Introduction. This study sought to develop and evaluate a medical ethics curriculum designed spec... more Introduction. This study sought to develop and evaluate a medical ethics curriculum designed specifically for surgical residents. Methods. The learning needs of surgical residents relevant to ethics were determined by using a structured literature review and synthesis strategy. We identified 5 primary areas of importance for ethics education for surgical residents: withdrawing and withholding treatment, advance directives, do-not-resuscitate orders, informed consent, and communicating bad news. Learning objectives were developed, and teaching plans were designed for four 90-minute interactive teaching episodes on the basis of adult learning principles. We surveyed residents using a published survey instrument modified for surgery to identify residents' beliefs about the usefulness of ethics training, confidence in addressing ethical issues, and factual knowledge of ethics questions. Results. Twenty surgical residents at a single institution completed the pretest and posttest close-ended surveys. Results showed that although 88% had formal ethics exposure in medical school, 93% considered ethics education at the resident level to be a "very important" or "important" topic. Residents' confidence in addressing ethical issues showed statistically significant improvement between pretest and posttest surveys for 13 of 23 items. There were no statistically significant linear relationships between postgraduate year of residency and the pretest confidence items or the number of correct responses on the pretest multiple-choice items. Conclusions. Despite the prevalence of ethics education during medical school, surgical residents welcome formal instruction on numerous ethical issues pertinent to surgical practice. A focused curriculum can be developed that has a measurable impact on residents' confidence in addressing ethical issues.
Clinical Trials Design in Operative and Non Operative Invasive Procedures, 2017
A conflict of interest is a source of bias. Conflicts of interest have been defined as "a set of ... more A conflict of interest is a source of bias. Conflicts of interest have been defined as "a set of conditions in which professional judgment concerning a primary interest tends to be unduly influenced by a secondary interest" [1]. They erode public trust in the medical researcher. The most commonly perceived conflict of interest pertains to financial support for the researcher. NIH funding has declined recently in support of clinical trials, and as a result, clinical trials are increasingly launched and supported by pharmaceutical companies. The physician or researcher thus gains monetarily by being an investigator on a drug trial [2]. Presentations and publications require declaration of industry financial backing for transparency regarding these conflicts of interest. In some extreme cases, study sponsors have tried to change results or stop publication [3, 4]. In academic settings, promotion and ambition toward tenure and professional standing can be just as influential as monetary support. The dual role of physician-scientist may create conflicts as the physician's duty as a healer sometimes contradicts the scientist's role as a researcher. Conflicts of interest are not inherently unethical but the physician-scientist's actions can cause concerns [2]. The Association of American Medical Colleges (AAMC) released guidelines to help ameliorate these conflicts of interest: full disclosure, aggressive monitoring and misconduct management [5]. Full disclosure applies to both individual and family financial and professional interests. Institutional review boards (IRBs) play a key role in research monitoring and determining if and to what extent conflicts of interest exist.
European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology, Mar 16, 2017
In recent years, the increasing numbers of small, apparently indolent thyroid cancers diagnosed i... more In recent years, the increasing numbers of small, apparently indolent thyroid cancers diagnosed in the world have encouraged investigators to consider non-intervention as an alternative to surgical management. In the following pages, the prospect of a non-intervention trial for thyroid cancer is considered with attention to the ethical issues that such a trial might raise. Such a non-intervention trial is analyzed relative to 7 ethical considerations: the social or scientific value of the research, the scientific validity of the trial, the necessity of fair selection of participants, a favorable risk-benefit ratio for trial participants, independent review of the trial, informed consent, and allowing the study participants to withdraw from the trial. A non-intervention trial for thyroid cancer is also considered relative to the central concept of equipoise.
