Browsing by Subject "clinical equipoise"

Now showing 1 - 2 of 2
  • Thumbnail Image
    Item
    Equipoise and Skepticism: Past, Present and Future
    (2008-08-22T14:35:30Z) Witt, John R.; Meslin, Eric Mark; Tilley, John J.; Lyons, Timothy D.
    Currently, the predominant view in research ethics maintains that physicians can morally justify offering randomized clinical trial enrollment to their patients only if some form of equipoise is present. Thus, the physician must experience (either individually or communally) a state of reasoned uncertainty concerning the relative merits of two or more competing treatments for a given disease before she may recommend that her patient participate in a clinical trial. Increasingly, however, this position has been subject to critical attention and considerable negative scrutiny. My argument engages this trend by turning to the history of philosophy; here I claim that the use of the term “equipoise” in the medical research context is extremely similar to terms and concepts from the philosophical tradition of skepticism, and as a result of this similarity it is possible to understand the principle of equipoise’s vulnerability to already published criticisms. A comparison of the criticisms of equipoise within the medical research literature to criticisms of philosophical skepticism reveals a potentially grim future for equipoise as a legitimate guiding principle for the ethical conduct of clinical research.
  • Thumbnail Image
    Item
    Variability in Surgical Treatment of Spondylolisthesis Among Spine Surgeons
    (Elsevier, 2018) Lubelski, Daniel; Alentado, Vincent J.; Williams, Seth K.; O'Rourke, Colin; Obuchowski, Nancy A.; Wang, Jeffrey C.; Steinmetz, Michael P.; Melillo, Alfred J.; Benzel, Edward C.; Modic, Michael T.; Quencer, Robert; Mroz, Thomas E.; Neurological Surgery, School of Medicine
    Background There are a multitude of treatments for low-grade lumbar spondylolisthesis. There are no clear guidelines for the optimal approach. Objective To identify the surgical treatment patterns for spondylolisthesis among United States spine surgeons. Methods 445 spine surgeons in the United States completed a survey of clinical/radiographic case scenarios on patients with lumbar spondylolisthesis with neurogenic claudication with (S+BP) or without (S−BP) associated mechanical back pain. Treatment options included decompression, laminectomy with posterolateral fusion, posterior lumbar interbody fusion, or none of the above. The primary outcome measure was the probability of 2 randomly chosen surgeons disagreeing on the treatment method. Results There was 64% disagreement (36% agreement) among surgeons for treatment of spondylolisthesis with mechanical back pain (S+BP) and 71% disagreement (29% agreement) for spondylolisthesis without mechanical back pain (S−BP). For S+BP, disagreement was 52% for those practicing 5 to 10 years versus 70% among those practicing more than 20 years. Orthopedic surgeons had greater disagreement than did neurosurgeons (76% vs. 56%) for S+BP. Greater clinical equipoise was seen for S−BP than for S+BP regardless of surgeon characteristics. For spondylolisthesis without mechanical back pain, neurosurgeons were significantly more likely to select decompression-only than were orthopedic surgeons, who more commonly selected fusion. Conclusions Clinical equipoise exists for the treatment of spondylolisthesis. Differences are greater when the patient presents without associated back pain. Surgeon case volume, practice duration, and specialty training influence operative decisions for a given pathologic condition. Recognizing this practice variation will hopefully lead to better evidence and practice guidelines for the optimal and most cost-effective treatment paradigms.