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Elliott D, Ochieng CA, Zahra J, McNair AG, Main BG, Skilton A, Blencowe NS, Cousins S, Paramasivan S, Hoffmann C, Donovan JL, Blazeby JM. What Are Patients Told About Innovative Surgical Procedures? A Qualitative Synthesis of 7 Case Studies in the United Kingdom. Ann Surg 2023; 278:e482-e490. [PMID: 36177849 PMCID: PMC10414150 DOI: 10.1097/sla.0000000000005714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate how information about innovative surgical procedures is communicated to patients. BACKGROUND Despite the national and international guidance that patients should be informed whether a procedure is innovative and has uncertain outcomes, little is known about current practice. METHODS This qualitative study followed 7 "case studies" of surgical innovation in hospitals across the United Kingdom. Preoperative interviews were conducted with clinician innovators (n=9), preoperative real-time consultations between clinicians and patients were audio-recorded (n=37). Patients were interviewed postoperatively (n=30). Data were synthesized using thematic analytical methods. RESULTS Interviews with clinicians demonstrated strong intentions to inform patients about the innovative nature of the procedure in a neutral manner, although tensions between fully informing patients and not distressing them were raised. In the consultations, only a minority of clinicians actually made explicit statements about, (1) the procedure being innovative, (2) their limited clinical experience with it, (3) the paucity of evidence, and (4) uncertainty/unknown outcomes. Discussions about risks were generalized and often did not relate to the innovative component. Instead, all clinicians optimistically presented potential benefits and many disclosed their own positive beliefs. Postoperative patient interviews revealed that many believed that the procedure was more established than it was and were unaware of the unknown risks. CONCLUSIONS There were contradictions between clinicians' intentions to inform patients about the uncertain outcomes of innovative and their actual discussions with patients. There is a need for communication interventions and training to support clinicians to provide transparent data and shared decision-making for innovative procedures.
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Affiliation(s)
- Daisy Elliott
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Cynthia A. Ochieng
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Jesmond Zahra
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Angus G.K. McNair
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, North Bristol NHS Trust, University of Bristol, Bristol, England
| | - Barry G. Main
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University Hospitals Bristol, Weston NHS Foundation Trust, University of Bristol, Bristol, England
| | - Anni Skilton
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Natalie S. Blencowe
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University Hospitals Bristol, Weston NHS Foundation Trust, University of Bristol, Bristol, England
| | - Sian Cousins
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Sangeetha Paramasivan
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Christin Hoffmann
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Jenny L. Donovan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Jane M. Blazeby
- Centre for Surgical Research, National Institute for Health Research Bristol and Weston Biomedical Research Centre, Surgical Innovation Theme, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
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Hart JP. Percutaneous arteriovenous fistula: Which patient subsets might benefit most and how can we best avoid the potential pitfalls of surgical innovation? J Vasc Surg 2023; 77:1262-1263. [PMID: 36948681 DOI: 10.1016/j.jvs.2022.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 11/07/2022] [Indexed: 03/24/2023]
Affiliation(s)
- Joseph Patrick Hart
- Division of Vascular and Endovascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
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Moving innovation to practice: an Ethics Committee opinion. Fertil Steril 2021; 116:331-336. [PMID: 33926716 DOI: 10.1016/j.fertnstert.2021.03.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 11/20/2022]
Abstract
The introduction of new strategies, tests, and procedures into clinical practice raises challenging ethical issues involving evaluation of evidence, balancing benefits and harms, supporting patient autonomy, avoiding conflict of interest, and promoting advances in health-care. The purpose of this document is to assist reproductive health practitioners as they introduce new interventions into the clinical care that they provide to patients. This document replaces the previously published document of the same name, last published in 2016.