Over the previous several decades, numerous changes have occurred in the medical care of cancer p... more Over the previous several decades, numerous changes have occurred in the medical care of cancer patients in the United States. Medications and technologies not previously dreamed of are now commonplace as physicians treat patients with various malignancies. In the midst of these diagnostic and therapeutic advances, another significant change has occurred in how physicians talk to patients with cancer. Just a few decades ago, physicians routinely would not disclose the diagnosis of cancer with a patient. Today, such an approach would be unthinkable to most physicians and patients in the United States. In fact, the current discussions about advance directives assume that a certain minimum level of communication between doctor and patient has occurred.
The purpose of this study was to determine the extent to which first-year surgical residents are ... more The purpose of this study was to determine the extent to which first-year surgical residents are prepared to obtain informed consent from patients. The study was designed to answer the following research questions: 1) Are first-year residents who are asked to obtain informed consent sufficiently knowledgeable about the risks, benefits, and alternatives of the procedures? 2) Can first-year residents accurately answer the questions patients may pose about these procedures? First-year residents (n = 18) were asked to list the risks, benefits, and alternatives for open inguinal hernia repair, laparoscopic cholecystectomy, total thyroidectomy, esophagogastrectomy, and abdominal aortic aneurysm repair, assuming the procedures were elective on otherwise healthy individuals. Residents were also asked to answer questions that patients may pose about each of the procedures. The basic minimum risks, benefits, and alternatives to be listed and answers to the questions were validated by asking faculty representing general (n = 6) and vascular (n = 3) surgery to complete the questionnaires. Few residents were able to correctly list all risks, benefits, and alternatives of any of the procedures. Less than one-half of the questions that patients may ask about the procedures were correctly answered. Even though first-year residents are commonly obtaining consent for surgical procedures, many are unable to provide patients with the correct descriptions of the risks, benefits, and alternatives. Nor were they able to correctly answer common questions. Surgical faculty must take more time to educate first-year residents on the appropriate issues in informed consent for the procedures being performed.
Background The observation that obesity can be successfully treated by gastrointestinal surgery i... more Background The observation that obesity can be successfully treated by gastrointestinal surgery is a tribute to the innovative efforts by determined surgeons and the ever improving safety of general anesthesia. Yet as the body of knowledge and discovery on the root causes of human obesity accumulate, surgical approaches to treat morbid obesity are likely to change dramatically. While there is little doubt that dramatic weight loss can be achieved by surgically creating volume and absorption limitation to the reservoir and digestive functions of the gastrointestinal tract, human progress to more processed foods, less physical activity, and the pervasive public opinion that obesity is self-imposed are major obstacles to more widespread application of this approach. Discussion Here we provide a mechanico-physiologic analysis of current operations, their rationale and limitations, as well as a glimpse of how future interventions might develop as a result of current knowledge in the field. The future of bariatric surgery is discussed in the context of these emerging technologies and in the context of the politics of obesity.
The first case of thyroid carcinoma in a child was described in 1902. Following this, Crile publi... more The first case of thyroid carcinoma in a child was described in 1902. Following this, Crile published the first case series of pediatric thyroid cancer in 1959, whereby he characterized pediatric thyroid cancer in 18 children. He noted that pediatric thyroid cancer was more commonly metastatic to cervical lymph nodes and to the lungs than was described in the adult population. Despite finding these cancers to be more aggressive than in adults, only one of the patients died of thyroid cancer and four of them were alive with lung metastases. This publication spawned many subsequent studies confirming these findings. As a result, there has been much debate on the appropriate surgical treatment of thyroid cancer in the pediatric population both with respect to the extent of surgery and the use of radioactive iodine.
