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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Business Week in Pictures

Phil Libin, the chief executive of Evernote, during a staff meeting at Evernote’s headquarters in Redwood City, Calif. Evernote is among the privately held Silicon Valley start-ups that are worth more than $1 billion. An unprecedented number of high technology start-ups, easily 25 and possibly exceeding 40, have crossed that threshold. Many employees are quietly growing rich, or at least building a big cushion against a crash, as they sell shares to outside investors. Airbnb, Pinterest, SurveyMonkey and Spotify are among the better-known privately held companies that have reached $1 billion.

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IHT Rendezvous: French Communists Abandon Hammer and Sickle

LONDON — The Communist Party of France has sparked a revolution among the comrades by removing the hammer and sickle from their membership cards.

The iconic symbol of the international proletariat has been replaced with the star of the multi-party European Left alliance, much to the horror of traditionalists at the party’s 36th congress that opened near Paris on Thursday.

What was billed by the party leadership as a forward-looking move was denounced by others as revisionist backsliding and part of a conspiracy to abandon the movement to the embrace of social democracy.

Emmanuel Dang Tran, secretary of the party’s Paris section, told France Info radio that members were shocked at the abandoning of “what represents, for the working class of this country, a historic element in resistance against the politics of capitalism.”

An anonymous commenter on the radio’s website suggested wryly: “It’s natural that they’ve abandoned their tools. There’s no work anymore!”

Mr. Tran was among those who believed the symbol change amounted to the party paying allegiance to the European Left, a coalition of left-wing movements formed in 1999 to cooperate within the European Parliament.

He said the leadership was trying to create a social democracy mark-2 alongside “Greens, socialists, Trotskyists and I don’t know who else.”

Pierre Laurent, the party’s national secretary, defended the decision to dump the hammer and sickle, saying it no longer represented present-day realities. “We want to turn towards the future,” he said on Friday.

The internal spat was the latest upset for a communist party that was once powerful on the left in France, with ministers serving in a number of Socialist-led administrations.

It remains the country’s largest left-wing party in terms of membership. But its standing has declined rapidly since the collapse of communism in Eastern Europe.

For the first time last year, it failed to put up its own candidate at a presidential election and opted instead to support Jean-Luc Mélenchon of the Left Front.

Although the Communist Party is the largest grouping in the Left Front, hardliners complain it risks playing second fiddle to other movements in the alliance despite being its “sole historically revolutionary component.”

The 20Minutes news Website asked whether the loss of the hammer and sickle meant the party was becoming a “Communist Party light” and noted that this week’s congress had also adopted Mr. Mélenchon’s “people first” slogan.

“That is something to chew on for the many who fear the party will be dissolved into a Left Front led by Jean-Luc Mélenchon,” it wrote.

L’Humanité, the former official Communist newspaper that retains close links with the party, managed to remain upbeat as the congress opened. It ran a poll that indicated the party’s public image had improved since the creation of the Left Front.

It also interviewed the rank and file at the party congress who said that, among other things, they saw the gathering as an occasion for communists to go on the offensive, continue a citizens’ revolution, or simply spend a “fraternal moment with all the comrades.”

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Super Bowl blackout was caused by electrical relay

NEW ORLEANS (AP) — The company that supplied electricity to the Super Bowl says the blackout that halted the big game was caused by a device it installed specially to prevent a power failure.

But the utility stopped short of taking all the blame and said Friday that it was looking into whether the electrical relay at fault had a design flaw or a manufacturing defect.

The relay had been installed as part of a project begun in 2011 to upgrade the electrical system serving the Superdome in anticipation of the championship game. The equipment was supposed to guard against problems in the cable that links the power grid with lines that go into the stadium.

"The purpose of it was to provide a newer, more advanced type of protection for the Superdome," Dennis Dawsey, an executive with Entergy Corp., told members of the City Council. Entergy is the parent company of Entergy New Orleans, the city's main electric utility.

Entergy officials said the relay functioned with no problems during January's Sugar Bowl and other earlier events. It has been removed and will be replaced.

All systems at the Superdome are now working, and the stadium was to host a major Mardi Gras event Saturday night, said Doug Thornton, an executive with SMG, the company that manages the stadium for the state.

