Do the Right Thing

Ethics (from the Greek word ethikos, meaning arising from habit): A branch of philosophy that deals with good, bad, right, and wrong. An informal code of moral principles and behavior that represents a consensus…. The rules or standards governing the conduct of a person or members of a profession.

The word ethics is not easily defined. Yes, ethics is a discipline that analyzes whether behavior in a specific situation is either right or wrong, but how do we define these two terms? A contestant on a television quiz show may be asked to answer a question, and the answer is either right or wrong, the determination being unequivocally and irrevocably made by the show’s master of ceremonies. If the contestant is right, the contestant’s reward is a prize, usually financial in nature. Similarly, a plaintiff in a lawsuit may claim to be right and allege that the defendant, whether an institution or an individual, is wrong. There, the determination of right or wrong is unequivocally and irrevocably made by a jury and/or judge. If the litigant is judged in the courtroom to be right, the litigant’s reward is compensation, usually financial in nature.

But if a question is raised regarding whether a person’s personal or professional conduct or behavior in their day-to-day activities is right (ie, ethical) or wrong, who makes that determination? And is that determination unequivocal and irrevocable? And if the conduct is right from an ethical point of view, what is that person’s reward?

Two forces tend to propel us to act ethically and do what is right: internal and external. Internally, we all possess a conscience, defined as “the awareness of a moral or ethical aspect to one’s conduct, together with the urge to prefer right over wrong.” Thus, if we do what is ethically right, our conscience will be satisfied—perhaps not unequivocally and irrevocably, but nonetheless to a degree that gives us the reward of feeling good about ourselves, and allowing us to be able to look at ourselves in the mirror with pride and contentment.

Externally, many organizations and most professional societies have published codes of ethics, guidelines designed to help us conduct ourselves in a manner that is considered to be ethical. For example, the Code of Medical Ethics from the American Medical Association (AMA) are “standards of conduct which define the essentials of honorable behavior for the physician.” The Principles of Ethics from the American College of Radiology (ACR) “serve as goals of exemplary professional conduct for which members of the College should constantly strive.” In general, these codes of ethics tell us what we should do. Of course, our conduct also is guided by the law, which mandates certain behavior—in other words, it tells us what we must do. Ethical values and legal principles usually are closely related, but ethical obligations typically exceed legal duties.

We are faced with ethical dilemmas almost daily, in both our personal and professional lives. While in the final analysis our course of action in these instances is dictated by our conscience (ie, by what we ourselves think is the right thing to do), nonetheless, we frequently seek advice and guidance from our colleagues. With that in mind, this article describes eight typical ethical dilemmas that currently confront and will undoubtedly in the near future continue to confront —and perplex—radiologists in their day-to-day practices. They deal with ethical considerations relating to:

• advertising of radiological services;
• scientific journal conflicts of interest;
• aiding and abetting self-referral schemes;
• expert witness testimony;
• inappropriate or unprofessional behavior;
• disclosing errors and complications;
• leasing imaging time to referring physicians; and
• conflicts of interest related to purchases of radiological equipment.

Axis Imaging News has asked radiologists and/or radiology-related associates to offer their opinions as to how these dilemmas should be handled in an ethically appropriate manner. Are their opinions right or wrong? Many readers will feel that the responses fall into the former category; others may feel that they fall into the latter. Some readers might feel that the responses are sufficiently provocative to coax them into formulating their own response, in the form of a Letter to the Editor. Such responses from the readers of Axis Imaging News will, of course, be welcomed.

With 1 month remaining until the year 2006 passes into history, the ethical dilemmas presented in this issue are quite timely. These dilemmas will eventually pass into history as well, but we can be certain that they will be replaced by new and unpredictable ethical dilemmas in the months and years to come.

Leonard Berlin, MD, is chairman, Department of Radiology, Rush North Shore Medical Center, Skokie, Ill, professor of radiology, Rush Medical College, Chicago, chairman of the American College of Radiology’s ethics committee, vice chairman of the Radiological Society of North America’s professionalism committee, and a member of Axis Imaging News’ Editiorial Advisory Board.

Taking the High Road: Advertising of Radiological Services

You have hired an aggressive marketing agency to design a marketing program for your practice, and the agency wants to brand you as the “leader in subspecialty radiology” in your market. The problem is that another practice in town associated with a university is the clear leader in subspecialty radiology. But your practice does have strong (if not the strongest) subspecialty expertise and this is what referrers want, and your agency is pushing hard. What is the ethical response?

