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Chapter 4: Research Ethics

2014, Doing Research in the Real World, 3rd edn

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Ethics in research involving humans were first codified in 1946 as Nuremberg code. Subsequently other ethical declarations and guide lines were developed to protect the research participants as well as the researchers. The basic research bioethics includes three principles-respects for person, beneficence, and justice. To make a research with human subjects ethically sound the research protocol should have social and scientific values, fair subject selection, favorable risk benefit ratio, independent review, and informed consent of and respect for the participants. Above all the researcher should be honest and responsible enough to safeguard the rights and welfare of the research subjects. DOI: 10.3329/bjpp.v24i1.5734Bangladesh J Physiol Pharmacol 2008; 24(1&2) : 24-26

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Research involving human subjects are important to develop new therapeutics for the betterment of the human race. To take part in such research as volunteers is moral duty of any human. But such experiments should be justifiable and minimal risky for the participants. History of unethical research involving humans led to the development of many guidelines to make such research ethical as well as to gain maximum possible output. Several guidelines have been formulated to ensure research with human participants ethical. All the guidelines emphasize on one thing in particular- informed consent of the human subjects. Other considerations include rational benefit-harm ration, beneficence, justice, adequate research design and approval from proper authorities. All these guidelines aim to prevent any unethical research involving humans against their will.

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The twentieth century witnessed a succession of heinous experiments on human subjects in the name of science. The deplorable nature of these experiments led to the development of several guidelines that laid down the principles of research ethics. Respect, bene cence, and justice are the principles that form the foundation of research ethics today. These principles should be implemented through the channels of the informed consent process, privacy and con dentiality, risk bene t analysis, and fair recruitment. Proper implementation of research ethics ensures the protection of the rights and well-being of the participants. Some individuals are considered to be “vulnerable” in the research context because their autonomy is either diminished or lacking. Examples include children, some elderly persons, those with temporary or permanent cognitive impairment, prisoners, and refugees. Vulnerable groups require additional protection measures if they are involved in research. Public health research differs from general health research that necessitates additional ethical considerations. Research involving public health interventions or research conducted during public emergencies, such as natural disasters and disease outbreaks, has unique ethical challenges. Furthermore, in public health research, an understanding or familiarity with the community in which the research will be done is essential to ethical conduct of research. research ethics committees [otherwise known as institutional review boards (IRB)] play a central role in research involving human participants. The proposed research must be reviewed and approved prior to initiation and monitored thereafter with ongoing reviews of safety reports, progress reports, and emerging information or circumstances that may impact the study. A substantial number of conditions need to be met to ensure research starts and then remains ethical. Researchers should be quali ed by education, training, and experience to take on the role of investigators. The scienti c aspects of the research should be robust and valid and the research itself should be purposeful. It is important that ethical considerations be a constant, integrated into the research undertaking, from inception right through to the dissemination and or sharing of the results.

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Ethical abuse of human subjects is still prevalent in researches. Biomedical research as the use of modern day medical technology to test hypothesis so as to deduce conclusions that are generalisable as theories and principles involve human subjects. If such research is not morally guided, it runs the danger of abusing the sacredness of human life and dehumanising the human person. Therefore, ethics as the philosophical science, which establishes the moral order of human acts would necessarily be required to check and balance the procedural systems of such research. It is within this context that this paper interrogates the role of ethics in biomedical research. This paper carefully and critically analyses how and why researchers abuse the human subject. Appealing to the Kantian moral imperatives, it opines that human subjects should never be treated as means to an end but as end in themselves. It succinctly points out the relevance of ethics in researches involving human subjects, particularly, biomedical research.

udo schuklenk

ABSTRACT This module will introduce you to the ethical concepts underlying applied ethical decision-making in the area of research involving human participants. We will also learn what the issues are that people involved in research on research ethics are concerned with. Ethics without an understanding of historical and legal context makes arguably little sense. It is for this reason that this module will begin with a brief history of research ethics and ends with a brief overview of the relevant national and international guidelines pertaining to ethical issues in research involving human participants.