The relay was installed in a building near the stadium known as "the vault," which receives a line directly from a nearby Entergy substation. Once the line reaches the vault, it splits into two cables that go into the Superdome.

Sunday's power failure cut lights to about half of the stadium, halting play between the Baltimore Ravens and San Francisco 49ers and interrupting the nation's most-watched sporting event for 34 minutes.

Not long after the announcement, the manufacturer of the relay, Chicago-based S&C Electric Co., released a statement saying that the blackout occurred because system operators had put the relay's so-called trip setting too low to allow the device to handle the incoming electric load.

The equipment was owned and installed by Entergy New Orleans.

"If higher settings had been applied, the equipment would not have disconnected the power," said Michael J.S. Edmonds, vice president of strategic solutions for S&C.

In a follow-up statement, Entergy said that tests conducted by S&C and Entergy on the two relays at the Superdome showed that one worked as expected, the other did not.

Entergy spokesman Mike Burns said both relays had the same trip setting.

Entergy's announcement came shortly before company officials went before a committee of the City Council, which is the regulatory body for the company.

During the committee hearing, council member Susan Guidry asked Entergy executives whether they were "fairly certain" that the relay was faulty.

"That is correct," Dawsey said.

However, when asked if the outage was caused by the design or a defect in a part of the equipment, Entergy New Orleans CEO Charles Rice said that had not been determined.

"The equipment did not function properly," Rice said. "At this particular time, based upon our analysis, we cannot say definitively that there was a defect in design. What we do know is that the equipment for some unknown reason, at this particular time, did not react the way that it should have."

Asked if Entergy and SMG still plan to hire a third-party investigator to get to the bottom of the cause, Rice said that possibility remains open.

"We'll work closely with SMG, and if there is a need for a third-party investigation, we will do that," Rice said, adding that Entergy was also working with the relay manufacturer.

Shabab Mehraeen, an assistant professor of electrical engineering at Louisiana State University, said relays are common electrical fixtures in businesses and massive facilities such as the Superdome.

"They are designed to keep a problem they sense from becoming something bigger, like a fire or catastrophic event," he said.

The devices vary in size. Mehraeen, who was not familiar with the relay at the Superdome, said he "wouldn't be surprised if it was bigger than a truck."

The reasons the devices fail are the subject of much academic research into the interaction of relays with the complex electrical systems they regulate.

"It's not unusual for them to have problems," Mehraeen said. "They can be unpredictable, despite national testing standards recommended by manufacturers."

Entergy and SMG had both upgraded lines and equipment in the months leading up to the Super Bowl. Rice said the new gear, with the faulty relay, was installed as part of a $4.2 million upgrade by Entergy that included a new power line dedicated solely to the stadium.

In a separate project, SMG replaced lines coming into the stadium after managers expressed concerns the Superdome might be vulnerable to a power failure like the one that struck Candlestick Park during an NFL game in 2011.

Thornton stressed Friday that the dome was drawing only about two-thirds of its power capacity Super Bowl night. He said typical NFL games in late August or September can draw a little more.

Friday's announcement appeared to absolve Superdome officials of any missteps in the blackout.

City officials had worried that the Super Bowl outage might harm New Orleans' chances of getting another NFL championship game.

But NFL Commissioner Roger Goodell downplayed that possibility, saying the league planned to keep New Orleans in its Super Bowl plans. Mayor Mitch Landrieu said the city intends to bid for the game again in 2018.

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Associated Press Writer Michael Kunzelman in New Orleans contributed to this report.

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Well: Think Like a Doctor: A Confused and Terrified Patient

The Challenge: Can you solve the mystery of a middle-aged man recovering from a serious illness who suddenly becomes frightened and confused?

Every month the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult case and solve a diagnostic riddle. Below you will find a summary of a case involving a 55-year-old man well on his way to recovering from a series of illnesses when he suddenly becomes confused and paranoid. I will provide you with the main medical notes, labs and imaging results available to the doctor who made the diagnosis.

The first reader to figure out this case will get a signed copy of my book, “Every Patient Tells a Story,” along with the satisfaction of knowing you solved a case of Sherlockian complexity. Good luck.

The Presenting Problem:

A 55-year-old man who is recovering from a devastating injury in a rehabilitation facility suddenly becomes confused, frightened and paranoid.

