Embodying performance excellence in medicine: Can The Six Viewpoints help?

Performance excellence in healthcare relies on skilled situational awareness, but there is no comprehensive framework articulating what within a situation requires awareness. Envisioning medicine as a performing artform, we introduce Mary Overlie's The Six Viewpoints-a comprehensive, yet flexible, conceptual framework used in the performing arts world, for teaching, learning, and creating, for over 50 years. We imagine The Viewpoints could serve as a framework to help improve verbal and non-verbal communication and collaboration on medical teams and between providers and their patients. We call on health professions educators to experiment with The Viewpoints to determine how they could be adapted to support performance excellence in the medical arena.

Who will receive the last ventilator: why COVID-19 policies should not prioritise healthcare workers

Policies promoted and adopted for allocating ventilators during the COVID-19 pandemic have often prioritised healthcare workers or other essential workers. While the need for such policies has so far been largely averted, renewed stress on health systems from continuing surges, as well as the experience of allocating another scarce resource-vaccination-counsel revisiting the justifications for such prioritisation. Prioritising healthcare workers may have intuitive appeal, but the ethical justifications for doing so and the potential harms that could follow require careful analysis. Ethical justifications commonly offered for healthcare worker prioritisation for ventilators rest on two social value criteria: (1) instrumental value, also known as the 'multiplier effect', which may preserve the ability of healthcare workers to help others, and (2) reciprocity, which rewards past usefulness or sacrifice. We argue that these justifications are insufficient to over-ride the common moral commitment to value each person's life equally. Institutional policies prioritising healthcare workers over other patients also violate other ethical norms of the healthcare professions, including the commitment to put patients first. Furthermore, policy decisions to prioritise healthcare workers for ventilators could engender or deepen existing distrust of the clinicians, hospitals and health systems where those policies exist, even if they are never invoked.

Minding the Form That Transforms: Using Kegan's Model of Adult Development to Understand Personal and Professional Identity Formation in Medicine

The formation of a physician's professional identity is a dynamic process shaped by and intertwined with the development of that person's larger adult identity. Constructive-developmentalist Robert Kegan's model of adult development describes four mental lenses used for meaning-making and the trajectory through which they transform over time. These lenses determine the way people take in and integrate complex influences into forming their adult identities.When people use a particular lens to construct meaning, Kegan describes them as being "subject" to that lens: The lens "has them," and they are unaware of the ways it shapes their world. Transformations occur when individuals are able to take a lens to which they were subject and regard it objectively. Kegan's lenses that are relevant to medical educators are called instrumental-focused on rules and rewards; socialized-attending to social norms and expectations; self-authoring-seeking to build internal values; and self-transforming-seeing gaps in one's closely held value systems and being open to those of others.When individuals have difficulty facing current challenges, they begin to grow a more complex lens. Subsequent lenses bring the ability to deal with more complexity but also bring their own challenges. Familiarity with Kegan's model can help educators provide more effective support to groups of learners as well as individuals, support learners' transformational growth through the challenging situations inherent in medical education, and supply a common language for many important areas of medical education, including competencies and entrustable professional activities, remediation, leadership development, and curriculum planning.

Using Instrument-Guided Team Reflection and Debriefing to Cultivate Teamwork Knowledge, Skills, and Attitudes in Pre-Clerkship Learning Teams

Drawing on the science of teamwork and the science of learning, we designed an instrument-guided team reflection and debriefing activity to foster teamwork knowledge, skills, and attitudes (KSAs) in medical students. We then embedded this activity within and between a biweekly series of pre-clerkship Team-Based Learning sessions with the goal of encouraging medical students to cultivate a practical and metacognitive appreciation of eight foundational teamwork KSAs that are applicable to both healthcare teams and classroom learning teams. On evaluations, 144 learners from a class of 156 reported increased appreciation for and team improvement with these teamwork KSAs.

Personal Control Over Decisions to Participate in Research by Persons With Histories of Both Substance Use Disorders and Criminal Justice Supervision

Individuals must feel free to exert personal control over decisions regarding research participation. We present an examination of participants' perceived personal control over, as well as reported pressures and threats from others, influencing their decision to join a study assessing the effectiveness of extended-release naltrexone in preventing opioid dependence relapse. Most participants endorsed a strong sense of control over the decision; few reported pressures or threats. Although few in number, participants' brief narrative descriptions of the pressures and threats are illuminating and provide context for their perceptions of personal control. Based on this work, we propose a useful set of tools to help ascertain participants' sense of personal control in joining research.

