Conflicts of Interest,Integrity, and Wrongdoing

Question 1

Situations in which PT’s have interests that threaten theirrole responsibilities or that would do so for a typical person intheir role = ?

Conflicts, Integrity, and Wrong

Answer 1

Conflicts of Interest:

• Situations in which PT’s have interests that threaten theirrole responsibilities or that would do so for a typical person intheir role.
• A breach of an obligation to one’sPT ethics which has the effect, or intention, of advancingone’s own interest in a way detrimentalto the interest of the client, or potentially harmful to the integrityof the physical therapy profession.
• Many conflicts of interest involve competing interests in business and professional life.

Question 2

Three reasons to avoid preventable conflicts of interest = ?

Conflicts, Integrity, and Wrong

Answer 2

Reasons to Avoid Preventable Conflicts of Interest Professionally:

1. They threaten responsibilities and can undermine professional integrity.
2. Even the appearance of conflicts of interest can endanger trust of patients and of the public.
3. Most conflicts of interest involve deception and other failures of truthfulness.

Question 3

A conflict of interest arises when a physical therapist’s actions ordecisions may reasonably beperceived to be motivatedorinfluenced by= ?

Conflicts, Integrity, and Wrong

Answer 3

• A conflict of interest arises when a physical therapist’s actions ordecisions may reasonably beperceived to be motivatedorinfluenced byfinancialgain.
• This doesn’t mean that we can’t conduct a health-care business!
• However, it must be done in a manner that doesn’t compromise professional integrity or standard of practice.

Question 4

2 Forms of Conflicts of Interest:

• Episodic = ?
• Systemic = ?

Conflicts, Integrity, and Wrong

Answer 4

2 Forms of Conflicts of Interest:

(1) Episodic:

• Those conflicts that arise from choices madevoluntarily.
• E.g. Giving and accepting personal gifts from patient on the job.

(2) Systemic:

• Arise from the verystructure of the profession.
• E.g. Fee for service reimbursement system which would possibly providepatients with unnecessary servicesin order toincrease profits

Question 5

Medically Necessary Services:

• The physical therapist only provides professional services in situationswhere there is = ?

Conflicts, Integrity, and Wrong

Answer 5

Medically Necessary Services:

• The physical therapist only provides professional services in situationswhere there is a demonstratedneedfor the services.
• The physical therapist must not continue services to a client when theservices are no longer required by the client.
• E.g. Is 80 sessions no longer medically necessary?
• E.g. Is it “overutilization”?

Question 6

Explain the common systemic conflict of interest of the PT’s dual role as adviser and provider = ?

Conflicts, Integrity, and Wrong

Answer 6

PT’s Dual Role - Adviser and Provider:

• A common systemic conflict of interest for us as PT’s = the dual role of adviser and provider.
• We advise patients on options, decide course of action and then provide PT services.
• Adviser can conflict with provider.
• The implications of this vary according to the payment system.

(1) Fee for Service:

• Provider has a systematic incentive to advise for unnecessary services, leading to increased cost of care.
• Can cause increased costs to the patients, unnecessary tests, and unnecessary procedures.

(2) Managed Care:

• Managed care attempts to control the clients served, the range of benefits and services offered and thecosts.
• Systematic incentive to not advise patients of all needed services and thusminimizeusage ofservices.
• Conflict is between thedurationof treatment and the best interest of the client and what is permissible(reimbursable) under the managed careplan.
• The conflict of interest here is the business component to healthcare.

Note:

• The conflict between business standards and professional standards

Question 7

One example of problematic physician referrals = ?

Conflicts, Integrity, and Wrong

Answer 7

Problematic Physician Referrals:
There is state and federal legislation in effect to help contain problematic referral practices.

• Kickbacks: physician gives or receives payment or incentives to induce/reward patient referrals.
• Anti-kickback legislation: Prohibits medical providers from paying or receiving money or anything of value in exchange for referrals of patients who will receive treatment paid for by the government (Medicare, Medicaid).

Referral Relationships:

• E.g. Wife MD and husband PT private practice.
• Stark Law: (Federal Physician Self-Referral laws): Pertains to physician self-referral to any service (payable by Medicare and Medicaid) in which they or a family member have a financial interest.

Notes:

• Exceptions exist for both.
• Even if you meet the exception,
  disclose your relationship to the patients prior to first appointment.
  Physician should provide lists of other therapists in the area with similar training.

Question 8

A good rule of thumb for patient and vendor gifts = ?

Conflicts, Integrity, and Wrong

Answer 8

Patient and Vendor Gifts:

(a) Principle 7C of APTA Code of Ethics:

• “Physical Therapists shall not accept gifts or other considerations that influence or give an appearance of influencing their professional judgment.”

