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Background: Nazi Germany surrendered to the Allies on May 8, 1945. Six months later, the Allies tried the surviving leaders of Nazi Germany at the first Nuremberg trial. Later, the United States conducted 12 additional trials. The first one, The Unites States of America versus Karl Brandt et al., has been dubbed the Doctors' Trial. During the trial, the prosecution relied on the testimony of Dr. Andrew Ivy and Dr. Leo Alexander. At the end of the trial, Judge Sebring enunciated 10 principles needed to conduct human subject research-the Nuremberg Code. Authorship of the Code has been the subject of dispute, with both Ivy and Alexander claiming sole authorship.Methods: In the summer of 2017, I visited Duke University Medical Center's Archives and surveyed the contents of boxes labeled "Alexander's papers." I also explored online databases with information on the Doctors' Trial. Pertinent documents were compared across collections, and against scholarly works on the topic.Results: Box 3 of Alexander's papers at Duke University Medical Center's Archives contains a three-page document with six principles that, nearly word for word, were included in what is known as the Nuremberg Code. Alexander's name and appointment are typed at the end of the document.Conclusions: Although the Nuremberg Code is likely to have been an unplanned collaboration among members of the prosecuting team and the judges, I present evidence suggesting that Alexander drafted the blueprint and was the main contributor to the final version of the Code. [ABSTRACT FROM AUTHOR]

This paper describes the design and protocol of a pragmatic, randomized trial to evaluate the comparative effectiveness of shared decision making versus motivational interviewing plus cognitive behavioral therapy for chronic pain for the voluntary tapering of opioid dose in adults with chronic noncancer pain. Integrated Services for Pain: Interventions to Reduce Pain Effectively (INSPIRE) is a multicenter, randomized trial conducted at three academic health centers in the southeastern United States. Participants are adults receiving long-term opioid therapy of at least 20 morphine milligram equivalents daily for chronic noncancer pain. Participants were randomized to either the shared decision-making intervention or the motivational interviewing session and cognitive behavioral therapy for chronic pain intervention. All participants also received guideline-concordant care supporting opioid pharmacotherapy. The primary outcome was change from baseline in average daily prescribed opioid dose at 12 months, using prescribing data from electronic health records. Secondary outcomes were Patient-Reported Outcomes Measurement Information System Pain Interference and Physical Function at 12 months. This trial evaluates the comparative effectiveness of shared decision making versus motivational interviewing plus cognitive behavioral therapy for chronic pain for the voluntary tapering of opioid dose in adults with chronic noncancer pain. Results from this study can guide clinicians, researchers, and policymakers as they seek to reduce opioid prescribing and improve management of chronic pain. ClinicalTrials.gov Identifier: NCT03454555 (https://clinicaltrials.gov/ct2/show/record/NCT03454555). Participant enrollment began on June 26, 2019. [ABSTRACT FROM AUTHOR]

Antimicrobial resistance (AMR) continues to present a challenge to international healthcare systems and structures of public health. The focus on optimizing antibiotic prescribing in human populations has challenged healthcare systems charged with making responsible their physician-prescribers. In the United States, physicians in almost every specialty and role use antibiotics as part of their therapeutic armamentariums. In United States hospitals, most patients are administered antibiotics during their stay. Therefore, antibiotic prescribing and utilization is a commonly accepted part of medical practice. In this paper, we utilize social science work on antibiotic prescribing to examine a critical space of care in United States hospital settings. From March to August 2018, we used ethnographic methods to study hospital-based medical intensive care unit physicians at the offices and hospital floors they frequent in two urban United States teaching hospitals. We focused on eliciting the interactions and discussions surrounding antibiotic decision-making that are uniquely influenced by the context of medical intensive care units. We argue that antibiotic use in the medical intensive care units under study was shaped by urgency, hierarchy, and uncertainty representative of the medical intensive care unit's role within the larger hospital system. We conclude that by studying the culture of antibiotic prescribing in medical intensive care units, we can see more clearly both the vulnerability of the looming antimicrobial resistance crisis and by contrast the perceived insignificance of stewarding antibiotic use when considered alongside the fragility of life amidst acute medical concerns regularly experienced in the unit. • Antibiotic prescribing in the intensive care unit was shaped by existing workflows. • The pressure to treat patients in an urgent manner led to increased antibiotic use. • Felt urgency combined with complicated patient cases fostered uncertainty. • Participants recognized an interconnectedness with other teams working in the unit. • Participants used timeliness as a rationale for antibiotic prescribing. [ABSTRACT FROM AUTHOR]

A number of conceptual frameworks have emerged with the goal of helping clinicians understand and navigate the intersections of the health system and broader political, economic, and cultural processes when they care for patients. In this study, we analyze the impact that one emerging framework, "structural competency," had on medical students' and physicians' understanding of societal problems affecting patient health and the practices of health systems. In this sub-analysis of a longitudinal qualitative study conducted between August and December 2020, we analyzed 19 semi-structured interviews with 7 first-year medical students, 7 upper-level medical students, and 5 physician course facilitators who participated in a course called Introduction to Medicine and Society at an medical school in the United States affiliated with a large urban academic medical center. This paper focuses on three main findings: how medical students and faculty describe "structures" and their effects on patients and patient care; how they use or imagine using structural competency to improve patient-physician communication and work interprofessionally to address social needs; and the emotional and personal reactions that confronting societal challenges provokes. We conclude that structural competency enhances existing efforts to improve patient-physician communication and to address patients' social needs. However, we highlight how structural competency efforts might fall short of their goal to shift physicians' perspectives "upstream" to the determinants of health due to both critical ambiguities in the concept and inattention to the emotional and personal impacts of addressing societal problems in the clinic. These findings have practical implications for how clinicians are trained to act on societal issues from within the health system and conceptual implications for refining how existing frameworks and curricula conceive of the intersection between healthcare and broader processes. • Ambiguity of 'structure' and 'structural competency' hinders applicability. • Emphasis on 'structure' may unintentionally essentialize marginalized patients. • Trainees' affective responses are key to addressing societal factors in the clinic. • Humility and self-reflection helped trainees better address 'structure'. [ABSTRACT FROM AUTHOR]