Cost-effectiveness of extended release naltrexone to prevent relapse among criminal justice-involved individuals with a history of opioid use disorder

BACKGROUND AND AIMS

Criminal justice-involved individuals are highly susceptible to opioid relapse and overdose-related deaths. In a recent randomized trial, we demonstrated the effectiveness of extended-release naltrexone (XR-NTX; Vivitrol^® ) in preventing opioid relapse among criminal justice-involved US adults with a history of opioid use disorder. The cost of XR-NTX may be a significant barrier to adoption. Thus, it is important to account for improved quality of life and downstream cost-offsets. Our aims were to (1) estimate the incremental cost per quality-adjusted life-year (QALY) gained for XR-NTX versus treatment as usual (TAU) and evaluate it relative to generally accepted value thresholds; and (2) estimate the incremental cost per additional year of opioid abstinence.

DESIGN

Economic evaluation of the aforementioned trial from the taxpayer perspective. Participants were randomized to 25 weeks of XR-NTX injections or TAU; follow-up occurred at 52 and 78 weeks.

SETTING

Five study sites in the US Northeast corridor.

PARTICIPANTS

A total of 308 participants were randomized to XR-NTX (n = 153) or TAU (n = 155).

MEASUREMENTS

Incremental costs relative to incremental economic and clinical effectiveness measures, QALYs and abstinent years, respectively.

FINDINGS

The 25-week cost per QALY and abstinent-year figures were $162 150 and $46 329, respectively. The 78-week figures were $76 400/QALY and $16 371/abstinent year. At 25 weeks, we can be 10% certain that XR-NTX is cost-effective at a value threshold of $100 000/QALY and 62% certain at $200 000/QALY. At 78 weeks, the cost-effectiveness probabilities are 59% at $100 000/QALY and 76% at $200 000/QALY. We can be 95% confident that the intervention would be considered 'good value' at $90 000/abstinent year at 25 weeks and $500/abstinent year at 78 weeks.

CONCLUSIONS

While extended-release naltrexone appears to be effective in increasing both quality-adjusted life-years (QALYs) and abstinence, it does not appear to be cost-effective using generally accepted value thresholds for QALYs, due to the high price of the injection.

Relapse to opioid use disorder after inpatient treatment: Protective effect of injection naltrexone

BACKGROUND

Opioid use disorder is often treated with short term hospitalization and medically supervised withdrawal from opioids followed by counseling alone without medication assisted treatment (MAT). More evidence is needed to confirm the expectation that the rate of relapse would be high after short term inpatient treatment and withdrawal from opioids without follow-up MAT.

OBJECTIVE/METHODS

To examine relapse to opioid use disorder in a randomized, multi-site effectiveness trial of extended-release injection naltrexone (XR-NTX) vs community-based treatment as usual (TAU) without medication, as a function of the type of clinical service where treatment was initiated-short-term inpatient (N=59), long-term inpatient (N=48), or outpatient (N=201). Inpatients typically were admitted to treatment actively using opioids and had completed withdrawal from opioids before study entry. Outpatients typically presented already abstinent for varying periods of time.

RESULTS

One month after randomization, relapse rates on TAU by setting were: short-term inpatient: 63%; long term inpatient: 14%; outpatient: 28%. On XR-NTX relapse rates after one month were low (<12%) across all three settings. At the end of the 6 month trial, relapse rates on TAU were high across all treatment-initiation settings (short term inpatient 77%; long term inpatient 59%; outpatient 61%), while XR-NTX exerted a modest protective effect against relapse across settings (short term inpatient: 59%; long term inpatient 46%; outpatient 38%).

CONCLUSIONS

Short term inpatient treatment is associated with a high rate of relapse among patients with opioid use disorder. These findings support the recommendation that medically supervised withdrawal from opioids should be followed by medication assisted treatment.

Do patient characteristics moderate the effect of extended-release naltrexone (XR-NTX) for opioid use disorder?

BACKGROUND

Extended release naltrexone (XR-NTX) injected intramuscularly monthly has been shown to reduce relapse in persons with opioid use disorder. Baseline factors, including patients' demographics, comorbidities and lifestyle, may help identify patients who will benefit most or least from XR-NTX treatment.

METHODS

Potential moderators of XR-NTX's effect were examined in the largest North American randomized open-label effectiveness trial of XR-NTX. Relapse status (Yes/No) at 6-month follow-up was regressed on treatment group (XR-NTX, N=153; or Treatment-as-Usual [TAU], N=155), baseline covariates, and their two-way interaction to identify moderator effects. Baseline covariates included age, gender, summary scores for depression, suicidal thoughts, drug abuse risk, substance use, medical, psychiatric and employment status, socialization, legal and family/social issues, history of abuse and quality of life measures.

RESULTS

Alcohol use to intoxication in the 30days before randomization was a significant moderator: during the treatment phase, those who reported being recently intoxicated before randomization to XR-NTX relapsed to opioids at a rate (56%) similar to TAU (58%), while those without alcohol intoxication in the prior 30days had a lower rate of opioid relapse (41% vs. 65%, respectively, P<0.04).

