participate in self-regulation by setting, maintaining, and enforcing practice standards
- Improve care by evaluating its processes and outcomes
- Inform the public about subjects within our expertise
- Advocate for strategies to improve individual and public health through communication with government, health care organizations, and industry
- Work with society to establish just, effective, and efficient distribution of health care resources
- Provide necessary surgical care without regard to gender, race, disability, religion, social status, or ability to pay
- Participate in educational programs addressing professionalism
As surgeons, we acknowledge that we interact with our patients when they are most vulnerable. Their trust and the privileges we enjoy depend on our individual and collective participation in efforts to promote the good of both our patients and society. As Fellows of the American College of Surgeons, we commit ourselves and the College to the ideals of professionalism.
I. Qualifications of the Responsible Surgeon
A surgeon should acquire and maintain competence in all six necessary general competencies identified by the American Board of Medical Specialties (ABMS) Task Force on Competence and published by the Accreditation Council for Graduate Medical Education (ACGME):1 patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. A responsible surgeon should demonstrate competence in the following areas:
- Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of good health
- Medical knowledge of established and evolving biomedical, clinical, and cognate (for example, epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
- Practice-based learning and improvement that involves investigation and evaluation of a surgeon’s patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
- Interpersonal and communication skills that result in effective information exchange and effective interaction with patients, their families, and other health care professionals
- Professionalism manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
- Systems-based practice, manifested through actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively utilize system resources to provide care that is of optimal value
Maintenance of these competencies requires a commitment to lifelong learning through self-study, formal continuing medical education, and periodic assessment.
B. Commitment to Scientific Knowledge and Research
The surgeon should base care on the best available scientific evidence and should seek and give consultation appropriately. Responsible surgeons should uphold scientific standards, promote research, and create new knowledge and strive for the appropriate use of this knowledge and these findings.
C. Commitment to Maintain Fitness
The surgeon should maintain a satisfactory level of mental and physical fitness. A surgeon who becomes temporarily impaired by illness or injury, chemical dependence, fatigue, or other conditions that affect surgical judgment or performance should arrange for a qualified colleague to assume his or her clinical responsibilities until the impairment has been resolved.
D. Eligibility to Perform Surgical Procedures
The responsible surgeon’s eligibility to perform a surgical procedure is based upon the surgeon’s education, training, experience, and demonstrated proficiency. The surgeon should be a member in good standing of the department or service through which privileges are to be recommended. The granting and continuation of surgical privileges should be based upon the staff member’s qualifications and upon a record of appropriate performance as evaluated by an established peer review mechanism and medical audit process.
Surgeons are expected to study and evaluate new procedures and to become knowledgeable of and proficient with advances that are appropriate. Technical skill alone is insufficient to qualify a surgeon to perform new procedures. Procedural skills should be acquired within the context of in-depth knowledge about the disease to be treated.
E. Educational Requirements
Only qualified surgeons can deliver high-quality surgical care to the sick and injured patient. Qualified surgeons are those physicians who have completed a surgical residency/fellowship approved by the ACGME or the Royal College of Physicians and Surgeons of Canada (RCPSC); are certified or qualified for examination by a surgical board recognized by the ABMS or the RCPSC; and who maintain continuing education and proficiency in their specialty. These qualifications are required for Fellowship in the American College of Surgeons.
Some hospitals permit arrangements through which a staff member can achieve surgical privileges under the tutelage of a qualified surgeon in the operating room without serving in a formal, organized, accredited residency training program. This situation is undesirable, because it frequently results in an inadequately trained physician who may aspire to be a surgeon.
F. Confining Practice within a Specialty
Qualification of a surgeon as a specialist carries the commitment and responsibility to conduct a surgical practice that conforms to his or her defined specialty. The appropriate surgical specialty board recognized by the ABMS or the RCPSC determines a surgeon’s scope of practice. Procedures performed are dictated by the guidelines set by a specialty board. Performing procedures outside of the field defined by a specialty board mandates that the surgeon obtain additional education and experience, as well as any appropriate certification. The College may take disciplinary action against Fellows who engage in surgical procedures outside their scope of practice as previously described or who falsely advertise their training, certification, or experience.
