Why some Patients Benefit from Participating in a Sham Surgery Trial.

OBJECTIVE: We analyze the ethics of sham surgical trials from a utilitarian perspective and explore whether patients can benefit from participating in these trials. BACKGROUND: Sham-controlled randomized trials are an essential tool to evaluate the risks and benefits of some surgical procedures. However, sham trials are controversial because they expose patients to the harms of a sham procedure without the possibility of benefit. We argue that ethical analyses of sham trials have focused only on the harms of sham surgery and neglected to account for the harms of the procedure being studied. METHODS: We develop a theoretical model to estimate the harms and benefits experienced by patients who enter a sham surgery trial, taking into account the harms and benefits of the sham and intervention. RESULTS: When the procedure in question is found to be ineffective, sham trials typically result in a net benefit to participants because some participants are only exposed to the harms of the sham procedure, which are much lower than the harms of the full procedure. When the procedure is found to be beneficial, the primary harm to patients who underwent the sham is not due to the sham itself but because they suffer a delay in receiving an effective intervention. CONCLUSIONS: Patients often benefit from participating in sham surgery trials because the harms of the sham procedure are lower than the harms of the full procedure, which may turn out to be ineffective. Our results call for re-thinking the ethics of sham surgery trials.

Management of Thoracic Aortic Dissection.

This JAMA Clinical Guidelines Synopsis summarizes the 2021 guidelines from the American Association for Thoracic Surgery and the Society of Thoracic Surgeons on management of type A and type B thoracic aortic dissection.

The Bucksbaum Institute for Clinical Excellence and the Doctor-Patient Relationship: Origins, Programs, and Future Directions.

The Bucksbaum Institute for Clinical Excellence at the University of Chicago was established in 2011 with the mission to improve patient care, strengthen the doctor-patient relationship, enhance communication and decision making in health care, and reduce health care disparities. The Bucksbaum Institute supports the development and activities of medical students, junior faculty, and senior clinicians who devote themselves to improving doctor-patient communication and clinical decision making. The institute seeks to enhance the skills of physicians as advisers, counselors, and navigators to help patients make informed decisions when facing complex treatment choices. To achieve its mission, the institute recognizes and supports the activities of physicians who excel in clinical care, supports an array of educational programs, and funds research into the doctor-patient relationship. As the Bucksbaum Institute enters a second decade, its focus will begin to extend beyond the University of Chicago, leveraging alumni and other relationships to improve patient care everywhere.

Well, That Could Have Gone Better.

Most physician-patient relationships take little effort. The physician acts with the kindness, patience, empathy, and professionalism that they have brought to the field and honed over years of training and practice. However, there are a subset of patients with whom, to be successful, the doctor needs insight into their own weaknesses and countertransference. In this reflection, the author recounts his troubled relationship with a patient. The source of the tension was the physician's countertransference. Self-awareness allows a physician to understand how countertransference can threaten good medical care and how it can be managed.

Defeating Cancel Culture in Surgical Site Infection Research: A Plea to Include Microbial Cultures and Antibiotic Sensitivity Data.

Background: Despite advances in infection control measures, surgical site infections (SSIs) remain a real and present danger to patients. In most studies addressing SSI prevention measures, recommendations are often made in the absence of information such as culture results, the antibiotic agents used for prophylaxis, and antibiotic sensitivity data. The aim of this study is to document this latter claim by reviewing studies published in the last five years in highly read and cited surgical journals. Methods: A systematic review evaluating SSIs from four highly cited surgical journals, Annals of Surgery, the British Journal of Surgery, JAMA Surgery, and the Journal of the American College of Surgeons was conducted for articles published between 2016 and 2021. We focused our analysis on the following key features: how SSI is defined; bacterial culture information; antibiotic sensitivity data; and identification of the antibiotic chosen for prophylaxis. We hypothesized that, in most cases among the journals queried, this information would be unavailable. Results: Of the 71 studies included, 32 diagnosed SSIs based on criteria developed by the U.S. Centers for Disease Control and Prevention while five provided no definition of SSI. Of the 27 articles recommending increasing antibiotic usage, only one study performed antibiotic sensitivity testing to guide the antibiotic choice. Of 71 studies reviewed, only one reported all key features we considered to be important for SSI antibiotic decision-making; 46 reported none of the key features. Conclusions: Among publications addressing SSIs in four highly cited surgical journals, key information regarding diagnosis and with which to base antibiotic recommendations, is routinely unavailable.

Management of Heart Failure.

This JAMA Clinical Guidelines Synopsis summarizes the 2022 ACC/AHA/HFSA guidelines for management of heart failure in adults with a diagnosis of or at risk for heart failure.

Discarding Dichotomization: Retrieving Data in the Service of Patient Care.

Content available: Author Interview and Audio Recording.