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ethical dilemma

  • 1.  ethical dilemma

    Posted 2 days ago

    Hello. I'm just a year into my budding solo consulting business (finally retiring from day job in 2 weeks!) and already I face an ethical dilemma.

    A fellow at another medical university asked me to help with a project. Fellows in this program are required to do some sort of scholarly project. Fellow's deadline (end of fellowship) is December. The attending physician is the PI. Their goals are (1) submission to a conference by mid-October, and (2) hopefully publication thereafter.  By the fellow's telling, the in-house statistical consultants did not have the bandwith to help.

    Briefly, this would be a historical cohort study based on retrospective review of electronic medical records.

    Last we'd left it, Fellow was awaiting IRB approval. I said great, get back in touch when that's obtained, and we can get started.

    Some months went by. Fellow and Attending just got back in touch with me. Turns out they had assembled a team and had already abstracted records and stored data in a very messy Excel spreadsheet (of course!). That was done as IRB process was underway, but before IRB approval. (I suspect the IRB submission was rather delayed.) Institutional policy is as customary: "all research must be sumbitted . . . before the study is conducted, including recruitment and data collection."  The gist of the IRB determination was "We don't offer retrospective approvals.  If we'd had the opportunity to review it prospectively, we believe we would have found it Exempt. . . . Any publication must include a statement that the study did not receive prospective IRB review."

    There has also been brief reference to grant funding, so I wonder what the grantor's IRB requirements are.

    I'm skeptical about getting an abstract accepted for a conference, or a manuscript accepted for a journal, given the IRB determination above.

    I have many reservations about participating in this.  I don't want to get involved with a project that did not adhere to ethical principles and regulations, both internal and external. It also just seems a bit "loose" in execution. On the other hand, I want to support the Fellow. I don't know what sort of guidance and training Fellow received in how to execute this project. Fellow should not suffer if that was inadequate.

    Appreciate any thoughts/perspectives.

    Thanks.



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    Christopher Ryan
    Clinical Associate Professor of Family Medicine
    SUNY Upstate Clinical Campus
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  • 2.  RE: ethical dilemma

    Posted 2 days ago

    The best way to support the fellow is to stand your ground and refuse to participate on the grounds of ethical issues. How else is the fellow supposed to learn that the IRB actually matters and that ethical review by an external body for human subjects research is a necessary step?

    Just my two cents - hurts in the short term, but you can look in the mirror at night.

    Best,

    Jana



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    Jana Asher
    Independent Consultant, PStat
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  • 3.  RE: ethical dilemma

    Posted 2 days ago

    I agree with Jana. I wouldn't participate. Also, not sure if any legitimate journal would publish an article with a statement saying "study did not receive IRB approval".

     

    Thanks-

    Shah

     

    Shahidul (Shah) Islam, DrPH, MPH, PStat®

    Senior Biostatistician, Northwell Health

    Adjunct Assistant Professor of Biostatistics, NYU Grossman Long Island School of Medicine

     






  • 4.  RE: ethical dilemma

    Posted 2 days ago

    They could still get IRB approval and claim they had approval even if they started without it - so they could still theoretically end up published!



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    Jana Asher
    Goucher College
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  • 5.  RE: ethical dilemma

    Posted 2 days ago
    Hi,

    I'm not sure I fully understand the situation, but tell me if this is correct:
    • The study does not currently have any IRB approval
    • The only IRB to which the study was submitted says they will not review it because of the type of approval requested.
    • The only IRB to which the study was submitted says they believe they would have found it to be exempt if not for the retrospective approval request.
    If all of the above is correct, it seems to me that you should suggest they take it to another IRB. Ordinarily "IRB shopping" is a huge no-no, but this feels like a different scenario where they are saying they won't approve this sort of study even though many (most?) IRBs do review these kinds of studies.

    Good luck!

    Dave






  • 6.  RE: ethical dilemma

    Posted 2 days ago

    Dave--

    The institution's IRB does in fact review these types of studies---when the proposal is submitted before the research starts. If it's a study based on retrospective review of existing medical records, they consider the start of records review and data abstraction to be the start of the research. I think that's appropriate. By that definition, these researchers started their research before IRB approval. 

    It probably would have been more clear if the IRB had written "Stop, you cannot proceed with this, since you did not follow the rules." Instead they said, basically, "Well, we don't vouch for this. If you do it, you need this disclaimer." An awkward bit of fence-straddling.