In those instances in which no appropriately trained surgeon is available to perform a necessary procedure, it may be necessary for the surgeon to engage in practice outside of his or her specialty limits. Appropriate consultation and/or assistance should be obtained whenever possible. These decisions must be dictated by what is in the best interests of the patient.
The medical staff and the governing body of hospitals should periodically review the quality, number, and variety of surgical procedures being performed, as well as the surgical referral policies of the staff, to ensure that the practice pattern of the community does not discourage properly trained and qualified surgeons from applying for staff membership. Performance of surgical procedures by those individual who are lacking the proper training should not be a frequent or continuing practice.
G. Surgical Assistants
The first assistant in a surgical operation should be a trained individual who is able to participate in and actively assist the surgeon in completing the operation safely and expeditiously by helping to provide exposure, maintain hemostasis, and serve other technical functions. The qualifications of the person in this role may vary with the nature of the operation, the surgical specialty, and the type of hospital or ambulatory surgical facility.
The American College of Surgeons supports the concept that, ideally, the first assistant at the operating table should be a qualified surgeon or a resident in an approved surgical training program. Residents who have appropriate levels of training should be provided with opportunities to assist and participate in operations. If such assistants are unavailable, other physicians who are experienced in assisting may participate.
It may be necessary to have nonphysicians serve as first assistants. Surgeon assistants (SAs) or physician assistants (PAs) with additional surgical training should meet national standards and be credentialed by the appropriate local authority. These individuals are not authorized to operate independently. Formal application for appointment to a hospital as a SA or PA should include the following qualifications and credentials:
- Specification of which surgeon the applicant will assist and of the duties that will be performed.
- Indication of which surgeon will be responsible for the supervision and performance of the SA or PA.
- Review and approval of the application by the hospital board.
- Registered nurses with specialized training also may function as first assistants. If such a situation should occur, the size of the operating room team should not be reduced; the nurse assistant should not simultaneously function as the scrub nurse and instrument nurse when serving as the first assistant. Nurse assistant practice privileges should be granted based upon the hospital board’s review and approval of credentials. Registered nurses who act as first assistants must not have responsibility beyond the level defined in their state nursing practice act.
Surgeons are encouraged to participate in the training of allied health personnel. Such individuals perform their duties under the supervision of the surgeon.
II. Relation of the Surgeon to the Patient
A. Informed Consent
Informed consent is more than a legal requirement. It is a standard of ethical surgical practice that enhances the surgeon/patient relationship and that may improve the patient’s care and the treatment outcome. Surgeons must fully inform every patient about his or her illness and the proposed treatment. The information must be presented fairly, clearly, accurately, and compassionately. The surgeon should listen carefully to understand the patient’s feelings and wishes and should answer all questions as accurately as possible. The informed consent discussion conducted by the surgeon should include:
- The nature of the illness and the natural consequences of no treatment.
- The nature of the proposed operation, including the estimated risks of mortality and morbidity.
- The more commonly known complications, which should be described and discussed. The patient should understand the risks as well as the benefits of the proposed operation. The discussion should include a description of what to expect during the hospitalization and posthospital convalescence.
- Alternative forms of treatment, including nonoperative techniques.
- A discussion of the different types of qualified medical providers who will participate in their operation and their respective roles.
The surgeon should not exaggerate the potential benefits of the proposed operation nor make promises or guarantees. For minors and incompetent adults, parents or legal guardians must participate in the informed consent discussion and provide the signature for elective operations. Any adequately informed, mentally competent adult patient can refuse any treatment, including operation. When mentally incompetent patients or the parents (guardians) of minors refuse treatments, jeopardizing the patient’s best interests, the surgeon can request legal assistance.
When patients agree to an operation conditionally or make demands that are unacceptable to the surgeon, the surgeon may withdraw from the case.