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ETHICS IN BIOMEDICAL RESEARCH

Published by Brett Dickerson Modified over 5 years ago

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Ethics in Health Research

Jul 25, 2014

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Ethics in Health Research. Prof. Ashry Gad Mohamed & Dr. Amna R. Siddiqui Department of Family and Community Medicine. OBJECTIVES OF THE LECTURE. At the end of the lecture students should: 1-define ethics in health research. 2-recognize the need for ethics in health research.

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Ethics in Health Research Prof. Ashry Gad Mohamed & Dr. Amna R. Siddiqui Department of Family and Community Medicine

OBJECTIVES OF THE LECTURE At the end of the lecture students should: 1-define ethics in health research. 2-recognize the need for ethics in health research. 3-Understand the general ethical principles. 4- Understand the role of ethical committee in health research.

Contents Definition Concern Globalization General ethical principles Responsibility for ethics Research requiring ethical approval Ethics in clinical trial History of ethical guidelines Ethical Review Committee in EMR.

Health Research Ethics The rules or standards ( moral principles) governing the conduct of researchers during planning, implementation, analysis, interpretation and publication of health research.

DEFINITION The rules or standards ( moral principles) governing the conduct of a person or the members of a profession in respect to a particular class of human actions or a particular group, culture e.g. medical ethics

Research ethics is a concern? Major expansion of health research. Significant public & private investment in research. Increasing need for experimentation on human subjects. Increasing acceptance and appreciation of human rights. New areas: organ transplantation, assisted pregnancy, genomics……etc.

Growing collaboration between researchers in developed and developing countries. Multi-centre trials specially funded by drug companies. Tissue and information moves across borders. International networks. Globalization of ethics

Risks Advantages may be taken to countries that do not have or do not enforce high ethical standards. Benefits go other population. HR as an engine to economic development may push research beyond ethical standards.

Tuskegee syphilis experiment (1932-72) A research project conducted by the U.S. Public Health Service. Six hundred low-income African-American males, 400 of whom were infected with syphilis, were monitored for 40 years. Free medical examinations were given; however, subjects were not told about their disease. Even though a proven cure (penicillin) became available in the 1950s, the study continued until 1972 with participants being denied treatment. In some cases, when subjects were diagnosed as having syphilis by other physicians, researchers intervened to prevent treatment. Many subjects died of syphilis during the study. The study was stopped in 1973 by the U.S. Department of Health, Education, and Welfare only after its existence was publicized and it became a political embarrassment. In 1997, under mounting pressure, President Clinton apologized to the study subjects and their families.

examples 2001: Clinical trial of nordihydroguairetic acid ; a chemical with anti-cancer properties was tested in the Indian Kerala for a US-based researcher in 26 cancer patients. Two died and a third one turned critical. 2003: more than 400 women who had been trying to conceive were enrolled without their knowledge or consent to take part in clinical trial to see if a drug called letrozole induced ovulation.

Cincinnati radiation experiments • Cancer patients (mostly Negroes of below-average intelligence who were charity patients) during 1960-72 in Cincinnati were exposed to large doses of whole body radiation as part of an experiment sponsored by the U.S. military. • None of the subjects gave informed consent, they thought they were receiving treatment for their cancer. Subjects experienced nausea and vomiting from acute radiation sickness, pain from burns on their bodies, and some died prematurely as result of radiation exposure.

Hepatitis in retarded children • Severely retarded children at the Willowbrook State Hospital in New York injected with hepatitis virus. Physician made excuse: fecally-borne viral hepatitis was so prevalent at the Hospital that children routinely became infected 6 to 12 months after admission (because approximately 70% of children had IQ below 20 and were not toilet trained). • This Hospital did not admit new patients after 1964, unless their parents "consented" to the experiment. • Consent forms implied that children were to receive a vaccine against hepatitis, when the protection was actually from a hopefully "subclinical" infection.