B efore the development of general anesthesia, barber surgeons operated with the patient screamin... more B efore the development of general anesthesia, barber surgeons operated with the patient screaming and strapped to the operative table. Understandably, the historical surgeon was valued for technical ability above all else, with little regard for bedside manner. However till today, surgeons are perceived as the specialty most likely to exhibit disruptive behavior. In the modern world of patient-cantered care, however, tolerating disruptive behavior in exchange for technical mastery is no longer an option. The American College of Surgeons defines professionalism in surgery by stating: ‘‘a good surgeon is more than a technician, and reliance on technical expertise alone as the basis of professionalism might weaken our claim to public legitimacy.’’ Deft fingers and a steady hand may be required for surgical excellence, but professionalism in surgery demands something more. The latter half of the 20th century saw a major shift in the physician-patient relationship, moving from paternalism to an era of shared medical decision making. The magnitude of this change can be fully appreciated by contrasting 2 similar studies on medical communication, performed just 18 years apart. In 1961, Dr Donald Oken surveyed physicians at Chicago’s Michael Reese hospital, asking whether they regularly disclose a cancer diagnosis to their patients. Overall, 88%of physicians, and the samefractionof surgeons, indicated that they did not. A follow-up survey in 1977 revealed a reversal of this policy with 98% of physicians indicating they disclose the diagnosis to cancer patients. This remarkable shift in concept and behavior informs our ideal of the surgical professional in the modern age. Patient-centeredness has placed emphasis not only on communication skills, but also on transparency of practice outcomes and publically available patient satisfaction scores. Modern surgical practice requires engagement with multiple reporting regulations, such as the Centers for Medicare and Medicaid Services’ (CMS) Physician Quality Reporting System; or the inpatient, outpatient, and ambulatory surgery quality programs; the Joint Commission’s Surgical Care Improvement Project; the Agency for Healthcare Research and Quality’s (ARQH) Patient Safety Indicators; or the joint CMS and ARQH Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS), which is publically reported on the internet.
The opinions represented in the AACE/ACE Disease State Clinical Review: Pancreatic Neuroendocrine... more The opinions represented in the AACE/ACE Disease State Clinical Review: Pancreatic Neuroendocrine Incidentalomas are the expressed opinions of the Neuroendocrine and Pituitary Scientific Committee of the American Association of Clinical Endocrinologists. AACE/ACE Disease State Clinical Reviews are systematically developed documents written to assist health care professionals in medical decision making for specific clinical conditions, but are in no way a substitute for a medical professional's independent judgment and should not be considered medical advice. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment of the authors was applied. This review article is a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with, and not a replacement for, their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances.
Introduction. This study sought to develop and evaluate a medical ethics curriculum designed spec... more Introduction. This study sought to develop and evaluate a medical ethics curriculum designed specifically for surgical residents. Methods. The learning needs of surgical residents relevant to ethics were determined by using a structured literature review and synthesis strategy. We identified 5 primary areas of importance for ethics education for surgical residents: withdrawing and withholding treatment, advance directives, do-not-resuscitate orders, informed consent, and communicating bad news. Learning objectives were developed, and teaching plans were designed for four 90-minute interactive teaching episodes on the basis of adult learning principles. We surveyed residents using a published survey instrument modified for surgery to identify residents' beliefs about the usefulness of ethics training, confidence in addressing ethical issues, and factual knowledge of ethics questions. Results. Twenty surgical residents at a single institution completed the pretest and posttest close-ended surveys. Results showed that although 88% had formal ethics exposure in medical school, 93% considered ethics education at the resident level to be a "very important" or "important" topic. Residents' confidence in addressing ethical issues showed statistically significant improvement between pretest and posttest surveys for 13 of 23 items. There were no statistically significant linear relationships between postgraduate year of residency and the pretest confidence items or the number of correct responses on the pretest multiple-choice items. Conclusions. Despite the prevalence of ethics education during medical school, surgical residents welcome formal instruction on numerous ethical issues pertinent to surgical practice. A focused curriculum can be developed that has a measurable impact on residents' confidence in addressing ethical issues.
