Position Statements:
POTENTIAL ETHICAL ISSUES | PODIATRIST-PATIENT RELATIONS

NC Board of Podiatry Examiners' Position Statement
POTENTIAL ETHICAL ISSUES

Sale of goods from podiatrist offices || Self-treatment and treatment of family members and others with whom significant emotional relationships exist || Professional obligation to report incompetence, impairment and unethical conduct || Advertising and publicity || Medical Testimony

Sale of goods from podiatrist offices

NCBPE Adopted : 4/22/10

Inherent in the in-office sale of products is a perceived conflict of interest. On this issue, it is the position of the North Carolina Board of Podiatry Examiners that the following instructions should guide the conduct of podiatrists or licensees.

Sale of practice-related items such as orthopedic shoes, ointments, creams and lotions, splits and appliances, etc., by podiatrists is acceptable if, in the doctor's reasoned judgment, he or she is the best source, or after the patient has been told that those or similar items can be obtained locally from other sources. Any charge made should be reasonable.

Due to the potential for patient exploitation, the Board opposes licensees participating in exclusive distributorships and/or personal branding, or persuading patients to become dealers or distributors of profit making goods or services.

Licensees should not sell any non health-related goods from their offices or other treatment settings. (This does not preclude selling of such low cost items on an occasional basis for the benefit of charitable or community organizations, provided the licensee receives no share of the proceeds, and patients are not pressured to purchase.)

All decisions regarding sales of items by the podiatrist or his/her staff from the podiatrist's office or other place where health care services are provided, must always be guided by what is in the patient's best interest.

Sale of goods from podiatrist offices || Self-treatment and treatment of family members and others with whom significant emotional relationships exist || Professional obligation to report incompetence, impairment and unethical conduct || Advertising and publicity || Medical Testimony

Self-treatment and treatment of family members and others with whom significant emotional relationships exist

NCBPE Adopted : 4/22/10

It is the position of the North Carolina Board of Podiatry Examiners that, except for minor illnesses and emergencies, podiatrists should not treat, medically or surgically, or prescribe for themselves, their family members, or others with whom they have significant emotional relationships. The Board strongly believes that such treatment and prescribing practices are inappropriate and may result in less than optimal care being provided. A variety of factors, including personal feelings and attitudes that will inevitably affect judgment, will compromise the objectivity of the podiatrist and make the delivery of sound medical care problematic in such situations, while real patient autonomy and informed consent may be sacrificed.

When a minor illness or emergency requires self-treatment or treatment of a family member or other person with whom the podiatrist has a significant emotional relationship, the podiatrist must prepare and keep a proper written record of that treatment, including but not limited to prescriptions written and the medical indications for them. Record keeping is too frequently neglected when podiatrists manage such cases.

The Board expects podiatrists to delegate the medical and surgical care of themselves, their families, and those with whom they have significant emotional relationships to one or more of their colleagues in order to ensure appropriate and objective care is provided and to avoid misunderstandings related to their prescribing practices.

Sale of goods from podiatrist offices || Self-treatment and treatment of family members and others with whom significant emotional relationships exist || Professional obligation to report incompetence, impairment and unethical conduct || Advertising and publicity || Medical Testimony

Professional obligation to report incompetence, impairment and unethical conduct *

NCBPE Adopted : 4/22/10

It is the position of the North Carolina Board of Podiatry Examiners that podiatrists have a professional obligation to act when confronted with an impaired or incompetent colleague or one who has engaged in unethical conduct.

When appropriate, an offer of personal assistance to the colleague may be the most compassionate and effective intervention. When this would not be appropriate or sufficient to address the problem, podiatrists have a duty to report the matter to the institution best positioned to deal with the problem. For example, impaired podiatrists and podiatrist assistants should be reported to the Impaired Physicians Committee of the NC Foot and Ankle Society. Incompetent podiatrists should be reported to the clinical authority empowered to take appropriate action. Podiatrists also may report to the North Carolina Board of Podiatry Examiners, and when there is no other institution reasonably likely to be able to deal with the problem, this will be the only way of discharging the duty to report.

