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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Boeing 787 Dreamliner takes test flight to assess batteries

SEATTLE — Aerospace giant Boeing Co. sent a 787 Dreamliner passenger jet on a test flight Saturday, the first since the new airliner was grounded three weeks ago because of a battery fire.

The aircraft took off from Boeing Field in Seattle and spent more than two hours flying back and forth over the inland Columbia Plateau. It landed at Boeing Field shortly before 3 p.m. Pacific Time. According to flight-tracking website FlightAware, the aircraft flew 1,131 miles, slightly more than the 919 planned.

The Federal Aviation Administration granted permission for test flights Thursday.

The 787 is the first commercial airliner to rely heavily on lithium-ion batteries, the same kind used in cellphones. Each plane has two of the 63-pound blue power bricks, one near the front to provide power to the cockpit if the engines stop and one near the back to start up the auxiliary power unit, which is essentially a backup generator.

On Jan. 7, a battery on a plane that had recently landed in Boston short-circuited and caught fire. Nine days later, a battery on an All Nippon Airways plane started smoking, leading to an emergency landing in Japan.

Boeing said Saturday's flight was to assess the in-flight performance of the batteries. Data would be used to support continuing investigations of the recent incidents.

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Big Bear locked down amid manhunt

The bustling winter resort of Big Bear took on the appearance of a ghost town Thursday as surveillance aircraft buzzed overhead and police in tactical gear and carrying rifles patrolled mountain roads in convoys of SUVs, while others stood guard along major intersections.

Even before authorities had confirmed that the torched pickup truck discovered on a quiet forest road belonged to suspected gunman Christopher Dorner, 33, officials had ordered an emergency lockdown of local businesses, homes and the town's popular ski resorts. Parents were told to pick up their children from school, as rolling yellow buses might pose a target to an unpredictable fugitive on the run.

By nightfall, many residents had barricaded their doors as they prepared for a long, anxious evening.

PHOTOS: A tense manhunt amid tragic deaths

"We're all just stressed," said Andrea Burtons as she stocked up on provisions at a convenience store. "I have to go pick up my brother and get him home where we're safe."

Police ordered the lockdown about 9:30 a.m. as authorities throughout Southern California launched an immense manhunt for the former lawman, who is accused of killing three people as part of a long-standing grudge against the LAPD. Dorner is believed to have penned a long, angry manifesto on Facebook saying that he was unfairly fired from the force and was now seeking vengeance.

Forest lands surrounding Big Bear Lake are cross-hatched with fire roads and trails leading in all directions, and the snow-capped mountains can provide both cover and extreme challenges to a fugitive on foot. It was unclear whether Dorner was prepared for such rugged terrain.

Footprints were found leading from Dorner's burned pickup truck into the snow off Forest Road 2N10 and Club View Drive in Big Bear Lake.

San Bernardino County Sheriff John McMahon said that although authorities had deployed 125 officers for tracking and door-to-door searches, officers had to be mindful that the suspect may have set a trap.

"Certainly. There's always that concern and we're extremely careful and we're worried about this individual," McMahon said. "We're taking every precaution we can."

PHOTOS: A fugitive's life on Facebook

Big Bear has roughly 400 homes, but authorities guessed that only 40% are occupied year-round.

The search will probably play out with the backdrop of a winter storm that is expected to hit the area after midnight.

Up to 6 inches of snow could blanket local mountains, the National Weather Service said.

FULL COVERAGE: Sweeping manhunt for rampaging ex-cop

Gusts up to 50 mph could hit the region, said National Weather Service meteorologist Mark Moede, creating a wind-chill factor of 15 to 20 degrees.

Extra patrols were brought in to check vehicles coming and going from Big Bear, McMahon said, but no vehicles had been reported stolen.

"He could be anywhere at this point," McMahon said. When asked if the burned truck was a possible diversion, McMahon replied: "Anything's possible."

Dorner had no known connection to the area, authorities said.

Craig and Christine Winnegar, of Murrieta, found themselves caught up in the lockdown by accident. Craig brought his wife to Big Bear as a surprise to celebrate their 28th wedding anniversary. Their prearranged dinner was canceled when restaurant owners closed their doors out of fear.

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NBC pulls 'Do No Harm' after 2 low-rated episodes

LOS ANGELES (AP) — NBC is pulling the drama series "Do No Harm" after two low-rated episodes.

