Gender inequality in leadership and academic rank in academic reproductive endocrinology programs.

PURPOSE: To identify gender differences in leadership and academic rank within academic reproductive endocrinology (REI) programs with fellowships in the USA. METHODS: Official institutional websites of the 2017-2018 American Board of Obstetrics and Gynecology (ABOG)-accredited reproductive endocrinology fellowship programs were reviewed, and gender representation at each leadership position and academic rank (Division and Fellowship Director and Full, Associate, and Assistant Professor) was recorded. Univariate comparisons were performed using Chi-square tests, with significance at p < 0.05. RESULTS: Among 49 ABOG-accredited reproductive endocrinology programs, 263 faculty were identified, 129 (49.0%) male and 134 (51.0%) female. Division directors were 69.3% male and 30.7% female (p = 0.006). Similarly, fellowship directors were 65.3% male and 34.6% female (p = 0.03). Full professors (n = 101) were more frequently male (70.3% vs. 29.7%, p < 0.001). There was no difference in gender among associate professors (n = 60, 51.7% male vs. 48.3% female, p = 0.79), while significantly more assistant professors were female than male (n = 102, 73.6% vs. 26.4%, p < 0.001). CONCLUSION: While a majority of residents in obstetrics and gynecology and half of reproductive endocrinology academic faculty are female, women are still underrepresented among leadership positions and full professors in academic reproductive endocrinology programs with fellowship programs.

Diabetes, from the Origins of the Problem to the Nobel Prize. Bioethics.

Analysis of scientific works from the creation of an experimental model of diabetes before discovery insulin was done. Emphasized is the priority of the Russian pathologist L. W. Sobolew (1876-1919) in the discovery of the endocrine function of the pancreas in experimental animals - rabbits, dogs, cats. In 1923 Canadian scientists Banting and Macleod were awarded the Nobel prize for the discovery of insulin. However, the methods and the idea of Nobel laureates were the same that had been developed 20 years earlier by the Russian scientists. Currently, the incidence of diabetes and related pathologies of organs and systems are growing. The use of animals in experimental biology and medicine will continue for the foreseeable future. The benefits to science and medicine derived from the use of animals in research are undeniable, but this process inevitably increases the responsibility of researchers. It is required constant work on improvement of the experimental methods in order to minimize pain, stress, and the number of animals used in the experiment.

A legal-ethical analysis of reproductive endocrinologists' right to refuse ovulation induction to patients with diminished ovarian reserve.

PURPOSE: Review of the legal and ethical basis for reproductive endocrinologists to refuse ovulation induction to patients with diminished ovarian reserve. METHODS: The Lexis-Nexis search engine was used to perform a legal review pertaining to refusal of treatment. Ethical opinions of medical organizations were also reviewed. RESULTS: Federal antidiscrimination laws provide legal recourse for patients with diminished ovarian reserve who are denied ovulation induction. However, the same laws also permit refusal of care when there is bona fide medical justification to decline services. In addition, the codes of ethics for relevant professional organizations support physicians' decisions to refuse treatment when treatment is futile. CONCLUSION: Although it is ethically and legally permissible to deny ovulation induction to patients with diminished ovarian reserve when medically justified, refusal may invite retaliatory litigation. Counseling remains a cornerstone in directing these patients to options with more potential for success, such as donor eggs and adoption.

Disorders of sex development-when and how to tell the patient.

Physicians and other providers are often confronted with difficult decisions in the area of disclosure. This article examines a hypothetical situation relevant to the practice of pediatric endocrinology. The parents of a child with a disorder of sex development (DSD) wish the physician to treat their child, but without revealing key medical information to the child. Herein, we will explore the legal and ethical responsibilities of a provider to disclose information to an under-age DSD patient and to provide insight on when and how to tell the patient.

Casting a Health Equity Lens on Endocrinology and Diabetes.

As endocrinologists we have focused on biological contributors to disparities in diabetes, obesity and other endocrine disorders. Given that diabetes is an exemplar health disparity condition, we, as a specialty, are also positioned to view the contributing factors and solutions more broadly. This will give us agency in contributing to health system, public health, and policy-level interventions to address the structural and institutional racism embedded in our medical and social systems. A history of unconsented medical and research experimentation on vulnerable groups and perpetuation of eugenics theory in the early 20th century have resulted in residual health care provider biases toward minority patients and patient distrust of medical systems, leading to poor quality of care. Historical discriminatory housing and lending policies resulted in racial residential segregation and neighborhoods with inadequate housing, healthy food access, and educational resources, setting the foundation for the social determinants of health (SDOH) contributing to present-day disparities. To reduce these disparities we need to ensure our health systems are implementing the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care to promote health equity. Because of racial biases inherent in our medical systems due to historical unethical practices in minority communities, health care provider training should incorporate awareness of unconscious bias, antiracism, and the value of diversity. Finally, we must also address poverty-related SDOH (eg, food and housing insecurity) by integrating social needs into medical care and using our voices to advocate for social policies that redress SDOH and restore environmental justice.

Potential liability of reproductive endocrinologists for high order multiple gestation.

BACKGROUND: In light of the recent octuplet birth and the accompanying intensive media coverage, there has been much attention on high order multiple births resulting from assisted reproductive technology. OBJECTIVES: The purpose of this commentary is to review 1) the relative contribution of ART to high order multiple gestation and its impact on infant morbidity, mortality, and health care dollar loss; 2) American Society of Reproductive Medicine's guidelines for the number of embryos transferred in ART; and 3) how reproductive endocrinologists can lessen their exposure to litigation by following the ASRM guidelines for the number of embryos transferred and documenting proper informed consent in the medical records. RECOMMENDATIONS: In situations in which the number of embryos transferred is in excess of the ASRM guidelines, justification for deviating from the ASRM guidelines should be justifiable and documented in the medical records.