CONCLUSIONS

XR-NTX appeared to work equally well across subgroups with diverse demographic, addiction, mental health and environmental characteristics, with the possible exception of working better among those without recent alcohol intoxication. These findings should be reassuring to practitioners increasingly using XR-NTX as medical addiction therapy in diverse and often vulnerable populations.

Extended-Release Naltrexone to Prevent Opioid Relapse in Criminal Justice Offenders

BACKGROUND

Extended-release naltrexone, a sustained-release monthly injectable formulation of the full mu-opioid receptor antagonist, is effective for the prevention of relapse to opioid dependence. Data supporting its effectiveness in U.S. criminal justice populations are limited.

METHODS

In this five-site, open-label, randomized trial, we compared a 24-week course of extended-release naltrexone (Vivitrol) with usual treatment, consisting of brief counseling and referrals for community treatment programs, for the prevention of opioid relapse among adult criminal justice offenders (i.e., persons involved in the U.S. criminal justice system) who had a history of opioid dependence and a preference for opioid-free rather than opioid maintenance treatments and who were abstinent from opioids at the time of randomization. The primary outcome was the time to an opioid-relapse event, which was defined as 10 or more days of opioid use in a 28-day period as assessed by self-report or by testing of urine samples obtained every 2 weeks; a positive or missing sample was computed as 5 days of opioid use. Post-treatment follow-up occurred at weeks 27, 52, and 78.

RESULTS

A total of 153 participants were assigned to extended-release naltrexone and 155 to usual treatment. During the 24-week treatment phase, participants assigned to extended-release naltrexone had a longer median time to relapse than did those assigned to usual treatment (10.5 vs. 5.0 weeks, P<0.001; hazard ratio, 0.49; 95% confidence interval [CI], 0.36 to 0.68), a lower rate of relapse (43% vs. 64% of participants, P<0.001; odds ratio, 0.43; 95% CI, 0.28 to 0.65), and a higher rate of opioid-negative urine samples (74% vs. 56%, P<0.001; odds ratio, 2.30; 95% CI, 1.48 to 3.54). At week 78 (approximately 1 year after the end of the treatment phase), rates of opioid-negative urine samples were equal (46% in each group, P=0.91). The rates of other prespecified secondary outcome measures--self-reported cocaine, alcohol, and intravenous drug use, unsafe sex, and reincarceration--were not significantly lower with extended-release naltrexone than with usual treatment. Over the total 78 weeks observed, there were no overdose events in the extended-release naltrexone group and seven in the usual-treatment group (P=0.02).

CONCLUSIONS

In this trial involving criminal justice offenders, extended-release naltrexone was associated with a rate of opioid relapse that was lower than that with usual treatment. Opioid-use prevention effects waned after treatment discontinuation. (Funded by the National Institute on Drug Abuse; ClinicalTrials.gov number, NCT00781898.).

Extended-release naltrexone to prevent relapse among opioid dependent, criminal justice system involved adults: rationale and design of a randomized controlled effectiveness trial

BACKGROUND

Extended-release naltrexone (XR-NTX, Vivitrol; Alkermes Inc.) is an injectable monthly sustained-release mu opioid receptor antagonist. XR-NTX is a potentially effective intervention for opioid use disorders and as relapse prevention among criminal justice system (CJS) populations.

METHODS

This 5-site open-label randomized controlled effectiveness trial examines whether XR-NTX reduces opioid relapse compared with treatment as usual (TAU) among community dwelling, non-incarcerated volunteers with current or recent CJS involvement. The XR-NTX arm receives 6 monthly XR-NTX injections at Medical Management visits; the TAU group receives referrals to available community treatment options. Assessments occur every 2 weeks during a 24-week treatment phase and at 12- and 18-month follow-ups. The primary outcome is a relapse event, defined as either self-report or urine toxicology evidence of ≥10 days of opioid use in a 28-day (4 week) period, with a positive or missing urine test counted as 5 days of opioid use.

RESULTS

We describe the rationale, specific aims, and design of the study. Alternative design considerations and extensive secondary aims and outcomes are discussed.

CONCLUSIONS

XR-NTX is a potentially important treatment and relapse prevention option among persons with opioid dependence and CJS involvement. ClinicalTrials.gov: NCT00781898.

Educational impact of a psychiatric liaison in the medical intensive care unit: effects on attitudes and beliefs of trainees and nurses regarding delirium

OBJECTIVE

Despite high rates and increased risk of mortality, delirium remains underdiagnosed and a minimal focus of formal medical education. This is the first study to examine the educational impact of a psychiatric liaison on beliefs and knowledge about delirium among both nurses and residents.

METHOD

One psychiatrist spent 9 months rounding weekly in the medical intensive care unit, interacting with critical care nurses and internal medicine residents. Preintervention and postintervention surveys were distributed in July 2009 and June 2010, respectively, to staff (critical care nurses: n = 23 and n = 25, respectively; internal medicine residents: n = 31 and n = 23, respectively) and a comparison group (psychiatry residents: n = 29 and n = 23, respectively). Participants responded to 12 statements regarding delirium on a 5-point Likert scale.

