In Nigeria, Polio Vaccine Workers Are Killed by Gunmen





At least nine polio immunization workers were shot to death in northern Nigeria on Friday by gunmen who attacked two clinics, officials said.




The killings, with eerie echoes of attacks that killed nine female polio workers in Pakistan in December, represented another serious setback for the global effort to eradicate polio.


Most of the victims were women and were shot in the back of the head, local reports said.


A four-day vaccination drive had just ended in Kano State, where the killings took place, and the vaccinators were in a “mop-up” phase, looking for children who had been missed, said Sarah Crowe, a spokeswoman for the United Nations Children’s Fund, one of the agencies running the eradication campaign.


Dr. Mohammad Ali Pate, Nigeria’s minister of state for health, said in a telephone interview that it was not entirely clear whether the gunmen were specifically targeting polio workers or just attacking the health centers where vaccinators happened to be gathering early in the morning. “Health workers are soft targets,” he said.


No one immediately took responsibility, but suspicion fell on Boko Haram, a militant Islamist group that has attacked police stations, government offices and even a religious leader’s convoy.


Polio, which once paralyzed millions of children, is now down to fewer than 1,000 known cases around the world, and is endemic in only three countries: Nigeria, Pakistan and Afghanistan.


Since September — when a new polio operations center was opened in the capital and Nigeria’s president, Goodluck Jonathan, appointed a special adviser for polio — the country had been improving, said Dr. Bruce Aylward, chief of polio eradication for the World Health Organization. There have been no new cases since Dec. 3.


While vaccinators have not previously been killed in the country, there is a long history of Nigerian Muslims shunning the vaccine.


Ten years ago, immunization was suspended for 11 months as local governors waited for local scientists to investigate rumors that it caused AIDS or was a Western plot to sterilize Muslim girls. That hiatus let cases spread across Africa. The Nigerian strain of the virus even reached Saudi Arabia when a Nigerian child living in hills outside Mecca was paralyzed.


Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who tracks vaccine issues, said the newest killings “are kind of mimicking what’s going on in Pakistan, and I feel it’s very much prompted by that.”


In a roundabout way, the C.I.A. has been blamed for the Pakistan killings. In its effort to track Osama bin Laden, the agency paid a Pakistani doctor to seek entry to Bin Laden’s compound on the pretext of vaccinating the children — presumably to get DNA samples as evidence that it was the right family. That enraged some Taliban factions in Pakistan, which outlawed vaccination in their areas and threatened vaccinators.


Nigerian police officials said the first shootings were of eight workers early in the morning at a clinic in the Tarauni neighborhood of Kano, the state capital; two or three died. A survivor said the two gunmen then set fire to a curtain, locked the doors and left.


“We summoned our courage and broke the door because we realized they wanted to burn us alive,” the survivor said from her bed at Aminu Kano Teaching Hospital.


About an hour later, six men on three-wheeled motorcycles stormed a clinic in the Haye neighborhood, a few miles away. They killed seven women waiting to collect vaccine.


Ten years ago, Dr. Larson said, she joined a door-to-door vaccination drive in northern Nigeria as a Unicef communications officer, “and even then we were trying to calm rumors that the C.I.A. was involved,” she said. The Iraq and Afghanistan wars had convinced poor Muslims in many countries that Americans hated them, and some believed the American-made vaccine was a plot by Western drug companies and intelligence agencies.


Since the vaccine ruse in Pakistan, she said, “Frankly, now, I can’t go to them and say, ‘The C.I.A. isn’t involved.’ ”


Dr. Pate said the attack would not stop the newly reinvigorated eradication drive, adding, “This isn’t going to deter us from getting everyone vaccinated to save the lives of our children.”


Aminu Abubakar contributed reported from Kano, Nigeria.



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Career Couch: Moving On From a Job That Has Defined You





Q. You want to move into management or a higher executive position, but you’re so good at your current job that you’re now defined by it. How can you find a way out of this pigeonhole?




