A Staff Ethics Journey

By: Kirsten Olean

Your association may have a code of ethics for members, but have you considered whether your internal processes and policies live up to that code? The American Association of Medical Colleges rose to that challenge and looked at meetings, fundraising, and more in a whole new way. (Titled "Bringing Ethics to Light" in print version.)

In November 2000, Jordan J. Cohen, M.D., president of the Association of American Medical Colleges, titled his annual address at the AAMC Annual Meeting "Trust Us to Make a Difference: Ensuring Public Confidence in the Integrity of Clinical Research." At the time, public trust in clinical research was high, but the recent death of a healthy patient in a gene-therapy clinical trial had raised concerns about whether the interests of research subjects were being adequately protected.

At that same time, commercial support for academic research was increasing due not only to federal-funding shortfalls but also in an effort to speed the translation of research discoveries into products that improved health. Ensuring that faculty relationships with the industry were ethical would become critical to maintaining public trust in research and ensuring that the interests of research subjects remain the faculty's primary concern.

Rather than wait and see how this trend would develop, Cohen appointed a task force on financial conflicts of interest in clinical research to "recast and extend the AAMC's existing and time-honored conflict of interest guidelines as a set of contemporary principles." As the chief staff officer of AAMC, an association representing all 132 accredited U.S. and 17 accredited Canadian medical schools, approximately 400 major teaching hospitals and health systems, and nearly 90 academic and scientific societies, Cohen knew the importance of these ethical issues for the medical profession: "I'm not persuaded to sit tight. The issue for me is the future," he said. The task force's work launched a decade of AAMC leadership on the issue of conflict of interest in research, medical education, and clinical care.

It is not unusual for an association to engage its members to achieve consensus around issues important to the community, nor is it unique to issue recommendations or guidelines to members. AAMC took it a step further, however, by also seizing the opportunity to examine its internal ethics policies.

AAMC's Ethics Journey

In 2008, Darrell G. Kirch, M.D., Cohen's successor as AAMC president and CEO, and the AAMC Leadership Team created an internal task force to evaluate potential conflicts of interest related to external funding.

At the time, AAMC accepted external funding for support of its meetings, program development, research, and awards. AAMC also received funds through exhibitor fees related to its annual meeting. The annual meeting did not receive external financial support outside of the exhibit hall, although this was practice and not policy. There were no written criteria for accepting exhibitors, beyond a "sniff test"; commercial, nonprofit, and educational exhibitors all participated.

For meetings, external support was accepted in accordance with written AAMC guidelines and Accreditation Council of Continuing Medical Education policy where applicable. External support was allowed for specific meeting activities, except for continuing-medical-education meetings where ACCME policies applied. External supporters were allowed "podium time" and advertising to promote their products and services. Commercial representatives could also register for meetings and serve as speakers if they had relevant expertise. (It's worth noting, however, that only a limited number of AAMC meetings solicited external support of any kind.)

There were no formal restrictions on where AAMC sought funding for philanthropic activities such as awards, research projects, symposia, and monographs, and funding at the time included relationships with the pharmaceutical industry. Corporate and foundation donors were also permitted to play a role in award selection, projects, or symposia.

Five Models to Consider

The internal task force ultimately developed five models for consideration by AAMC leadership and also recommended a set of guiding principles for the association (see sidebar below).

The models ranged from maintaining the status quo to a purist approach where the association would accept no external support for the annual meeting, group meetings, or philanthropy and would not permit any commercial exhibitors in the annual meeting exhibit hall. Between these two ends of the spectrum, the task force offered several alternatives, where the recommended guiding principles would serve as criteria for accepting exhibitors and philanthropic funding. Options for external support for group meetings included accepting unrestricted funding for a meeting, accepting funding into a general education fund instead of for specific meetings, or eliminating external support but allowing the purchase of exhibit booths.

The Leadership Team selected and recommended a model to the board of directors, which ultimately approved the AAMC Organizational Policy for Accepting External Support in February 2009. The leadership recognized the value of commercial partnerships in supporting AAMC's mission and chose to allow those partnerships to continue within stricter parameters.

Relative to meetings, the leadership was relatively comfortable with the commercial presence at the AAMC Annual Meeting. A recent survey had confirmed that 94 percent of annual meeting attendees were comfortable or somewhat comfortable with that commercial presence as well. The model selected allowed for commercial participation in meetings in a manner that closely mirrored the annual meeting practice.

Under the approved policy, AAMC does not accept external support for meetings outside of an exhibit hall. AAMC accepts commercial, nonprofit, educational, and other charitable exhibitors for the annual and group meetings, with the guiding principles used as criteria.