The Patient’s Story:

The patient, who was recovering from a terrible injury and was too weak to walk, had been found on the floor of his room at the extended care facility, raving that there were people out to get him. He was taken to the emergency room at the Waterbury Hospital in Connecticut, where he was diagnosed with a urinary tract infection and admitted to the hospital for treatment. Doctors thought his delirium was caused by the infection, but after 24 hours, despite receiving the appropriate antibiotics, the patient remained disoriented and frightened.

A Sister’s Visit:

The man’s sister came to visit him on his second day in the hospital. As she walked into the room she was immediately struck by her brother’s distress.

“Get me out of here!” the man shouted from his hospital bed. “They are coming to get me. I gotta get out of here!”

His brown eyes darted from side to side as if searching for his would-be attackers. His arms and legs shook with fear. He looked terrified.

For the past few months, the man had been in and out of the hospital, but he had been getting better — at least he had been improving the last time his sister saw him, the week before. She hurried into the bustling hallway and found a nurse. “What the hell is going on with my brother?” she demanded.

A Long Series of Illnesses:

Three months earlier, the patient had been admitted to that same hospital with delirium tremens. After years of alcohol abuse, he had suddenly stopped drinking a couple of days before, and his body was wracked by the sudden loss of the chemical he had become addicted to. He’d spent an entire week in the hospital but finally recovered. He was sent home, but he didn’t stay there for long.

The following week, when his sister hadn’t heard from him for a couple of days, she forced her way into his home. There she found him, unconscious, in the basement, at the bottom of his staircase. He had fallen, and it looked as if he may have been there for two, possibly three, days. He was close to death. Indeed, in the ambulance on the way to the hospital, his heart had stopped. Rapid action by the E.M.T.’s brought his heart back to life, and he made it to the hospital.

There the extent of the damage became clear. The man’s kidneys had stopped working, and his body chemistry was completely out of whack. He had a severe concussion. And he’d had a heart attack.

He remained in the intensive care unit for nearly three weeks, and in the hospital another two weeks. Even after these weeks of care and recovery, the toll of his injury was terrible. His kidneys were not working, so he required dialysis three times a week. He had needed a machine to help him breathe for so long that he now had to get oxygen through a hole that had been cut into his throat. His arms and legs were so weak that he could not even lift them, and because he was unable even to swallow, he had to be fed through a tube that went directly into his stomach.

Finally, after five weeks in the hospital, he was well enough to be moved to a short-term rehabilitation hospital to complete the long road to recovery. But he was still far from healthy. The laughing, swaggering, Harley-riding man his sister had known until that terrible fall seemed a distant memory, though she saw that he was slowly getting better. He had even started to smile and make jokes. He was confident, he had told her, that with a lot of hard work he could get back to normal. So was she; she knew he was tough.

Back to the Hospital:

The patient had been at the rehab facility for just over two weeks when the staff noticed a sudden change in him. He had stopped smiling and was no longer making jokes. Instead, he talked about people that no one else could see. And he was worried that they wanted to harm him. When he remained confused for a second day, they sent him to the emergency room.

You can see the records from that E.R. visit here.

The man told the E.R. doctor that he knew he was having hallucinations. He thought they had started when he had begun taking a pill to help him sleep a couple of days earlier. It seemed a reasonable explanation, since the medication was known to cause delirium in some people. The hospital psychiatrist took him off that medication and sent him back to rehab that evening with a different sleeping pill.

Back to the Hospital, Again:

Two days later, the patient was back in the emergency room. He was still seeing things that weren’t there, but now he was quite confused as well. He knew his name but couldn’t remember what day or month it was, or even what year. And he had no idea where he was, or where he had just come from.

When the medical team saw the patient after he had been admitted, he was unable to provide any useful medical history. His medical records outlined his earlier hospitalizations, and records from the nursing home filled in additional details. The patient had a history of high blood pressure, depression and alcoholism. He was on a long list of medications. And he had been confused for the past several days.

On examination, he had no fever, although a couple of hours earlier his temperature had been 100.0 degrees. His heart was racing, and his blood pressure was sky high. His arms and legs were weak and swollen. His legs were shaking, and his reflexes were very brisk. Indeed, when his ankle was flexed suddenly, it continued to jerk back and forth on its own three or four times before stopping, a phenomenon known as clonus.