B. Scope of Surgical Care
Surgical care includes providing preoperative diagnosis and care, educating the patient about the risks and benefits of operation and obtaining informed consent, selecting and performing the operation, and providing postoperative surgical care.
C. Preoperative Diagnosis and Care
Because a team of specialists undertakes much of modern patient care, nonsurgeon physicians often may conduct the initial evaluation of patients. However, the surgeon bears the ultimate responsibility for determining the need for and the type of operation. In making this decision, the surgeon must give precedence to sound indications for the procedure over pressure by patients or referring physicians or the financial incentive to perform the operation. The surgeon is responsible for the patient’s safety throughout the preoperative, operative, and postoperative period, including ensuring the elimination of risk of wrong site, wrong procedure, and wrong patient surgery.
D. The Operation—Intraoperative Responsibility of the Primary Surgeon
The primary attending surgeon is personally responsible for the patient’s welfare throughout the operation. In general, the patient’s primary attending surgeon should be in the operating suite or should be immediately available for the entire surgical procedure. There are instances consistent with good patient care that are valid exceptions. However, when the primary attending surgeon is not present or immediately available, another attending surgeon should be assigned to be “immediately available.”
The definitions at the end of this Statement provide essential clarification for terms used herein.
Concurrent or Simultaneous Operations
Concurrent or simultaneous operations occur when the critical or key components of the procedures for which the primary attending surgeon is responsible are occurring all or in part at the same time. The critical or key components of an operation are determined by the primary attending surgeon. A primary attending surgeon’s involvement in concurrent or simultaneous surgeries on two different patients in two different rooms is inappropriate.
Overlap of two distinct operations by the primary attending surgeon occurs in two general circumstances.
The first and most common scenario is when the key or critical elements of the first operation have been completed, and there is no reasonable expectation that the primary attending surgeon will need to return to that operation. In this circumstance, a second operation is started in another operating room while a qualified practitioner performs noncritical components of the first operation—for example, wound closure—allowing the primary surgeon to initiate the second operation. In this situation, a qualified practitioner must be physically present in the operating room of the first operation.
The second and less common scenario is when the key or critical elements of the first operation have been completed and the primary attending surgeon is performing key or critical portions of a second operation in another room. In this scenario, the primary attending surgeon must assign immediate availability in the first operating room to another attending surgeon.
The patient needs to be informed in either of these circumstances. The performance of overlapping procedures should not negatively affect the seamless and timely flow of either procedure.
Contemporary surgical care often involves a multidisciplinary team of surgeons. During such operations, it is appropriate for surgeons to be present only during the part of the operation that requires their surgical expertise. However, an attending surgeon must be immediately available for the entire operation.
Delegation to Qualified Practitioners
The surgeon may delegate part of the operation to qualified practitioners including but not limited to residents, fellows, anesthesiologists, nurses, physician assistants, nurse practitioners, surgical assistants, or another attending under his or her personal direction. However, the primary attending surgeon’s personal responsibility cannot be delegated. The surgeon must be an active participant throughout the key or critical components of the operation. The overriding goal is the assurance of patient safety.
A primary attending surgeon may have to leave the operating room for a procedure-related task, such as review of pertinent pathology (“frozen section”) and diagnostic imaging, discussion with the patient’s family, and breaks during long procedures. The surgeon must be immediately available for recall during such absences.
Unanticipated circumstances may arise during procedures that require the surgeon to leave the operating room before completion of the critical portion of the operation. In this situation, a backup attending surgeon must be identified and available to come to the operating room promptly.
Circumstances in this category might include sudden illness or injury to the surgeon, a life-threatening emergency elsewhere in the operating suite or contiguous hospital building, or an emergency in the surgeon’s family.
If more than one emergency occurs simultaneously, the attending surgeon may oversee more than one operation until additional attending surgeons are available.
Surgeon-Patient Communication (see Section II.A.)