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    Christopher Ryan
    Clinical Associate Professor of Family Medicine
    SUNY Upstate Clinical Campus
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  • 7.  RE: ethical dilemma

    Posted 2 days ago

    The trouble with IRBs, and they are legion, is that there is no real standards about how they operate and they make it up as they go along.  Here the study obviously does not rise to any serious issues, since it is using that already has been collected.  The only issue is that they seem unhappy that you did not contact them ahead of time, even though they think it should be exempt from review.  Sounds to me like they are simply exerting their power, and are stopping what very likely is reasonable research.  Is there any "higher authority" to which you can go.  Run away IRBs exist all over the US.  Here it seem to me that your only actual potential harm is breaching of confidentiality of medical records.  

    At CUNY this would go up a level to the administrator who overseas the IRBs.

    Andy

    Andy Beveridge, Professor of Sociology Emeritus, Queens College and Grad Center CUNY.



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    Andrew Beveridge
    Professor of Sociology Emeritus / President, Social Explorer
    Queens and Grad Center CUNY and Social Explorer, Inc
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  • 8.  RE: ethical dilemma

    Posted 2 days ago

    Thanks Shah and Jana.  Those are my instincts as well, but I will continue to appreciate all perspectives from this group.

    Could get ugly, but a clean professional conscience is important.

    I hope to explore with the attending physician (PI) what guidance was provided the Fellow. If a scholarly activity is required, and if this one isn't going to happen, perhaps some learning about research ethics and execution, and a presentation to other residents/fellows, would fulfill this Fellow's requirement. Make it a learning experience. And maybe head off future problems. 



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    Christopher Ryan
    Clinical Associate Professor of Family Medicine
    SUNY Upstate Clinical Campus
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  • 9.  RE: ethical dilemma

    Posted 2 days ago

    I have been a consultant in a solo practice since 1977.

    Short answer: DON'T DO IT!



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    Nelson Lipshutz
    Regulatory Research Corp.
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  • 10.  RE: ethical dilemma

    Posted 2 days ago
    Hi Christopher,

    I work in the veterinary medical field so IRBs are not normally required so admittedly this is not my area of expertise. But I do work with a ton of veterinary medical interns and residents who are under huge time pressure to publish as it is a requirement of sitting for boards (which can affect their jobs and salaries) so here is my perspective.

    I would guess they were under time pressure to get the fellow going and the IRB panel at the university was slloooww going. And it was a retrospective study so while medical data privacy is certainly an ethical issue no patients were enrolled in a prospective study. My understanding from your email is that the study would have been found EXEMPT. What does "exempt" mean? Maybe people sign waivers saying if seen in a medical research hospital they give permission for their data to be used in a depersonalized way. I ask these questions with no experience again with IRBs.

    Worth a phone call to the PI/fellow where you engage them in a conversation to understand what happened before making a final decision. That is good to leave things on a positive note regardless.

    Also my general experience in 20 years on consulting is that there is often a gap between "ideal" and what really happens in practice so part of being a good consultant is sometimes working with what you get that is less than ideal while balancing not crossing any ethical or letting a client step all over you which is hard to navigate. Also if someone wants to pay you to do unpublishable research if you are a consultant vs an academic it might not matter to you if it gets published. So partly depends on how much you need business and will this lead to more projects you want. Just make clear to the client your concerns.

    Good luck!
    Deborah






  • 11.  RE: ethical dilemma

    Posted 2 days ago

      I have a slightly different take than the rest of the group but I largely share and completely understand their concerns.

    • If you say no to them, they will probably just email some other consultants or maybe rope in a grad student unpaid, and never mention the IRB thing to them. You have a chance to intervene and stop the problem from spreading.
    • So I would probably still help them, but at an arms length - especially if it's an easy problem, ie clean the data and do a chi-square test, I might show them how to do that ON THEIR COMPUTER. Or maybe work it out with simulated data. I would /not/ run it my self on the actual data.
    • I would /not/ let them add me as a coauthor or otherwise lend them my credibility.
    • The publication component ought to be out-of-scope in this case - they could have IRB'd earlier, they can figure it out what that means for them. Maybe they go find a third-tier journal that doesn't care, I don't know. Not my problem.
    • I would /absolutely not/ let them share (ie email) the dataset with me - if they can't follow IRB, then HIPPA and the other hospital security etc is probably not being followed either, you don't want the liability in the worst case scenario. 
    • I /would/ up-charge them for the hassle, however much time you spent on figuring out the IRB mess, at least an extra hour or two. Email time is still time worked.

    Just my two cents. You don't have to think about it in terms of all-or-nothing. As a private consultant, it's your job to help the client, not to be the IRB police, and if you do decide to tell them no (and to be clear, I think that would be an entirely reasonable thing to do), it will go down a lot smoother if you can offer them some other options or advice. Or at least, that's how I approach the business.