His labs were unchanged from the previous visit except for his urine, which showed signs of a serious infection. A CT scan of the brain was unremarkable, as was a chest X-ray. He was started on an intravenous antibiotic to treat the infection. The thinking was that perhaps the infection was causing the patient’s confusion.

You can see the notes from that second hospital visit here.

His sister had come to visit him the next day, when he was as confused as he had ever been. He was now trembling all over and looked scared to death, terrified. He was certain he was being pursued.

That is when she confronted the nurse, demanding to know what was going on with her brother. The nurse didn’t know. No one did. His urinary tract infection was being treated with antibiotics, but he continued to have a rapid heart rate and elevated blood pressure, along with terrifying hallucinations.

Solving the Mystery:

Can you figure out why this man was so confused and tremulous? I have provided you with all the data available to the doctor who made the diagnosis. The case is not easy — that is why it is here. I’ll post the answer on Friday.

Friday Feb. 8 4:13 p.m. | Updated Thanks for all your responses. You can read about the winner at “Think Like a Doctor: A Confused and Terrified Patient Solved.”

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Rules and Regulations: Post your questions and diagnosis in the comments section below.. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Correction: The patient’s eyes were brown, not blue.

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Trade Deficit Narrows, Brightening Outlook

The United States economy most likely expanded slightly in the fourth quarter, instead of contracting, according to trade data released Friday that suggested a surprise drop in gross domestic product reported last week may have been overstated.

The country’s trade deficit narrowed to $38.5 billion in December, its lowest reading in nearly three years, Commerce Department data showed. The decrease was driven by a drop in oil imports and a surge in exports. The overall trade gap was far smaller than analysts polled by Reuters had expected.

“Trade data for December paint a reassuring and encouraging picture of the U.S. economy at the end of last year,” said Chris Williamson, chief economist at Markit.

A separate report from the Commerce Department showed that wholesale inventories unexpectedly declined in December, a factor that could hamper the stronger trade figures’ effect on growth.

Still, the two reports together suggested the government could revise up its reading on fourth-quarter G.D.P., which showed the economy contracting at a 0.1 percent annual rate. That decline was driven by an expected drop in exports, smaller gains in inventories and a plunge in military spending.

Barclays said that even with December’s decline in wholesale inventories, the economy most likely expanded 0.3 percent in the fourth quarter, thanks to the higher export numbers in Friday’s trade report.

American exports increased by $8.6 billion in December over the year-ago month, lifted by sales of industrial supplies, including a $1.2 billion rise from November in nonmonetary gold.

Reflecting the country’s current boom in oil and natural gas, petroleum exports rose by nearly $1 billion during the month to a record high.

A fall in petroleum purchases led overall imports to decline by $4.6 billion in December from the year-ago period.

For the entire year, the country’s imports of crude oil fell to their lowest levels since 1997 in terms of volume.

Stocks prices on American exchanges rose as investors took note of the strong trade data, which included the United States figures as well as readings showing stronger exports and imports in China during January. The price of the benchmark 10-year Treasury note also rose.

For all of 2012, the United States trade gap shrank by 3.5 percent, to $540.4 billion. Running trade deficits means the country loses dollars, which drags on the economy; rising exports reduce that effect.

Exports last year rose 4.4 percent.

Even the American trade balance with China had a silver lining. While imports from China increased to a record high last year, so did American exports there. The December trade deficit in goods with China, not seasonally adjusted, narrowed by $4.5 billion from the previous month on a drop in imports.

Also in December, United States wholesale inventories unexpectedly fell as auto dealers and agricultural suppliers drew down their stocks.

The Commerce Department said stocks of unsold goods at wholesalers dropped 0.1 percent during the month and grew less than initially estimated in November.

Economists polled by Reuters had expected wholesale inventories to rise 0.4 percent.

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China Makes Arrests in Crackdown on Immolations

HONG KONG — The police in a restive Tibetan area have arrested 12 people and detained dozens more accused of playing a part in acts of self-immolation by Tibetan monks and others protesting Chinese rule, the state-run news media said Thursday, as the government stepped up its campaign of attributing the protests to a plot inspired by the exiled Dalai Lama.

