FA-5015 Policy on Educational Conflicts of Interest and Recusal

1.0      Purpose

In accordance with Liaison Committee on Medical Education (LCME) Element 1.2: Conflict of Interest Policies, VTCSOM upholds fairness, impartiality, and integrity in all deliberations and decisions by requiring faculty, staff, students, and committee members to disclose any actual or perceived conflicts of interest and, when appropriate, recuse themselves from participation in related matters.

This policy establishes standards for identifying, disclosing, avoiding, and managing conflicts of interest and conflicts of commitment among faculty, staff, students, residents/fellows, and committee members. This policy reflects VTCSOM’s commitment to ensuring that students are educated and evaluated by healthcare professionals and trainees whose primary interest is the student’s educational growth and professional development. This policy applies to all VTCSOM faculty, staff, students, residents/fellows, and members of committees involved in teaching, assessment, advising, admissions, promotions, or other student-facing decisions.

Student related committees (including admissions, promotion, and assessment) focus on decisions that directly affect individual students’ academic standing, progression, and opportunities. Other committees such as curriculum, research and faculty governance committees may also involve situations where conflicts of interest could arise.

2.0      Policy

VTCSOM faculty will follow a code of conduct that avoids any conflict of interest, or appearance of conflict of interest, between the performance of the faculty member’s academic duties and any outside personal interests. Conflicts of private interest may include, but are not limited to, personal activities, appearances, or scheduled visits; or absences that interfere with the faculty member’s ability to fulfill teaching, facilitating, clinical oversight, research oversight, mentorship or other VTCSOM academic responsibilities. Similarly, a conflict of private interest may occur when a faculty member has financial, political, religious, ethnic, or other obligations that interfere with the ability to fulfill VTCSOM academic responsibilities.

Individuals must disclose any actual, potential, or perceived conflict of interest immediately. When a conflict exists, the individual must recuse themselves from related academic, clinical, or committee roles. Recusal is required in situations involving family relationships, close personal relationships, financial interests, dual roles, prior healthcare provider relationships, adversarial relationships, or personal biases that could affect judgment.

The recusal process provides a clear mechanism for identifying and addressing potential conflicts among students, faculty, resident/fellow physicians, and committee members, thereby maintaining the ethical standards and integrity required by both the LCME and the institution.

• A member of any VTCSOM standing committee must recuse themselves if:
  • The individual has or has had a family relationship with the student (e.g., current or former significant other, partner, spouse, child, sibling, or parent).
  • The individual has or has had a close social relationship with the student.
  • The individual has a private financial interest in the outcome of the decision related to the student.
  • The individual has provided health services to the student (e.g., physician, therapist, or other healthcare provider, except in context of emergencies).
  • The individual is aware of any personal bias, prejudice, or favoritism—either positive or negative—that could impair their judgment regarding the student.
  • The individual believes that recusal is necessary to preserve the fairness and integrity of the process.
  • The individual holds or has held an adversarial or legal relationship with the individual.
• Student committee members must recuse themselves from any discussion, deliberation, or decision involving an individual with whom they have a potential conflict, including being in the same cohort, sharing recent study or research projects, or having a personal disagreement or dispute.
• Violations will be addressed on a case-by-case basis. Those who violate this policy may be subject to disciplinary action.

The common core principles of this policy apply across several distinct categories including and in addition to those described and delineated below:

Category 1:  Providers of Health Care and Educational Assessments

If a faculty member, resident/fellow physician, or healthcare professional is assigned to a role whereby they will assess a student and they have previously provided healthcare services (e.g., medical care, counseling services) the individual must recuse themselves by communicating with the course/clerkship director.  If a student identifies a potential conflict of interest in a course or clinical experience, they are expected to communicate with the course or clinical clerkship/elective director.  In these scenarios, the student will be reassigned.

