Another doctor suicide

[Mass Effect]

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Someone said she was at Mount Sinai in NYC. I don't know if that's true.

America's leading voice for ideal medical care

 

[Psai]

That email is a great description of New York hospitals. It's funny how all the top hospitals there are the same.

 

[Crayola227]

"I hold our medical system to the highest standard when it comes to protecting human life—and that includes the lives of our doctors."

Do we really think the current system does that??? Do we really think improvements are impossible???

"We can no longer walk away from the very people who have dedicated their lives to serving others. It’s just wrong."

 

[mimelim]

I am incredibly sensitive to the burnout in physician circles and mental healthcare in general. But, that site (and authors) tends to exaggerate and mislead more than advocate.

 

[mstpdude]

From what I can tell, that building is operated by Mt Sinai and there was a death there in March 2016. Mt. Sinai also had a suicide in August 2016 which inspired the NEJM article, "Kathryn." Is this #3?

 

[WingedOx]

I am incredibly sensitive to the burnout in physician circles and mental healthcare in general. But, that site (and authors) tends to exaggerate and mislead more than advocate.

yup. I have to credit Wible for for wanting to highlight a problem, but she sometimes seems to get hung up on certain points and misses the bigger picture. IIRC she was one of the people who managed to get quoted a lot in articles talking about the elimination of the intern 16 hour rule.

 

[Mass Effect]

I am incredibly sensitive to the burnout in physician circles and mental healthcare in general. But, that site (and authors) tends to exaggerate and mislead more than advocate.

What part of her message is misleading or exaggerating? I don't think she exaggerates and misleads. I think she's just loud and has been screaming this from the rooftops for years because no one was paying attention once upon a time.

From what I can tell, that building is operated by Mt Sinai and there was a death there in March 2016. Mt. Sinai also had a suicide in August 2016 which inspired the NEJM article, "Kathryn." Is this #3?

Yes.

 

[nlax30]

I am incredibly sensitive to the burnout in physician circles and mental healthcare in general. But, that site (and authors) tends to exaggerate and mislead more than advocate.

I disagree. She’s one one of the view reviewing these cases, advocating for publicity of this problem, offering to speak with physicians, collecting the data, etc.... not sure how things are exaggerated.

 

[WingedOx]

Screaming is easy. Workable solutions are hard.

 

[tridentsplash]

From what I can tell, that building is operated by Mt Sinai and there was a death there in March 2016. Mt. Sinai also had a suicide in August 2016 which inspired the NEJM article, "Kathryn." Is this #3?

No. There are more.

I can't stay silent anymore.

Ask the other New York programs what their stats are. What kind of self-reflection took place at those institutions after each. death. What kind of workplace they are proud to provide to their employees including and especially the trainees. What steps are being taken to prevent this from happening again tomorrow. Or just, what week is their house staff appreciation week.

 

[evilbooyaa]

Yeesh. Don't do residency in NYC, kiddos. I've heard it's hell on earth.

 

[Mass Effect]

Screaming is easy. Workable solutions are hard.

It begins with a scream.

 

[Mass Effect]

More in NYC or more at Mount Sinai? I mean, damn. Just what the hell is going on up there?

Why is Dr. Wible the only one keeping track of these suicides? Should we doing a root cause analysis whenever it happens?

Every physician suicide deserves an M&M.

 

[dermmom17]

Are all the residencies at Sinai dysfunctional or so stressful that residents are driven to suicide, or is it limited to certain residencies?

 

[Psai]

Yeesh. Don't do residency in NYC, kiddos. I've heard it's hell on earth.

Who told you that

 

[evilbooyaa]

Who told you that

People I know doing residency in NYC, lol.

 

[FrustratedFamDoc]

Did 3rd and 4th year of med school in Queens. First day of IM 3rd year, the intern I was paired with looked at me and said "This place is jungle!" The IM residents there were worked like rented mules.

1st day trauma surgery rotation. "Trauma team to the emergency room" over the intercom. My very first trauma experience was the chief resident of IM had jumped from the 8th floor of the hospital parking deck. Had Ortho, Neuro and gen surg all operating on him at the same time. Miraculously, he survived but finished the job about a year later after he was allowed to return to the program.

 

[WingedOx]

Every physician suicide deserves an M&M.

conducted by whom?