Response from Michael J. Kelley, MD:

The bottom line ethical principle here is that honesty is the best policy. A good marketing plan is an honest marketing plan where the claims of professional expertise and reputation are true and verifiable and are not exaggerated. According to the scenario given here, it would be false to state that “Radiology Group A Is the Best Subspecialty Radiology Group in the City of ____.”

The marketing plan could take a more general approach and emphasize that the group is “One of the Leaders in Subspecialty Radiology in the Area.” Or the agency could hone in on subspecialty areas of the practice where, based on patient volume or number of subspecialists, they are truly the area leaders: “Radiology Group A Is the Leader in the Field of Mammography.”

Michael J. Kelley, MD

The group might emphasize its subspecialty connections in other ways, such as its close relationships with other subspecialty groups (orthopedic surgeons, neurologists, etc) or with a medical center that has a strong reputation in the community.

In the field of medicine, even though business aspects seem to be playing a larger role, cutthroat marketing practices should not overcome honesty and integrity. These values constitute an important part of a group’s reputation. It is fine to play up the group’s strong points, but keep the facts accurate and the marketing campaign honest.

Michael J. Kelley, MD, is a cardiovascular/interventional radiologist with Charlotte Radiology, PA. He is chief of radiology and chairman of the ethics committee at Carolinas Medical Center, Charlotte.

Scientific Journal Conflict of Interest

You have achieved expertise in GI radiology and have invented a radiographic means of visualizing the small bowel. A company has been organized to market this product. You have stock in the company and receive royalties on sales of the product, and the company has asked you to write several scientific articles and lecture across the country on the efficacy of the product. What is the ethical response?

Response from Alexander R. Margulis, MD:

One of the greatest problems of our society, not only medicine, is the blurring of ethical guidelines and equating success with the accumulation of wealth, no matter how it is achieved. The scandals involving huge companies like Enron are examples that the disease is general and that the involvement of medicine is only a manifestation of the fact that no part of our society and no profession have escaped.

It is painful to witness, however, that a profession, which has, in the past, been among the most admired and respected, is presently widely criticized for neglecting its obligations to patients and becoming involved with the pharmaceutical and equipment industries for personal gain. Articles in prestigious newspapers and magazines as well as several books are dealing with this problem; probably the best is On the Take by the former editor of the New England Journal of Medicine, Jerome E. Kassirer, MD.

Most journals and scientific organizations demand full disclosure of financial involvement in the subject published or presented in lectures. Disclosure also is required from presenters at meetings where CME credit is obtained, and attendees are obligated to declare in their attendance record sheet whether commercial overtones were present. This, however, eliminates only the most egregious set of unethical behavior.

So far, radiologists have spared our specialty regarding egregious misconduct, probably because the incomes in private practice are so high that there is no need to engage in anything that may appear unethical. The income differential between academic and private radiology, however, may bring temptations. To my knowledge, no blaring ethical misconduct has hit the pages of the national press yet, but the temptation clearly exists.

Alexander R. Margulis, MD

To discuss the problem presented in the dilemma, it is crystal clear that financial involvement as outlined disqualifies the radiologist from writing articles on the value of the approach to visualizing the small bowel, no matter how good that approach is, as there is strong financial bias.

As for lectures on the approach described, the radiologist must clearly state their financial interest in the company and the approach from which they derive income. As this may be degrading, the best modus operandi is to have the radiologist decline giving lectures on the subject and leave the sales pitch to employees of the company.

In my own past, physicists of the department of radiology at the University of California, San Francisco, founded two companies on their inventions. My shares of these two companies were donated to the departmental foundation. Because the clinical members of the department were writing papers on the applications of the invented technology, I insisted that they do the same. Although this did not contribute to my popularity, it greatly enhanced the respect that the department enjoyed worldwide.

Alexander R. Margulis, MD, is an internationally recognized radiologist who served for more than 26 years as the chairman of the Department of Radiology at the University of California at San Francisco. He continues to teach at Weill Medical College of Cornell University, New York City.

Aiding and Abetting Self-Referral Schemes

You are a radiation oncologist and have been approached by a successful urology group that has just purchased a linear accelerator. They offer you an “opportunity” to join their practice. They want you to treat all of their prostate cancer patients using intensity-modulated radiation therapy (IMRT), whether it is indicated or not. They will pay you well, since IMRT reimburses better than other therapy techniques, but you will never be a partner, and you know that IMRT is not the proper treatment for all of these patients. What is the ethical response?

