Canadian Association of Pathologists
Association canadienne des pathologistes

The guidelines were reviewed and approved by the CAP Executive, July 15, 2006 and printed in the CAP 2006 Summer Newsletter.

PREAMBLE

Professionalism is the basis of Medicine’s contract with society. The principles of medical professionalism include: service, expertise, and ethics. These guiding principles apply equally to Laboratory Medicine as they do to all other fields of medicine.

The practice of Laboratory Medicine embodies the physician patient relationship, as each request for service constitutes a referral for medical consultation. The laboratory physician-patient relationship is most often through a delegated process involving primary care physicians/specialists, laboratory technologists and other allied health care workers. The laboratory physician has multiple points of contact with the patient either directly, or through a second physician consultant to the patient or through the staff of the institution. It is most usual for direct contact in a setting of fine needle aspirations, bone marrow/core biopsy, stimulation and suppression tests, multi-disciplinary clinics and participation in rounds. In every instance, the laboratory physician is the medical consultant. Laboratory physicians are frequently in a supportive role in the continuum care in either anatomical or clinical laboratory practices, as direct care is provided through physician colleagues.

Service embodies a commitment to patients first. Patient welfare is at the heart of everything we do and professionalism in laboratory medicine requires us to serve the interests of the patient above our own self-interest. This entitles us to the trust, respect and values of integrity of our patients, colleagues and society.

Expertise derives from a mastery of an expanding body of knowledge and skills. We realize that graduation from medical school is just the beginning of a lifelong education and that we must stay committed to maintaining the knowledge and skills necessary for the provision of quality patient care. The laboratory physician should use their knowledge about disease acquired through analysis of clinical specimens and material to advance scientific knowledge of disease.

Ethical behaviour flows from a combination of values and standards from the profession and society. This is characterized by the values and integrity, dedication, compassion, beneficence,
non-malfeasance, respect for persons, justice, and adherence to professional codes.

A code of ethics is useful as a recommendation of appropriate and proper conduct. It is intended to be useful as a guide to physicians faced with ethical decisions in their practices. It does not have the power of law, but represents the standards of the profession as established by the physician’s peers and societal norms by which he or she may determine their appropriate ethical conduct.

The Code of Ethics of the Canadian Medical Association, as adopted by the CAP, is based on the work of Thomas Percival, who had grounded his Code of Ethics in a collective professional fiduciary responsibility – caring for the sick.

A Physician Charter entitled “Medical Professionalism in the New Millennium”, published simultaneously in the Lancet and the Annals of Internal Medicine (February 2002), describes 10 commitments that physicians offer society as their component of the contract. It helps to crystallize and illuminate the Code of Ethics. The contractual relationship between the physician and the patient is the essence of Laboratory Medicine practice.

A. THE LABORATORY PHYSICIAN

1. Recognizes the College of Physicians and Surgeons in the province/territory in which he/she practices as the body responsible for regulating conduct and has the power and authority to discipline unprofessional conduct. Ethical medical practice is the expected conduct of laboratory physicians.
2. Should perform their professional duties in a manner consistent with current standards of good practice in the specialty.
3. Should use currently accepted methods and practices of the specialty. They should not voluntarily associate professionally with other professionals or practitioners who do not practice in a recognized scientific method.
4. Should not direct or supervise a laboratory if he/she lacks experience or adequate training in any aspect of the laboratory’s operations, unless he/she can ensure that the appropriate specialist’s skills are readily available to such laboratories.
5. Should complete their medical consults in a prompt, accurate and complete form. Preliminary communication (written or verbal) with documentation should be made whenever possible if undue delays are anticipated in completion of the referral consultation. Critical results should be communicated in a timely manner.
6. Medical consultations are generally in the form of a written report, sent to the patients of attending physicians. The laboratory physician should be prepared, however, to speak directly to the patient (or a patient-appointed delegate) at their request or as the need arises. This information should be conveyed in a manner understandable by the patient or their delegates.
7. Should seek consultation in difficult cases where it appears that the quality of medical care might be enhanced by such consultation. He/she should seek consultation whenever the patient or patient’s physician requests it. It is unethical to prevent or refuse to seek such consultation.
8. Should acquire and use managerial and administrative skills appropriate to their practice of laboratory medicine. One aspect of managerial skills consists of appropriate resource allocation in the laboratory, so that these resources are best used for the maximum number of patients.
9. Should recognize and avoid conflicts of interest. Any conflict of interest should be resolved in the favor of patients. If, for some reason, he/she cannot avoid being in a position of conflict of interest, the conflict should be declared to any individuals who are party to the situation and efforts initiated to modify the relationship.
10. Should not advertise their services, or those of their laboratories, by methods contrary to the guidelines of the provincial College of Physicians and Surgeons.