(b) Patient gifts:

• We are engaged with our patients over significant periods of time, and patients often see us as their primary advocate and primary hope for restoration of function.
• As a result, gifts from patients to therapists are common.
• At times these can actually strengthen a component of care.
• Cause for concern is if the patient is trying to influence care.

A good rule of thumb:

• “Gifts should be expressions of gratitude, not manipulation or coercion; they should have minimal monetary value; they should not significantly shape relationships with patients or vendors…. and, more importantly, one should be willing to disclose the gift to interested parties”. Finley C

Question 9

Recommending (and/or Selling) Products or Services:

• If you recommend that the patient purchase a product/service in which you (or a relative) have a financial interest, then the PT must = ?

Conflicts, Integrity, and Wrong

Answer 9

Recommending (and/or Selling) Products or Services:

(a) PT’s must not recommend products or services to patients that are not clinically indicated.

• APTA code of ethics Principle 7D = “Physical therapists shall fully disclose any financial interest they have in products or services that they recommend to patients/clients”/

(b) If you recommend that the patient purchase a product/service in which you (or a relative) have a financial interest, then the PT must:

• Be Transparent! Disclose the nature of the financial interest to the patient in advance.
• Make sure the patient is aware of any practical alterative sources for the product/service.
• Remind the patient that if they choose an alternative supplier, it will not adversely affect their care.
• Document the discussion in the patient’s record.

Notes:

• Some cities/states may have regulations or require you to have a license/permit to sell items

Question 10

One example of tolerable conflicts of interest = ?

Conflicts, Integrity, and Wrong

Answer 10

Tolerable Conflicts of Interest:

(a) Some conflicts of interest are inescapable, accepted and morally tolerable

(b) “In general, conflicts of interest aretolerablewhen the relevant systems are morally permissible, when effective procedures for overseeing abuses are in place, andwhen the relevant parties voluntarily accept the arrangement.”

(c) Examples when they may be accepted:

• In rural/underserved areas where a family member requires intervention that only the PT is qualified to provide.
• The Commission on Accreditation in Physical Therapy allows faculty from competing schools to sit in on review teams when a school is being considered for accreditation.

Question 11

If we’re unable to avoid a conflict of interest, we should = ?

Conflicts, Integrity, and Wrong

Answer 11

Transparency:

If unable to avoid a conflict of interest:
* (1) Be transparent, disclose the conflict to the patient.
* (2) Document the conversation.

Note:

• Transparency doesn’t remove the conflict of interest, but failing to disclose is a breach of our fiduciary duty and our Standard of Practice.

Question 12

Any unwanted verbal or physical “conduct of a sexual nature” = ?

Conflicts, Integrity, and Wrong

Answer 12

Sexual harassment:

• Any unwanted verbal or physical “conduct of a sexual nature”.

Notes on SH:

• Anabuse of power involving sex.
• Isa form of discrimination that is based on a person’s sex/gender
• Violates a person’s autonomy - right to pursue their interests without harmful interference by others.
• Sexual harassment was made illegal in Title VII of the Civil Rights Act of 1964

Question 13

A threat or physical act that creates a reasonable apprehension of imminent harmful or offensive contact = ?

Conflicts, Integrity, and Wrong

Answer 13

Assault:

• A threat or physical act that creates a reasonable apprehension of imminent harmful or offensive contact.

Question 14

A physical act that results in harmful or offensive contact = ?

Conflicts, Integrity, and Wrong

Answer 14

Battery:

• A physical act that results in harmful or offensive contact.

Question 15

Three primary forms of sexual harassment that we can encounter in PT = ?

Conflicts, Integrity, and Wrong

Answer 15

Three primary forms we can encounter in PT:

1. Harassment among employees.
2. Harassment of patients by therapists.
3. Harassment of therapists by patients.

Question 16

Quid pro quo = ?

Conflicts, Integrity, and Wrong

Answer 16

(1) Harassment among employees:

• Unwelcome sexual advances, requests for sexualfavors, andotherverbal or physical conduct of asexualnature.
• The perpetrator may be a man or a woman and the victim does not have to be of the opposite gender.
• This often occurs from someone in a position of power over the victim(boss or supervisor) but not always.

(2) Quid pro quo:

• “This for that”
• Unwelcome sexual advances, requests or other sexual conduct that is made a condition of employment, promotion, pay raise, or other job benefit.

Question 17

The APTA “adopted an approach that forbids allsexualrelationships with current patients while allowing= ?

Conflicts, Integrity, and Wrong

Answer 17

(a) (2) Harassment of Patients by Therapists:

• Forbidden
• Violates autonomy of patients
• Violates patient’strust.