This duty is subordinate to the duty to maintain patient confidences. In other words, when the colleague is a patient or when matters concerning a colleague are brought to the podiatrist's attention by a patient, the podiatrist must give appropriate consideration to preserving the patient's confidences in deciding whether to report the colleague.

*See also Position Statements on Prescriptions & Controlled Substances

Sale of goods from podiatrist offices || Self-treatment and treatment of family members and others with whom significant emotional relationships exist || Professional obligation to report incompetence, impairment and unethical conduct || Advertising and publicity || Medical Testimony

Advertising and publicity

NCBPE Adopted : 4/22/10

It is the position of the North Carolina Board of Podiatry Examiners that podiatrist advertising or publicity* that is deceptive, false, or misleading is unprofessional conduct. The key issue is whether advertising and publicity, regardless of format or content, are true and not materially misleading.

Information conveyed may include:

• the basis on which fees are determined, including charges for specific services;
• methods of payment;
• any other non-deceptive information.

Advertising and publicity that create unjustified medical expectations, that are accompanied by deceptive claims, or that imply exclusive or unique skills or remedies must be avoided. Similarly, a statement that a podiatrist has cured or successfully treated a large number of patients suffering a particular ailment is deceptive if it implies a certainty of results and/or creates unjustified or misleading expectations. If patient photographs are used, they should be of the podiatrist's own patients and demonstrate realistic outcomes.

Consistent with federal regulations that apply to commercial advertising, a podiatrist who is preparing or authorizing an advertisement or publicity item should ensure in advance that the communication is explicitly and implicitly truthful and not misleading. Podiatrists should list their names under a specific specialty in classified telephone directories and other commercial directories only if they are board certified or have successfully completed a training program in that specialty accredited by the American Board of Podiatric Surgery.

* Business letterheads, envelopes, cards, and similar materials are understood to be forms of advertising and publicity for the purpose of this Position Statement.

Sale of goods from podiatrist offices || Self-treatment and treatment of family members and others with whom significant emotional relationships exist || Professional obligation to report incompetence, impairment and unethical conduct || Advertising and publicity || Medical Testimony

Medical Testimony

NCBPE Adopted : 4/22/10

The Board recognizes that medical testimony is vital to the administration of justice in both judicial and administrative proceedings. In order to provide further guidance to those podiatrists called upon to testify, the Board adopts and endorses the APMA Code of Ethics ME5.2 entitled "Accountability in Providing Expert Testimony":

ME5.21 The podiatrist providing expert testimony is expected to have relevant experience, training, and knowledge in the area in which the podiatrist has agreed to testify. Testimony must be objective and be limited to the area of expertise held by the podiatrist. Expert testimony should be based upon recognized medical and scientific principles, theories, facts, and standard of care.

ME5.22 The podiatrist serving as an expert witness shall offer testimony that is honest and truthful. A breach of these ethics would exist if a podiatrist knowingly provides false or misleading testimony.

ME 5.23 The podiatrist may accept compensation for testimony offered, but such compensation should not in any way be related to or based upon the outcome of the litigation.

NC Board of Podiatry Examiners' Position Statement
PODIATRIST-PATIENT RELATIONS

The podiatrist-patient relationship || Guidelines for avoiding misunderstandings during physical examinations || Sexual exploitation of patients || Care of the patient undergoing surgical or other invasive procedure

The podiatrist-patient relationship

NCBPE Adopted : January 15, 2010

The duty of the podiatrist is to provide competent, compassionate, and economically prudent care to all of his or her patients. Having assumed care of a patient, the podiatrist may not neglect that patient nor fail for any reason to prescribe the full care that patient requires in accord with the standards of acceptable podiatric medical practice. Further, it is the Board's position that it is unethical for a podiatrist to allow financial incentives or contractual ties of any kind to adversely affect his or her medical judgment or patient care.

Therefore, it is the position of the North Carolina Board of Podiatry Examiners that any act by a podiatrist that violates or may violate the trust a patient places in the podiatrist places the relationship between podiatrist and patient at risk. This is true whether such an act is entirely self-determined or the result of the podiatrist's contractual relationship with a health care entity. The Board believes the interests and health of the people of North Carolina are best served when the podiatrist-patient relationship remains inviolate. The podiatrist who puts the podiatrist-patient relationship at risk also puts his or her relationship with the Board in jeopardy.