Response from Cassandra Foens, MD:

Many physicians are seeking ways to supplement declining incomes. Adding highly reimbursed services is becoming more widespread, and for-profit companies are heavily marketing these “opportunities” to physicians. Over the past several years, imaging has been the focal point of most of these opportunities but hardly the only one. A relatively new company is now marketing this described scenario to urologists.

This scenario can be legal. If the urology practice fully owns the facility, and it employs the radiation oncologist, it is not technically in violation of federal Stark laws. Whether it is ethical, however, is another matter. When medicine and money conflict, there is always a risk that patients will not receive what is best for them, but rather what will make the most money for their physicians, particularly when the additional income comes from work done by others. Prostatectomy is reimbursed by Medicare at approximately $5,000 to $6,000, but IMRT is reimbursed at the much higher rate of $36,000 to $41,000. In the prostatectomy situation, the urologist is being reimbursed for work they actually have done. In the IMRT situation, however, the radiation oncologist performing the work is likely being paid a salary, and the urologist is receiving the additional reimbursement above the cost of that salary as profit. And the urologist can make even more money by self-referring more patients to their IMRT center, rather than individualizing treatment. Some patients may really not require treatment at all, but could still be referred for IMRT at the wholly owned center, since the urologist profits from any patient being treated.

The ACR has taken a strong stand that any economically motivated self-referral of radiologic procedures, whether in diagnostic imaging or in radiation oncology, is not only unethical, but is actually driving up the cost of medicine. Numerous articles have been published in the peer-review literature showing that those who own and self-refer to ancillary services, such as imaging, use more resources, cost more money, and may actually have lower quality.

Cassandra Foens, MD

A 1990 article by Hillman et al in the New England Journal of Medicine found that utilization by self-referring physicians was 4 to 4.5 times as high as utilization by physicians who refer their patients to radiologists for imaging. Charges were 4.4 to 7.5 times as high. An update of this research published in the Journal of the American Medical Association by some of the same investigators in 1992 dealt with a broader range of health conditions and included the full range of imaging. The results are the same: Self-referral produces much higher utilization, 1.1 to 7.7 times as high, depending on the health condition being studied, and therefore much higher costs. Costs were 1.6 to 6.2 times as high as for non-self-referrers. And in a 2002 article published in the American Journal of Roentgenology, Kouri et al not only found similar increases in utilization and cost but also found that deficiencies in image quality and patient safety were up to 10 times as common among nonradiologists as among radiologists. There is no reason to believe that the same results would not be applicable to self-referred radiation oncology. Unfortunately, other professional societies have been unwilling to take as strong a stand against this behavior as the ACR.

These relationships pose difficult ethical problems. If the radiation oncologist is a full partner in such a facility and is allowed to exercise independent medical judgment regarding patient needs, and if patients are completely informed about the ownership of the IMRT center and the investment status of referring physicians, then this may be an ethical offer to accept. If not, or if patients are selected solely on their insurance status, then I would suggest it is not an ethical offer to accept.

Cassandra Foens, MD, is a radiation oncologist with Clinical Radiologists, PC, and currently serves as medical director of radiation oncology at the Covenant Cancer Treatment Center in Waterloo, IA.

In the Interest of Justice: Expert Witness Testimony

An attorney has asked you to review chest radiographs, interpreted as normal by another radiologist, obtained on a 64-year-old man 15 months before a diagnosis of lung cancer was established. On careful examination, you note a 7-mm, ill-defined density in the right upper lobe, partially obscured by the overlying clavicle. It is in the same location as the carcinoma that was diagnosed on the subsequent radiographs. In your own mind, you believe that many radiologists, possibly even you, would have interpreted the radiographs as normal. The attorney, who represents the family of the now-deceased patient in a malpractice lawsuit filed against the radiologist who had rendered the original interpretation, would like you to act as an expert witness against the now defendant-radiologist, mentioning incidentally that you would be paid $500 per hour for your time. What is the ethical response?

Response by Leonard Berlin, MD:

Both the AMA and the ACR encourage physicians to assist in the administration of justice by providing expert medical testimony. The ACR’s Rules of Ethics admonish potential expert witnesses to “exercise extreme caution to ensure that the testimony provided is non-partisan, scientifically correct, and clinically accurate.”