RESULTS

There were no statistically significant differences between the presurveys and postsurveys for any item when examining all respondents together, as well as psychiatry and internal medicine residents as individual groups. Critical care nurses showed a significant change between surveys for the statements, "Patients with new-onset anxiety or depression in the intensive care unit most commonly have delirium" (17.4% agree presurvey vs 56.0% agree postsurvey, χ(2) = 7.62, P = .006) and "Delirium is diagnosed less often than it actually occurs" (100% agree presurvey vs 80% agree postsurvey, χ(2) = 5.13, P = .023).

CONCLUSIONS

Though introduction of a psychiatric liaison was very well received by clinical staff, we did not meaningfully affect the attitudes and beliefs of trainees and nurses regarding delirium. Robust and lasting changes in attitudes regarding delirium may require more intensive efforts involving longer intervention periods, greater rounding frequency, or additional didactic teaching.

Genome-wide association study meta-analysis of European and Asian-ancestry samples identifies three novel loci associated with bipolar disorder

Meta-analyses of bipolar disorder (BD) genome-wide association studies (GWAS) have identified several genome-wide significant signals in European-ancestry samples, but so far account for little of the inherited risk. We performed a meta-analysis of ∼750,000 high-quality genetic markers on a combined sample of ∼14,000 subjects of European and Asian-ancestry (phase I). The most significant findings were further tested in an extended sample of ∼17,700 cases and controls (phase II). The results suggest novel association findings near the genes TRANK1 (LBA1), LMAN2L and PTGFR. In phase I, the most significant single nucleotide polymorphism (SNP), rs9834970 near TRANK1, was significant at the P=2.4 × 10(-11) level, with no heterogeneity. Supportive evidence for prior association findings near ANK3 and a locus on chromosome 3p21.1 was also observed. The phase II results were similar, although the heterogeneity test became significant for several SNPs. On the basis of these results and other established risk loci, we used the method developed by Park et al. to estimate the number, and the effect size distribution, of BD risk loci that could still be found by GWAS methods. We estimate that >63,000 case-control samples would be needed to identify the ∼105 BD risk loci discoverable by GWAS, and that these will together explain <6% of the inherited risk. These results support previous GWAS findings and identify three new candidate genes for BD. Further studies are needed to replicate these findings and may potentially lead to identification of functional variants. Sample size will remain a limiting factor in the discovery of common alleles associated with BD.

Advising patients about obtaining genomic profiles

Neurologists, as all physicians, should begin to familiarize themselves with elements of genomic medicine to help their patients navigate the promises and pitfalls of obtaining genomic profiles. The neurologist should encourage a realistic assessment of the patient's expectations regarding the genetic information to be provided and apprise the patient of the challenges involved in obtaining interpretable, clinically useful information. A review of risks of obtaining genomic information is equally important. Discrimination, loss of privacy, receiving inaccurate or unwanted information, and learning information that may create obligations to disclose to others are all possibilities. As genomic research and direct-to-consumer opportunities to obtain genomic information expand, reliance on personal physicians for ethical advice based on current advancements in genomic profiling should be anticipated.

When, why, and how to conduct research in child and adolescent psychiatry: practical and ethical considerations

Changes in the clinical research enterprise to involve practicing psychiatrists in gathering evidence in real-world settings are truly exciting. The CAPTN breaks important ground as a PBRN in psychiatry. The authors anticipate that more practical clinical trials will come. These changes challenge psychiatrists to reach an entirely new level of understanding and appreciation of the ethical and practical challenges of commingling clinical practice and research. It is time that all practicing psychiatrists prepare to meet these challenges.

Tools for tomorrow's health care system: a systems-informed mental model, moral imagination, and physicians' professionalism

Physician educators have been charged with incorporating systems-based approaches into medical education and residency training to help future physicians understand how their ability to provide high-quality health care depends on other individual and organizational stakeholders with whom and, in some cases, for whom they work. In part, this also requires that physicians accept that they have responsibilities to various system stakeholders. These changes are controversial because some fear they might distract physicians from their primary ethical obligation to their patients. However, systems theories and their applications in organizational management and business ethics support the notions that individuals can maintain primary professional ethical obligations while working within complex systems and that organizational systems can be constructed to support individual professional practice. If physicians are to commit to working within and, ultimately, improving systems of care as part of their ethical practice of medicine, then they will need a new mental model. Leading thinkers have used various models of systems and have highlighted different aspects of systems theories in describing organizations, groups of organizations, and organizational processes. This essay draws from these models some basic concepts and elements and introduces a simple but comprehensive mental model of systems for physicians. If it is used with professionalism and moral imagination, physicians might have a tool that they can use to understand, work with, and, ultimately, improve the systems of care that they rely on in their practice of medicine and that critically affect the welfare of their patients.