Category 2:  Admissions Committee

All Admissions Committee members, interviewers, and screeners must attest annually that they have reviewed the Policy on Conflict of Interest and Recusal. Committee members are required to recuse themselves if they have or have had a family relationship with an applicant in the current admissions cycle, such as a current or former significant other, partner, spouse, child, sibling, or parent.  In this situation, they must recuse themselves from all participation in the admissions process involving that applicant until a final determination of the applicant’s status has been made.

Category 3:  Medical Student Performance and Promotion Committee

An individual on the Medical Student Performance and Promotion Committee must recuse themselves from any part of the review process, including deliberations, voting, case review, or interviews, if they have a potential conflict of interest. In addition to the general indications for recusal, for the MSPPC specifically, a member must recuse themselves if they are the director of a course, clerkship, or elective that prompted the referral to the committee. Prior to deliberations, the student will be provided with a list of committee members and asked to indicate whether any conflicts of interest exist.

Category 4: Individuals Who Provide Confidential Advice and/or Guidance

Faculty and staff who provide students with confidential guidance or support on personal or sensitive matters should not participate in assessing the student or making decisions regarding their advancement, graduation, or dismissal.

3.0      Procedures

Recusal Procedures

The faculty member should recognize that a conflict of interest may be occurring or has the potential to occur. It is expected that faculty will disclose any new conflict of interest immediately upon such conflict occurring. If a faculty member has a conflict of interest that is interfering with VTCSOM academic responsibilities, the faculty member should approach or be directed to the department chair to discuss steps to be taken that would avoid or mitigate the conflict.  The chair should seek resolution of the conflict.  If no resolution is reached, the faculty member, or the chair on the faculty member’s behalf, should begin the process of reducing academic responsibilities. This may include decreased teaching, facilitating, oversight or other opportunities. If no satisfactory reduction in responsibilities can be reached, the faculty member will be expected to resign from their faculty appointment.

Committee members must recuse themselves from any discussion, deliberation, or decision in which they have a real or perceived conflict of interest, stating the recusal at the start of the discussion and leaving the room or virtual meeting. All members, including students, must complete an annual COI attestation identifying relationships or interests that could present conflicts and must notify the committee chair of any potential conflict, either in writing before a meeting or immediately if one arises during the meeting.

Student members should specifically disclose if they have shared classes, rotations, or extracurricular activities with an individual under review, particularly if the relationship is close or adversarial. If recusal is required, the member may not participate in discussion or voting, although limited participation to provide factual information may be allowed with prior chair approval. If recusals reduce the number of voting members below quorum, the chair may postpone the matter, assign alternate members, or follow an approved contingency procedure.

For admissions committees, any student member with a conflict must be reassigned to review other applicants or excused from that admissions cycle. All recusals, including the member’s name, agenda items involved, general basis for the recusal, and any actions taken to address the conflict, must be documented in the committee minutes, reported to the appropriate oversight team, and maintained for at least four years.

Enforcement and Appeals

Failure to disclose a conflict or to recuse when required may result in disciplinary action, including a written warning, removal from the committee, or referral to the Faculty Affairs Office. Student members who fail to comply may also be referred to the Honor Board or equivalent student professionalism body. A member may appeal a recusal determination to the Dean or their designee within ten business days.

4.0      Definitions

• Conflict of Interest (COI): Any situation in which a personal, professional, financial, academic, or other relationship could compromise or reasonably appear to compromise a member’s ability to act impartially.
• Conflict of Commitment (COC): Any outside activity interfering with the ability to fulfill VTCSOM responsibilities.
• Recusal: Withdrawal from discussion, deliberation, decision making, and voting on a specific matter, including physical absence from the meeting during such discussion or vote.
• Immediate Family: Spouse or partner, parent, child, sibling, in-law, or any household member.
• Close Personal Relationship: Includes romantic partners, significant friendships, and mentoring relationships.
• Duality of Interest: Holding multiple roles with respect to an individual, such as serving as both mentor and evaluator.

5.0      References

• Virginia Tech Conflict of Interest policy 13010
• Virginia Tech Faculty Handbook, section 2.2.4.1 (Conflict of Interest and Commitment), 2.36 (Conflicts of Interest) and section 3.4 (Promotion and Tenure)