General ethical principles 1-Respect for persons Respect for autonomy ((الاستقلال People capable of deliberation about their personal choices should be treated with respect for their capacity for self determination. Protection of persons with impaired or diminished autonomyto give them security against harm or abuse.

Privacy should be protected by ensuring confidentiality. Respect to the community means respecting its values and having its approval for the research.

2-Beneficence )(الاحسان Maximize benefits and minimize harms. Investigators should be competent both to conduct the research and safeguard the welfare of research subjects

3-Justice (العدل ) Treat each person in accordance with what is morally right and proper to him/her. Equitable distribution of both the burdens and the benefits of participation in the research. (distributive justice) Protect the rights and welfare of vulnerable persons.

Research project should leave low –resources countries or communities better than previously

Responsibility for ethics in health research 1-Investigators. 2-Research institution. 3-National Drug Regulatory Agency. 4-Editors of Health journals. 5-Funding agencies and organization.

Researches requiring ethical approval 1- Research using animal or human participants. 2- Animal or human materials (Any matter living or dead taken from a human or animal and including genetic materials. 3-Personal information. -confidential files. - personal identifiers. -sensitive data -Not included in the consent .

4- Clinical trials. 5-Combination of the previous studies.

Research involving humans or human materials Balance between potential risk of harm to individuals and the possible benefits to society at large. During research implementation reviews the ethics at least annually.

Informed consent Written informed consent is required and should include at least the following elements: The participant’s legal competence and ability to understand. Comprehensive information about the proposed research. (information sheet) The consent must be voluntary not involved by financial reward, duress in any manner, nor dependent or vulnerable groups.

Free to withdraw at any time. Those unable to give their own consent proxy consent should be sought from a person with appropriate legal authority. For children, parent or guardian signature should be obtained + child’s assent. WHO developed consent forms available at WWW.WHO.INT∕RPC∕RESEARCH_ETHICS

Rights of a study participant: to be addressed when taking informed consent

Payments for participation in research Any payment, gift of money, goods or services to participants or body or organization assisting in recruitment of participants is unacceptable. Examples: Marks for participating students. Money for instructors allowing data collection in classroom. Access to Specific health care services. Reimbursement or participants’ out-of-expenses is allowed.

Social, community-based, public health or health services interventions Focus: whole community (e.g. food enrichment) All reasonable means should be used by the investigators to inform the population the study aim, all possible advantages and disadvantages. Get consent from the community representatives.

Surveys of the general population Local health authority approval Inform local health practitioners about the study. Informed individual consent in physical or lab investigations. (e.g. IDA) Inform about any consequences. Right to withdraw.

Collection and use of human materials Organs, tissue, secretion or excretion, human fetus, placenta & human gametes. From livings = consent dead = consent before death. No harm to donors. No commercial gain Significant benefit to recipient.

Ethics in Clinical Trials -RCT is the gold standard in the chain of evidence in medical practice. -Investment in clinical trials is estimated to be around 30 billion $. and is growing 12% annually. -A quarter of clinical trials is conducted in developing countries and did not undergo strict ethical review.

example 1996: 100 Nigerian children received Trovan as a part of efforts to determine the effectiveness of that drug. 11 children died and others suffered brain damage and were paralyzed or became deaf.

Ethical interactions in CT Patients Investigators Institutions Sponsor

Investigators Knowledge Qualifications: Scientifically qualified Clinically competent medical person Institutions • Facilities • Staff • Meet the standard • Ethical committee. Sponsor • Consider ethical issues • Staff • Monitors • Is there a real need for this CT. • Early termination.

Patients Gender. Age. Pregnancy & lactation. History of other diseases. Present clinical status. Participation in other trials. Occupation. How informed consent was obtained? Patient privacy

Ethical questions timing Regulators Ethical Committee Peer Reviewers Development Design Conduct Analysis Interpretation Publication

History of guidelines Nuremberg Code (1947) Declaration of Helsinki (1964) & revised 1975, 1983, 1989,1996,2000 & 2008. Belmont Report (1979). Universal Declaration on the human Genome and Human Rights, UNESCO 1997. Operational guideline s for ethics committees that review Biomedical research , World health organization 2000.

