1. Initial review and notice
All complaints against College physician members should be submitted to the Executive Vice President (EVP) or ACP Ethics and Professionalism staff. 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. Such complaints will be forwarded along with any supporting documentation to the President and relevant Governor (or if necessary, Chair of the Board of Governors or his/her designee) 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 submitted to the EVP and then forwarded for review to the President and relevant Governor (or if necessary, Chair of the Board of Governors or his/her designee) only if deemed worthy of further review by the EVP.
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 shall be asked to respond in writing within 30 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 proposed place, date and time of hearing at least 30 days in advance of the hearing and shall be encouraged to attend. The member shall also be provided a list of any witnesses or experts expected to testify at the hearing at the request 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 process. All correspondence will be conducted by certified mail, return receipt requested, or otherwise trackable 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.
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 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, 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.
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 verbatim record shall be kept of the hearing. 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.
The Board of Regents must approve sanctions in all cases as provided in Section 6 (b). 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 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 affected member shall be advised of the procedures and possible sanctions by the EVP when he receives notice of the complaint or information 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, Professionalism and Human Rights Policy 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, Professionalism and Human Rights Policy Committee for review. This review shall consider any matter, substantive or procedural, which may have come before the hearing committee. The Ethics, Professionalism and Human Rights Policy 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 Policy Committee within 30 days of issuance of the recommendation and findings of the hearing committee. The Ethics, Professionalism and Human Rights Policy 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, Professionalism and Human Rights Policy 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, Professionalism and Human Rights Policy 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, Professionalism and Human Rights Policy 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, Professionalism and Human Rights Policy Committee, the Board of Regents shall advise the affected member, the Governor and the hearing committee of its decision.
Board of Regents Approved, April 19, 2010.
Previous updates of the procedures:
November 1985 (original procedures)