 

[Apollyon]

jumped from the 8th floor

Was it on Pamela Wible's website that someone had written that they researched that you had to jump from the 6th floor or higher to ensure death? Thank heavens that didn't occur!

 

[Mass Effect]

conducted by whom?

Doctors from another hospital. There should be investigations into these things, especially when it happens more than once at the same hospital.

 

[WingedOx]

Doctors from another hospital. There should be investigations into these things, especially when it happens more than once at the same hospital.

Like, actual trained auditors or what? You'd still have to attempt to do such a thing while the medical and psychiatric records of the victim remain confidential. Good luck making anything useful from it.

 

[mstpdude]

Doctors from another hospital. There should be investigations into these things, especially when it happens more than once at the same hospital.

If we're making a list of suggestions, I'd add this: confidential mental health support provided by a peer institution in the same locale. I know physicians who have avoided their home institution's support systems, because they don't want a record of mental health visits to appear their EMR.

 

[Crazy342]

More in NYC or more at Mount Sinai? I mean, damn. Just what the hell is going on up there?

Why is Dr. Wible the only one keeping track of these suicides? Should we doing a root cause analysis whenever it happens?

Just to clarify, none of the resident suicides were from Sinai hospital. They were from st lukes, an affiliate. Either way, it's a tragic story.

 

[Mass Effect]

Like, actual trained auditors or what? You'd still have to attempt to do such a thing while the medical and psychiatric records of the victim remain confidential. Good luck making anything useful from it.

I know it says you're an attending, but I have to ask. You have attended an M&M in the past, right??? Because if so, then the answer to your question and your concern should be pretty obvious if you understand the basis of an M&M, what it's for, what it does, and the level of confidentiality involved.

If we're making a list of suggestions, I'd add this: confidential mental health support provided by a peer institution in the same locale. I know physicians who have avoided their home institution's support systems, because they don't want a record of mental health visits to appear their EMR.

Yes, absolutely. And this begins with medical licensing boards, which need to be held accountable for asking questions that have proven to be in violation of the ADA.

Just to clarify, none of the resident suicides were from Sinai hospital. They were from st lukes, an affiliate. Either way, it's a tragic story.

It's my understanding these were Mt. Sinai people, whether they worked at the affiliate hospital or not.

 

[WingedOx]

I know it says you're an attending, but I have to ask. You have attended an M&M in the past, right??? Because if so, then the answer to your question and your concern should be pretty obvious if you understand the basis of an M&M, what it's for, what it does, and the level of confidentiality involved.

How does that change what I said?

 

[Mass Effect]

How does that change what I said?

In every way imaginable. Only someone who's never participated in an M&M would ask those questions.

 

[WingedOx]

In every way imaginable. Only someone who's never participated in an M&M would ask those questions.

Go on, smart guy...

Sorry, but if you're implying the victim's treating providers should M&M the case, absolutely. The program and victim's employer (what I'm assuming was asked about here)? They can absolutely review any of their own documentation and interactions with the employee but if can't just pull PHI if the resident was not a patient there.

 

[Mass Effect]

Go on, smart guy...

Sorry, but if you're implying the victim's treating providers should M&M the case, absolutely. The program and victim's employer (what I'm assuming was asked about here)? They can absolutely review any of their own documentation and interactions with the employee but if can't just pull PHI if the resident was not a patient there.

They don't need to pull her private records. No one said that. But many of these physician suicide cases are directly related to their work environment and the culture of medicine and THAT'S what deserves the M&M.

 

[WingedOx]

They don't need to pull her private records. No one said that. But many of these physician suicide cases are directly related to their work environment and the culture of medicine and THAT'S what deserves the M&M.

That's perfectly fair, but I also think those are ultimately aren't going to be super useful, and possibly harmfully speculative.

 

[Mass Effect]

That's perfectly fair, but I also think those are ultimately aren't going to be super useful, and possibly harmfully speculative.

I disagree. I think some introspection and accountability is necessary.

 

[VA Hopeful Dr]

I disagree. I think some introspection and accountability is necessary.

We have reasonably good data on the major causes of burnout. That's what's most likely to come out during these M&M sessions you want.

Once that information is more widely known among Hospital leadership, exactly what outcome do you expect to get from this?

Hospitals are not going to get rid of their terrible Mrs. They're not going to let us work less without a significant cut in pay. They don't have the power to decrease our paperwork burden unless they hire staff to do it all for us, and that's not going to happen.