The California octuplets and the duties of reproductive endocrinologists.

The recent birth of octuplets unleashed a firestorm of publicity, casting a harsh light on the mother and her presumed inadequacies as a parent. It also raised questions about the role of reproductive endocrinologists. Herein we consider 3 aspects of this question: should reproductive endocrinologists consider the economic interests of society, should they consider parenting abilities, and should the number of embryos transferred be limited? We conclude that the ethical obligation of reproductive endocrinologists does not extend to protection of society's economic interests; that reproductive endocrinologists, although poorly trained and situated to gauge an individual's ability to parent, can in extreme circumstances refuse to provide assisted reproductive technology; and that a firm limit on the number of transferred embryos is ethically and medically appropriate.

Research ethics dilemmas in thyroid disease.

PURPOSE OF REVIEW: Since research ethics dilemmas frequently fall outside the purview of the Institutional Review Board (IRB), we present three unique recent research ethics cases in thyroidology that demonstrate research ethics dilemmas. RECENT FINDINGS: The cases presented raise questions surrounding epistemic/scientific integrity, publication ethics, and professional, and personal integrity. SUMMARY: Research ethics dilemmas that fall outside the purview of the IRB are appropriate for a Research Ethics Consultation, a common service in many large academic medical centers.

Ethics in Pediatric Endocrinology: Curriculum for Fellows and Faculty.

Introduction: In clinical practice, ethical dilemmas are frequently faced by pediatric endocrinologists. This initiative's objectives were to (a) determine if endocrine fellows and faculty perceived that an effective ethics curriculum existed and (b) evaluate whether case-based modules would be an effective tool for ethics education. Methods: Participation was sought from eight large pediatric endocrine programs (home programs and affiliates of the Pediatric Endocrine Society's Ethics Committee members) after the distribution of eight case-based modules (geared mainly to fellows) and pre- and postsurveys. Questions examining self-reported knowledge (K) of the ethical pillars (beneficence, nonmaleficence, autonomy, and justice), attitudes (A) towards these, and the individual's likelihood of utilizing them in clinical practice (P), in addition to the need for/benefit of this curriculum, were assessed using a 5-point Likert scale. Results: Six out of eight programs participated, with surveys completed by fellows (n = 29), faculty (n = 7), and advanced practitioners (n = 3). Of the respondents, only 20.3% believed an effective ethics curriculum was already in place. After module completion, KAP scores improved, with the greatest improvement seen in knowledge scores. Additionally, 94.9% of respondents strongly agreed (n = 26) or agreed (n = 11) that the curriculum would be a valuable addition to fellowship training. All faculty believed that the curriculum was helpful in imparting ethical principles of clinical practice. Discussion: The findings suggest that this curriculum would be useful in knowledge advancement of ethical principles and could fulfill a long-standing need to provide clinical ethics education for faculty and fellows.

Financial Conflicts of Interest Among Authors of Endocrine Society Clinical Practice Guidelines.

Context: There has been a proliferation of clinical practice guidelines in endocrinology and a coincident increased interest in transparency regarding relationships between physicians and industry. Evidence Acquisition: We collected self-reported disclosures and Open Payments data for 169 authors of 26 clinical practice guidelines published between 2010 and 2017 by the Endocrine Society. Conflicts of interest in which pharmaceutical and device companies manufactured drugs or products pertinent to an author's specific clinical practice guideline(s) were deemed relevant. Open Payments data were grouped into research and nonresearch (consultancies, honoraria, travel, food) categories. Evidence Synthesis: We compared the policies of the Endocrine Society regarding seven conflict of interest recommendations issued by the National Academy of Medicine in 2011. Conclusion: Relevant nonresearch financial conflicts of interest were self-reported by 42% of authors of clinical practice guidelines. Open Payments were recorded for 74% (84 of 113) of US authors between 2013 and 2016. Payments to 84 US authors totaled $5.5 million for nonresearch activities and $30.9 million for research. The nonresearch payments were divided into consulting (46%), honoraria (26%), travel (25%), and food (3%). The Endocrine Society partially follows the National Academy of Medicine recommendations to limit conflicts of interest. Readers should be aware of how clinical practice guidelines are developed and the policies of the organizations and journals that publish them. Professional societies and journal editors should strive to ensure that their policies and practices promote objective and unbiased clinical practice guidelines.

Dyshormonia Iatrogenica: crossroads of medicine, malpractice law, and professional ethics in clinical endocrinology.

OBJECTIVE: To present 2 challenging cases of patients who request endocrine therapies that their physician considers to be outside of the standard of care. METHODS: With these complex cases as a backdrop, we explore the constructs of medicine, malpractice law, and professional ethics that guide physicians' medical decision-making processes. RESULTS: These cases illustrate a common conundrum for clinical endocrinologists, who often find themselves struggling to balance patient satisfaction and well-being with generally accepted standards of medical care. From the perspective of a malpractice lawyer, we review the keys to limiting medicolegal liability, with emphasis on thorough documentation, informed consent, and effective doctor-patient communication. We then review the constructs of professional ethics that guide patient care, with emphasis on virtues of the "good physician," patients' right to self-determination, and paternalism. Finally, we explore some justifications for a compassionate physician to refuse a patient's desired treatment plan. CONCLUSION: In the end, we hope that this manuscript helps to facilitate best medical, legal, professional, and ethical practices of clinical endocrinology.