Complying with these lofty goals is not as easy as it sounds, however. When discussing radiologic findings with referring physicians in the congenial setting of a radiology office where there is a cooperative and mutually respectful effort to arrive at an accurate diagnosis, it is not uncommon for radiologists to characterize the likelihood of various potential diagnoses with such terms as “could,” “possibly,” or “maybe.” The setting in the courtroom, however, is far different. The court is adversarial, where each party presents only data that support its position, but omits data that detract from its position. The witness stand is no place to express doubt or uncertainty. Courts demand that experts who render opinions regarding breaches of the standard of medical care speak in terms of “more likely than not.” Testimony must be above speculation and conjecture; experts who use such terms as “might be,” “could be,” or “possibly” are of no value in our system of civil litigation.

Leonard Berlin, MD

Defining the standard of radiologic care is simple: It is that course of action that a reasonable radiologist would have taken under the same or similar circumstances. But applying that definition to a specific case being adjudicated, and then opining whether that standard has been breached, is not so simple. The radiologist in this scenario already has determined that other radiologists as well as he could have missed the abnormality. Yet, in retrospect, the radiologist can now identify the missed lesion. Thus, the answer to the question of whether the defendant–radiologist breached the standard of radiologic care by not identifying the lesion could well be answered in the affirmative by some radiologists, in the negative by others. Such differences in opinion are not uncommon, inasmuch as studies have shown that there is poor agreement among physicians in determining whether a specific conduct of a physician did or did not constitute negligence. Indeed, the courts have stated that it is not surprising that opposing medical expert witnesses do not agree. It is the jury’s job, according to the courts, to listen to conflicting evidence and use its best judgment to determine the “truth.”

Should the radiologist accept the plaintiff’s attorney’s invitation to testify that the defendant–radiologist was negligent? The radiologist must be guided by his conscience in determining whether to act as an expert witness. If the radiologist truly believes that he can render an honest opinion, then he should, by all means, take on the role of expert witness. If the radiologist cannot do so in good conscience, he should decline. In either event, the radiologist’s decision should not be influenced by financial considerations.

Leonard Berlin, MD, is chairman, Department of Radiology, Rush North Shore Medical Center, Skokie, Ill, professor of radiology, Rush Medical College, Chicago, chairman of the American College of Radiology’s ethics committee, and vice chairman of the Radiological Society of North America professionalism committee.

Inappropriate and Unprofessional Behavior: What Is Your Responsibility?

Your colleague is acting unprofessionally, brushing up accidentally against patients and visiting the mammography room to speak with patients prior to the final interpretation. If you complain and your colleague leaves the service, your workload goes sky-high until a replacement is found. What is the ethical response?

Response from R. James Brenner, MD, JD:

The situation invites redress—legal and otherwise—if not resolved. A number of facilities have instituted formal harassment policies and procedures. For example, in California, state law mandates completion of a course on the matter with guidelines for responding to this and other situations. At times, risk-management guidelines may be constructed so broadly as to escape reasonable implementation; however, fundamental notions of ethics and propriety require intervention. Thus, one should review applicable institutional guidelines; those institutions that have not yet developed guidelines are advised to do so.

R. James Brenner, MD, JD

The scenario lends itself to some interpretation and, accordingly, different levels of intervention. For conduct that is not overt and may be sufficiently defensible, facility-wide instruction and meetings may resolve the situation. Even the law protects innocent “touching,” although the circumstances presented here suggest something more than innocent. In addition, women often desire to speak to the mammographer. Any perceived impropriety can be aimed at such consultations or discussions occurring only after the woman has changed from her examining gown and is fully dressed. If the conduct so warrants, direct counseling—often best served by a designated (beforehand) third party—documentation, and monitoring may be necessary. Follow-up counseling sessions serve both the facility and the individual in validating improved working circumstances. If such intervention is unsuccessful, continued employment may not be feasible. Virtually all corrective situations are somewhat adversarial in nature, so that the intent of the intervention should be made clear as a constructive effort with a goal to making things work well for everyone.

Harsh responses are easy to suggest when one does not suffer the consequences of the actions. Losing otherwise valuable personnel has its own consequences. However, the “value” of that personnel diminishes when co-workers and the facility itself are vulnerable to recourse.

R. James Brenner, MD, JD, is chief of breast imaging and professor of radiology, University of California, San Francisco-Mt Zion Hospital Cancer Center.

Is Honesty the Ethical Policy?

You interpreted a mammogram showing probable breast cancer, the patient has had surgery, and all nodes are negative. You now find that the patient had a mammogram 2 years earlier and on review, you see a subtle finding that, in retrospect, most likely represented the cancer in an earlier stage. Should you inform the patient?