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Balch JA, Cooper LA, Filiberto AC, Chan PE, Sarosi GA, Tan SA. Prevalence and extent of industry support for program directors of surgical fellowships in the United States. Surgery 2020; 168:1101-1105. [PMID: 32943202 DOI: 10.1016/j.surg.2020.07.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/01/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Fellowship program directors have a considerable influence on the future practice patterns of their trainees. Multiple studies have demonstrated that industry can also exert substantial influence on the practice patterns of physicians as a whole. The purpose of this study is to quantify industry support of fellowship program directors across surgical subspecialties and to assess the prevalence of this support within specific subspecialties. METHODS Fellowship program directors for acute care, breast, burn, cardio-thoracic, critical care, colon and rectal, endocrine, hepato-pancreato-biliary, minimally invasive, plastic, oncologic, pediatric, and vascular surgery for 2017 were identified using a previously described database. The Open Payments Database for 2017 was queried and data regarding general payments, research, associated research payments, and ownership were obtained. The national mean and median payouts to nonfellowship program director surgeons were used to determine subspecialties with substantial industry support. RESULTS Five hundred and seventy-six fellowship program directors were identified. Of these, 77% of the fellowship program directors had a presence on the Open Payments Database. The subspecialties with the most fellowship program directors receiving any industry payment, regardless of amount, included vascular (93.5%), cardio-thoracic (92.8%), minimally invasive surgery (90.5%), plastics (85.3%), and colon and rectal (81.0%). The subspecialty with the greatest mean payment was minimally invasive surgery (21,175 US dollars); the greatest median payment was vascular (1,871 US dollars). The 3 most common types of payments were for general compensation (31.4%), consulting fees (28.7%), and travel and lodging (14.7%). Vascular surgery had the greatest percentage of fellowship program directors receiving research payments (48%). The greatest amount paid to any individual fellowship program director was 382,368 US dollars. Excluding outliers, fellowship program directors received substantially more payments than those received on average by general surgeons. CONCLUSION The majority of fellowship program directors receive some industry support. Most payments are for compensation for noncontinuing medical education related services and consulting fees. Certain specialties were more likely to have industry payments than others. Overall, only a minority of fellowship program directors received research support from industry. We advocate for transparent discussions between fellowship program directors and their trainees to help foster healthy academic-industry collaborations.
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Affiliation(s)
- Jeremy A Balch
- University of Florida Department of Surgery, Gainesville, FL
| | - Lou Ann Cooper
- University of Florida Department of Surgery, Gainesville, FL
| | | | - Patricia E Chan
- University of Florida Department of Surgery, Gainesville, FL
| | - George A Sarosi
- University of Florida Department of Surgery, Gainesville, FL
| | - Sanda A Tan
- University of Florida Department of Surgery, Gainesville, FL.
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Abstract
Improving surgical interventions is key to improving outcomes. Ensuring the safe and transparent translation of such improvements is essential. Evaluation and governance initiatives, including the IDEAL framework and the Macquarie Surgical Innovation Identification Tool have begun to address this. Yet without a definition of innovation that allows non-surgeons to identify when it is occurring, these initiatives are of limited value. A definition seems elusive, so we undertook a conceptual study of surgical innovation. This indicated common conceptual areas in discussions of (surgical) innovation, that we categorised alliteratively under the themes of "purpose" (about drivers of innovation), "place" (about contexts of innovation), "process" (about differentiating innovation), "product" (about tangible and intangible results of innovation) and "person" (about personal factors and viewpoint). These conceptual areas are used in varying-sometimes contradictory-ways in different discussions. Highlighting these conceptual areas of surgical innovation may be useful in clarifying what should be reported in registries of innovation. However our wider conclusion was that the term "innovation" carries too much conceptual baggage to inform normative inquiry about surgical practice. Instead, we propose elimination of the term "innovation" from serious discourse aimed at evaluation and regulation of surgery. In our view researchers, philosophers and policy-makers should consider what it is about surgical activity that needs attention and develop robust definitions to identify these areas: for our own focus on transparency and safety, this means finding criteria that can objectively identify certain risk profiles during the development of surgery.
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Affiliation(s)
- Giles Birchley
- Centre for Ethics in Medicine, University of Bristol, Canynge Hall, Bristol, UK.
| | - Jonathan Ives
- Centre for Ethics in Medicine, University of Bristol, Canynge Hall, Bristol, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, University of Bristol, Canynge Hall, Bristol, UK
| | - Jane Blazeby
- Centre for Surgical Research, University of Bristol, Canynge Hall, Bristol, UK
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Birchley G, Huxtable R, Ives J, Blazeby J. Have We Made Progress in Identifying (Surgical) Innovation? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:25-27. [PMID: 31135303 DOI: 10.1080/15265161.2019.1602181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Johnson J, Hutchison K. They Know How to Work It, That’s Their Focus in Life: The Complex Role of Industry Representatives in Surgical Innovation. J Empir Res Hum Res Ethics 2018; 13:461-474. [DOI: 10.1177/1556264618785037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Relationships between health care providers and industry can generate conflicts of interest with their attendant harms. However, the types of relationships that involve conflicts of interest have often been understood narrowly as material ones between individual clinicians and industry. In research we undertook with surgical teams, we found the role of industry representatives has become normalized in the context of surgical innovation. In this article, we report the findings of our study and unpack the features of both surgery and innovation which contribute to the scope and normalization of industry involvement. We argue that these relationships generate significant ethical challenges and conclude by commenting on how our conceptualization of the situation might inform change.