AAMC seeks and accepts philanthropy and support for sponsored programs only from nonprofit organizations and individuals, with no restrictions on that support beyond the general designation of the initiative (the specific award, research project, or report). The association also accepts support for awards from nonprofit entities and individuals, but the donor may not be engaged in setting award criteria or in the promotion, selection, or presentation of the recipient. The guiding principles are used as criteria for accepting gifts, sponsored program funding, and awards.

Drilling Down to the Details

Naturally, the new policy resulted in changes in AAMC's practices. For example, a pharmaceutical foundation had financially supported the Humanism in Medicine award and the Medicine in the Community program for years. As a result of the new policy, AAMC discontinued the relationship with that company.

The association was able to secure funding for the award from the Arnold P. Gold Foundation, a nonprofit whose mission aligns with AAMC's, but not at the same level as the original corporate funding. AAMC has not yet found a new donor for the Medicine in the Community program. As a result, the association currently provides significant support for both initiatives.

The biggest impact was on group meetings, since meetings that previously solicited support had to transition to an exhibitor model. To put the policy into practice, the Leadership Team approved an internal policy specific to meetings. Under these internal guidelines, all exhibitor fees must be equal, and exhibit fees cannot exceed 25 percent of the total cost of the meeting. This translated to reduced revenue for some meetings. In most cases, registration fees were increased to cover the cost of the meeting.

In addition, commercial representatives are no longer permitted to register for AAMC meetings (with the exception of the allowable number of booth staff for exhibitors). In some cases, this meant informing a longstanding participant that he or she could no longer attend—often a difficult conversation.

Although these policy changes were challenging and had a financial impact on the association, it was deemed worthwhile. By ensuring the association's policy reflects the same professional and ethical standards it recommends to its members, AAMC can work more positively with its institutions in this area.

Ethics and the Staff

Next, AAMC's focus shifted to staff professional conduct. The Leadership Team appointed the Ethical Conduct for AAMC Staff Team to review existing AAMC staff policies related to ethics, bring clarity and consistency to the policies, and identify missing content. The team was also asked to consider how to actively integrate ethics into the association's employment policy and culture.

AAMC's set of core organizational values is referred to as STRIVE (see sidebar to the right). The Ethical Conduct for AAMC Staff Team did its work within the STRIVE framework and sought to ensure that staff have the resources to put those values into practice.

Kirch explains, "AAMC is a values-driven organization, and while we did not sense major issues around our 'act ethically' value, our leadership wanted to ensure appropriate guidelines were articulated and understood throughout AAMC. Thinking about how our colleagues manage their individual conflicts of interest and commitment is vital to ensuring we all engage in with our members appropriately."

The team systematically reviewed AAMC's existing policies and extensively researched other organizations' staff ethics policies. Although the team found a number of member- or profession-focused ethics policies, surprisingly few were targeted at association staff.

Through their research, team members identified a list of ethics-policy categories that resonated with them and aligned with AAMC's values, including conflict of interest, workplace conduct, reporting of financial irregularities, conduct on behalf of AAMC, privacy of data, and stewardship of resources. The team then crossreferenced the list with existing AAMC policies to identify gaps.

The team also engaged AAMC staff in their deliberations. A survey was designed to evaluate staff familiarity with current policies and solicit feedback on how to improve them. Staff were least familiar with policies regarding conflict of interest, conduct on behalf of AAMC, and reporting financial irregularities; they were most familiar with those on workplace conduct, data privacy, and stewardship of resources. This was logical, given that many workplace conduct policies are highly visible HR policies. Additionally, AAMC conducts an enormous amount of research, so data-privacy issues are highly publicized and top of mind for employees with access to data.

Survey respondents suggested the development of a new policy on vendor relationships, an area the team had already identified as a gap. Staff also indicated a desire to have all ethical conduct policies topically organized and easy to find.

Based on its research, the staff survey, and further discussion, the team recommended that AAMC aggregate all ethics policies on its intranet, develop a new policy on vendor relationships, revise policies related to financial conflicts of interest and the reporting of financial irregularities, and publicize ethics policies to improve staff knowledge of them. Additionally, the team recommended that AAMC retain an outside expert to implement a communications and integration plan for building ethics policies into the culture of AAMC and to provide organizationwide training, ideally using vignettes to illustrate ethical dilemmas and methods AAMC staff should use to resolve or manage them.

The Leadership Team approved the recommendations in January 2010. Since then, AAMC's CFO, Bernard K. Jarvis, has spearheaded the revision of policies on financial conflicts of interest and the reporting of financial irregularities. Jarvis was also tasked with developing the new policy on vendor relationships, in cooperation with key staff.

Once the new and revised policies are drafted, vetted, and finalized, training will be conducted to ensure that all staff understand the policies and know where to go for guidance. Ethics training has been required for new AAMC employees since 2009, but in an organization with more than 500 employees and significant staff longevity, there is a need to reach all staff to increase their awareness and knowledge of ethics policies and best practices. In the long run, AAMC may opt to appoint an ethics advisor or an ethics advisory council to be an ongoing point of contact for ethics-related issues.