The show is a take on the story of Dr. Jekyll and Mr. Hyde, and stars Steven Pasquale of "Rescue Me." He plays a respected neurosurgeon who turns into a dangerous alter ego each night. Other cast members include Alana De La Garza and Phylicia Rashad.

"Do No Harm" started with a historically small audience for a major network debut and then dropped further in its second Thursday airing.

NBC will replace "Do No Harm" with reruns of "Law & Order: Special Victims Unit" for the next two weeks.

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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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HealthCare Partners seeks license to operate as managed-care plan

HealthCare Partners, the medical-group giant acquired last year by dialysis chain DaVita Inc. for $4.4 billion, is seeking a state license to operate as a managed-care plan after questions were raised about its compliance with California law.

The California Department of Managed Health Care has been looking into the nation's largest operator of physician groups since last fall when a patient sued the Torrance company and accused it of acting like a health plan without the necessary Knox-Keene Act license. A spokeswoman for the managed-care agency said the allegations against HealthCare Partners "are still under review."

The case is part of a wider debate about whether regulatory oversight is keeping pace with consolidation among doctors, hospitals and insurers and changes in medical payment sparked by the federal healthcare law. A state healthcare board is expected to discuss these matters Monday in Sacramento.

HealthCare Partners, which runs large medical groups in Southern California and four other states, had $2.4 billion in revenue in 2011 and serves about 750,000 patients, including more than 190,000 in Medicare Advantage plans. The combined company, called DaVita HealthCare Partners, is based in Denver.

William Chin, executive medical director at HealthCare Partners, said the company is in full compliance with current law and its application for a limited health plan license is unrelated to the recent complaint.

Chin said the state license hasn't been necessary before because the company contracted with licensed health plans to care for their patients, but new initiatives with Medicare require a different arrangement.

"We are in violation of no statute or law," Chin said. The state "has reviewed these relationships and contracts for decades."

State regulators require insurers and other "risk-bearing organizations" to hold adequate reserves to pay medical bills and to comply with patient protections.

California Senate President Pro Tem Darrell Steinberg (D-Sacramento) asked officials to address these concerns about licensing in November, records show.

In December, Brent Barnhart, director of the Department of Managed Health Care, responded in a letter that the agency "has been actively engaged in discussions with HealthCare Partners regarding its business model."

Steinberg also asked whether the state had a conflict of interest because a HealthCare Partners executive and physician, Keith Wilson, serves as chairman of the agency's Financial Standards Solvency Board. The board advises the agency on certain rules for health plans and medical providers.

"Dr. Wilson's hand in advising the regulation of accountable-care organizations could be viewed as a contributing factor to a biased investigation," Steinberg wrote in his Nov. 20 letter.

The board is scheduled to discuss this potential conflict of interest at its meeting Monday. Barnhart told Steinberg that he plans to "reconfigure the makeup of the board to include additional consumer representation" later this year.

A spokesman for Steinberg said the lawmaker is awaiting more information from the healthcare agency before commenting further.

The senator's concerns stemmed from a lawsuit filed in September by Healthcare Partners patient Juan Carlos Jandres in Los Angeles County Superior Court. The suit alleges that the company engaged in unfair and fraudulent business practices. An additional plaintiff and former HealthCare Partners employee, Corey Hambrick, joined the suit last month.

Jandres sought care in 2010 for a growth in his mouth, according to his suit. He contends HealthCare Partners denied him access to appropriate hospital care because it was trying to avoid hospital claims it was responsible for paying. As a result, according to the suit, Jandres lost most of his jaw to cancer. Chin said the allegations of poor patient care are untrue.

chad.terhune@latimes.com

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Ex-cop called 'depraved,' 'cowardly'

Authorities confirmed Thursday that a door-to-door search for an ex-L.A. police officer wanted in connection with a string of shootings was underway in Big Bear after his vehicle was found burning on a forest road.

San Bernardino Sheriff John McMahon said officials matched the VIN number on the burnt truck to that of suspect Christopher Jordan Dorner, 33, the subject of an intensive hours-long manhunt that stretched across Southern California.

Big Bear Lake Fire Department Asst. Chief Mark Mills told The Times that fresh tracks spotted in the snow were believed to be Dorner's.

McMahon declined to reveal details about what was inside the truck or how it caught fire but said authorities had confirmed Dorner was not inside. He did not discuss which direction Dorner might have traveled.