APTA Code of Ethics:

• 4C. Physical therapists shall not engage in anysexualrelationshipwith any of their patients/clients,supervisees, orstudents.
• 4D. Physical therapists shall not harass anyoneverbally,physically,emotionally, or sexually.

(b) Yet,what about when it is a mutual attraction?

• Does aban onthis violate the autonomy and the sexual freedomof consentingadults?
• The APTA “adopted an approach that forbids allsexualrelationships with current patients while allowingconsentingadults to pursue a relationship after formallyending theprofessional-client relationship”
• The code of ethics leaves open situations where patients/students are transferred to another therapist or when supervisors transfer.

Question 18

(3) Harassment of therapists by patients occurs at several levels:

• Mild = ?
• Moderate = ?
• Severe = ?

Conflicts, Integrity, and Wrong

Answer 18

(3) Harassment of Therapists by patients:

• This form of inappropriate sexual behavior is far more common.
• Study in the Physical Therapy Journal: surveyed 892 PT’s and PT students and found that 84% of them experienced some sort of inappropriate interaction/behavior from patients over their career.
• Much more common if working with patients with cognitive impairment

Occurs at several levels:

• Mild: suggestive stories or solicitations for dates.
• Moderate: deliberate touching, direct propositions.
• Severe: forceful fondling and attempts to secure sexualintercourse.

Question 19

Three possible recourses to sexual harassment = ?

Conflicts, Integrity, and Wrong

Answer 19

Recourses:

• Mild offenses: Often handledbyignoring or beingnon-responsiveto the behavior thusescapingtheconflict.
• The victim should attempt to inform the perpetrator that the behavior is unwelcome and that it needs to stop.
• If from a patient, some ideas include: note the behavior in patient’s chart,and assign patient to a different therapist as needed.
• If the behavior continues, the victim should file an official complaint with their employer.
• The supervisor is responsible for taking immediate action to preventrecurrence; can include getting HR or an EEOC official involved, andremoving from the clinic a patient who continues to harass staffsexually.
• Prevention is the best tool in stopping sexual harassment, including training employees and establishing an effective grievance process.

Note:

• TheAPTA has taken a strong stance against harassment; resources are available through their website to help PTs.

Question 20

Avoiding Charges of Misconduct:

• Provide two reasons why health care professionals are at risk for misconduct charges = ?

Conflicts, Integrity, and Wrong

Answer 20

Reasons why health care professionals are at risk for these charges:

• Our patients are in a vulnerable position.
• There is a skewed balance of power in the PT/patient relationship.
• The nature of our work is in close contact with patients.
• May create situations with increased potential for abuse or perceived abuse.

Importance of being diligent:

• Act in the patients’ best interest.
• Protect ourselves from litigation.
• Elevate our reputation as responsible health care professionals.

Question 21

Practical suggestions to avoiding charges ofmisconduct include = ?

Conflicts, Integrity, and Wrong

Answer 21

Some practical suggestions:

• Chose words and language well; be respectful and cultivate trust.
• Always properly drape your patient to maintain modesty.
• Obtain informed consent (see lecture); this includes asking permission to touch or move their body parts.
• Choose our words and language thoughtfully; educate and explain why you are doing what you’re doing.
• Use third party witnesses when appropriate.
• Ask if your patient would prefer a PT of another gender.
• Avoid being the sole treating PT in the clinic.
• Communicate
• Document

Question 22

Warning signs for substance abuse by professionals = ?

Conflicts, Integrity, and Wrong

Answer 22

Some warning signs in co-workers:

• Poor documentation
• Trouble concentrating
• Treatment errors
• Absenteeism or tardiness
• Paranoia and mood swings
• Deterioration of personal appearance and hygiene
• Loss of interest in work… or becoming a super PT

(a) Peer actions to take:

• Group intervention with a caring group of family, friends or other associates.
• Trusted friend or another colleague speak with them.
• In extreme situations, file a formalcomplaintwith one’s employer or other authority

(b) In many states the PT with substance abuse can voluntarily go through a professional recovery network and receive help unknown to the licensing board.

• If there has been a complaint filed to the licensing board, it will do an investigation and decide licensing course of action.

Question 23

Whistle-blowing:

• Internal = ?
• External = ?
• Open = ?
• Anonymous = ?

Conflicts, Integrity, and Wrong

Answer 23

Whistle-blowing:

(1) Internal:

• Information conveyed to higher authorities within the organization

(2) External:

• Information conveyed outside the organization perhaps to a journalist or a government official.

(3) Open:

• Identifies self as source of information

(4) Anonymous:

• Withholds one’sidentitywhen reporting

Question 24

Mandatory Reporting = ?