So seriously, how do you think this is going to improve things?

 

[Mass Effect]

We have reasonably good data on the major causes of burnout. That's what's most likely to come out during these M&M sessions you want.

Once that information is more widely known among Hospital leadership, exactly what outcome do you expect to get from this?

Hospitals are not going to get rid of their terrible Mrs. They're not going to let us work less without a significant cut in pay. They don't have the power to decrease our paperwork burden unless they hire staff to do it all for us, and that's not going to happen.

So seriously, how do you think this is going to improve things?

First of all, I don't think this is all about just burnout. That's a catch-phrase these days but it minimizes the serious systematic problems within medical training, specifically, to the extreme. I mention training because those in training are most vulnerable to the affects of an abusive/malignant environment. There are many other contributors that actually can be directly traced back to how things are run. For instance, residents working beyond the 80-hour work week and being highly encouraged to lie, being yelled at, humiliated, and even physically assaulted by senior residents/attendings, etc. When a doctor commits suicide, I think everything in his/her professional life needs to be examined.

 

[neoexile]

First of all, I don't think this is all about just burnout. That's a catch-phrase these days but it minimizes the serious systematic problems within medical training, specifically, to the extreme. I mention training because those in training are most vulnerable to the affects of an abusive/malignant environment. There are many other contributors that actually can be directly traced back to how things are run. For instance, residents working beyond the 80-hour work week and being highly encouraged to lie, being yelled at, humiliated, and even physically assaulted by senior residents/attendings, etc. When a doctor commits suicide, I think everything in his/her professional life needs to be examined.

Honestly medical training is not efficient. Asking questions which aren't considered "intelligent" is usually considered a felony. There are times where I've grown to distrust attendings to the point where I make it a point to learn everything on my own with minimal help.

I hate to use this analogy, but it's like League of Legends or any online MOBA. The team around you is toxic and unhelpful most of the time, so you just mute everyone and push objectives until you win with as minimal interaction as possible. And it makes me angry because the exercise of rounding is supposed to be a teaching tool. If the attending thinks teaching is "know everything about your patient and dont ask me questions" and "I'll call you out, because I had a bad day", then it is a waste of time. I've had the ill-experience of residents and attending arguing in the middle of the nurse's station on how bad their experience was in the rotation like some Gray's Anatomy episode. It's ridiculous sometimes

 

[VA Hopeful Dr]

First of all, I don't think this is all about just burnout. That's a catch-phrase these days but it minimizes the serious systematic problems within medical training, specifically, to the extreme. I mention training because those in training are most vulnerable to the affects of an abusive/malignant environment. There are many other contributors that actually can be directly traced back to how things are run. For instance, residents working beyond the 80-hour work week and being highly encouraged to lie, being yelled at, humiliated, and even physically assaulted by senior residents/attendings, etc. When a doctor commits suicide, I think everything in his/her professional life needs to be examined.

Ah, OK so you're going after suicides among residents/fellows. That does change things a bit.

 

[WingedOx]

Ah, OK so you're going after suicides among residents/fellows. That does change things a bit.

An internal investigation is absolutely warranted, but a format resembling an M&M would be grossly inappropriate, even questionably legal.

 

[neoexile]

An internal investigation is absolutely warranted, but a format resembling an M&M would be grossly inappropriate.

Agreed. I don't think if a colleague died from suicide that a Powerpoint presentation should be made about him or her and he or she should be presented in front of the group that he or she left behind. It would be grotesque and wrong.

 

[Mass Effect]

An internal investigation is absolutely warranted, but a format resembling an M&M would be grossly inappropriate, even questionably legal.

How would it be questionably legal? Based on what?

Agreed. I don't think if a colleague died from suicide that a Powerpoint presentation should be made about him or her and he or she should be presented in front of the group that he or she left behind. It would be grotesque and wrong.

Have you been part of an M&M? Most don't include a powerpoint and he or she would not be "presented" so much as the conditions he/she worked under would be. I'm actually surprised that people find the M&M to be the "grotesque" part of a resident suicide.

 

[NotAProgDirector]

I think you're talking past each other here. The idea proposed is that if a physician suicide happens, the institution should do a case analysis not of the physician themselves (as is usually done in an M&M when a patient's record is dissected), but instead an M&M of the "system" to see what, if anything, contributed to the death.

