As I watch the current debacle of our children preparing to return to school, I more and more feel it is time to take a moment to talk about the errors we have made. My original thoughts turned to responsibility and accountability, words that have occupied my professional life as a surgeon, words molding my thinking just as they molded my character.
First, let me thank Peter Attia, MD, who wrote a piece that reminded me of the definitions and words I was searching for that were mostly free of emotional connotations. Let’s first address the elephant in the room, the politicization of the errors made in managing this pandemic. Most of this discussion concerns intent – “the needless destruction of our economy,” or “racism in medical care,” come to mind. But unlike The Shadow [1], I “know not what evil lurks in the minds of men.” No physician that I know intended to injure a patient, those that did had not committed malpractice; they had committed assault, battery, or even murder; a very different type of “error.” [2]
I can’t ascribe intent to the actions of institutions or individuals that I only know from reading. My general approach is to be trusting of someone until they prove otherwise. For example, my conception of the World Health Organization is a collaborative effort to raise healthcare standards and supplement care globally. I wasn’t too concerned with its internal politics. China, on the other hand, has made me worried since Tiananmen Square and reinforced by their current behavior in Hong Kong? When it comes to errors, the intent is not the main issue.
“You are only as good as your last case.”
Physicians make errors, by the nature of our work, a surgical error is evident more quickly, making the linkage of error and bad outcome easier to identify. Surgeons make technical errors. “When a surgeon makes a technical error, he is performing his role conscientiously, but his skills fall short of what the task requires.” Surgeons also make errors in judgment. Those errors frequently involve decisions about the ifs and whens of applying surgical management.
There is no doubt that there have been many errors of technique and judgment in our personal and societal responses to the novel virus that results in COVID-19. There were errors in the methods of our pandemic models, not accounting for our subsequent behavior stands out, as does the choice of various values like the R0 used in the predictions. There were errors in the judgment of when and what to close down, just as there are currently errors in when and what to open up.
These are errors where you accept responsibility, acknowledging with hindsight, where you erred, learning from these failures, and moving on. These are the mistakes we must learn from and not only promise but actually do better in the future. Even before COVID-19, it has been fashionable “to take responsibility” for those events. Usually, responsibility meant a public mea culpa with little personal impact. Ah, there it is, the key phrase, the personal impact. Corporate officers and politicians are big on taking responsibility, although corporations are legal entities specifically designed to shield employees and owners from liability. Similarly, the high re-electability of incumbents suggests that the ballot box shields more than holds accountable. Being “responsible” can be optically advantageous.
A far graver error, to my mind, is a normative error, acting against the accepted norms and responsibilities. Medical malpractice is a result of normative errors, not meeting the “standard of care.” These misdeeds draw closest to the understanding of intent, and while often couched as errors in judgment or technique, they come from misaligned values; when your interests conflict with mine. The purest example comes from sales where the commission for the transaction may be more important than your satisfaction with the object. In economics, this misalignment is addressed through fiduciary responsibility – for the agent to act solely on your behalf, not on theirs.
Our current dilemma
Governor Cuomo made a mistake when he allowed patients recovering from COVID-19 to return to nursing homes in order to make room for patients who were more ill. His instructions were ambiguous, but he was acting upon the best information he had. On the other hand, the Chinese government made a mistake in not sharing their concerns more quickly with the world, but that was not the best they could have done. Same for the World Health Organization that allowed internal politics to deflect from their mission. These are normative errors.
Consider New York City’s reopening of schools. I recognize that the Governor waited for a long time to put forth the standards for the new school year. But the NYC’s Department of Education knew that they would have to make some sort of plan, and so did the city’s teachers union, the United Federation of Teachers. Both the DOE and UFT have made mistakes, but their most significant mistake was not beginning to look at the problem and seek solutions together three months ago – they didn’t do their best for the city’s children, not by a longshot. While the greatest public tragedy will be the impact on our children, it is none the less tragic that no one will be held responsible or accountable. Mayor de Blasio is termed out, and the union can describe their passivity as being “blindsided.”
Just as surgeons face their peers and discuss their errors at a weekly conference, as a society, we must speak to our mistaken responses to this pandemic. But when we apportion blame and shame, it might be wise to remember the different errors we make and to focus our most significant concern on those normative errors, when individuals and institutions chose themselves over us.
[1] A fictional radio character of the ’30s
[2] Forgive and Remember: Managing Medical Failure Charles Bosk