A. Start with some self-reflection, says Michael L. Buckman, managing director of executive advisory services at the BPI Group, a management consulting firm in Chicago. You can’t just walk into your boss’s office and say, “I want a different job,” so list for yourself your passions, skills and abilities and how those could translate to another position in the organization, he says. “Is there another role you really aspire to?” he asks. “And how will you, in that role, add value to the company?”


Once you determine where in the company you see yourself moving, create a plan to get there. Start by talking to your manager. Express your gratitude for all you’ve learned and accomplished and emphasize how much you value being a part of the organization, says Susan Battley, chief executive of Battley Performance Consulting in East Setauket, N.Y.


Be sure to come to the conversation with ideas about how to begin your transition. “Don’t just say you feel your career needs to grow, because then you’ve put all this on your boss,” Ms. Battley says. “Instead, say things like, ‘I’m looking for opportunities to manage a team or have more exposure to customers.’ ”


Q. What if your boss is only reluctantly on board?


A. Your manager may have anxieties tied to a change like this, so be reassuring. Make it clear that you understand how heavily your boss relies on you and that you will help to find and develop a good replacement. Stress that “you are committed to the department meeting its goals and that you would never go off and leave him in the lurch,” says Allan R. Cohen, a management professor at the San Francisco campus of Babson College.


Don’t just talk about how this transition will benefit you; think about how it will benefit your boss, too. For instance, Professor Cohen says, note that the department “will look good for developing people who have an interest in wider aspects of the business. ”


You should also meet with senior people at the company who can influence your boss, says John Beeson, principal at Beeson Consulting, a management consulting firm in Manhattan. “Let them know you feel frustrated and want a new role that allows you to spread your wings, but are also committed to the company,” he says.


Q. In order to move into a different position at the company, you need to find opportunities to learn and demonstrate other skills. How do you do that?


A. If you’ve worked for the same person for years and are seen as the right-hand man or woman, you are probably known for executing strategy but not necessarily for developing it. Your boss can help find projects where you can take on a leadership role, Mr. Beeson says, and can schedule a briefing on those projects with senior managers to raise your visibility. Showcasing your skills and talents to a broader set of managers will keep you at the top of everyone’s mind as positions within the company become available.


Ms. Battley suggests volunteering for a task force or a committee that deals with issues removed from what you’re currently handling. In small companies, you can sometimes preview a possible new job by taking on a few tasks and getting a feel for it, she says.


Q. Who else, inside or outside the company, can help you make this transition?


A. Anyone who is influential in your organization or industry could help you achieve your goals, so meet with as many of those people as you can. “Tell them you are looking for some career guidance and ask for their input about the kinds of jobs and experiences you need to have,” says Mr. Buckman of the BPI Group. They may not know you have an interest in a particular area or that you have certain valuable skills.


Try to include among your allies at least one person from human resources, Ms. Battley advises. The people in H.R. “know where vacancies are or can advocate for you if they know you’re interested in gaining other skills,” she says.


It’s possible that you will receive feedback you didn’t expect. “You could be told, ‘That’s a great idea, but it’s not something that would fit here’ or that the company doesn’t really need what you’re offering,” Mr. Buckman says. That may signal that it is time to look for opportunities outside your organization.


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The Lede: Social Media Images From Tunisia, as an Opposition Leader Is Buried

Video of Friday’s funeral for Chokri Belaid, a Tunisian opposition leader assassinated two days ago, from the independent news site Nawaat.

Last Updated, 3:44 p.m. Activists, bloggers and journalists in Tunisia posted a stream of images on social networks Friday, showing thousands of mourners packed into the largest cemetery in the capital, Tunis, for the funeral of Chokri Belaid, a leading opposition figure whose assassination two days ago triggered a wave of street protests against the Islamist ruling party.

Among those uploading images of the funeral — which took place as the police fired tear gas at protesters and cars were set alight during clashes outside the graveyard — were my Times colleagues Kareem Fahim and Tara Todras-Whitehill, Thierry Brésillon of the French news site Rue 89, and Tunisian activists including Selim Kharrat of the rights organization Al Bawsala.

In video streamed live during the funeral by the activist blogger Slim Amamou, the 2011 revolutionary chant calling for the downfall of the regime could be heard echoing around the graveyard.