Not all programs / institutions are miserable places to work. Sure, residents work long hours. But if you're enjoying what you do and (especially) whom you're working with, it can make all the difference.

Decreasing burnout (when possible, within reason)
building a collaborative, supportive environment
De-stigmatizing and lowering the barrier for accessing mental health support services for physicians

These are things that institutions can do that can help.

The group at Mayo has done some great work in this area. Not the greatest article, but a reasonable summary of their ideas: ACHE 2017: 6 evidence-based actions to cut staff burnout | FierceHealthcare

 

[PlutoBoy]

Did 3rd and 4th year of med school in Queens. First day of IM 3rd year, the intern I was paired with looked at me and said "This place is jungle!" The IM residents there were worked like rented mules.

1st day trauma surgery rotation. "Trauma team to the emergency room" over the intercom. My very first trauma experience was the chief resident of IM had jumped from the 8th floor of the hospital parking deck. Had Ortho, Neuro and gen surg all operating on him at the same time. Miraculously, he survived but finished the job about a year later after he was allowed to return to the program.

That's awful. Many doctors have committed suicide in my city, including at the university hospital. The whole thing is getting ridiculous. We NEED to do better than this.

 

[PlutoBoy]

We have reasonably good data on the major causes of burnout. That's what's most likely to come out during these M&M sessions you want.

Once that information is more widely known among Hospital leadership, exactly what outcome do you expect to get from this?

Hospitals are not going to get rid of their terrible Mrs. They're not going to let us work less without a significant cut in pay. They don't have the power to decrease our paperwork burden unless they hire staff to do it all for us, and that's not going to happen.

So seriously, how do you think this is going to improve things?

So your solution is to do nothing? Just because you can't think of anything doesn't mean that there's nothing to be done. See the article posted by APD.

 

[VA Hopeful Dr]

So your solution is to do nothing? Just because you can't think of anything doesn't mean that there's nothing to be done. See the article posted by APD.

Yes that's exactly what I said, do nothing. Good reading comprehension there champ.

 

[PlutoBoy]

Yes that's exactly what I said, do nothing. Good reading comprehension there champ.

Given the context, that's exactly what your comment implies. That because you assume that hospitals won't do anything to change the current state of affairs we shouldn't study it more.

Since you asked, I'll tell you what I expect from this: I expect reform. I expect that doctors treat each other more humanly, that boards stop threatening to end a physician's career if he admits that he needs help. I expect that doctors, the public, hospitals, and the government recognize our humanity and understand that we are fallible and that we need rest.

We can't work 70-100 hours a week witnessing a world of hurt and expect that our emotions won't be affected. We can't work under the sword of Damocles, under threat of lawsuits, government intrusion, and board meddling into our affairs, and not be affected.

We are fallible and emotional human beings. When all of the parties involved in health care accept this (including ourselves) we will start moving in the right direction.

 

[VA Hopeful Dr]

Given the context, that's exactly what your comment implies. That because you assume that hospitals won't do anything to change the current state of affairs we shouldn't study it more.

Since you asked, I'll tell you what I expect from this: I expect reform. I expect that doctors treat each other more humanly, that boards stop threatening to end a physician's career if he admits that he needs help. I expect that doctors, the public, hospitals, and the government recognize our humanity and understand that we are fallible and that we need rest.

We can't work 70-100 hours a week witnessing a world of hurt and expect that our emotions won't be affected. We can't work under the sword of Damocles, under threat of lawsuits, government intrusion, and board meddling into our affairs, and not be affected.

We are fallible and emotional human beings. When all of the parties involved in health care accept this (including ourselves) we will start moving in the right direction.

OK so first, I didn't imply anything. You inferred. That makes you wrong since I know what I meant and your interpretation is not it.

Second, I later realized he was talking about residents and fellows which is an entirely different problem than with attendings (as the former group is essentially powerless). I even made a brief post admitting as much.

Third, I'm not sure what to do about residents. I mean, residency does pretty much suck and I don't see a way around that. It can probably be made to suck less but that's likely institution dependent. For example: we all hear stories about residents having to do their own daily blood draws and transport their patients to radiology and whatnot at some NYC hospitals. Since most of us didn't have to do that, seems like an easy fix that would reduce stress somewhat. Not sure we can reduce hours without lengthening residency and most of us aren't OK with that.