The surgical team involved in an operation is dependent on the type of facility where the operation is performed and on the complexity of the surgical procedure. At a freestanding outpatient surgery center, many procedures are performed solely by the primary attending surgeon with no assistant. In contrast, a complex procedure at an academic medical center may involve multiple qualified medical providers in addition to the primary attending surgeon. As part of the preoperative discussion, patients should be informed of the different types of qualified health care professionals who will participate in their operation (assistant attending surgeon, fellows, residents and interns, physician assistants, nurse practitioners, and so forth) and their respective role should be explained. If an urgent or emergent situation arises that requires the surgeon to leave the operating room unexpectedly, the patient should be informed subsequently.
In an effort to provide some standardization of nomenclature, the following definitions are provided:
Backup surgeon/surgical attending
The qualified surgical attending who has been designated to provide immediately available coverage for an operation, during a period when the primary surgeon might be unable to fill this role.
Concurrent or simultaneous operations
Surgical procedures when the critical or key components of the procedures for which the primary attending surgeon is responsible are occurring all or in part at the same time.
“Critical” or “key” portions of an operation
The “critical” or “key” portions of an operation are those stages when essential technical expertise and surgical judgment are necessary to achieve an optimal patient outcome. The critical or key portions of an operation are determined by the primary attending surgeon.
Reachable through a paging system or other electronic means, and able to return immediately to the operating room. This term should be defined more completely by the local institution.
Described in American College of Surgeons Statements on Principles II.A.
An example of a multidisciplinary operation is a procedure in which a surgeon of one specialty provides the exposure required by a second surgeon who performs the main surgical intervention (such as a general or thoracic surgeon providing exposure for a neurosurgeon or orthopaedist to operate on the spine). Another example would be an operation that requires the involvement of two or more surgeons of different specialties (such as chest wall or head and neck resection followed by plastic surgical reconstruction, face or hand transplantation, and repair of complex craniofacial defects).
“Overlapping or sequenced” operations for surgeons
The practice of the primary surgeon initiating and participating in another operation when he or she has completed the critical portions of the first procedure and is no longer an essential participant in the final phase of the first operation. These are by definition surgical procedures where key or critical portions of the procedure are occurring at different times.
Located in the same room as the patient.
Primary attending surgeon
Considered the surgical attending of record or the principal surgeon involved in a specific operation. In addition to his or her technical and clinical responsibilities, the primary surgeon is responsible for the orchestration and progress of a procedure.
Any licensed practitioner with sufficient training to conduct a delegated portion of a procedure without the need for more experienced supervision and who is approved by the hospital for these operative or patient care responsibilities.
E. Postoperative Care
The responsibility for the patient’s postoperative care rests primarily with the operating surgeon. The emergence of critical care specialists has provided important support in the management of patients with complicated systemic problems. It is important, however, that the operating surgeon maintain a critical role in directing the care of the patient. When the patient’s postoperative course necessitates the involvement of other specialists, it may be necessary to transfer the primary responsibility for the patient’s care to another physician. In such cases, the operating surgeon continues to be involved in the care of the patient until surgical issues have been resolved. Except in unusual circumstances, it is unethical for a surgeon to relinquish responsibility for the postoperative surgical care to any other physician who is unqualified to provide similar surgical care.
If the operating surgeon must be absent during a portion of the critical postoperative period, coverage should be provided by another surgeon who is skilled and who can render surgical care—including reoperation, if necessary—equivalent to that provided by the surgeon who performed the operation. The patient should be informed of this arrangement in advance.
The surgeon’s responsibility extends throughout the surgical illness. When this period has ended, it is appropriate for the surgeon to relinquish the responsibility for management of the patient. When a patient is ready for discharge from the surgeon’s care, it may be appropriate to transfer the day-to-day care to another physician.
F. Continuity of Care of the Surgical Patient
The surgeon will ensure that the surgical patient receives appropriate continuity of care. An ethical surgeon should not perform elective surgery at a distance from the usual location where he or she operates without personal determination of the diagnosis and of the adequacy of preoperative preparation. Postoperative care should be rendered by the operating surgeon unless it is delegated to another physician who is equivalently qualified to continue this essential aspect of total surgical care.