The announcement of the crackdown in Qinghai Province in western China comes as the number of self-immolations reported in Tibetan parts of the country over the past four years approached 100, a somber milestone that has appeared to spur efforts by the Chinese police and officials to crack down on people and groups seeking greater freedom for Tibetans.

China’s state-run Xinhua news agency said that since November, the police in Huangnan, a heavily Tibetan prefecture of Qinghai, have formally arrested 12 suspects and detained 58 other people over self-immolations in the area.

One of those arrested, whose Tibetan name is rendered as Puhua in the Chinese-language report, was charged with homicide and accused of giving speeches encouraging self-immolations at funerals for people who died by engulfing themselves in fire, the news agency report said. It did not give details about the other suspects, when they were held by the police or the accusations against them.

Like other official Chinese reports on the self-immolations, Xinhua presented them as the outcome of a conspiracy inspired by the Dalai Lama, the exiled Tibetan spiritual leader, and groups outside China seeking to challenge the Communist Party’s hold over Tibetan regions in the country. The Dalai Lama has not made any explicit statements in support of the acts, and his supporters have dismissed the accusations as groundless attempts to divert attention from the failings of Chinese rule.

The Xinhua report said the self-immolations were “incited by the Dalai’s clique abroad and then implemented within the country, with photos and other personal information about the self-immolators then sent abroad to stir up attention.”

The self-immolations began in February 2009 as protests against Chinese policies that many Tibetans see as a threat to their traditional homeland and Buddhist beliefs. Reports and pictures of the protests and other acts of defiance against Chinese authorities have been spirited out of the areas to advocacy groups abroad. At least 81 Tibetans died after their protests, according to the International Campaign for Tibet, a group based in London that advocates self-rule for Tibet.

The Voice of America broadcast service on Wednesday denied accusations made by a Chinese television program and newspaper that Voice of America encouraged Tibetan self-immolations. Many self-immolations have occurred in traditionally Tibetan areas of provinces next to the Tibetan Autonomous Region, the administrative area that China established in 1951. Qinghai Province is among those areas, as are parts of Sichuan and Gansu Provinces.

Chinese courts rarely find in favor of suspects in crime cases, and the latest reported arrests and detentions are likely to end in at least some trials and convictions. A court in Sichuan Province imposed heavy sentences on Jan. 31 on two Tibetans after declaring them guilty of urging eight people to burn themselves. Three of those people died.

Despite the Chinese government’s crackdown, there have already been three self-immolations by Tibetans this year. The second one died.

The Dalai Lama fled his homeland in 1959 after a failed uprising against Chinese Communist forces that entered Lhasa, his seat of power, in 1951. Many Tibetans revere the Dalai Lama, who is 77, and observers have said that when he dies, contention could intensify between the Chinese government and his supporters about designating his successor.

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NFL's Redskins, others should junk names, make money: panel

WASHINGTON (Reuters) - Showing the profits of rebranding is more effective than moral arguments in prodding sports teams such as the NFL's Washington Redskins to drop names seen as offensive to Native Americans, symposium panelists said on Thursday.

Arguments against stereotyping Native Americans will carry less weight than new revenue in changing names such as the Redskins, the target of political debate and a legal fight, the panelists at the National Museum of the American Indian said.

Teams could launch a new revenue stream by junking their mascots and names - such as Major League Baseball's Cleveland Indians, the NFL's Kansas City Chiefs and the Florida State University Seminoles - and then selling new jerseys and other items to fans, they said.

"From a financial point of view, there are a lot of reasons showing that it's a gain and not a loss," said Ellen Staurowsky, a sports management professor at Drexel University in Pennsylvania.

Newton Jackson, a sports management professor at the University of North Florida, said: "It's about money."

The discussion on "Racist Stereotypes and Cultural Appropriation in American Sports" carried special resonance in Washington, where activists have pressed the NFL club to change its name for decades without success.

Washington Mayor Vincent Gray told the Washington Post in an interview last month that he would like to see the club move back to the District of Columbia. The Redskins play in Landover, Maryland, and have their offices in Ashburn, Virginia.

But he said the move would be a hard sell if the team kept a name seen as a racial slur.

Gray avoided saying Redskins in his State of the District speech on Tuesday, calling the NFL franchise instead "our Washington football team."