Fourth, attending burnout is easy - change jobs. We have the ability to do that (which residents really don't). If you're miserable in your job, find a new one. Its actually quite easy to do. I've done it often. I also haven't worked over 50 hours/week since I left residency. Rarely over 40 hours but I used to moonlight more my first year out.

Fifth, medical boards aren't going to take away your licence for seeking help with burnout/depression/anxiety/whatever. If you're admitted to a psych ward they'll pay attention, but if your psychiatrist says you're safe to practice that's usually the end of it. If your state is super strict on that, move to a better one (SC has a very lenient medical board).

 

[WingedOx]

I know it says you're an attending, but I have to ask. You have attended an M&M in the past, right???

Have you been part of an M&M?

Perhaps instead of acting like a dick about your proposal, you could discuss this like a grownup and actually lay out how you would handle an "M&M" for an employee suicide? Who (specifically) would conduct it, what type of information would be presented, what manner would it be gathered, what types of information would and wouldn't be available to be shared? Who is invited to take part?

Plenty of us in this forum are involved in MedEd, and actually want to hear legit proposals, and I'm not sure how this would be difficult for you to specify; however, since it's clear that none of us here are at the level of your brilliance and expertise, please remember to speak slowly and use small words.

 

[arcus]

Given the context, that's exactly what your comment implies. That because you assume that hospitals won't do anything to change the current state of affairs we shouldn't study it more.

Hospitals wont do anything to reform for the simple reason that all of medicine today in America is a business, and business does not operate out of a compassionate, moral or caring paradigm. Physicians and patients both need to reboot their memory, and clear the old cache from how medicine was practiced decades ago. Hospitals respond to government regulations, accrediting bodies and payer reimbursement formulas. Nothing else. Physician suicides? NIMBY is their response.

Any large organization, particularly of a non-charitable bent, will do that which is in the best interest to itself, particularly shareholders. There was a time in America when businesses also included stakeholders in their metrics formula. Stakeholders (e.g. employees, Residents, Fellows) are no longer part of the metrics of businesses today. Our current economy is an employer dominated market. Employees are just widgets to businesses (including hospitals).

Consider our current USA economy and the labor market. Think of the millions and millions of Americans who are employed at retail big box businesses, and yet are underemployed, over qualified, receive meager wagers and most of whom take these jobs because they need health insurance. This “business first” trend has been in existence since circa 2008. Extrapolate from this trend the outrage you rightly have and yet the lip service that teaching hospitals give. Physician suicides for them are blips in the big scope of things. Precisely because suicides fall under mental health, businesses will see the victim as having “issues”....outliers. The onus is not on them because the victims are “mental” especially since their colleagues can keep their wits about themselves. So the business concludes the suicide was something not caused by their business operation since clearly scores of physicians within one hospital are not following suit. Again, its a metrics thing one devoid of the priorities you / I have in our lives: compassion.

Whatever you and I think “should” occur because of these suicides does not square with an “ought” or “ontology” (i.e. Rene Descartes). There is no ontology in America today. The nature of becoming, being, a priori reasoning within the context of the universe, are not part of our national fabric. We have in our nation a dictatorship of relativism. The notion of an “us” and a “moral imperative” are no where on the collective psyche of America today

In my homeland we had a saying that my mother would often say. It was quite simple but profound: “somos tu y yo” (we are you and me). In America it is “tu o yo” (you or me).

E pluribus unum?

Nope.

Your Christianity is your /my / our answer. Sprinkle seeds of Faith where we work but keep in mind that our generation is a very lost one.

Physician suicides are our new normal. American businesses yawn. Predictable.

 

[Mass Effect]

Perhaps instead of acting like a dick about your proposal, you could discuss this like a grownup and actually lay out how you would handle an "M&M" for an employee suicide? Who (specifically) would conduct it, what type of information would be presented, what manner would it be gathered, what types of information would and wouldn't be available to be shared? Who is invited to take part?

Plenty of us in this forum are involved in MedEd, and actually want to hear legit proposals, and I'm not sure how this would be difficult for you to specify; however, since it's clear that none of us here are at the level of your brilliance and expertise, please remember to speak slowly and use small words.