Elements of the podiatrist-patient relationship

The North Carolina Board of Podiatry Examiners licenses podiatrists as a part of regulating the practice of podiatric medicine in this state. Receiving a license to practice podiatry grants the podiatrist privileges and imposes great responsibilities. The people of North Carolina expect a licensed podiatrist to be competent and worthy of their trust. As patients, they come to the podiatrist in a vulnerable condition, believing the podiatrist has knowledge and skill that will be used for their benefit.

Patient trust is fundamental to the relationship thus established. It requires that:

• there be adequate communication between the podiatrist and the patient;
• the podiatrist report all significant findings to the patient or the patient's legally designated surrogate/guardian/personal representative;
• there be no conflict of interest between the patient and the podiatrist or third parties;
• personal details of the patient's life shared with the podiatrist be held in confidence;
• the podiatrist maintain professional knowledge and skills;
• there be respect for the patient's autonomy;
• the podiatrist be compassionate;
• the podiatrist respect the patient's right to request further restrictions on medical information disclosure and to request alternative communications;
• the podiatrist be an advocate for needed podiatric care, even at the expense of the podiatrist's personal interests; and
• the podiatrist provide neither more nor less than the medical problem requires.

The Board believes the interests and health of the people of North Carolina are best served when the podiatrist-patient relationship, founded on patient trust, is considered sacred, and when the elements crucial to that relationship and to that trust -communication, patient privacy, confidentiality, competence, patient autonomy, compassion, selflessness, appropriate care-are foremost in the hearts, minds, and actions of the podiatrists licensed by the Board.

This same fundamental podiatrist-patient relationship also applies to mid-level health care providers such as podiatrist assistants, and nurses in all practice settings.

Termination of the podiatrist-patient relationship

The Board recognizes the podiatrist's right to choose patients and to terminate the professional relationship with them when he or she believes it is best to do so. That being understood, the Board maintains that termination of the podiatrist-patient relationship must be done in compliance with the podiatrist's obligation to support continuity of care for the patient.

The decision to terminate the relationship must be made by the podiatrist personally. Further, termination must be accompanied by appropriate written notice given by the podiatrist to the patient or the patient's representative sufficiently far in advance (at least 30 days) to allow other care to be secured. A copy of such notification is to be included in the medical record. Should the podiatrist be a member of a group, the notice of termination must state clearly whether the termination involves only the individual podiatrist or includes other members of the group. In the latter case, those members of the group joining in the termination must be designated. It is advisable that the notice of termination also include instructions for transfer of or access to the patient's medical records.

The podiatrist-patient relationship || Guidelines for avoiding misunderstandings during physical examinations || Sexual exploitation of patients || Care of the patient undergoing surgical or other invasive procedure

Guidelines for avoiding misunderstandings during physical examinations

NCBPE Adopted : January 15, 2010

It is the position of the North Carolina Board of Podiatry Examiners that proper care and sensitivity are needed during physical examinations to avoid misunderstandings that could lead to charges of sexual misconduct against podiatrists. In order to prevent such misunderstandings, the Board offers the following guidelines.

• Sensitivity to patient dignity should be considered by the podiatrist when undertaking a physical examination. The patient should be assured of adequate auditory and visual privacy and should never be asked to disrobe in the presence of the podiatrist. Examining rooms should be safe, clean, and well maintained, and should be equipped with appropriate furniture for examination and treatment. Gowns, sheets and/or other appropriate apparel should be made available to protect patient dignity and decrease embarrassment to the patient while a thorough and professional examination is conducted.
• Whatever the sex of the patient, a third party, a staff member, should be readily available at all times during a physical examination It is the podiatrists responsibility to have a staff member available at any point during the examination. The board does not envision any situation in which a podiatrist would find it necessary to perform an examination of the breast(s), genitalia, or rectum.
• The podiatrist should individualize the approach to physical examinations so that each patient's apprehension, fear, and embarrassment are diminished as much as possible. An explanation of the necessity of a physical examination, the components of that examination, and the purpose of partial (e.g., for vascular exams, palpation of lymph nodes, or neurologic testing) may be necessary in order to minimize the patient's possible misunderstanding.
• The podiatrist and staff should exercise the same degree of professionalism and care when performing diagnostic procedures as well as during surgical procedures and postsurgical follow-up examinations when the patient is in varying stages of consciousness.
• The podiatrist should be on the alert for suggestive or flirtatious behavior or mannerisms on the part of the patient and should not permit a compromising situation to develop.