A photograph in a set uploaded to Facebook by the blogger Mon Massir appeared to show that even the late opposition leader’s young daughter was forced to shield her face from the tear gas fired by the police.

After the funeral, as photographs uploaded by Mr. Amamou and the rights activist Amira Yahyaoui showed, the security forces enforced a ban on gathering on the main Avenue Habib Bourguiba in central Tunis.

Emna Chebâane, who also works with the rights organization Al Bawsala, posted video on Facebook showing how the police moved in to clear a small number of protesters from the avenue.

It was not hard to imagine what the kind of protest the authorities were concerned about might look like. Two days earlier, when an ambulance carrying Mr. Belaid’s body to the morgue had passed through the same street, thousands of protesters swarmed around the vehicle. Video posted on YouTube late Wednesday by Jadal, a Tunisian news site, showed that scene.

Video recorded on Wednesday in Tunis as protesters gathered around an ambulance carrying the body of Chokri Belaid, a murdered opposition leader.

There were reports of protests in other parts of Tunisia on Friday, as many workers observed calls for a nationwide strike.

Video uploaded to YouTube by a blogger who said he was in the town of Sousse appeared to show the security forces, and officers in plain clothes, firing tear gas and dragging protesters away from a traffic circle pictured in a Wikipedia entry on the old town.

Video uploaded to YouTube on Friday, said to show the police cracking down on protesters in the Tunisian town of Sousse.

Two clips posted online earlier Friday by the same blogger appeared to show the divisions in Sousse, between supporters and opponents of the new government, which have emerged nationwide. One clip showed a loud march in favor of Ennahda, the Islamist party that now rules Tunisia; in another, a second group of protesters declared that they were committed to “bringing down the regime and avenging the death of Chokri Belaid.”

Video said to show supporters of Tunisia’s Islamist ruling party, marching in Sousse on Friday.

Video of antigovernment protesters, said to have been recorded in the Tunisian city of Sousse on Friday.

Video shot by bloggers for the independent news site Nawaat showed what they described as a demonstration in the city of Bizerte in honor of Mr. Belaid, outside the local headquarters of Ennahda. According to a description on Nawaat’s French-language live blog, the video shows an Islamist calling for calm and telling the demonstrators that the nation’s secularists have lost the struggle for power.

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State of the Art: Microsoft’s Surface Pro Works Like a Tablet and a PC





For decades, Microsoft has subsisted on the milk of its two cash cows: Windows and Office. The company’s occasional ventures into hardware generally haven’t ended well: *cough* Zune, Kin Phone, Spot Watch *cough*.




But the new Surface Pro tablet, which goes on sale Saturday, seemed to have more going for it than any Microsoft hardware since the Xbox.


Everybody knows what a tablet is, right? It’s a black touch-screen slab, like an iPad or an Android tablet. It doesn’t run real Windows or Mac software — it runs much simpler apps. It’s not a real computer.


But with the Surface Pro ($900 for the 64-gigabyte model, $1,000 for a 128-gig machine), Microsoft asks: Why not?


The Surface Pro looks like a tablet. It can work like a tablet. You can hold it in one hand and draw on it with the other. It even comes with a plastic stylus that works beautifully.


But inside, the Pro is a full-blown Windows PC, with the same Intel chip that powers many high-end laptops, and even two fans to keep it cool (they’re silent). As a result, the Pro can run any of the four million Windows programs, like iTunes, Photoshop, Quicken, and, of course, Word, Excel and PowerPoint.


The Surface Pro is beautiful. It’s clad in matte-black metal, beveled at the edges like a Stealth helicopter. Its connectors immediately suggest its post-iPad capabilities, like a memory-card slot for expanded storage. The screen is bright and beautiful, with 1080p high-definition resolution (1,080 by 1,820) — but when you connect the tablet to a TV or desktop monitor, it can send out an even bigger, sharper picture (2,550 by 1,440). There’s one USB 3.0 jack in the tablet, and a second ingeniously built into the power cord, so you can charge your phone as you work. Or you can connect anything you’d connect to a PC: external drives, flash drives, keyboard, mouse, speakers, cameras and so on.