Authorities were going door-to-door in the mountain community that includes a total of about 400 homes, of which authorities guessed only about 40% were occupied year-round. Extra patrols were brought in to check vehicles coming and going from Big Bear, McMahon said, but no vehicles had been reported stolen.
"He could be anywhere at this point," McMahon said. When asked if the burnt truck was a possible diversion, McMahon replied: "Anything's possible."

Dorner had no known connection to the area, authorities said.

Television footage showed a fatigue-clad SWAT team combing the woods, rifles pointed, and the truck being towed away. Federal authorities later ordered media helicopters away from the area.

McMahon called Thursday a "sad and tragic day for all of us in law enforcement."

Several law enforcement agencies are involved in the manhunt for Dorner and alerts have been issued all across California and in Nevada. The Los Angeles Police Department had dispatched units across the region to protect at least 40 officers and others named in a rambling online manifesto that law enforcement officials attributed to Dorner.

Dorner, who was fired from the LAPD in 2009, is suspected of shooting three police officers, one of whom died, in Riverside County early Thursday.

Dorner also is suspected of killing a couple in Orange County earlier this week who were found shot in a car. One of the victims was the daughter of a former LAPD captain named in the purported manifesto.

Dorner was believed to be carrying multiple weapons, including an assault rifle.

Law enforcement authorities said they were concerned about Dorner's military background and weapons training. The lengthy online message allegedly written by the former Navy Reserve lieutenant threatened "unconventional and asymmetrical warfare" against police.

Dorner received awards for his expertise with a rifle and pistol, according to military records obtained by The Times. He received an Iraq Campaign Medal and was a member of a mobile inshore undersea warfare unit.
Riverside Police Chief Sergio Diaz, calling the attack a "cowardly ambush," said Dorner is suspected of opening fire with a rifle about 1:30 a.m. Thursday as he pulled up to two police officers waiting at a traffic light.

The attack was carried out about 20 minutes after Dorner wounded an LAPD officer in a shooting in nearby Corona, police said.
Early Thursday, two women delivering newspapers in Torrance were shot by Los Angeles police who were guarding an officer named in the manifesto.

The women, shot in the 19500 block of Redbeam Avenue, were taken to area hospitals, Torrance Police Lt. Devin Chase said. One suffered a minor wound, and the other was struck twice and listed in stable condition, LAPD Chief Charlie Beck told reporters.

"Tragically," Beck said, "we believe this is a case of mistaken identity."

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Bieber's mom trying to stay out of abortion debate

NEW YORK (AP) — Justin Bieber's mom wants to set the record straight: She's not interested in the political fray on abortion as she promotes "Crescendo," a new film she hopes will raise $10 million for centers that help pregnant girls.

Pattie Mallette, an unmarried teen herself when she had Bieber, signed on as an executive producer after the film was finished. She said Thursday that she connected personally with the story about a suicide and abortion attempt by Beethoven's mother.

"The press has been saying that I'm producing an anti-abortion film and taking this big stance. You know, I haven't shared my stance with anyone and I'm not here to make a political statement, so there's been a lot of assumptions made."

Mallette, in numerous interviews and her autobiography, "Nowhere but Up," has recounted her own suicide attempt, pressure to have an abortion when she became pregnant at 18 and struggles with drugs and alcohol before becoming a Christian.

The movie does include some producers who have anti-abortion beliefs, she said, but her goal is simple: to support residential programs like the one that helped her after her parents kicked her out of the house in Canada.

"The pregnancy center that I lived in is now closed because of lack of funds, so I thought it was a really important thing that they're doing to raise money," Mallette said.

The movie will be released Feb. 28 worldwide.

Mallette has had her share of mom moments of late with her only child, who at 18 is the youngest singer to have five chart-topping albums and will be both host and musical guest for the Feb. 9 episode of "Saturday Night Live" on NBC.

Like his Instagram photo (since deleted) of his butt crack. What ran through her head?

"I thought, I'm a mom, I don't want to see that," Mallette sighed, shaking her head. "I don't want to see him doing that kind of stuff. But, you know, he's 18. He's making some of his own decisions and he's going to make some mistakes and he's going to make some good choices, too."

What of reports of pot smoking and partying with "sizzurp"-downing hip hop singers — sizzurp being a purplish mixture of cough syrup with codeine and promethazine, a carbonated soft drink and pieces of Jolly Rancher candy.

"It's hard, you know, as a mom of an 18-year-old because that's the time when you just gotta start letting go," she said. "And, you know, I had to make some of my own mistakes. I gotta kind of let go and let him make some of his own mistakes and just hope that I put all the right things in him."