Response by Richard B. Gunderman, MD:

The discovery of medical error is a frequent occurrence, no less in radiology than in other medical specialties. In fact, errors in radiology are probably easier to uncover, at least to the extent that findings are permanently preserved in images and accessible to any observer who inspects them at a later date. By contrast, missed physical examination findings, such as palpable masses and heart murmurs, are not directly accessible to other physicians who review a case.

Every radiology department with a quality assurance program regularly identifies failures to detect lesions, though rates vary from person to person. It is unrealistic to expect radiology to be error free, and there is not a radiologist in the world who never makes mistakes. Although steps can be taken to improve performance, comparisons with substantially lower error rates in other industries, such as manufacturing and air travel, are largely misleading. Each light bulb and aircraft should be identical to all the others, but each patient is unique.

Every error should not result in a medical malpractice claim. For one thing, the standard of care is not perfection. Moreover, many errors do not harm patients. Industries that have achieved substantial reductions in error rates, such as the airline industry, have done so through a largely “no-fault” approach that spends less time heaping blame on personnel and more time looking for opportunities to prevent such errors in the future. Insofar as the current medical malpractice system drives errors underground, it actually might undermine the welfare of patients.

Richard B. Gunderman, MD, PhD.

When errors do occur, how should radiologists respond? First, we should determine whether the lesion could have been detected. Frequently, a finding is apparent only in retrospect, and no one could reasonably blame a radiologist for failing to see it without the benefit of hindsight. Second, when it seems that a lesion should have been detected, radiologists, like all physicians, should err on the side of open communication. In general, patients should be informed. In sharing information with patients, it is not necessary to speculate on why an error may have occurred.

Third, we need to apologize. We can always express regret that an error occurred, whether or not we are personally responsible for it. If we did not interpret the initial examination, it is important to notify colleagues who were involved with the case, so that they can learn from it. We cannot learn from errors we do not know about or fail to acknowledge. Finally, we should look for opportunities to improve performance throughout the system. For example, enhanced equipment or training might decrease the incidence of such errors in the future.

In short, we need a paradigm shift in medicine. We need to see errors less as signs of personal failure than as learning opportunities that can spawn systematic improvements in the quality of care.

Richard B. Gunderman, MD, PhD, is vice chair, radiology, and director, pediatric radiology, and associate professor, radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy, Indiana University, Indianapolis.

Joint Ventures: What Is Outside the Boundaries?

You own an imaging center whose volume has suffered due to the proliferation of technology in your market sphere. A referring physician comes to you and proposes to lease excess space on your equipment at a per-slot fee. He is willing to purchase five slots per week for a very low flat fee, $325 per slot, but will prepay and will “use them or lose them.” He will do the billing himself from his own practice. Of course, he must be able to market your facility as part of his practice to his patients and affiliated physicians, and since he is a prestigious surgeon and well thought of at the hospital, you believe his affiliation could even help your own marketing effort, as well as your cash flow. You also know that if you say no, he will ask another facility, and you will lose the opportunity and the referrals for the scans he currently sends you today, lowering your volume even further and putting your facility at risk. What is the ethical response?

Response by Cherrill Farnsworth:

This is not a legal issue in that the referring physician will bill under the physician practice exemption of the Stark Law. However, the ethics are very clear. It was never the intent of the Stark Law to launch a new industry to feed self-referral through “slot leasing.” Stark was trying to slow down unnecessary self-referral. We also know that this referring physician, who makes plenty of money through his own practice, is doing this only to make incremental profits through this existing loophole that he can exploit.

Regulations and laws exist to control costs, quality, and safety for the beneficiaries of the Medicare system and for the enrollees of health insurance in the private sector. Moving forward and closing a deal such as this will produce short-term financial safety for the facility. Long term, however, it will harm the facility and the greater imaging provider space. All of us know that agreeing to do this with one referring physician is a slippery slope. It will just bring the next referring physician knocking at the door asking for the same or, worse yet, a better deal. And what about those referring physicians that completely disapprove of such arrangements, knowing that many or most of these arrangements lead to unnecessary examinations, a greater number of patient days out of work, and the dissipation of money from funds that go toward paying for the right examinations for the right patients. I know, it may appear that those physicians are few, but they do exist, and they will not want to align with facilities that do this.

Cherrill Farnsworth

Eventually, the Medicare program and the private sector will take notice of this arrangement, and they will want to become slot leasers at a low rate as well. Why would they reimburse at traditional or even reduced rates, when someone else is receiving what is presumed to be your best deal? If that occurs, revenue will be reduced further.