Stroke genetic research and adults with impaired decision-making capacity: a survey of IRB and investigator practices

BACKGROUND AND PURPOSE

In stroke and other brain disorders, severely affected phenotypes often impair decision-making capacity. Severity is in part under genomic control. Therefore, scientifically valid research into genetic risk may require inclusion of such impaired individuals. U.S. Federal regulations do not detail rules governing enrollment of adults with impaired decision-making capacity into genetic research. Rather, policy and practice are locally determined. This study was conducted to obtain data on how investigators and IRBs handle surrogate authorization to enroll probands into a genetic study where some may lack capacity because of ischemic stroke.

METHODS

Sequential surveys of sites from an ongoing North American study investigating genetic risks for ischemic stroke (2003: 49 sites, response rate=100%; 2007: 53 sites; response rate=91%) assessed whether and how investigators enroll adults with impaired decision-making capacity and determined frequency of IRB approval for enrollment by surrogate authorization.

RESULTS

Approximately 40% of sites report that their IRBs do not approve surrogate authorization to enroll stroke patients-43% (21/49) in 2003 and 35% (17/48) in 2007. Thirty-three percent of sites report evaluating eligible adults who lacked capacity to provide their own informed consent; 18% (9/49) in 2003 and 15% (7/48) in 2007 have enrolled these individuals. Surrogate enrollment is the most common method used. Most sites have not enrolled any individual lacking capacity to give his or her own consent.

CONCLUSIONS

Our study suggests that enrollment by surrogate authorization into stroke genetic research is often not approved by IRBs, and even when allowed is frequently not used. For disorders like stroke, this situation has significant implications for scientific validity.

Impact of restricting enrollment in stroke genetics research to adults able to provide informed consent

BACKGROUND AND PURPOSE

The extent of potential consent bias in observational studies elucidating genetic and environmental contributions to ischemic stroke is largely unknown. The purpose of this study was to assess differences in stroke cohort characteristics between those who provided informed consent and those whose enrollment was authorized by surrogate decision makers.

METHODS

The Ischemic Stroke Genetics Study (ISGS) is a prospective, 5-center, case-control study of first-ever ischemic stroke. Demographic, clinical, and stroke characteristics were compared between cases enrolled by self versus by surrogate. Data from one site that limits enrollment only to those able to self-consent were also analyzed to compare those who enrolled with those not able to consent.

RESULTS

Overall, 10% (54 of 517) were enrolled using surrogate authorization. Self-consented and surrogate-authorized cases did not differ significantly in age, sex, or conventional risk factors. Surrogate-authorized cases had significantly more severe stroke deficits, larger infarcts, and infarcts localizing to left supratentorial regions. Similarly, at the site restricting enrollment, stroke severity and characteristics differed between self-consented individuals and those otherwise eligible but unable to provide consent.

CONCLUSIONS

Failure to permit surrogate authorization in genetic studies of ischemic stroke may skew enrollment toward less severe strokes caused by smaller infarcts. This potential consent bias may undermine the ability to identify genetic determinants of risk and severity and suggests that surrogate enrollment in these studies can be ethically justifiable.

National recommendations for enhancing the conduct of ethical health research with human participants in post-disaster situations

The intricacies and time- sensitivity of conducting high- quality and clinically relevant health-related human subject research in post-disaster situations challenges traditional approaches to ensuring optimal protection that study participants are protected from exploitation and harm. This article briefly reviews the ethics and guidelines for conducting research in post-disaster periods and offers recommendations to improve human subjects research conducted in situations defined by the National Response Framework as 'disasters' and 'emergencies.'

Role of organization ethics in critical care medicine

The authors view the activities involved in critical care medicine as composing a complex adaptive system that is itself operating within a complex adaptive system, the healthcare organization. The authors explain why it is necessary that these systems be viewed this way, and they explain what is necessary to allow them to produce creative or emergent outcomes. They provide a justification for the role of an organization ethics program within this context. They provide a definition of organization ethics and outline the characteristics that an effective organization ethics program would possess.

The CREATE Act: increasing costs associated with the biotech industry?

A new law intended to promote collaborative research may end up costing the biotech industry more and inhibiting innovation.

Practice-based clinical research and ethical decision making--Part I: deciding whether to incorporate practice-based research into your clinical practice

Calls for increasing clinical research in routine care settings aim to improve the empirical and ethical foundations of evidence-based practice. In the treatment and prevention of stroke many troubling management questions remain uninvestigated by the clinical research enterprise. Many practicing physicians perceive available data as having limited applicability to their average patients. Recent efforts by the National Institute of Neurological Disorders and Stroke seek to establish clinical research networks that will expand the role of private practice physicians in the conduct of research on stroke and other neurological diseases, akin to practice-based research networks supported by the Agency for Healthcare Research and Quality and other National Institutes of Health institutes. Adding clinical research to one's practice of medicine has practical and ethical implications. Furthermore, because of the growth and expansion of clinical research, all practicing physicians should have a fundamental understanding of clinical research and the differences between clinical care and clinical research, even if they are not directly involved in the conduct of clinical research, to appropriately advise their patients. In this and the following article, we offer two practical frameworks to aid physicians contemplating adding clinical research to their everyday practice of medicine.

