Procedures for Addressing Ethical Complaints Against College Physician Members

The mission of the American College of Physician is “To enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine.”  To those ends, College members take a pledge to “uphold the ethics of medicine as exemplified by the standards and traditions of this College,” as articulated in the ACP Ethics Manual and other College ethics policy.  Peer review is an essential part of medicine and medical practice as professionalism entails membership in a self-regulating and self-correcting community based in ethics.  These procedures govern the collegial peer review of ethical complaints against College physician members. 

1.  Initial review and notice

All complaints against College physician members should be submitted to the Executive Vice President (EVP) or the Center for Ethics and Professionalism.  Any individual may raise concerns regarding unprofessional, unethical, or illegal conduct on the part of a physician member of the College.  Complaints should be in writing and signed by the complainant, and describe the act or conduct in question with reasonable particularity.  Any patient information included in the complaint should be de-identified. Such complaints will be forwarded along with any supporting documentation to the Chair of the Ethics, Professionalism and Human Rights Committee and/or the Director of the Center for Ethics and Professionalism and the relevant ACP Governor by the EVP.  The College will also consider information brought to its attention that does not meet the standards for a complaint, but such information shall be considered only if deemed worthy of further review by the EVP. ACP does not consider individual matters regarding training under these procedures.

If a complaint is about expert testimony, the College shall have the option of consultation with appropriate experts of its choosing at any point in the review, including for an initial review in determining whether the complaint should move forward.  

College deliberations and determinations on complaint matters shall be treated as confidential and privileged, and as per the sanctions section of these procedures.

If further study by the College is warranted, the member about whom the concern was raised shall be notified, shall be sent a copy of the complaint or information and the procedures including possible sanctions, and shall be asked to respond in writing within 30 days to the EVP.  The EVP and the Ethics, Professionalism and Human Rights Committee Chair and/or Center for Ethics and Professionalism Director and relevant Governor shall review any response and determine if professional review action by the College is warranted, or if no further study is required.  If it is decided that no further study is warranted, the matter shall be closed. 

It should also be decided if any file should remain open pending another investigative body's examination involving the member's alleged conduct or if other authorities should be notified about the alleged conduct.  

If the EVP, and the Ethics, Professionalism and Human Rights Committee Chair and/or Center for Ethics and Professionalism Director, and Governor determine that a hearing is warranted, the Governor shall announce the date of that hearing within 60 days of the decision to hold a hearing.  The member shall be provided notice of the proposed place, date and time of hearing and the option to attend at least 30 days in advance of the hearing.  The member shall also be provided a list of any witnesses or experts expected to testify at the hearing if the College has requested witnesses or experts. 

Any individual with a financial or other conflict of interest in the review of a member shall not participate in the review process.  All correspondence will be conducted by trackable mail and/or confidential email and the term "days" will refer to calendar days.  The complainant and the member will be informed on a periodic basis of the status of the review.  Each deadline in these procedures shall be extended 30 days in matters involving international members.

If a member resigns during the peer review process the review will conclude.  Review  will be restarted if the member applies for reinstatement. 

2.  Local hearing

2.1  Hearing committee composition

The hearing will be conducted by a hearing committee of at least three Masters or Fellows of the College, none of whom shall have a conflict or be in direct economic competition with the member, and none of whom may have participated in any prior review of the member's activities.  Committee members, one of whom will serve as chair, will be appointed by the Governor. 

2.2 Hearing committee proceedings

The chair will preside over the hearing, maintain decorum and ensure that all parties have a reasonable opportunity to present evidence.  The affected member shall be invited to attend the hearing and to question those presenting evidence or testimony.  The member may also present witnesses. In lieu of or in addition to attending, the member may submit a written response to the charges.  

Because these proceedings are meant to be intracollegial for the determination of professional issues, not judicial proceedings, the member shall not be represented at the hearing by an attorney unless the College elects to have an attorney present to participate on its behalf at the hearing.

2.3 Findings

Following presentation of all evidence, the hearing committee shall deliberate and vote to recommend an action to be taken.  The chair is a voting member of the committee.  Only those present for all the testimony may vote.  A majority vote shall decide the issue.  A recommendation with written findings must be issued within 60 days of the conclusion of the hearing and sent to the EVP and  the affected member by trackable mail and/or confidential email.  The hearing committee shall also forward the entire record of the case, including its recommendation and written findings, to the Ethics, Professionalism and Human Rights Committee for its review as provided in Section 4.

2.4 Record

A verbatim record shall be kept of the hearing.  The member has the right to a record of the proceedings.

3.  Sanctions

The Board of Regents must approve sanctions in all cases as provided in Section 5 .  Possible sanctions, in accordance with the terms set forth in the bylaws of the College, may include: (1) a letter of reprimand; (2) probation, a specified period during which the rights and privileges of membership are limited and other conditions may be required; (3) suspension of membership, the withdrawal of the rights and privileges of membership for a specified period with publication of the determination and the member’s name for the specified period on the College website; and (4) expulsion with publication of the determination and the member’s name for 10 years on the College website.  Sanctions (1) reprimand and (2) probation shall not include publication on the College website.  Sanctions (2) and (3) will include conditions for reinstatement after the period of probation or suspension.

The member shall  be advised that reporting laws of various jurisdictions may require the College to report action taken regarding membership status or to report evidence of unethical or unprofessional physician conduct.  

4.  Ethics, Professionalism and Human Rights Committee review

The Ethics, Professionalism and Human Rights  Committee review shall consider any matter, substantive or procedural, which may have come before the hearing committee.  The  Committee shall conduct its review solely on the basis of the written record before it, and shall not receive testimony or review any evidence not reviewed by the hearing committee, except the affected member may submit a written statement to the Ethics, Professionalism and Human Rights  Committee within 30 days of issuance of the recommendation and findings of the hearing committee.  The Ethics, Professionalism and Human Rights  Committee may, at its discretion, require the hearing committee to submit a written response to any matter raised by the member's statement.  

Within 30 days of reaching its decision, the Ethics, Professionalism and Human Rights  Committee shall forward its recommendation to the Board of Regents for review and implementation, as well as to the affected member.

5.  Board of Regents review

Unless the recommendation of the Ethics, Professionalism and Human Rights  Committee is considered arbitrary or capricious by the Board, that recommendation shall be adopted by the Board of Regents.  If not in agreement, the Board of Regents may vote to remand the matter to the Ethics, Professionalism and Human Rights  Committee when two-thirds of those members present and voting shall so vote.  Expulsion shall require a two-thirds vote of the total members of the Board of Regents, acting at a meeting.

Within 30 days of its decision on a recommendation of the Ethics, Professionalism and Human Rights Committee, the EVP shall advise the affected member, the Governor and the hearing committee of the Board of Regents decision.

Board of Regents Update Approved: February 2026

Original Procedures: November 1985