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    Neal Fultz
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  • 12.  RE: ethical dilemma

    Posted 2 days ago

    First of all, congratulations on the upcoming retirement :-)

    My rule of thumb around ethics has always been: if it does not feel right, it probably is not (especially if the feel is of nagging nature). This has not failed me. So, I would not proceed as is if you're not comfortable.

    That said, there is also an opportunity here as a few people have already pointed out, be it an opportunity to educate, course-correct, come up with alternative solutions, etc. In one of the section's Pathways to Promotions webinars last year, I talked about presenting options rather than answering with a no as a singular response. What are the things you are willing to do? Then I would think along the lines of "I will not do this, but here are some things we can do (and still preserve my integrity)." This can make the working relationship a little easier by showing that you are willing to work with them and that you've given that a careful thought. If they reject that, they were not likely to change their mind anyway; it's a different problem, and you move on. I have walked away from a number of engagements this way, and I am at peace having protected my own integrity.

    FWIW: As a Certified Management Consultant, I abide by and am evaluated on ethics by the standards by the Institute of Management Consultants - its Code of Ethics is a useful guide for matters that are not strictly statistical in nature, so I post it here: https://imcusa.org/about/ethics/code-of-ethics/



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    Michiko Wolcott
    Principal Consultant
    Msight Analytics
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  • 13.  RE: ethical dilemma

    Posted 2 days ago

    I am re-visiting the ASA statement on ethical statistical practice and finding much helpful guidance in it.

    As an academic family physician for my first 30 working years,

    1) I always try to make encounters educational,

    2) I try to look out for the interests of the "lowest" folks on the med ed hiearchy, which in this case is the Fellow. Imbalances of power are real in med ed.

    3) and I always come back to a touchstone of clinical practice: "all care is negotiated."  I think this fits well with the theme expressed by several discussants, about figuring out mutually-agreeable solutions and finding a way forward, while preserving limits.

    In the interim, I had an interesting conversation with the IRB official. Seems this is not this particular PI's first go-round with these issues.. They have been impervious to previous educational interventions by the research admin folks.



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    Christopher Ryan
    Clinical Associate Professor of Family Medicine
    SUNY Upstate Clinical Campus
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  • 14.  RE: ethical dilemma

    Posted 2 days ago

    Interesting -- 

    I think the regulatory guidances here are pretty black and white. 'No research procedures prior to IRB approval of research procedures' seems crystal clear. 

    In addition, since the research involves review of personally identifiable medical records, it seems very unlikely that this 'retrospective chart review' would qualify for 'exemption' (there are a very limited number of 'exemption' types and very specific rules), or be classified as 'not involving human subjects'. The latter situation can occur when a third party ('honest broker') retrieves and completely de-identifies data or biospecimens. Based on your description, it seems more likely that the research would qualify for a 'waiver of the requirement for informed consent'.

    I work at an institution that requires that I also conform to these rules, and I would not participate in the research. I am surprised, based on your description and the possible continuing nature of the problem, that research compliance is not involved. 



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    Susan Hilsenbeck
    Professor
    Baylor College of Medicine
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  • 15.  RE: ethical dilemma

    Posted yesterday

    I agree with the advice , paraphrasing "if it looks like a duck , walks like a duck, quacks like a duck..."  There is no undoing ethical taint. however, re-re-reading your note, the IRB was moving slowly. Probably because they're busy.  IN the pharma world, FDA has a guidance as to who and how an IRB selects members.

    This is one of several guidances FDA has for IRB. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/institutional-review-boards-frequently-asked-questions

    google search for the other IRB guidances from FDA. And  in pharma, there are many times when the clinical people make arrangements for an expedited review of a research protocol by an IRB. IRB's usually have a process for expediting a review.  IRB's operate to protect innocent humans from unnecessary or possibly harmful experiments. on some occasions the clinical people will arrange for a "central IRB" rather than at each institution. There is a fee ($$$) for the central IRB services.

    You do have an option (you might not prefer to use it) for a "speak softly and carry a big stick" . There should be a chief compliance officer. and there may be a way to submit a report anonymously. Better for your colleagues to get them to follow the procedures and contact the IRB themselves. They are medical fellows, so you could contact the chief of medicine or similar. Last but not least, They will probably need to destroy the records they collected so far, and collect them again. 

    your best negotiation strategy may be to sit down with then and layout the options - and have them contact the IRB.



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    Chris Barker, Ph.D.
    Past Chair
    Statistical Consulting Section
    Consultant and
    Adjunct Associate Professor of Biostatistics
    www.barkerstats.com


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    "In composition you have all the time you want to decide what to say in 15 seconds, in improvisation you have 15 seconds."
    -Steve Lacy
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