Ethics of clinical research within a community-academic partnered participatory framework

Recommendations for reducing racial and ethnic disparities in health and health care suggest that clinical researchers try community-based participatory research (CBPR). While the body of literature discussing the ethics of CBPR continues to grow, we are not aware of a specific attempt to provide a structure for analyzing the ethics of clinical research using a CBPR approach. We adapt a framework developed by Emanuel, Wendler, and Grady articulating seven requirements for ethical clinical research to clinical research using a CBPR approach. We incorporate findings from the literature on CBPR and identify some of the ethical and practical challenges from our experiences working in CBPR as academics and community members. We find Emanuel et al's framework easily adaptable for CBPR. Six of the requirements are flexible enough to accommodate the needs of CBPR; they are: social or scientific value, scientific validity, fair subject selection, favorable risk-benefit ratio, independent review, and informed consent. We suggest that the seventh requirement, respect for potential and enrolled participants, be amended to respect for potential and enrolled participants, community, and research partners to acknowledge that separate attention should be paid to relationships on these three levels. This adapted framework can guide community-academic partnerships as they evaluate whether to proceed with potential clinical research studies and as they work to enhance the ethics of clinical research studies using a CBPR approach.

Practice-Based Clinical Research and Ethical Decision Making-Part II: Deciding Whether to Host a Particular Research Study in Your Practice

Due to the growth and expansion of clinical research, particularly research conducted in practice-based settings, all practicing physicians should have a fundamental understanding of clinical research and the differences between clinical care and clinical research. Physicians considering adding clinical research to their everyday practice of medicine should carefully assess the practical and ethical dimensions of this decision on their practice. We discuss a framework that can help physicians assess a study they are considering hosting in their practice for seven requirements for ethical clinical research. Such an assessment can help them determine whether they are comfortable that the study is ethical and whether they can adhere to the requirements of the protocol in an ethically appropriate manner to maintain the ethics of the study. Together with the systems-informed professionalism framework presented in the preceding article, using the seven requirements of ethical clinical research framework can help practicing physicians with ethical decision making regarding incorporating practice-based research into their everyday practice of medicine.

The impact of privacy protections on recruitment in a multicenter stroke genetics study

The authors reviewed the recruitment of stroke-affected sibling pairs using a letter-based, proband-initiated contact strategy. The authors randomly sampled 99 proband enrollment forms (Phase 1) and randomly sampled 50 sibling reply cards (Phase 2). The sibling response rate was 30.6%, for a pedigree response rate of 58%. Of the siblings who replied, 96% authorized further contact. Median time from proband enrollment to pedigree DNA banking, which required 3+ probands, was 134 days.

A survey of the SWISS researchers on the impact of sibling privacy protections on pedigree recruitment

To understand the perceptions and attitudes about privacy safeguards in research and investigate the impact of letter-based proband-initiated contact on recruitment, we surveyed researchers in the Siblings With Ischemic Stroke Study (SWISS). All 49 actively recruiting sites provided at least 1 response, and 61% reported that potential probands were enthusiastic. Although 66% of researchers valued proband-initiated contact, only 23% said that probands viewed this strategy as important to protecting the privacy of siblings. A substantial minority of researchers (37%) said the strategy impeded enrollment, and 44% said it was overly burdensome to probands.

Research With Stored Biological Samples

BACKGROUND

There is widespread disagreement about the type of consent needed for research with stored biological samples. Many believe consent for each future use is required to respect individuals. Others worry this approach may block important research.

METHODS

We analyzed 1670 consent forms signed by research participants at the Warren G. Magnuson Clinical Center, National Institutes of Health, between January 1, 2000, and May 31, 2002, that offer options for future research with participants' biological samples. The research participants were healthy volunteers, family members of affected individuals, and individuals with a broad range of medical conditions enrolled in clinical research studies with and without the prospect of direct medical benefit.

RESULTS

Overall, 87.1% of research participants given the option chose to authorize future research on any medical condition. More than 85% permitted unlimited future research with their stored biological samples regardless of sex, age, geographic location, or whether the individual was affected by the disease being studied or a healthy volunteer. Only 6.7% of those given the option to refuse all future research did so. Although African Americans were less likely to permit future research, 75.0% of African Americans still authorized unlimited future research with their samples.

CONCLUSIONS

Most research participants authorize the unlimited future research use of their biological samples when given the opportunity to do so. These findings suggest that providing research participants with a simple binary choice to authorize or refuse all future research might allow individuals to control use of their samples, simplify consent forms, and allow important research to proceed.