And what of Bieber's relationship with Selena Gomez?

"I have no idea if they're on-again, off-again," she said. "It's a constant thing. Today I'm not sure where they stand. I try to stay out of it. He's 18. He doesn't want me getting involved in his romantic life."

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Follow Leanne Italie on Twitter at http://twitter.com/litalie

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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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Hedge fund manager steps up attack on Herbalife

NEW YORK — It might be easy to make a movie about Bill Ackman, the handsome and confident Wall Street tycoon whose actions over the last two months have won him as many friends as they have enemies.

Whether he'd be the hero or the villain depends on whom you ask.

In his own eyes, Ackman is the righteous investor, protecting low-income people from the clutches of health food-and-supplement maker Herbalife Ltd. by betting $1 billion that the Los Angeles company will fail. To Herbalife, he's a nemesis making specious allegations about a company he knows little about, just to make a buck.

Ackman launched a second public-relations assault against Herbalife on Thursday, releasing more than 270 detailed questions and mocking Chief Executive Michael Johnson for comparing the company to the Girl Scouts.

Ackman's 40-page missive also questioned whether Herbalife was complying with a 1986 injunction won by the California attorney general's office that prohibits the company from paying commissions for recruiting. A spokeswoman for Atty. Gen. Kamala Harris declined to say whether her office was investigating the matter.

Wall Street seemed to shrug Thursday; Herbalife's stock rose 13 cents, or about 0.4%, to $35.92. The muted stock movement comes the same day Ackman was to face his own investors at his hedge fund Pershing Square Capital Management's annual dinner in New York.

Either way, Ackman's assault highlights the cutthroat brawls of high finance and thrusts into the spotlight discussions that might otherwise take place behind the closed doors at his marble-and-glass office suite overlooking Central Park. Rather than investing in Herbalife to improve the company, Ackman "shorted," or bet against the stock, and is very publicly trying to help bring the company down.

"I believe it's good for America for this company to disappear," Ackman said in an interview.

He's part of a new breed of activist investors who make public their doubts about a company and put money on the idea that such attention will help topple the company. It's an aggressive tactic, but in the world after the financial crisis, many investors argue that a little skepticism about business is a good thing.

"This idea of people publicly raising issues at companies and short-selling them is really something that we've seen come into the public only really since the financial crisis," said Ron Orol, author of "Extreme Value Hedging: How Activist Hedge Fund Managers Are Taking On the World." "The financial crisis exposed a lot of problems at companies, and so some activists build on that information and publicly try to explain their case."

Because they profit on companies' declining fortunes, short sellers do not always have the rosiest of reputations. But Ackman sees greater need for short sellers on Wall Street.

"If you knew [Bernard] Madoff was a fraud, and you had done 18 months' worth of work and you knew it for a certainty, and you just kept your mouth shut … I think you have a moral obligation," he said. "A whistle-blower-slash-short-seller is a healthy thing for the market and a good thing for the world."

Other money managers disclosed positions on either side of Ackman's bet. Among them are Dan Loeb, founder of the hedge fund Third Point, who sided with Icahn, and Whitney Tilson, co-founder of T2 Partners, who also reportedly shorted Herbalife.

Ackman's crusade against Herbalife seems uniquely passionate and has inspired an equally personal response. Corporate raider Carl Icahn recently slammed Ackman on live TV in what money manager John Hempton went so far as to call "hedge fund porn."

At a recent dinner of 15 or so hedge fund investors, discussion turned to the odd nature of the battle between Icahn and Ackman, said Wilbur Ross, the billionaire best known for buying out steel and coal companies.

"I'm a bit surprised that this is happening," Ross said. "Carl has a good track record. Loeb has a good track record. Ackman has a good track record. At the end of the day, Wall Street people will be interested in who got what and how."

Ackman casts his campaign as a matter of conviction, saying he has plenty of other investment opportunities.

"Why do I feel a moral obligation here?" he said in the interview. "The answer is: Because this company is harming millions of people, and it's done it for 32 years, and the list of heart-[wrenching], disastrous life stories of the people that this company has wrecked is incredible."

Herbalife has angrily fought back against Ackman's claims.

In a statement Thursday, the company said: "Herbalife is a financially strong and successful global nutrition company, having created meaningful value for shareholders, significant opportunities for distributors and positively impacted the lives and health of consumers since our founding in 1980. Pershing Square's latest tome is motivated by a reckless $1-billion short bet."

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