It is recognized that for many operations performed in an ambulatory setting, the pattern of the patient’s postoperative visits to the surgeon may vary considerably; it is, however, the responsibility of the operating surgeon to establish communication to maintain proper continuity of care. Similar circumstances may apply when patients travel great distances for elective surgery.
Emergency surgery performed in locations unusual for the surgeon may be necessary on occasion, but habitual or even frequent performance of operations under these circumstances cannot be condoned. If the condition of the patient permits and additional skills are required, the patient should be transported to a medical center where adequate resources and appropriately trained health care professionals are available.
G. Freedom of Choice
Patients usually choose their surgeons, and surgeons, in turn, may accept or refuse patients. In emergencies or when required by law, the surgeon should provide the needed care and arrange for follow-up care. Certain circumstances (for example, the military and health maintenance organizations) restrict freedom of choice, and patient and surgeons are assigned. An ethical surgeon should abstain from a system that denies serving the best interests of the patient by refusing referral out of the system.
Freedom of choice means that either the patient or the surgeon may terminate the physician-patient relationship. When a patient exercises this right, the surgeon should transfer copies of the medical record to the new surgeon or another appropriate physician. When a surgeon exercises this right, he or she should notify the patient in writing and provide copies of the medical record to the new surgeon or physician. All parties should cooperate to ensure continuity of care during the transfer.
H. Confidentiality of Medical Records
Patient confidentiality is a fundamental tenet of medical care. The information in the medical record belongs to the patient but is shared with those health care professionals responsible for providing care. However, in most jurisdictions, the records belong to the physician or institution that compiles and maintains them for the caregivers. Access to medical records by caregivers, insurers, government, and other parties places patient privacy in jeopardy. Nevertheless, every health care worker is honor bound to protect patients’ confidentiality. U.S. law—the Health Insurance Portability and Accountability Act (HIPAA), which went into effect April 14, 2003—protects all medical records from unauthorized disclosure. All surgeons in the U.S. are obliged to understand and abide by HIPAA regulations. HIPAA provides for the use of medical information in the public interest—for example, reducing public health risks and accumulating vital statistics.
Surgeons should avoid disclosing identifiable health care information to any person without authorization from the patient. Also, discussion of identifiable patient information in public places is unethical.
I. Conflict of Interest
The physician-patient relationship requires that the patient’s interests supersede all other interests, including the personal and financial interests of the surgeon, the corporate and financial interests of the payor, and the corporate and financial interests of all vendors including pharmaceutical companies and the manufacturers of instruments, equipment, prosthetic devices, supplies, and services. Modern marketing strategies and tactics place extraordinary pressure on surgeons. Surgeons must strive to maintain the knowledge, insight, and discipline required to keep the patient’s interests above all others.
J. Unnecessary Operations
No operation should be performed without suitable justification. It is the surgeon’s responsibility to perform a careful evaluation, including consultation with others when appropriate, and to recommend surgery only when it is the best method of treatment for the patient’s problem.
K. Quality Assurance
Quality assessment and improvement have become integral concepts in the effort to improve patient outcome. Hospitals have established formal committees to assess and improve the quality of patient care. Fellows are strongly encouraged to be actively involved as leaders of quality assessment and improvement activities in their own hospitals.
L. Surgical Fees
In the U.S., government and private insurance carriers establish many professional fee schedules. Payments for services may require documentation. Surgeons should accurately document services in compliance with government standards.
Fellows of the College are urged to hold to the traditional principles of ethics and compassion in providing patient care and must not participate in any arrangements that encourage unnecessary operations or referrals made primarily for reasons other than optimal patient care.
Surgeons provide many uncompensated services, particularly when patients are unable to pay. If the surgeon expects the patient to personally pay a fee, he or she or a qualified representative should discuss the fee with the patient before the operation. Fees should be commensurate with services rendered and may be related to the economic status of the patient.
III. Interprofessional Relations
A. Surgeons and Colleagues
The surgeon’s relationship with colleagues is often an important part of ensuring the best care is provided to the patient. No single physician or surgeon can be an expert in all areas of medicine. Team medicine has become the norm, and surgeons have a responsibility to work with colleagues.
