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All complaints against College members should be submitted to
the Executive Vice President (EVP) or ACP Ethics and
Professionalism staff. Any member physician, non-member physician
or lay person may raise concerns regarding unprofessional,
unethical or illegal conduct on the part of a member of the
College. Formal complaints must be in writing and signed by the
complainant, and must describe the act or conduct in question with
reasonable particularity. Such complaints will be forwarded along
with any supporting documentation to the President and relevant
Governor by the EVP. Information brought to the College's attention
that does not meet the standards for a complaint shall be submitted
for review to the President and relevant Governor only if deemed
worthy of further review by the EVP.
If further study by the College is warranted, the member about
whom the concern was raised shall be notified that a complaint was
filed, shall be sent a copy of the complaint, and shall be asked to
respond in writing within 20 days to the EVP. The President, EVP
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. They shall also decide 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 President, EVP
and Governor decide that no further study is warranted, the matter
shall be closed. If the President, EVP 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 place, date and time of
hearing at least 30 days in advance of the hearing and shall be
provided a list of any witnesses expected to testify at the hearing
on behalf of the College.
Any individual with a financial or other conflict of interest in
the review of a member shall not participate in the review
All correspondence will be conducted by certified mail, return
receipt requested, and the term "days" will refer to calendar days.
Each deadline in these procedures shall be extended 30 days in
matters involving international members.
The hearing will be conducted by a hearing committee of at least
three Masters or Fellows of the College, none of whom shall 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 chairperson, will be
appointed by the Governor. The chairperson is to 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 against him. The member may also
present witnesses on his behalf. He may, in lieu of or in addition
to his appearance, submit a written response to the charges.
Because these proceedings are meant to be intracollegial for the
determination of professional issues, not judicial proceedings,
neither the College nor the member should be represented at the
hearing by an attorney. However, if the College elects to have an
attorney present to participate on its behalf at the hearing, the
affected member must also be given the opportunity to be
represented by counsel at the hearing.
Following presentation of all evidence, the hearing committee
shall deliberate and vote to recommend an action to be taken. 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. Said
recommendation shall be sent simultaneously to the President of the
College, the EVP and to the affected member by certified mail,
return receipt requested.
A record shall be kept of the hearing, by tape or stenographic
recording. The member has the right to a record of the proceedings,
copies of which may be obtained by the member upon payment of any
reasonable charges associated with the preparation thereof.
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; and (4)
expulsion. The affected member shall be advised of the procedures
and possible sanctions by the EVP when he receives notice of the
complaint filed against him as provided under Section 1. The member
shall also 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. At the conclusion of the hearing provided under
Section 2, the hearing committee shall forward the entire record of
the case, including its recommendation and written findings, to the
Ethics and Human Rights Committee for its review as provided in
Section 6 (a).
(a) Within 30 days of the issuance of its recommendation and
written findings, the hearing committee shall forward the entire
record to the Ethics and Human Rights Committee for review. This
review shall consider any matter, substantive or procedural, which
may have come before the hearing committee. The Ethics and Human
Rights 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, although
the affected member may submit a written statement to the Ethics
and Human Rights Committee within 30 days of issuance of the
recommendation and findings of the hearing committee. The Ethics
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 10 days of reaching its decision,
the Ethics and Human Rights Committee shall forward its
recommendation to the Board of Regents for review and
implementation, as well as to the affected member.
(b) Unless the recommendation of the Ethics and Human Rights
Committee is considered arbitrary or capricious by the Board, that
recommendation shall be adopted by the Board of Regents. The Board
of Regents may vote to remand the matter to the Ethics 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.
(c) Within 10 days of its decision on a recommendation of the
Ethics and Human Rights Committee, the Board of Regents shall
advise the affected member, the Governor and the hearing committee
of its decision.
Board of Regents Approved, October 29, 2005 (updating December
For more information on complaints against members contact Lois
Snyder Sulmasy at firstname.lastname@example.org , or at