Ethical and policy issues in International Research: Clinical trials in developing countries 2001. Universal Declaration on Bioethics & Human Rights, UNESCO (2005) Ethics of research related to health care in developing countries: a follow up discussion Report 2005.

Role of Research Ethics Committee (REC). Does this research have a rationale? Have risks to the participants been minimized? Have benefits been maximized? Has the process of informed consent been optimized? Would I allow my mother, my child, myself to participate in this research protocol as it has been written?

Reference book & page number for the lecture resource WWW.WHO.INT∕RPC∕RESEARCH_ETHICS Abou-Zaid A ,Afzal M , Silverman HJ. Capacity mapping of national ethics committees in EMR. BMC Medical Ethics 2009;10:8 Creswell JW. Research Design. Quantitative , Qualitative, and Mixed Methods. 3rd edition. Chapter 3. Writing Strategies and Ethical Considerations. Pages 64-65. Sage Publishers 2003

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• Preferences

Research Ethics in the Allied Health Professions - PowerPoint PPT Presentation

Research Ethics in the Allied Health Professions

Research ethics in the allied health professions monika s. markowitz, ph.d. director, office of education and compliance oversight vice president s office for research – powerpoint ppt presentation.

• Monika S. Markowitz, Ph.D.
• Director, Office of Education and Compliance Oversight
• Vice Presidents Office for Research
• Virginia Commonwealth University
• Research ethics and its underlying principles
• Considerations by the IRB in ethics review of human subjects research
• Tensions within and between the ethical principles and challenges for review
• A normative ethics Which moral norms for guidance and evaluation of conduct should we accept and why?
• Comprises morally informed policies and regulations
• Nazi medical war crimes
• Nuremberg Code 1947
• Tuskegee Syphillis Study
• Jewish Chronic Disease Hospital
• Willowbrook
• Respect for Persons
• Individual autonomy
• Protection of individuals with diminished autonomy
• Beneficence
• Maximize benefits and minimize harms
• Do good, not just avoid harm
• Equitable distribution of research costs and benefits
• Respect for persons informed consent
• privacy confidentiality
• Beneficence benefit/risk (burden)
• Justice distribution of risk and
• inclusion/exclusion
• Requirement of prospective IRB review and approval of human subjects research
• Requirement for a formal informed consent process for research that is not exempt
• Risk is 1) minimized, and 2) reasonable in relation to anticipated benefits
• Additional requirements for 3 groups of vulnerable populations pregnant women, fetuses, and neonates prisoners children
• Requirement for continuing review on expedited and full board studies at least annually
• Additional requirements for drugs, devices, biologics or other research disciplines with specific regulation
• Requirement of IRB review and approval for human subjects research
• Established to provide ethical review of research
• Assure that federal regulations are followed
• Members include researchers, non-researchers and members of the local community
• 5 IRBs at VCU
• Regulatory and ethical charge review and approve human subjects research to protect the rights and welfare of research participants
• 45CFR46.103(b)
• A systematic investigation designed to develop or contribute to generalizable knowledge.
• 45 CFR 46.102(d)
• HUMAN SUBJECT
• A living individual about whom an investigatorconducting research obtains
• 1) data through intervention or interaction with the individual, or
• 2) identifiable private information
• 45 CFR 46.102(f)
• Requirement for consideration of a formal informed consent process for research that is not exempt
• Disclosure of relevant information
• Understanding of disclosure and recommendation
• Capacity to understand and decide
• Voluntariness
• Risk is 1) minimized, and 2) is reasonable in relation to anticipated benefits
• Exempt Expedited Full
• Minimal Risk means that the probability and magnitude of harm or discomfort anticipated in the research are not greater in and of themselves than those ordinarily encountered in daily life or during the performance of routine physical or psychological examination or tests.
• IRB considers the risk of criminal/civil liability, financial risk, employment risk, stigmatization, insurability, and embarrassment in deciding if risk is truly minimal.