A group of Native Americans are carrying out a long-running legal battle challenging the team's trademark.

Although the museum discussion focused on American Indian mascots in general, the Redskins surfaced again and again in the debate and in comments from the audience.

A spokesman for the Redskins declined to comment about changing the team name or about alleged insensitivity to Native Americans.

Asked this month if he had any problems with the Redskins' name, NFL Commissioner Roger Goodell told reporters that he understood fans' affinity for it and the issue had been long discussed.

"I think (Redskins owner) Dan Snyder and the organization have made it very clear that they're proud of that heritage and that name, and I believe the fans are, too," he said.

(Additional reporting by Steve Ginsburg)

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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.

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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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U.S. Official Faults F.A.A. for Missing 787 Battery Risk

The nation’s top transportation safety official said Thursday that the Federal Aviation Administration accepted test results from Boeing in 2007 that failed to properly assess the risks of smoke or fire leaking from the batteries on Boeing’s new 787 jets.  

Deborah Hersman, the chairwoman of the National Transportation Safety Board, told reporters that the problems seemed to have originated in the battery, when one of the eight cells had a short circuit and the fire spread to the rest of the cells. But she said that Boeing’s tests showed no indication that the new lithium-ion batteries on its 787 planes could erupt in flame and concluded they were likely to emit smoke less than once in every 10 million flight hours.

Once the planes were placed in service, though, the batteries overheated and emitted smoke twice last month, and caused one fire, after about 50,000 hours of commercial flights.

“The assumptions used to certify the batteries must be reconsidered,” Ms. Hersman said.

Late Thursday, the F.A.A. said it would allow Boeing to conduct test flights with its 787 to collect data on the batteries and the plane’s electrical system. The agency said the flights “will be an important part of our efforts to ensure the safety of passengers and return these aircraft to service.” It did not immediately specify the number of test flights or when they would begin.

Ms. Hersman, at her news conference, said that before the F.A.A. certified the batteries, Boeing’s tests found no evidence that a short circuit in one of the eight cells could spread to other cells.

But Ms. Hersman said the fire on a 787 parked at an airport in Boston on Jan. 7 started with a short-circuit in one cell and then spread to the other cells.

She said investigators have still not been able to tell what caused the short-circuit in that cell and led to a “thermal runaway,” overheating up to 500 degrees, that then cascaded to the rest of the cells.

Still, she said, “This investigation has demonstrated that a short-circuit in a single cell can propagate to adjacent cells and result in a fire.”

Battery experts said that the finding pinpointed one step Boeing could take to make the batteries safer: It could expand the size of the battery to create more physical separation between the cells. Ralph J. Brodd, a battery industry consultant in Henderson, Nev., said Boeing and its Japanese battery subcontractor, GS Yuasa, could make the design and manufacturing changes needed to do that fairly quickly.

But unless investigators can determine what caused the first cell to short-circuit, federal officials said, Boeing will also be required to make other changes to prevent any of the possible causes and to better contain or vent any overheated materials. And given the safety board’s findings about how poorly Boeing gauged the original safety risks, the F.A.A. is likely to take its time in assessing the validity of any new tests.

The 787 is the first commercial airplane to use large lithium-ion batteries for major flight functions. All 50 of Boeing’s 787s that were delivered to airlines have been grounded since mid-January, when a 787 made an emergency landing in Japan after the pilots smelled smoke in the cockpit. That incident occurred nine days after the Boston fire.

In searching for the cause of the fire on the plane in Boston, Ms. Hersman said the safety board was still looking at the battery’s charging mechanism and potential manufacturing defects or contamination, and whether the cells were not as isolated as they should have been.

Investigators have so far ruled out two possible reasons for the short-circuit — a mechanical or electrical shock from outside the battery.

“We have not yet identified what the cause of the short-circuit is,” she said. “We are looking at the design of the battery, at the manufacturing, and we are also looking at the cell charging. There are a lot of things we are still looking at.”

Boeing said in a statement Thursday that it viewed the safety board’s findings as narrowing the likely source of the problem to within the battery itself, as opposed to other components of the plane’s extensive new electric system. But company officials said they also recognized that it would take a combination of changes to restore confidence in the battery system.

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