Surgeons who have intimate personal relationships with individuals at their workplace should seek to minimize their supervisory responsibilities with those individuals and should excuse themselves from the evaluation process.
B. Discrimination or Harassment
The ethical practice of medicine establishes and ensures an environment in which patients, staff, colleagues, students, residents, and all other individuals are treated with respect and tolerance. Discrimination, harassment, or creation of a hostile working environment on the basis of personal attributes, including but not limited to age, sexual preference, gender, race, disease, disability, or religion, is inconsistent with the ideals and principles of the American College of Surgeons.
The surgeon is responsible for obtaining consultation for his or her patients when appropriate, and for providing consultation for the patients of colleagues when requested. These consultations may be for opinion only, to assist with management, or for the transfer of care. The patient should be informed in any instance that requires such a consultation. An appropriate report that is, by letter or by placement in a common chart or medical record, should be made available to the referring physician.
Payment of any kind, or by any method, by the surgeon to a referring physician to induce referral of a patient (fee splitting) is unethical (and usually is illegal). Although a number of practices and procedures that represent modified and subtle forms of fee splitting now exist, surgeons are responsible for recognizing and avoiding them.
Payment to another physician for required assistance that is provided at operation may be made properly to that assistant by the patient. The patient should be informed of the nature and amount of the payment. The means and mechanisms of such payment may be dictated by certain contractual obligations of the patient and the surgeon.
E. Relationships to Nonphysicians
Dentists, podiatrists, and chiropractors are on staff at many institutions and may ask a surgeon to assist in the management of their patients. The surgeon, as always, must be guided by the overriding principle that the patient’s best interests are to be served.
Many oral surgeons possess MD and DDS degrees, and dental surgery has expanded to include maxillofacial surgery. In the care of patients with injuries or lesions that involve complicated dental surgical problems, oral surgeons may be an essential part of the surgical team and may act independently in the area of their special competence. In the hospital setting, oral surgeons and other dentists may be included as members of the department of surgery.
In many hospitals, licensed podiatrists may admit patients in collaboration with physicians who will assume responsibility for the overall care of the patient. Such an arrangement must be under the supervision of the collaborating physician, with the type and extent of their operative procedures determined by the institution’s credentialing process.
The American College of Surgeons declares that, except as provided by law, there are no ethical or collective impediments to full professional association and cooperation between doctors of chiropractic and medical physicians. Individual choice by a medical physician to voluntarily associate professionally or otherwise cooperate with a doctor of chiropractic should be governed only by legal restrictions, if any, and by the individual medical physician’s personal judgment as to what is in the best interests of a patient or patients.
*Adopted pursuant to settlement agreement in Wilk et al v. AMA et al, September 1987. See the Appendix for full text.
IV. Medical Education
It is vitally important that the practicing surgeon keep up with changes and advances in the art and science of his or her field of surgery and of medicine in general. To do so, a Fellow of the College should engage in a lifelong program of education and self-assessment.
A. Continuous Medical Education and Professional Development
A Fellow of the College should meet the obligation for continuous education and development using multiple pathways. The goal of continuous education and self-assessment is to assist the Fellow in providing high-quality care to the surgical patient.
The Fellow should engage in continuing educational programs to ensure a high level of skill in the domains of medical knowledge, technical proficiency, professionalism, interpersonal communications, and systems-based practice.
The Fellow may achieve these educational goals by attending programs sponsored by the College or other scientific organizations, through continuing study of current peer-reviewed journals and texts, and through participation in other continuing education programs. Ideally, the Fellow should engage in a variety of educational programs, including, at least once per year, programs that allow an interchange of ideas with faculty and other participants.
Acquisition of skills in new procedures should be fostered by attendance at courses with both didactic and hands-on training sessions. The Fellow should seek appropriate proctoring of cases as new procedures are added to the surgeon’s surgical portfolio. Continuous self-appraisal of surgical outcomes is strongly encouraged, with the goal of improving patient outcomes.