• When appropriate, there are adequate provisions to protect the privacy of subjects and to maintain the
• confidentiality of data 45CFR46111(a)
• Breaches of privacy and/or confidentiality are the main risk in social-
• behavioral research or
• research that is no greater
• than minimal risk
• Pregnant women - Subpart B
• Prisoners Subpart C
• Children Subpart D
• Current Events or Incidents
• Age (elderly)
• Age (adolescents)
• Educationally, economically disadvantaged
• Transient Cognitive Impairment
• Substance Use
• Health Status
• Presumptions of Informed consent, Assent, and Parental permission
• Presumption about the incapacity of certain vulnerable groups
• Presumption about the abilities of LARs
• Presumption about the extent to which potential subjects may be influenced to participate
• Definition of Minimal Risk45 CFR 46.102(i)
• Which type of risk is
• more or less probable,
• more or less severe?
• Whose daily life,
• what kinds of
• procedures or tests
• are routine?
• Whose benefit?
• Respect for persons
• Some persons are in need of extensive protection, even to the point of excluding them from activities which may harm them
• other persons require little protection beyond making sure they undertake activities freely and with awareness of possible adverse consequence.
• The Belmont Report
• Subjects give informed consent
• IRBs overinterpret probability and magnitude of risk thereby overprotecting subjects who should decide for themselves
• The point of regulations to protect research subjects is to assure that research protocols are consent-worthy that they agree with the values the agent her- or himself would deem relevant if she were in a position to accurately make such judgments.
• Miller Wertheimer, 2007, HCR, 37.3, 24-35.
• An Investigator wishes to determine the prevalence of repetitive behaviors in individuals with Alzheimers Disease
• PI proposes that nurses in chronic care facilities record the number and nature of such behaviors for individual residents
• PI decides the research should be exempt from IRB review under the federal regulations which allow such exemptions if the research is limited to observation of public behavior
• Upon initial review by the IRB, the investigator is advised to resubmit the proposal for expedited review and requests a waiver of the requirement to obtain informed consent. The main reason for the waiver request is that the research could not practicably be carried out without the waiver because many of the patients, due to cognitive deficits, choose not to participate in any activities. Since this is a prevalence study, such nonparticipation would markedly weaken the findings. The PI does not feel the rights or welfare of the subjects are impacted if consent is waived.
• Respect for persons Beneficence
• Justice and fairness requires their participation
• Research participation leads to benefit for the vulnerable group, but risk may be greater
• Informed decision making is often perilous potential subjects and/or use of LAR
• Unfair to exclude them and bar them from possible benefit principle of justice
• Should have access to an informed consent process which includes translated form and interpreter throughout the research process respect for persons
• Poor communication of adverse events or problems, thus placing themselves and other subjects at greater risk beneficence
• Minimized risks
• Reasonable risk/benefit relationship
• Equitable subject selection
• Informed consent process
• Informed consent documentation
• Data monitored for safety, if appropriate
• Confidentiality/privacy maintained
• Vulnerable populations protected
• Excerpt from an actual consent form describing risk
• The radiation to which you would be exposed in this study is no greater than that during a nuclear attack.

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Perspective

When pto stands for 'pretend time off': doctors struggle to take real breaks.

Mara Gordon

A survey shows that doctors have trouble taking full vacations from their high-stress jobs. Even when they do, they often still do work on their time off. Wolfgang Kaehler/LightRocket via Getty Images hide caption

A survey shows that doctors have trouble taking full vacations from their high-stress jobs. Even when they do, they often still do work on their time off.

A few weeks ago, I took a vacation with my family. We went hiking in the national parks of southern Utah, and I was blissfully disconnected from work.