Curricular approaches to research ethics training for psychiatric investigators

RATIONALE

Training in research ethics is crucial for psychiatric investigators. Addressing ethical dimensions of human subjects research requires knowledge about the rules and norms governing research; sensitivity to ethical implications of actions; and skills in ethics problem solving. Investigators in training who are physicians have the additional challenge of developing identities as investigators that sometimes conflict with their identities as physicians.

OBJECTIVES

To propose a curriculum for psychiatric research ethics training.

METHODS

Review of literature on ethics education and presentation of a curricular approach to research ethics training for psychiatric investigators.

RESULTS

Research ethics can be learned and should be taught. Involvement of active investigators in teaching research ethics is important. While core topics of psychiatric research ethics training have not yet been identified, there are available models from which to draw. Research ethics should be introduced early and integrated throughout the research training period. Lack of resources and institutional support can be obstacles to development of comprehensive research ethics curricula. Small-group, case-based discussion is best for teaching ethics problem-solving skills. Examples of teaching module ideas and a fully developed sample teaching module are presented.

CONCLUSIONS

There is opportunity for creative models for teaching psychiatric research ethics. Work is needed to identify core topics, target pedagogical strategies to trainees at different levels, and develop evaluation methods.

Bulb of penis as a marker for prostatic apex in external beam radiotherapy of prostate cancer

PURPOSE

To investigate the relationship between the bulb of the penis and the peak of the urethrogram, and to compare this measurement with the ischial tuberosities (ITs) to peak distance.

METHODS AND MATERIALS

Pelvic CT scans from 50 consecutive patients with localized prostate cancer were analyzed to identify the penile bulb. Each patient was required to undergo retrograde urethrography during CT-based treatment planning with 3-mm slices. The peak of the urethrogram was defined as the last CT slice in which the contrast dye in the urethra could be visualized. Measurements were taken from the slice containing the most superior aspect of the penile bulb to the last slice of the urethrogram peak. The superior aspect of the penile bulb was defined as the CT slice nearest the peak that contained a bulbous structure at the base of the penis. This distance was defined as the bulb-peak distance. Similarly, the IT-peak distance was recorded for comparison.

RESULTS

The mean bulb-peak and IT-peak distances were calculated for 47 of 50 patients. The peak of the urethrogram was unable to be evaluated in 3 patients. The mean, median, and range bulb-peak distance was 2.4 mm (SD 1.8), 3 mm, and 0-6 mm, respectively. The mean, median, and range IT-peak distance was 20.1 mm (SD 6.6), 21 mm, and 6-33 mm, respectively. No patient had the bulb located above the apex of the urethrogram.

CONCLUSION

The bulb of the penis is a relatively consistent soft-tissue landmark compared with the ITs and is located an average of 3 mm below the peak of the urethrogram. Therefore, the bulb of the penis is another landmark for the identification of the prostatic apex and is less invasive than retrograde urethrography.

Ethical aspects of research into the etiology of autism

Advances in understanding autism and other developmental neuropsychiatric disorders will come from an integration of various research strategies including phenomenologic, functional neuroimaging, and pharmacologic methods, as well as epidemiologic approaches aimed at identifying genetic and environmental risk factors. The highly heritable nature of autism makes it scientifically valuable to involve parents and siblings as research participants. However, many studies on autism pose ethical challenges because they do not offer the prospect of direct benefit to subjects. In this article, we present an in-depth ethical analysis of current nontherapeutic research strategies that are common in autism research. The ethical analysis applies a proposed ethical framework for evaluating clinical research focusing on seven ethical requirements: (1) social or scientific value, (2) scientific validity, (3) fair subject selection, (4) favorable risk-benefit ratio, (5) independent review, (6) informed consent, and (7) respect for potential and enrolled research participants.

Clinical research and the physician-patient relationship

All practicing physicians should be prepared to respond to requests from patients for advice about participating in clinical trials research. Even physicians who choose not to conduct clinical trials but rather devote their practice to clinical care may have patients who consider volunteering for research. In advising patients about clinical research, physicians enhance the physician-patient relationship and contribute to the overall goals of evidence-based medicine. We discuss several ethical and practical challenges facing physicians who wish to help their patients make decisions about volunteering for clinical trials. In addition, we suggest how preparation for advising patients about clinical research participation can be incorporated into the medical education process.

Rheological microscopy: local mechanical properties from microrheology

We demonstrate how tracer microrheology methods can be extended to study submicron scale variations in the viscoelastic response of soft materials; in particular, a semidilute solution of lambda-DNA. The polymer concentration is depleted near the surfaces of the tracer particles, within a distance comparable to the polymer correlation length. The rheology of this microscopic layer alters the tracers' motion and can be precisely quantified using one- and two-point microrheology. Interestingly, we found this mechanically distinct layer to be twice as thick as the layer of depleted concentration, likely due to solvent drainage through the locally perturbed polymer structure.