Are you getting it? This is a PC, not an iPad.


As though to hammer home that point, Microsoft has endowed the Surface Pro with two unusual extras that complete the transformation from tablet to PC in about two seconds.


First, this tablet has a kickstand. It’s a thin metal flap that disappears completely when closed, but holds the tablet at a nice angle when you’re working or watching a movie.


Second, you can buy Microsoft’s now-famous keyboard cover. There are two models, actually. One is about as thick as a shirt cardboard. You can type on it — slowly — but you’re tapping drawings of keys, not actual keys. It’s called the Touch Cover ($100 with Surface purchase).


The other keyboard, the Type Cover ($130) is thicker — a quarter-inch — but its keys really travel, and it has a trackpad. You can really type on this thing.


Either keyboard attaches to the tablet with a powerful magnetic click. For tablet use, you can flip either keyboard around to the back; it disables itself so you don’t type gibberish by accident.


And if you really want to go whole hog with the insta-PC idea, you should also spring for the matching Wedge Touch mouse. It’s a tiny $70 cordless wedge, not much bigger than the AA battery that powers it, with supercrisp buttons and a touch surface on top for scrolling.


Now, when I wrote a first-look post on my blog last month , I was surprised by the reader reactions. Over and over, they posted the same argument:


“For that money, I could buy a very nice lightweight laptop with a dedicated keyboard and much more storage. Why should I buy Surface Pro when I can have more for less?”


Why? Because the Surface Pro does things most laptops can’t do. Like it weighs two pounds, with touch screen. Or work in portrait orientation, like a clipboard. Or remain comfortable in one hand as you make medical rounds, take inventory or sketch a portrait. Or stay in a bag through airport security (the TSA says tablets are O.K. to stay in).


You also hear: “But haven’t there been full-blown PC tablets before?”


Yes, there are a couple. But without the kickstand and keyboard cover, they can’t change instantly into a desktop computer.


So it’s true: for this much money, you could buy a very nice laptop. You could also buy a five-day cruise, a Gucci handbag or 250 gallons of milk. They just happen to be different beasts.


All right then: the Surface Pro is fast, flexible and astonishingly compact for what it does; that much is unassailable. But in practice, there are some disappointments and confusions.


E-mail: pogue@nytimes.com



This article has been revised to reflect the following correction:

Correction: February 8, 2013

An earlier version of this column gave an incorrect price from the company for the Wedge Touch mouse for the Surface. It is $70, not $40.



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The New Old Age: The Executor's Assistant

I’m serving as executor for my father’s estate, a role few of us are prepared for until we’re playing it, so I was grateful when the mail brought “The American Bar Association Guide to Wills and Estates” — the fourth edition of a handbook the A.B.A. began publishing in 1995.

This is a legal universe, I’m learning, in which every step — even with a small, simple estate that owes no taxes and includes no real estate or trusts — turns out to be at least 30 percent more complicated than expected.

If my dad had been wealthy or owned a business, or if we faced a challenge to his will, I would have turned the whole matter over to an estate lawyer by now. But even then, it would be helpful to know what the lawyer was talking about. The A.B.A. guide would help.

Written with surprising clarity (hey, they’re lawyers), it maps out all kinds of questions and decisions to consider and explains the many ways to leave property to one’s heirs. Updated from the third edition in 2009, the guide not only talks taxes and trusts, but also offers counsel for same-sex couples and unconventional families.

If you want to permit your second husband to live in the family home until he dies, but then guarantee that the house reverts to the children of your first marriage, the guide tells you how a “life estate” works. It explains what is taxable and what isn’t, and discusses how to choose executors and trustees. It lists lots of resources and concludes with an estate-planning checklist.

In general, the A.B.A. intends its guide for the person trying to put his or her affairs in order, more than for family members trying to figure out how to proceed after someone has died. But many of us will play both these parts at some point (and if you are already an executor, or have been, please tell us how that has gone, and mention your state). We’ll need this information.