Fear causes even some of the best providers to bend their ethics because they are thinking in the short term. They fear their competitors will not take the ethical road and, consequently, will compromise. What a sad day in the physician community, but that is the day we live in.

The ethical response would be to decline the offer. And although the tendency would be to keep quiet about the issue, the more proactive response would be to raise awareness of the problem with the local and regional radiology associations, as well as Medicare, the private sector insurers, and the general public. A lot of compromised ethics happen because those involved do not want to talk about the issue, not publicly and not in print.

Cherrill Farnsworth is executive director of the National Coalition for Quality in Diagnostic Imaging and the president and CEO of HealthHelp, Houston.

Sidestepping Conflicts of Interest in Equipment Selection

A university medical center faculty member approaches his Radiology Department Chair, explaining that he and colleagues in orthopedic surgery have developed a portable MRI unit designed to image small body parts. With the assistance of the university legal department, the apparatus has been patented and is now being manufactured by a start-up company owned by the inventors and the university. The radiologist would like the Radiology Chair to authorize purchase of the unit, so that the company will have a showplace to which its salespeople can bring potential buyers. The Chair knows that funds are short and that he will probably be pressured to purchase the equipment by the Orthopedic Surgery Department Chair. Furthermore, the governor of the state is under pressure to show economic development, especially the high-tech industry. If the product is successful, the project could bring significant revenues to the university. But the Chair does not believe that the product is needed and has other, more urgent needs. What should the Chair do?

Response by N. Reed Dunnick, MD, and Deborah Biggs, JD:

Although all parties—the university, the departments, and the faculty—are pleased to have developed and commercialized this product, the university must make the best use of its resources and be sure that purchasing decisions follow appropriate procedures and best meet the needs of its patients. The difficulty of the position for the Radiology Chair can be minimized by having appropriate policies and procedures that the university must follow.

Various policies could apply to this situation. The Radiology Chair must be sure that any purchasing decision is free of bias and is the best decision for the institution as a whole. At a minimum, the Radiology Chair should request that all outside activities of faculty members be disclosed, reviewed, and approved by the university’s Conflict of Interest Review Board (COIRB). The COIRB should examine the relationships and suggest appropriate management procedures to be followed by the faculty, the departments, and the hospital in guiding any potential purchasing decisions. The COIRB should consider the individual conflicts of the faculty and potential institutional conflicts of the university’s ownership interest in the company.

First, is there a need for the product? The Radiology Chair could ask for a formal request by the faculty that would include a business plan detailing patient care needs, expected volumes, and revenues. This information, along with estimated expenses, would allow the finance department to generate an expected return on the investment.

Second, if it is felt that the product is needed, a request for proposals (RFP) should be generated. Other vendors might be in a position to respond to the RFP. If so, the products could be compared and a decision made as to which would better satisfy patient care needs.

The medical center should have purchasing polices and procedures in place that require the disclosure of a conflict of interest and provide procedures for disinterested parties to make the purchasing decision.

Many organizations are adopting Institutional Conflict of Interest Policies (ICOI), recognizing that the organization and not just the individual may be conflicted when the organization also has an ownership interest in a company or product. Some ICOI policies require that the purchasing decision be made by a part of the organization that will not directly benefit from the decision or it may require that a disinterested board with nonuniversity members review the conflict before a decision is made.

Serving as a show site for a vendor’s products often is beneficial to the department and the institution. The vendor works even harder to make sure that the department is happy with the equipment and the support provided by the vendor. This enhances the faculty’s experience with the product and increases the likelihood of a sale to the prospective customer.

N. Reed Dunnick, MD (left) and Deborah Biggs, JD.

It is likely that the medical center has a policy regarding visitation by vendors. Typically, these policies determine if and under what circumstances sales representatives of a company may visit a facility. Furthermore, the purchasing contract also can speak to under what conditions the vendor may be allowed to showcase the purchased product to other potential buyers.

Finally, if the medical center is a for-profit organization, the federal Sarbanes Oxley Act also applies. Nonprofit organizations also may follow these procedures in an effort to avoid conflicts of interest. These broad regulations govern many activities of an organization but also speak to conflict of interest and require that organizations have processes in place to ensure that decisions are impartial and do not personally benefit an individual.

N. Reed Dunnick, MD, is the Fred Jenner Hodges Professor and Chair, Department of Radiology, and Deborah Biggs, JD, is director of Regulatory and Business Affairs, and the Medical School Compliance Officer, University of Michigan, Ann Arbor.