Conflicts, Integrity, and Wrong

Answer 24

Mandatory Reporting:

• Legally mandatory reporting of injuries to patient caused by the wrongdoing of family and others.
• APTA Code of Ethics 4F: “Physical therapists shall report suspected cases of abuse involvingchildren or vulnerable adults to theappropriate authority, subject to law”.
• All members of families can be at risk for domestic violence including adult males.

However, those most vulnerable and at most risk:

• Children
• Women
• The elderly
• The disabled

Question 25

APTA’s position on domestic violence = ?

Conflicts, Integrity, and Wrong

Answer 25

APTA’s position on domestic violence:

• That PTs should routinely screen all patients for domestic violence.
• Due to a fiduciary duty to our patients.
• We as PTs are consistently involved with the family and uniquely positioned to identify family violence.

Question 26

Signs of domestic violence = ?

Conflicts, Integrity, and Wrong

Answer 26

Domestic Violence:

(a) Be informed in some basics:

• The most common batteries occur in central pattern around the head, neck, chest and abdomen.
• Bruising and abrasions are most common physical signs
• Other signs: Avoiding eye contact with the abuser, being easily startled by sudden noises, having psychosomatic complaints like headaches/stomachaches frequently.
• Document injuries that you observe.

Question 27

What should we do if we suspect a patient is dealing domestic violence = ?

Conflicts, Integrity, and Wrong

Answer 27

Domestic Violence:

• Patients often come to medical appointments with their abuser, and he may insist on coming in to the appointment.
• Find a way to separate them, and create a safe place to speak with your patient if you suspect abuse.
• Try to smoothly get her away to another area of the clinic to talk.
• Don’t give the appearance to her partner than anything is wrong.
• You could state that there is a clinic policy about privacy during exams.
• Establish trust: help her know her safety is your priority and you won’t take any action that puts her at risk.
• Start with broad questions:
• • “How is everything at home?”
• • “How is your relationship with your partner?”
• If he/she is responsive you can ask more pointed questions:
• • “Are you worried for your safety?”
• • “Are you afraid?”
• Stay compassionate, listen, offer local and national domestic violence resources, even if she denies abuse.
• Write the helpline phone number on a business card and say it’s your “on call number” so that he isn’t suspicious.

Question 28

Conflicts, Integrity, and Wrong

Question 29

Abuse:

• Physical Abuse = ?
• Child Neglect = ?
• Sexual Abuse = ?
• Emotional Abuse = ?

Conflicts, Integrity, and Wrong

Answer 29

Child Abuse: Reporting the abuse of children is a matter extensively required by federal and state law.

(a) Physical Abuse:

• Infliction of physical injury.

(b) Child Neglect:

• Failure to provide for the child’s basic needs (physical, educational or emotional).

(b.1) Physical Neglect:

• Refusal or delay in seeking health care; abandonment; expulsion from the home; inadequate supervision.

(b.2) Educational Neglect:

• Allowance of chronic truancy, failure to enroll a child in school;failure to attend to special educational needs.

(b.3) Emotional Neglect:

• Marked inattention to the child’s needs for affection; refusal to provide needed psychological care.

(c) Sexual Abuse:

• Fondling a child’s genitals, intercourse, incest, rape; exploitation of child through prostitution or the production of pornographic materials.

(d) Emotional Abuse:

• Psychological/verbal abuse, mental injury; acts or ommisions by the parents that have caused serious behavior, cognitive, emotional or mental disorders.

Question 30

Elder Abuse:

• Domestic Elder Abuse = ?
• Institutional Abuse = ?
• Physical Abuse = ?
• Sexual Abuse = ?
• Emotional or Psychological Abuse = ?
• Neglect = ?
• Abandonment = ?
• Financial or Material Exploitation = ?

Conflicts, Integrity, and Wrong

Answer 30

Elder Abuse: Reporting the abuse of the elderly is a matter extensively required by federal and state law.

(a) Domestic Elder Abuse:

• Maltreatment of an older person by someone who has a special relationship with them (spouse, sibling, child).

(b) Institutional Abuse:

• Abuse that occurs in residential facilities (nursing homes, group homes).

(c) Physical Abuse:

• The use of physical force that may result in bodily injury, physical pain or impairment.

(d) Sexual Abuse:

• Non-consensual sexual contact of any kind with an elderly person; includes with a person incapable of giving consent.

(e) Emotional or Psychological Abuse:

• Infliction of anguish, pain or distress through verbal or nonverbal acts (humiliation, threats, insults).

(f) Neglect:

• Refusal or failure to fulfill any part of a person’s obligations or duties to an elder, including food, water, shelter, medicine, comfort.

(g) Abandonment:

• Desertion of an elderly person by an individual who has assumed responsibility for providing care.

(h) Financial or Material Exploitation:

• Illegal or improper use of an elder’s funds, property, or assets.