The Fellow will maintain certification by a member board of the ABMS throughout his or her surgical career. Additionally, the College encourages periodic, voluntary self-assessment of medical knowledge by nonproctored testing formats.
It is the responsibility of surgeons, as members of the medical profession, to be “teachers” of patients, medical students, residents, and other health care professionals. Surgeons have a special responsibility to supervise resident training because of the unique characteristics of surgical conditions and operations.
V. Surgeons and Society
A. Surgical Research
Progress in medical care depends on research that often includes an informed collaboration between patients and physicians. Research should be distinguished from innovations that are departures from standard practice.2-4 Although new practices that are designed solely to benefit a patient may be described as “experimental” in the sense that they are new and untested, that does not automatically place them in the category of research. Research implies an activity intended to test a hypothesis so that scientific conclusions may be drawn. Research should be conducted under a formal written protocol that sets forth an objective and a set of procedures designed to reach the objective. When an innovation departs significantly from standard or accepted practice, the innovation should become the object of formal research at an early stage to determine its safety and effectiveness. It is the responsibility of individual surgeons and of medical practice committees to see that major innovations are incorporated into formal research protocols.
When applicable, humanely conducted animal studies should precede the testing of new techniques in humans. Before research programs involving human beings are undertaken, an impartial, qualified committee on human investigation should approve the protocol and the process for obtaining informed consent. Human research must meet the highest ethical standards.2-4 The primary principles of patient autonomy and safety must be preserved. Every patient has the right to understand completely the nature, as well as the risks, of such research activities and has the right to withdraw from the investigation at any time.
B. Scientific Publications
Presentation of results of an investigation must be governed by the principles of ethics. All authors must assume full public responsibility for the material presented. Surgeons should first report research contributions to professional audiences of peers and/or to peer-reviewed scientific publications. Many scientific organizations, scientific publications, and research facilities have rules governing news releases and require that approval be obtained before a news release is distributed to the media. In the event that an individual patient is identified, approval should be obtained from the physician who is providing care for any identified patient, and, equally important, permission should be obtained from the patient. The patient’s right to privacy must be protected.
C. Public Relations
A surgeon’s release of material to communications media or nonprofessional publications should be designated only for education and public information. Such releases must be accurate. They must not convey false, untrue, deceptive, or misleading information through statements, testimonials, photographs, graphics, or other means, and they must contain sufficient supporting material information. Releases must not create unjustified expectations of results. If treatment through a surgical procedure involves significant risks, realistic assessment of the safety and benefit of the procedure must be included, as well as the availability of alternative treatments and their benefits and hazards. Releases must not misrepresent a surgeon’s credentials, training, experience, or ability, and should contain only claims that can be substantiated. If a surgeon is reimbursed or sponsors a communication, that fact must be made clear to the public.
Advertising is legal; prohibitions of truthful advertising are considered to be restraints of trade. An advertisement may include information about specialty training, board certification, type of practice, office hours, languages spoken, and other such information that might assist the patient in contacting the surgeon. Advertising must be truthful, both in terms of what is said and in what is not said. Similarly, any illustrations or photographs must be truthful. Advertising should not entice patients to undergo operations if better alternative treatments are available.
E. Expert Testimony
When appropriate, physicians have an obligation to testify in court as expert witnesses. Physician expert witnesses are expected to be impartial and should not adopt a position as an advocate or partisan in the legal proceedings. The physician acting as an expert witness must have a current, valid, and unrestricted license to practice medicine in the state, province, or region in which he or she provides surgical services. The physician acting as an expert witness should be familiar with the standard of care provided at the time of the alleged occurrence and should be actively engaged in practice of the specialty or the subject matter of the case during the time the testimony or opinion is provided. The specialty of the physician acting as an expert witness should be appropriate to the subject matter in the case. The physician acting as an expert witness is ethically and legally obligated to tell the truth. Compensation of the physician acting as an expert witness should be reasonable and commensurate with the time and effort given to preparing for depositions and court appearances. It is unethical for a physician acting as an expert witness to link compensation to the outcome of the case.