Editor’s Note: More information about “The American Bar Association Guide to Wills and Estates” can be found here.


Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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The New Old Age: The Executor's Assistant

I’m serving as executor for my father’s estate, a role few of us are prepared for until we’re playing it, so I was grateful when the mail brought “The American Bar Association Guide to Wills and Estates” — the fourth edition of a handbook the A.B.A. began publishing in 1995.

This is a legal universe, I’m learning, in which every step — even with a small, simple estate that owes no taxes and includes no real estate or trusts — turns out to be at least 30 percent more complicated than expected.

If my dad had been wealthy or owned a business, or if we faced a challenge to his will, I would have turned the whole matter over to an estate lawyer by now. But even then, it would be helpful to know what the lawyer was talking about. The A.B.A. guide would help.

Written with surprising clarity (hey, they’re lawyers), it maps out all kinds of questions and decisions to consider and explains the many ways to leave property to one’s heirs. Updated from the third edition in 2009, the guide not only talks taxes and trusts, but also offers counsel for same-sex couples and unconventional families.

If you want to permit your second husband to live in the family home until he dies, but then guarantee that the house reverts to the children of your first marriage, the guide tells you how a “life estate” works. It explains what is taxable and what isn’t, and discusses how to choose executors and trustees. It lists lots of resources and concludes with an estate-planning checklist.

In general, the A.B.A. intends its guide for the person trying to put his or her affairs in order, more than for family members trying to figure out how to proceed after someone has died. But many of us will play both these parts at some point (and if you are already an executor, or have been, please tell us how that has gone, and mention your state). We’ll need this information.

Editor’s Note: More information about “The American Bar Association Guide to Wills and Estates” can be found here.


Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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Venezuela Announces Currency Devaluation







CARACAS, Venezuela (AP) — Venezuela's government announced Friday that is devaluing the country's currency, a change expected to push up prices in the heavily import-reliant economy.




Officials said the fixed exchange rate is changing from 4.30 bolivars to the dollar to 6.30 bolivars to the dollar.


The devaluation had been widely expected by analysts in recent months. It was the first devaluation to be announced by President Hugo Chavez's government since 2010.


Planning and Finance Minister Jorge Giordani said the new rate takes effect immediately, though the old rate would still be allowed for some transactions that already were approved by the state currency agency.


Venezuela's government has had strict currency exchange controls since 2003 and maintains a fixed, government-set exchange rate.


Under the currency controls, people and businesses must apply to a government currency agency to receive dollars at the official rate to import goods, pay for travel or cover other obligations.


While those controls have restricted the amounts of dollars available at the official rate, an illegal black market has also flourished and the value of the bolivar has recently been eroding. In black market trading, dollars have recently been selling for more than four times the official exchange rate of 4.30 bolivars to the dollar.


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At War Blog: U.S. and Allies Conduct Drills in Persian Gulf, a Signal to Iran

Deterring Iran is a delicate balance of diplomacy, sanctions and military muscle-flexing, all intended to send a strong signal – without proving so provocative that the region is pushed toward war. One piece of the effort – halting the proliferation of illicit weapons – got a practice run in the Persian Gulf this week.

Although the exercise did not explicitly name an adversary, geography certainly pointed to Iran, as well as to militants of Al Qaeda still operating in the region. The exercise, which ended Thursday, included a headquarters simulation to test the policy-making and coordination among the American military and two dozen nations that joined, as well as an extensive component of military drills at sea, in the air and on land.

Pentagon officials do not hide the fact that halting suspected smugglers, and boarding their vessels and inspecting them, is in some ways easier than knitting together a coalition of countries to operate under the decade-old Proliferation Security Initiative.

While there may be quiet agreement that Iran is a threat to regional stability, many nations – especially Iran’s neighbors – want to avoid any appearance of belligerence that might make relations even worse. In fact, several of the countries in this week’s exercise declined to officially confirm their participation.

That alliance cohesion problem is not new. When the Proliferation Security Initiative was begun by the administration of President George W. Bush, South Korea initially refused to join, for fear of angering North Korea. The government in Seoul eventually reversed the decision, and South Korea is among the nonproliferation program’s current members, a number that has expanded to 102 nations from the original 11.