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Affiliation(s)
- Jane Johnson
- Macquarie University, Sydney, New South Wales, Australia
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Sponsoring surgeons: An investigation on the influence of the da Vinci robot. Am J Surg 2018; 216:84-87. [DOI: 10.1016/j.amjsurg.2017.08.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 07/27/2017] [Accepted: 08/21/2017] [Indexed: 11/18/2022]
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Cherla DV, Viso CP, Olavarria OA, Bernardi K, Holihan JL, Mueck KM, Flores-Gonzalez J, Liang MK, Adams SD. The Impact of Financial Conflict of Interest on Surgical Research: An Observational Study of Published Manuscripts. World J Surg 2018; 42:2757-2762. [PMID: 29426969 DOI: 10.1007/s00268-018-4532-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Substantial discrepancies exist between industry-reported and self-reported conflicts of interest (COI). Although authors with relevant, self-reported financial COI are more likely to write studies favorable to industry sponsors, it is unknown whether undisclosed COI have the same effect. We hypothesized that surgeons who fail to disclose COI are more likely to publish findings that are favorable to industry than surgeons with no COI. METHODS PubMed was searched for articles in multiple surgical specialties. Financial COI reported by surgeons and industry were compared. COI were considered to be relevant if they were associated with the product(s) mentioned by an article. Primary outcome was favorability, which was defined as an impression favorable to the product(s) discussed by an article and was determined by 3 independent, blinded clinicians for each article. Primary analysis compared incomplete self-disclosure to no COI. Ordered logistic multivariable regression modeling was used to assess factors associated with favorability. RESULTS Overall, 337 articles were reviewed. There was a high rate of discordance in the reporting of COI (70.3%). When surgeons failed to disclose COI, their conclusions were significantly more likely to favor industry than surgeons without COI (RR 1.2, 95% CI 1.1-1.4, p < 0.001). On multivariable analysis, any COI (regardless of relevance, disclosure, or monetary amount) were significantly associated with favorability. CONCLUSIONS Any financial COI (disclosed or undisclosed, relevant or not relevant) significantly influence whether studies report findings favorable to industry. More attention must be paid to improving research design, maximizing transparency in medical research, and insisting that surgeons disclose all COI, regardless of perceived relevance.
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Affiliation(s)
- Deepa V Cherla
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Cristina P Viso
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
| | - Oscar A Olavarria
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
| | - Karla Bernardi
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA.
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Julie L Holihan
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Krislynn M Mueck
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Juan Flores-Gonzalez
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
| | - Mike K Liang
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sasha D Adams
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
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Shaul RZ, Borschel GH, Flynn J, Hanson MD, Wright L, Zuker RM. Ethical Issues in Pediatric Vascularized Composite Allotransplantation. ACTA ACUST UNITED AC 2016. [DOI: 10.1007/978-3-319-29185-7_10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
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Abstract
The introduction of new strategies, tests and procedures into clinical practice raises challenging ethical issues involving evaluation of evidence, balancing benefits and harms, supporting patient autonomy, avoiding conflict of interest, and promoting advances in health care. The purpose of this document is to assist reproductive health practitioners as they introduce new interventions into the clinical care that they provide to patients.
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Johnson J, Rogers W. Joint issues--conflicts of interest, the ASR hip and suggestions for managing surgical conflicts of interest. BMC Med Ethics 2014; 15:63. [PMID: 25128372 PMCID: PMC4140136 DOI: 10.1186/1472-6939-15-63] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 07/16/2014] [Indexed: 11/17/2022] Open
Abstract
Background Financial and nonfinancial conflicts of interest in medicine and surgery are troubling because they have the capacity to skew decision making in ways that might be detrimental to patient care and well-being. The recent case of the Articular Surface Replacement (ASR) hip provides a vivid illustration of the harmful effects of conflicts of interest in surgery. Discussion We identify financial and nonfinancial conflicts of interest experienced by surgeons, hospitals and regulators in the ASR case. These conflicts may have impacted surgical advice, decision-making and evidence gathering with respect to the ASR prosthesis, and contributed to the significant harms experienced by patients in whom the hip was implanted. Drawing on this case we explore shortcomings in the standard responses to conflicts of interest – disclosure and recusal. We argue disclosure is necessary but by no means sufficient to address conflicts of interest. Using the concept of recusal we develop remedies including second opinions and third party consent which may be effective in mitigating conflicts, but their implementation introduces new challenges. Summary Deployment of the ASR hip is a case of surgical innovation gone wrong. As we show, there were multiple conflicts of interest involved in the introduction of the ASR hip into practice and subsequent attempts to gloss over the mounting body of evidence about its lack of safety and effectiveness. Conflicts of interest in surgery are often not well managed. We suggest strategies in this paper which can minimise the conflicts of interest associated with surgical innovation.
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Affiliation(s)
- Jane Johnson
- Department of Philosophy, Macquarie University, Sydney, NSW 2109, Australia.
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