Clinical Trials Design in Operative and Non Operative Invasive Procedures, 2017
A conflict of interest is a source of bias. Conflicts of interest have been defined as "a set of ... more A conflict of interest is a source of bias. Conflicts of interest have been defined as "a set of conditions in which professional judgment concerning a primary interest tends to be unduly influenced by a secondary interest" [1]. They erode public trust in the medical researcher. The most commonly perceived conflict of interest pertains to financial support for the researcher. NIH funding has declined recently in support of clinical trials, and as a result, clinical trials are increasingly launched and supported by pharmaceutical companies. The physician or researcher thus gains monetarily by being an investigator on a drug trial [2]. Presentations and publications require declaration of industry financial backing for transparency regarding these conflicts of interest. In some extreme cases, study sponsors have tried to change results or stop publication [3, 4]. In academic settings, promotion and ambition toward tenure and professional standing can be just as influential as monetary support. The dual role of physician-scientist may create conflicts as the physician's duty as a healer sometimes contradicts the scientist's role as a researcher. Conflicts of interest are not inherently unethical but the physician-scientist's actions can cause concerns [2]. The Association of American Medical Colleges (AAMC) released guidelines to help ameliorate these conflicts of interest: full disclosure, aggressive monitoring and misconduct management [5]. Full disclosure applies to both individual and family financial and professional interests. Institutional review boards (IRBs) play a key role in research monitoring and determining if and to what extent conflicts of interest exist.
European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology, Mar 16, 2017
In recent years, the increasing numbers of small, apparently indolent thyroid cancers diagnosed i... more In recent years, the increasing numbers of small, apparently indolent thyroid cancers diagnosed in the world have encouraged investigators to consider non-intervention as an alternative to surgical management. In the following pages, the prospect of a non-intervention trial for thyroid cancer is considered with attention to the ethical issues that such a trial might raise. Such a non-intervention trial is analyzed relative to 7 ethical considerations: the social or scientific value of the research, the scientific validity of the trial, the necessity of fair selection of participants, a favorable risk-benefit ratio for trial participants, independent review of the trial, informed consent, and allowing the study participants to withdraw from the trial. A non-intervention trial for thyroid cancer is also considered relative to the central concept of equipoise.
Over the previous several decades, numerous changes have occurred in the medical care of cancer p... more Over the previous several decades, numerous changes have occurred in the medical care of cancer patients in the United States. Medications and technologies not previously dreamed of are now commonplace as physicians treat patients with various malignancies. In the midst of these diagnostic and therapeutic advances, another significant change has occurred in how physicians talk to patients with cancer. Just a few decades ago, physicians routinely would not disclose the diagnosis of cancer with a patient. Today, such an approach would be unthinkable to most physicians and patients in the United States. In fact, the current discussions about advance directives assume that a certain minimum level of communication between doctor and patient has occurred.
The purpose of this study was to determine the extent to which first-year surgical residents are ... more The purpose of this study was to determine the extent to which first-year surgical residents are prepared to obtain informed consent from patients. The study was designed to answer the following research questions: 1) Are first-year residents who are asked to obtain informed consent sufficiently knowledgeable about the risks, benefits, and alternatives of the procedures? 2) Can first-year residents accurately answer the questions patients may pose about these procedures? First-year residents (n = 18) were asked to list the risks, benefits, and alternatives for open inguinal hernia repair, laparoscopic cholecystectomy, total thyroidectomy, esophagogastrectomy, and abdominal aortic aneurysm repair, assuming the procedures were elective on otherwise healthy individuals. Residents were also asked to answer questions that patients may pose about each of the procedures. The basic minimum risks, benefits, and alternatives to be listed and answers to the questions were validated by asking faculty representing general (n = 6) and vascular (n = 3) surgery to complete the questionnaires. Few residents were able to correctly list all risks, benefits, and alternatives of any of the procedures. Less than one-half of the questions that patients may ask about the procedures were correctly answered. Even though first-year residents are commonly obtaining consent for surgical procedures, many are unable to provide patients with the correct descriptions of the risks, benefits, and alternatives. Nor were they able to correctly answer common questions. Surgical faculty must take more time to educate first-year residents on the appropriate issues in informed consent for the procedures being performed.