I'm a family physician, so taking a break from my job meant not seeing patients. It also meant not responding to patients' messages or checking my work email. For a full week, I was free.

Taking a real break — with no sneaky computer time to bang out a few prescription refill requests — left me feeling reenergized and ready to take care of my patients when I returned.

But apparently, being a doctor who doesn't work on vacation puts me squarely in the minority of U.S. physicians.

Research published in JAMA Network Open this year set out to quantify exactly how doctors use their vacation time — and what the implications might be for a health care workforce plagued by burnout, dissatisfaction and doctors who are thinking about leaving medicine.

"There is a strong business case for supporting taking real vacation," says Dr. Christine Sinsky , the lead author of the paper. "Burnout is incredibly expensive for organizations."

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Researchers surveyed 3,024 doctors, part of an American Medical Association cohort designed to represent the American physician workforce. They found that 59.6% of American physicians took 15 days of vacation or less per year. That's a little more than the average American: Most workers who have been at a job for a year or more get between 10 and 14 days of paid vacation time , according to the U.S. Bureau of Labor Statistics.

However, most doctors don't take real vacation. Over 70% of doctors surveyed said they worked on a typical vacation day.

"I have heard physicians refer to PTO as 'pretend time off,'" Sinsky says, referring to the acronym for "paid time off."

Sinsky and co-authors found that physicians who took more than three weeks of vacation a year had lower rates of burnout than those who took less, since vacation time is linked to well-being and job satisfaction .

And all those doctors toiling away on vacation, sitting poolside with their laptops? Sinsky argues it has serious consequences for health care.

Physician burnout is linked to high job turnover and excess health care costs , among other problems.

Still, it can be hard to change the culture of workaholism in medicine. Even the study authors confessed that they, too, worked on vacation.

"I remember when one of our first well-being papers was published," says Dr. Colin West , a co-author of the new study and a health care workforce researcher at the Mayo Clinic. "I responded to the revisions up at the family cabin in northern Minnesota on vacation."

Sinsky agreed. "I do not take all my vacation, which I recognize as a delicious irony of the whole thing," she says.

She's the American Medical Association's vice president of professional satisfaction. If she can't take a real vacation, is there any hope for the rest of us?

I interviewed a half dozen fellow physicians and chatted off the record with many friends and colleagues to get a sense of why it feels so hard to give ourselves a break. Here, I offer a few theories about why doctors are so terrible at taking time off.

We don't want to make more work for our colleagues

The authors of the study in JAMA Network Open didn't explore exactly what type of work doctors did on vacation, but the physicians I spoke to had some ideas.

"If I am not doing anything, I will triage my email a little bit," says Jocelyn Fitzgerald , a urogynecologist at the University of Pittsburgh who was not involved in the study. "I also find that certain high-priority virtual meetings sometimes find their way into my vacations."

Even if doctors aren't scheduled to see patients, there's almost always plenty of work to be done: dealing with emergencies, medication refills, paperwork. For many of us, the electronic medical record (EMR) is an unrelenting taskmaster , delivering a near-constant flow of bureaucratic to-dos.

When I go on vacation, my fellow primary care doctors handle that work for me, and I do the same for them.

But it can sometimes feel like a lot to ask, especially when colleagues are doing that work on top of their normal workload.

"You end up putting people in kind of a sticky situation, asking for favors, and they [feel they] need to pay it back," says Jay-Sheree Allen , a family physician and fellow in preventive medicine at the Mayo Clinic.

She says her practice has a "doctor of the day" who covers all urgent calls and messages, which helps reduce some of the guilt she feels about taking time off.

Still, non-urgent tasks are left for her to complete when she gets back. She says she usually logs in to the EMR when she's on vacation so the tasks don't pile up upon her return. If she doesn't, Allen estimates there will be about eight hours of paperwork awaiting her after a week or so of vacation.

"My strategy, I absolutely do not recommend," Allen says. But "I would prefer that than coming back to the total storm."