The podiatrist-patient relationship || Guidelines for avoiding misunderstandings during physical examinations || Sexual exploitation of patients || Care of the patient undergoing surgical or other invasive procedure

Sexual exploitation of patients

NCBPE Adopted : January 15, 2010

It is the position of the North Carolina Board of Podiatry Examiners that sexual exploitation of a patient is unprofessional conduct and undermines the public trust in the podiatric profession. Sexual exploitation encompasses a wide range of behaviors which have in common the intended sexual gratification of the podiatrist. These behaviors include sexual intercourse with a patient (consensual or non-consensual), touching genitalia, sexually suggestive comments, asking patients for a date, inappropriate exploration of the patients or podiatrist's sexual fantasies, touching or exposing genitalia, breast, or other parts of the body in ways not dictated by an appropriate and indicated physical examination, exchanging sexual favors for services. Sexual exploitation is grounds for the suspension, revocation, or other action against a podiatrist's license.

Sexual misconduct by podiatrists and other health care practitioners is a form of behavior that adversely affects the public welfare and harms patients individually and collectively. Podiatrist sexual misconduct exploits the podiatrist-patient relationship, is a violation of the public trust, and is often known to cause harm, both mentally and physically, to the patient.

Regardless of whether sexual misconduct is viewed as emanating from an underlying form of impairment, it is unarguably a violation of the public's trust.

As with other disciplinary actions taken by the Board, Board action against a podiatrist's licensee for sexual exploitation of a patient is published by the Board, the nature of the offense being clearly specified. It is also released to the news media, to state and federal government, and to medical and professional organizations.

The podiatrist-patient relationship || Guidelines for avoiding misunderstandings during physical examinations || Sexual exploitation of patients || Care of the patient undergoing surgical or other invasive procedure

Care of the patient undergoing surgical or other invasive procedure

NCBPE Adopted : January 15, 2010

The evaluation, diagnosis, and care of the surgical patient are primarily the responsibility of the podiatrist. He or she alone bears responsibility for ensuring the patient undergoes a preoperative assessment appropriate to the procedure. The assessment shall include a review of the patient's data and an independent diagnosis by the operating podiatrist of the condition requiring surgery. The podiatrist shall have a detailed discussion with each patient regarding the diagnosis and the nature of the surgery, advising the patient fully of the risks involved. It is also the responsibility of the podiatrist to reevaluate the patient immediately prior to the procedure.

It is the responsibility of the podiatrist to assure safe and readily available postoperative care for each patient on whom he or she performs surgery. It is not improper to involve other licensed health care practitioners in postoperative care so long as the operating surgeon maintains responsibility for such care. The postoperative note must reflect the findings encountered in the individual patient and the procedure performed.

When identical procedures are done on a number of patients, individual notes should be written for each patient that reflect the specific findings and procedures of that procedure.

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IMPORTANT!

Unauthorized Survey
Circulated to Podiatrists

Fact Sheet on Trends in Professional Supply of Podiatrists (2004)

It is Board policy (General Statutes of North Carolina, Article 12A Chapter 90 section 202.10) that all licensed podiatrists in the state of North Carolina must, on or before the first day of July of each year, apply for license renewal. Any license granted by the Board shall be considered non-renewed if the holder fails to secure the renewal within a period of 30 days after the first day of July of each year. A podiatrist is allowed to practice with a non-renewed or delinquent license for a six-month period (until January 1), following the July 1 deadline. Any podiatrist who fails to meet this January 1 deadline must appear before the Board and take a new examination before being allowed to practice podiatry in the State of North Carolina.