Separate from this current multinational exercise, American and Yemeni officials disclosed last week that a joint operation had interdicted a boat carrying a large load of explosives and weapons, including shoulder-launched antiaircraft weapons. Intelligence indicated that the shipment came from Iran and was destined for Houthi insurgent militants inside Yemen.

Even before the proliferation exercise ended this week, the American military’s Central Command announced the scheduling of another exercise to practice mine countermeasures and maritime security in waters of the Middle East. Those skills would be necessary if Iran tried to close the Strait of Hormuz. More than 20 nations will participate in the exercise, set to begin in May.

But budget difficulties in Washington may make sustaining a large American military presence in the region more difficult. The Pentagon announced this week that, temporarily at least, there would be only one aircraft carrier strike group on patrol in the region, down from the usual two. The reason: the Defense Department needs to save money.

Related Coverage:

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Television Review: ‘Silicon Valley,’ on ‘American Experience’ on PBS





“Silicon Valley” is a deceptively grand title for the new “American Experience” documentary Tuesday night on PBS. “Fairchild Semiconductor” would be more accurate. It could even be called “Robert Noyce” or, with a musical score and some dance numbers, “Noyce!”




But the film’s modest goals work in its favor. “Silicon Valley” takes one piece of the sprawling story of the electronics industry in Northern California and tells it with admirable clarity and detail. Stopping well short of the valley’s modern era — the action ends in the early 1970s, with the invention of the microprocessor — it’s rewarding as both history and nostalgia.



The documentary actually touches on several cycles of wistfulness. Nostalgia for the preindustrial Santa Clara Valley of orchards and farm stands, which has been heavy for more than three decades now, is indulged with grainy shots of apricots being picked and young men in letter sweaters and khaki pants walking past the History Corner of the Stanford quad. (Like many films about Silicon Valley, this one also cheats by including San Francisco vistas and cable cars.)



After that stage setting, the film gets to its central story: how in 1957 eight young men, led by a visionary physicist and engineer, Mr. Noyce, took the revolutionary step of leaving their company to form a start-up called Fairchild Semiconductor and in the process created Silicon Valley. Interviews with an array of industry veterans, including two of the three surviving defectors, outline how Fairchild and the companies it spawned both developed the technologies and established the business and financial cultures that would eventually produce behemoths like Apple and Google.



This is dramatic social and scientific history, revealing, among other things, how the semiconductor industry grew to serve the military and the space program long before the rise of the personal computer. But, again, the film’s visceral appeal has much to do with period detail: neatly groomed engineers wearing suits and ties, even on the production floor or at the bar of Walker’s Wagon Wheel in Mountain View; rows of women in smocks and hairnets assembling transistors. (The gender lines are inviolate in these early-’60s photos, and the men are almost invariably white.)



One startling image shows a handwritten list of the many corporations that declined to bankroll the eight pioneers before Fairchild Camera and Instrument said yes. If any of them had possessed more foresight, the silicon chip might have belonged to National Cash Register, Motorola, Philco, BorgWarner, Chrysler, General Mills or United Shoe.



Even with its relatively narrow focus, “Silicon Valley” is highly compressed, and people familiar with the industry may have complaints: that the infighting that made Fairchild Semiconductor’s reign short-lived isn’t fully explored, or that Intel, the chip giant later founded by Mr. Noyce and Gordon Moore, should receive more attention.



Any quibbling aside, though, the film is a captivating look at recent history that already feels ancient, when high technology involved inventing and building things rather than writing code and selling clicks.



American Experience



Silicon Valley



On PBS stations on Tuesday night (check local listings).



Produced by Film Posse for “American Experience.” Directed and edited by Randall MacLowry; written by Mr. MacLowry and Michelle Ferrari, based on a story by Mr. MacLowry; Mr. MacLowry and Tracy Heather Strain, producers; Mark Samels, executive producer for “American Experience”; Michael Murphy, narrator.