The American College of Surgeons has a more complete Statement on the Physician Acting as an Expert Witness.5
F. Impaired Physicians
It is every surgeon’s responsibility to safeguard patients from harm as a result of the action or decisions of a colleague impaired by illness, aging, or substance abuse. In addition, there is a collegial and a medical responsibility to assist the impaired colleague in obtaining care, even if the individual must be reported to the appropriate authority to begin the steps toward adequate care.
G. Incompetent Surgeons
When incompetent patient management is recognized, the surgeon’s responsibility is to assist the regular institutional peer review mechanism in remedying the situation. Physical, moral, or mental impairment that renders a colleague incompetent to care for patients, or that is associated with fraud or other malfeasance, should be disclosed to protect patients and society. On the other hand, it is indefensible to disparage the actions, knowledge, or skills of another physician for malicious reasons.
H. Maintenance of Fellowship
Maintenance of Fellowship is jeopardized by infractions of College principles as specified in the Bylaws of the American College of Surgeons. Fellows are expected to report knowledge of violations of these principles or of the Bylaws. When a Fellow is convinced that another Fellow is violating the Fellowship Pledge, the Bylaws of the College, or its principles, a confidential written communication should be sent to the Executive Director of the College. The information so submitted will then be further investigated and processed according to the provisions in the Bylaws.
- Accreditation Council for Graduate Medical Education (ACGME). General Competencies Vers. 1.3 (Approved September 1999). Accreditation Council for Graduate Medical Education website. Available at: https://asts.org/docs/default-source/education/rrc-core-competencies.pdf. Accessed June 2016.
- National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research. Washington, DC: U.S. Government Printing Office; 1979.
- World Medical Association. Declaration of Helsinki. Adopted by the 18th World Medical Assembly, Helsinki, Finland, June 1964, and amended by the 29th World Medical Assembly, Tokyo, Japan, October 1975; 35th World Medical Assembly, Venice, Italy, October 1983; and the 41st World Medical Assembly, Hong Kong, September 1989.
- The Nuremburg Code (from Trials of War Criminals before the Nuremburg Military Tribunals under Control Council Law No. 10). Washington, DC: U.S. Government Printing Office; 1949-1953.
- Patient Safety and Professional Liability Committee, American College of Surgeons. Statement on the physician acting as an expert witness. Available at: facs.org/about-acs/statements/8-expert-witness. Accessed August 9, 2016.
Statement on Interprofessional Relations with Doctors of Chiropractic*
The American College of Surgeons declares that, except as provided by law, there are no ethical or collective impediments to full professional association and cooperation between doctors of chiropractic and medical physicians. Individual choice by a medical physician voluntarily to associate professionally or otherwise cooperate with a doctor of chiropractic should be governed only by legal restrictions, if any, and by the individual medical physician’s personal judgment as to what is in the best interests of a patient or patients. Professional association and cooperation, as referred to above, includes but is not limited to the following:
- Referrals, consultations, group practice in partnerships, health maintenance organizations, preferred provider organizations, and other alternative health care delivery systems
- The provision of treatment privileges and diagnostic services in or through hospital facilities
- Collaboration with doctors of chiropractic in hospital settings where the hospital’s governing board, acting in accordance with the applicable law and that hospital’s standards, elects to provide privileges or services to doctors of chiropractic
- Association and cooperation in hospital training programs for students in chiropractic colleges under suitable guidelines arrived at by the hospital and chiropractic college authorities
- Participation in student exchange programs between chiropractic and medical colleges
- Cooperation in research programs and the publication of research material in appropriate journals in accordance with established editorial policy of said journals
- Participation in health care seminars, health fairs, or continuing education programs
- Any association or cooperation designed to foster better health care for patients of medical physicians, doctors of chiropractic, or both
*Adopted pursuant to settlement agreement in Wilk et al v. AMA et al, September 1987.
This version was published in print, September 2016 in the Bulletin of the American College of Surgeons.