Enrolling decisionally impaired adults in clinical research

Progress in diagnosing, treating, and preventing medical conditions that impair decision-making abilities depends on clinical research involving individuals who may be either unable to or have diminished ability to give informed consent. Such research, however, raises ethical concern and controversy about the potential exploitation of these vulnerable individuals. This article addresses a range of ethical and practical issues concerning the enrollment of adults who are decisionally impaired, and those at risk of becoming so, in clinical research. These include (1) the relationship of decision-making capacity to competence, and the framework for determining competence in adults receiving clinical care and making treatment decisions for those who lack competence; (2) the differences between clinical practice and clinical research that influence the criteria for permissible research involving incompetent adults and the applicability of the framework guiding treatment decisions to clinical research decisions; and (3) the regulatory framework developed to guide the ethical participation of children in research and its applicability to determining the scope and limits of research with incompetent adults.

Androgen regulation of the cell-cell adhesion molecule-1 (Ceacam1) gene

Previous studies have established that the cell-cell adhesion molecule-1 (CEACAM1, previously known as C-CAM1) functions as a tumor suppressor in prostate cancer and is involved in the regulation of prostate growth and differentiation. However, the molecular mechanism that modulates CEACAM1 expression in the prostate is not well defined. Since the growth of prostate epithelial cells is androgen-regulated, we investigated the effects of androgen and the androgen receptor (AR) on CEACAM1 expression. Transient transfection experiments showed that the AR can enhance the Ceacam1 promoter activity in a ligand-dependent manner and that the regulatory element resides within a relatively short (-249 to -194 bp) segment of the 5'-flanking region of the Ceacam1 gene. This androgen regulation is likely through direct AR-promoter binding because a mutant AR defective in DNA binding failed to upregulate reporter gene expression. Furthermore, electrophoretic mobility shift assays demonstrated that the AR specifically binds to this sequence, and mutation analysis of the potential ARE sequences revealed a region within the sequence that was required for the AR to activate the Ceacam1 gene. Therefore, the regulation of Ceacam1 gene expression by androgen may be one of the mechanisms by which androgen regulates prostatic function.

Ethical and methodological issues in pedigree stroke research

BACKGROUND

Stroke is a complex genetic disorder with a variable phenotype. Investigations of heritable factors in complex genetic disorders use pedigree and genetic techniques, which pose different ethical and methodological challenges than those routinely encountered in therapeutic research. Building consensus on acceptable research practices in this field is vital to the success of multicentered collaborations.

SUMMARY OF REVIEW

We review important ethical and methodological concerns related to the collection, storage, and release of pedigree research information. The human studies aspects of pedigree research are complicated methodologically because individuals can be active or passive participants and pedigrees can be proband derived, partially validated, or fully validated. Current research ethics frameworks do not work well outside of a dyadic researcher-subject relationship. Privacy and confidentiality for family members must be considered in pedigree research. Investigators should anticipate potential conflicts of interest among family members when designing a pedigree research protocol.

CONCLUSIONS

We propose a "proband-initiated contact" methodology in which the proband or the proband's designate allows identification of potential families without breaching the privacy of individuals in the family. In situations in which family history data are collected without direct contact between researchers and individuals in the proband's family, an Institutional Review Board may waive consent by family members after appropriate review of the protocol and application of rules for granting waivers of consent. Certificates of Confidentiality should be considered.

Signal transduction by the CEACAM1 tumor suppressor. Phosphorylation of serine 503 is required for growth-inhibitory activity

CEACAM1 is a cell-cell adhesion molecule that mediates homophilic cell adhesion. In addition, CEACAM1 was also shown to suppress the growth of prostate, breast, and colon tumors. Structural and functional analyses showed that the adhesion activity of CEACAM1 is mediated by its extracellular domain while its cytoplasmic domain is necessary and sufficient for growth-inhibitory activity. The signal pathways leading to CEACAM1-mediated growth suppression are not known. We studied the importance of phosphorylation of serine 503 in this growth-inhibitory signaling pathway. Full-length CEACAM1 was found to be phosphorylated in vivo in both tyrosine and serine residues. Mutation of tyrosine 488 to phenylalanine did not abolish the tumor-suppressive activity of CEACAM1, suggesting that phosphorylation at tyrosine 488 is not critical for CEACAM1's tumor-suppressive activity. Although expression of CEACAM1's cytoplasmic domain inhibited the growth of DU145 prostate cancer cells in vivo, mutation of serine 503 to alanine abolished the growth-inhibitory activity. In addition, the change of serine 503 to aspartic acid produced tumor-suppressive activity similar to that of the wild-type CEACAM1. These results suggested that phosphorylation at serine 503 is essential for CEACAM1's growth-inhibitory function in vivo.