B. PATIENTS, LABORATORY PHYSICIANS AND ATTENDING PHYSICIANS

1. Laboratory physicians should preserve the patient’s privacy and information in professional confidence, unless required to reveal such information by law.
2. Should carry out their professional acts for a patient, once undertaken, to their conclusion.
3. Laboratory physicians should perform the appropriate tests for the medical condition of the patient. Further medical consultation with the patient or attending (treating) physician may be required in the management of care. The laboratory physician should approach the patient if specific circumstances necessitate consent. The laboratory physician must document the analysis performed and assure the attending physician/patient are provided the results.

C. PROFESSIONAL COLLEAGUES

1. Laboratory physicians, providing consultation on the material previously reported on by another laboratory physician, should provide that physician with a copy of their report and should communicate directly with him or her if there is a significant difference of opinion. If a fee is charged for such a consultation, then only the professional component allowed by the fee schedule should be charged under the consultant’s Provincial Health Plan.
2. A Laboratory physician requesting consultation from a second laboratory physician, whether by request of the attending physician and/or patient or not, should provide the consultant with a copy of the original communication and all necessary slides or specimens.
3. The Laboratory physician has a duty and responsibility to uphold the welfare of the public and the honour of their profession. Unethical behaviour or unprofessional behavior of one’s colleagues shall be reported to the appropriate professional body.
4. Should not pay a commission to, or split fees with, any other individuals or organizations as an inducement to use their laboratory.
5. Should not accept commissions or fees as an inducement for the referral practice.
6. Laboratory physicians engaged in clinical research should assure patient consent, by either contacting the patient directly or through a delegated consent process. The consent to contact the patient should ideally be obtained and documented at the time of the initial consultation. In circumstances where this is not possible, the contact for consent should be specific to patients with the inferred, medical condition under investigation. For anatomical pathology, except for tissues registry data banks, contact should be directed to the patient/guardian/executor or other duly appointed individual to obtain consent. Such contact and consent procedures should always meet that required by law or other appropriate body including the College of Physicians and Surgeons and Research Ethic Boards.

D. THE LABORATORY

1. Should maintain all medical consults including records of laboratory reports and other documents, as required by law or recommended by the provincial College of Physicians and Surgeons, or other appropriate body.
2. Laboratory physicians should establish and maintain a quality improvement/quality assurance program in laboratory medicine areas under their direction.
3. The laboratory physician, as referred to physician, should assure the results are communicated to the patient to achieve the best possible care.
4. Should encourage efficient and effective use of laboratory services and discourage their mis-use or abuse.

E. HOSPITALS, INDUSTRY AND OTHER ORGANIZATIONS

Laboratory physicians

1. Should not enter into any arrangements which, by their terms, impair or interfere with their free and complete use of their medical knowledge and judgment. All laboratory physicians must recognize that any arrangement or relationship may impair and influence decision-making and therefore should be documented and noted to avoid any misrepresentation.
2. Should respect and abide by all by laws, rules and regulations of the medical staff and administrative policies of their regional or site authority.
3. Should serve on medical and administrative committees of their site facility or regional authority as required, and should assume a leading role where indicated.
4. Should participate actively in the continuing medical educational programs of their site facility or health authority.
5. Should recognize that their role as an expert witness in a legal case is not to help one side or the other to win, but to provide impartial scientific standards by which the judge or jury can make their own judgment about the facts of the case.

F. PARTNERSHIP, GROUP PRACTICE AND SALARIED PHYSICIANS
(Applies to any situation where two (2) or more pathologists are working together, regardless of the means of remuneration)

Laboratory physicians

1. Should select their colleagues on the basis of professional merit.
2. Should in group or partnership practice be informed, at least annually, about the details of the group or partnership income.
3. In situations where remuneration is in the form of a salary, a salary scale should be available, and the reason for increases (e.g. seniority) should be clearly stated and known to all members of the group.
4. Should be an equitable relationship between professional responsibilities and remuneration.
5. All prerequisites and benefits, particularly those relating to professional development (such as attendance at scientific meetings and courses, study leave, sabbaticals) should be distributed equitably in proportion to responsibilities. All laboratory physicians are required to remain current in their practice. Any funding or sponsorship of continuing medical education or clinical/clinical practice/development/ research should only be accepted if there is no interference with the free and complete use of their medical practice.

REFERENCES
This Code was originally based on the 1983 Code of Ethics of the Ontario Medical Association Section of Laboratory Medicine which was written by Dr. Verne Waldorf.
The subsequent major draft revision is based on revised Code of Ethics of the Canadian Medical Association and the Royal College of Physicians and Surgeons of Canada.
Stempsey W.E. The virtuous pathologist. An ethical basis for laboratory medicine. Am J Clin Pathol 1989; 91: 730 738.
Baron D.N. Ethical problems in clinical pathology. J App Philosophy 1992;9;189 202.