Keeping Ethics Real

AAMC is an ethical organization and was before these initiatives began. However, being an ethical organization does not prevent ethical dilemmas. It is important for any organization to have clear, strong, and consistent standards, so that ethical dilemmas can be prevented or resolved early. An association is able to maintain its integrity by ensuring that staff are familiar with and understand its ethics policies, providing strong organizational values to guide behavior, and making resources available to employees who need advice.

Over the last decade, AAMC has led multiple initiatives to promote better practices and consistent standards among its members regarding financial conflicts of interest in clinical research, medical education, and clinical care. But AAMC was not content to simply provide guidance for improvement at member institutions. The organization made a commitment to review and revise its own policies and practices to ensure that it was modeling behavior consistent with its recommendations to its members. AAMC's leadership is committed to holding the association and the academic medicine community to the highest ethical standards, and, through its collective actions, to serve as a role model for other organizations and professions. 

Kirsten Olean, CMP, IOM, is director of meetings at the Association of American Medical Colleges, Washington, DC. Email: [email protected]

Sidebar: AAMC Guiding Principles for Accepting External Support

The following principles will underlie all financial (and gift-in-kind) interactions between AAMC and commercial, nonprofit, and charitable organizations and are designed to minimize real or perceived conflicts of interest with external

  • AAMC acknowledges its role in facilitating prudent interactions between its members and commercial, nonprofit, and charitable entities.
  • AAMC will engage with all parties (external supporters, member institutions, and others) with the same level of professionalism and integrity.
  • AAMC is accountable primarily to its member institutions, and that relationship takes precedence in resolving conflict with a commercial, nonprofit, or charitable supporter.
  • AAMC seeks external support for projects, programs, and collaborative partnerships that align with its strategic priorities.
  • AAMC evaluates each prospective external supporter according to its mission alignment, funding interests, and related criteria before accepting that support. AAMC maintains the right to decline external funding from any source.
  • When sponsoring continuing-medical-education programs, AAMC will comply strictly with the regulations of the accrediting body.
  • AAMC does not endorse commercial, nonprofit, or charitable organizations. While AAMC always will disclose financial support from these organizations, that does not imply endorsement.
  • AAMC reserves the right to restrict attendance at AAMC meetings.

Online Extra: Extended AAMC's STRIVE Values for Excellence

Strive for Greatness:

  • Aim for the highest standard of quality
  • Continue to improve all aspects of our work
  • Contribute to an environment where everyone feels motivated to do his or her best
  • Invest in the development of people
  • Provide honest, useful, and respectful feedback to improve performance

Work Together:

  • Collaborate across AAMC for greater impact and true consensus
  • Seek openness and transparency in actions and decisions
  • Share knowledge, skills, and insight freely with colleagues, for the benefit of all
  • Build relationships with constituents to better understand and respond to their needs
  • Show appreciation for others—everyone's work is important

Take Responsibility:

  • Be personally accountable for the quality of your work and service
  • Honor commitments—do what you say you will do; be where you need to be
  • Exercise good stewardship in use of time and resources
  • Confront performance deficiencies early

Pursue Innovation:

  • Explore new ideas to increase the success of AAMC
  • Think beyond what now exists
  • Exhibit, encourage, and reward initiative
  • Enhance our efficiency, effectiveness, and customer service

Value Everyone:

  • Value the uniqueness of all individuals
  • Show respect for everyone
  • Listen deeply to understand diverse perspectives
  • Give weight to the views of others
  • Act to encourage diversity—in background, talents, and perspective—in all settings and at all levels in AAMC

Act Ethically:

  • Be guided by truthfulness and honesty
  • Work with others to clarify expectations for ethical behavior
  • Treat everyone fairly
  • Propose change that leads to higher levels of organizational integrity

Online Extra: AAMC Ethics Policy Categories

  • Conflict of interest
    • Business transactions
    • Political activity
    • Outside employment and consulting
    • Business with family members
  • Workplace conduct
    • General professional conduct
    • Ethical conduct in research
    • Workplace harassment
    • Equal employment
    • Opportunity in hiring/advancement
    • Diversity in the workplace
    • Personal appearance
  • Reporting financial irregularities
    • Disclosure of personal financial interests
    • Accuracy of accounting/financial records/expense reports
  • Conduct on behalf of AAMC
    • Development and fundraising
    • Offsite meetings
  • Privacy of data
    • Maintaining records and information
    • Protecting proprietary information
  • Stewardship of resources
  • Proper use of organizational materials

Find AAMC's policy on commercial and nonprofit participation in meetings and conferences in our Models & Samples database.