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Well: The 'Monday Morning' Medical Screaming Match

I did not think I would ever see another “morbidity and mortality” conference in which senior doctors publicly attacked their younger colleagues for making medical errors. These types of heated meetings were commonplace when I was a medical student but have largely been abandoned.

Yet here they were again on “Monday Mornings,” a new medical drama on the TNT network, based on a novel by Dr. Sanjay Gupta, CNN’s chief medical correspondent and one of the executive producers of the show. Such screaming matches may make for good television, but it is useful to review why new strategies have emerged for dealing with medical mistakes.

So-called M&M conferences emerged in the early 20th century as a way for physicians to review cases that had either surprising outcomes or had somehow gone wrong. Although the format varied among institutions and departments, surgery M&Ms were especially known for their confrontations, as more experienced surgeons often browbeat younger doctors into admitting their errors and promising to never make them again.

Such conferences were generally closed door — that is, attended only by physicians. Errors were a private matter not to be shared with other hospital staff, let alone patients and families.

But in the late 1970s, a sociology graduate student named Charles L. Bosk gained access to the surgery department at the University of Chicago. His resultant 1979 book, “Forgive and Remember,” was one of the earliest public discussions of how the medical profession addressed its mistakes.

Dr. Bosk developed a helpful terminology. Technical and judgment errors by surgeons could be forgiven, but only if they were remembered and subsequently prevented by those who committed them. Normative errors, which called into question the moral character of the culprit, were unacceptable and potentially jeopardized careers.

Although Dr. Bosk’s book was more observational than proscriptive, his depiction of M&M conferences was disturbing. I remember attending a urology M&M as a medical student in which several senior physicians berated a very well-meaning and competent intern for a perceived mistake. The intern seemed to take it very well, but my fellow students and I were shaken by the event, asking how such hostility could be conducive to learning.

There were lots of angry accusations in the surgical M&Ms in the pilot episode of “Monday Mornings.” In one case, a senior doctor excoriated a colleague who had given Tylenol to a woman with hip pain who turned out to have cancer. “You allowed metastatic cancer to run amok for four months!” he screamed.

If this was what Dr. Bosk would have called a judgment error, the next case raised moral issues. A neurosurgeon had operated on a boy’s brain tumor without doing a complete family history, which would have revealed a disorder of blood clotting. The boy bled to death on the operating table. “The boy died,” announced the head surgeon, “because of a doctor’s arrogance.”

In one respect, it is good to see that the doctors in charge were so concerned. But as the study of medical errors expanded in the 1990s, researchers found that the likelihood of being blamed led physicians to conceal their errors. Meanwhile, although doctors who attended such conferences might indeed not make the exact same mistakes that had been discussed, it was far from clear that M&Ms were the best way to address the larger problem of medical errors, which, according to a 1999 study, killed close to 100,000 Americans annually.

Eventually, experts recommended a “systems approach” to medical errors, similar to what had been developed by the airline industry. The idea was to look at the root causes of errors and to devise systems to prevent them. Was there a way, for example, to ensure that the woman with the hip problem would return to medical care when the Tylenol did not help? Or could operations not be allowed to occur until a complete family history was in the chart? Increasingly, hospitals have put in systems, such as preoperative checklists and computer warnings, that successfully prevent medical errors.

Another key component of the systems approach is to reduce the emphasis on blame. Even the best doctors make mistakes. Impugning them publicly — or even privately — can make them clam up. But if errors are seen as resulting from inadequate systems, physicians and other health professionals should be more willing to speak up.

Of course, the systems approach is not perfect. Studies continue to show that physicians conceal their mistakes. And elaborate systems for preventing errors can at times interfere with getting things done in the hospital.

Finally, it is important not to entirely remove the issue of responsibility. Sad to say, there still are physicians who are careless and others who are arrogant. Even if today’s M&M conferences rarely involve screaming, supervising physicians need to let such colleagues know that these types of behaviors are unacceptable.


Barron H. Lerner, M.D., professor of medicine at New York University Langone Medical Center, is the author, most recently, of “One for the Road: Drunk Driving Since 1900.”
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