We have too little flexibility about when we take vacation

Lawren Wooten , a resident physician in pediatrics at the University of California San Francisco, says she takes 100% of her vacation time. But there are a lot of stipulations about exactly how she uses it.

She has to take it in two-week blocks — "that's a long time at once," she says — and it's hard to change the schedule once her chief residents assign her dates.

"Sometimes I wish I had vacation in the middle of two really emotionally challenging rotations like an ICU rotation and an oncology rotation," she says, referring to the intensive care unit. "We don't really get to control our schedules at this point in our careers."

Once Wooten finishes residency and becomes an attending physician, it's likely she'll have more autonomy over her vacation time — but not necessarily all that much more.

"We generally have to know when our vacations are far in advance because patients schedule with us far in advance," says Fitzgerald, the gynecologist.

Taking vacation means giving up potential pay

Many physicians are paid based on the number of patients they see or procedures they complete. If they take time off work, they make less money.

"Vacation is money off your table," says West, the physician well-being researcher. "People have a hard time stepping off of the treadmill."

A 2022 research brief from the American Medical Association estimated that over 55% of U.S. physicians were paid at least in part based on "productivity," as opposed to earning a flat amount regardless of patient volume. That means the more patients doctors cram into their schedules, the more money they make. Going on vacation could decrease their take-home pay.

But West says it's important to weigh the financial benefits of skipping vacation against the risk of burnout from working too much.

Physician burnout is linked not only to excess health care costs but also to higher rates of medical errors. In one large survey of American surgeons , for example, surgeons experiencing burnout were more likely to report being involved in a major medical error. (It's unclear to what extent the burnout caused the errors or the errors caused the burnout, however.)

Doctors think they're the only one who can do their jobs

When I go on vacation, my colleagues see my patients for me. I work in a small office, so I know the other doctors well and I trust that my patients are in good hands when I'm away.

Doctors have their own diagnosis: 'Moral distress' from an inhumane health system

But ceding that control to colleagues might be difficult for some doctors, especially when it comes to challenging patients or big research projects.

"I think we need to learn to be better at trusting our colleagues," says Adi Shah , an infectious disease doctor at the Mayo Clinic. "You don't have to micromanage every slide on the PowerPoint — it's OK."

West, the well-being researcher, says health care is moving toward a team-based model and away from a culture where an individual doctor is responsible for everything. Still, he adds, it can be hard for some doctors to accept help.

"You can be a neurosurgeon, you're supposed to go on vacation tomorrow and you operate on a patient. And there are complications or risk of complications, and you're the one who has the relationship with that family," West says. "It is really, really hard for us to say ... 'You're in great hands with the rest of my team.'"

What doctors need, says West, is "a little bit less of the God complex."

We don't have any interests other than medicine

Shah, the infectious disease doctor, frequently posts tongue-in-cheek memes on X (formerly known as Twitter) about the culture of medicine. Unplugging during vacation is one of his favorite topics, despite his struggles to follow his own advice.

His recommendation to doctors is to get a hobby, so we can find something better to do than work all the time.

"Stop taking yourself too seriously," he says. Shah argues that medical training is so busy that many physicians neglect to develop any interests other than medicine. When fully trained doctors are finally finished with their education, he says, they're at a loss for what to do with their newfound freedom.

Since completing his training a few years ago, Shah has committed himself to new hobbies, such as salsa dancing. He has plans to go to a kite festival next year.

Shah has also prioritized making the long trip from Minnesota to see his family in India at least twice a year — a journey that requires significant time off work. He has a trip there planned this month.

"This is the first time in 11 years I'm making it to India in summer so that I can have a mango in May," the peak season for the fruit, Shah says.

Wooten, the pediatrician, agrees. She works hard to develop a full life outside her career.

"Throughout our secondary and medical education, I believe we've really been indoctrinated into putting institutions above ourselves," Wooten adds. "It takes work to overcome that."

Mara Gordon is a family physician in Camden, N.J., and a contributor to NPR. She's on X as @MaraGordonMD .

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