Background The observation that obesity can be successfully treated by gastrointestinal surgery i... more Background The observation that obesity can be successfully treated by gastrointestinal surgery is a tribute to the innovative efforts by determined surgeons and the ever improving safety of general anesthesia. Yet as the body of knowledge and discovery on the root causes of human obesity accumulate, surgical approaches to treat morbid obesity are likely to change dramatically. While there is little doubt that dramatic weight loss can be achieved by surgically creating volume and absorption limitation to the reservoir and digestive functions of the gastrointestinal tract, human progress to more processed foods, less physical activity, and the pervasive public opinion that obesity is self-imposed are major obstacles to more widespread application of this approach. Discussion Here we provide a mechanico-physiologic analysis of current operations, their rationale and limitations, as well as a glimpse of how future interventions might develop as a result of current knowledge in the field. The future of bariatric surgery is discussed in the context of these emerging technologies and in the context of the politics of obesity.
The first case of thyroid carcinoma in a child was described in 1902. Following this, Crile publi... more The first case of thyroid carcinoma in a child was described in 1902. Following this, Crile published the first case series of pediatric thyroid cancer in 1959, whereby he characterized pediatric thyroid cancer in 18 children. He noted that pediatric thyroid cancer was more commonly metastatic to cervical lymph nodes and to the lungs than was described in the adult population. Despite finding these cancers to be more aggressive than in adults, only one of the patients died of thyroid cancer and four of them were alive with lung metastases. This publication spawned many subsequent studies confirming these findings. As a result, there has been much debate on the appropriate surgical treatment of thyroid cancer in the pediatric population both with respect to the extent of surgery and the use of radioactive iodine.
B efore the development of general anesthesia, barber surgeons operated with the patient screamin... more B efore the development of general anesthesia, barber surgeons operated with the patient screaming and strapped to the operative table. Understandably, the historical surgeon was valued for technical ability above all else, with little regard for bedside manner. However till today, surgeons are perceived as the specialty most likely to exhibit disruptive behavior. In the modern world of patient-cantered care, however, tolerating disruptive behavior in exchange for technical mastery is no longer an option. The American College of Surgeons defines professionalism in surgery by stating: ‘‘a good surgeon is more than a technician, and reliance on technical expertise alone as the basis of professionalism might weaken our claim to public legitimacy.’’ Deft fingers and a steady hand may be required for surgical excellence, but professionalism in surgery demands something more. The latter half of the 20th century saw a major shift in the physician-patient relationship, moving from paternalism to an era of shared medical decision making. The magnitude of this change can be fully appreciated by contrasting 2 similar studies on medical communication, performed just 18 years apart. In 1961, Dr Donald Oken surveyed physicians at Chicago’s Michael Reese hospital, asking whether they regularly disclose a cancer diagnosis to their patients. Overall, 88%of physicians, and the samefractionof surgeons, indicated that they did not. A follow-up survey in 1977 revealed a reversal of this policy with 98% of physicians indicating they disclose the diagnosis to cancer patients. This remarkable shift in concept and behavior informs our ideal of the surgical professional in the modern age. Patient-centeredness has placed emphasis not only on communication skills, but also on transparency of practice outcomes and publically available patient satisfaction scores. Modern surgical practice requires engagement with multiple reporting regulations, such as the Centers for Medicare and Medicaid Services’ (CMS) Physician Quality Reporting System; or the inpatient, outpatient, and ambulatory surgery quality programs; the Joint Commission’s Surgical Care Improvement Project; the Agency for Healthcare Research and Quality’s (ARQH) Patient Safety Indicators; or the joint CMS and ARQH Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS), which is publically reported on the internet.
The opinions represented in the AACE/ACE Disease State Clinical Review: Pancreatic Neuroendocrine... more The opinions represented in the AACE/ACE Disease State Clinical Review: Pancreatic Neuroendocrine Incidentalomas are the expressed opinions of the Neuroendocrine and Pituitary Scientific Committee of the American Association of Clinical Endocrinologists. AACE/ACE Disease State Clinical Reviews are systematically developed documents written to assist health care professionals in medical decision making for specific clinical conditions, but are in no way a substitute for a medical professional's independent judgment and should not be considered medical advice. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment of the authors was applied. This review article is a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with, and not a replacement for, their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances.
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