Asking someone who comments about M&Ms if they've ever actually attended one is not a "dick" question. It's a legitimate one. Maybe if you stopped being so defensive about your lack of knowledge about M&Ms, you'd realize I answered the questions. I'm not making a proposal to you. I'm making suggestions in the course of conversation. My suggestion would be an M&M-like analysis of what went wrong. Period, end of story. You can feel free to expand that or not, but just because I don't have all the answers doesn't mean the proposal itself is worthless or that I deserve your condescending, patronizing, defensive retorts, especially when you refuse to answer a very straight-forward fact-based question.

 

[PTPoeny]

Asking someone who comments about M&Ms if they've ever actually attended one is not a "dick" question. It's a legitimate one. Maybe if you stopped being so defensive about your lack of knowledge about M&Ms, you'd realize I answered the questions. I'm not making a proposal to you. I'm making suggestions in the course of conversation. My suggestion would be an M&M-like analysis of what went wrong. Period, end of story. You can feel free to expand that or not, but just because I don't have all the answers doesn't mean the proposal itself is worthless or that I deserve your condescending, patronizing, defensive retorts, especially when you refuse to answer a very straight-forward fact-based question.

M&Ms vary quite dramatically. In my residency and fellowship all M&Ms involved a power point presentation on the medical history and course of the patient in question. So if you are proposing something other than a powerpoint presentation that goes over the deceased medical history, psych history and the details of what happened it isn't going to look like much like a lot of M&Ms I have been to. Hence some more details about what you are suggesting might help other people picture the type of presentation you are thinking about. Then if we are all thinking about the same thing we can talk about how it would help.

 

[Mass Effect]

M&Ms vary quite dramatically. In my residency and fellowship all M&Ms involved a power point presentation on the medical history and course of the patient in question. So if you are proposing something other than a powerpoint presentation that goes over the deceased medical history, psych history and the details of what happened it isn't going to look like much like a lot of M&Ms I have been to. Hence some more details about what you are suggesting might help other people picture the type of presentation you are thinking about. Then if we are all thinking about the same thing we can talk about how it would help.

Actually, the point of the M&M is what I've been referring to and have referenced multiple times. Getting hung up on the logistics is neither helpful nor productive in moving the discussion forward. The point of an M&M is analysis of what went wrong and why in regards to hospital/department involvement. It doesn't need to involve the resident's personal history or life, as I said above already, but rather the professional contributions to the ultimate death. This is what I am suggesting. You don't need to call it an M&M. You can call it whatever you want. You don't need a powerpoint. You can use whatever presentation modality you want. The point -- as I said -- is introspection, which will do most of us some good.

 

[gutonc]

Actually, the point of the M&M is what I've been referring to and have referenced multiple times. Getting hung up on the logistics is neither helpful nor productive in moving the discussion forward. The point of an M&M is analysis of what went wrong and why in regards to hospital/department involvement. It doesn't need to involve the resident's personal history or life, as I said above already, but rather the professional contributions to the ultimate death. This is what I am suggesting. You don't need to call it an M&M. You can call it whatever you want. You don't need a powerpoint. You can use whatever presentation modality you want. The point -- as I said -- is introspection, which will do most of us some good.

Stop calling it an M&M then. That's a loaded phrase in this world, and you should know that. The point of an M&M is never to actually figure out what went wrong and fix a systemic error so that it doesn't happen again. It's to make sure somebody publicly takes the blame for what happened and everybody can move on.

As much as I hate to bust out the douche-y management speak, what you seem to want (and it's not unreasonable...although you started this thread without a clue of the details and the information you did have turns out to have been incorrect) is a root cause analysis, or a kaizen.

 

[Mass Effect]

Stop calling it an M&M then. That's a loaded phrase in this world, and you should know that. The point of an M&M is never to actually figure out what went wrong and fix a systemic error so that it doesn't happen again. It's to make sure somebody publicly takes the blame for what happened and everybody can move on.

As much as I hate to bust out the douche-y management speak, what you seem to want (and it's not unreasonable...although you started this thread without a clue of the details and the information you did have turns out to have been incorrect) is a root cause analysis, or a kaizen.

Actually, at my institution, the M&M is precisely about figuring out what went wrong and fixing a systemic error. It's a shame your hospital doesn't have the same goals in mind. As for a clue of the details, another doctor is dead and it's emblematic of a problem within the field. Any other details are extras. Now, what exactly was incorrect?