Re: Queries: ROOT CAUSE

[Michael Kay <mikekay@teleport.com>]

Sandy Perle wrote:
> 
> > addressing only the surface cause will not prevent
> > future accidents or incidents from happening in the same way. You need
> > to address the underlying generic problem--radiophobia
> 
> Having studied TQM from the JUSE (Japanese Union of
> Scientists and Engineers) Counselors for approximately 4 years, I
> agree with Michael, basically. However, this issue, that of a
> physician either misusing his knowledge, or, just ignoring facts, or
> too damned stubborn in not receiving more definitive information
> prior to recommending an assinine prescription for his patient,
> can't be solved by addressing the public's general radiophobia.
> 
> > Root causes always go back the the system, be it management,
> > supervision, procedures, protocols, purchasing, etc. In this case, it is
> > quite clear that the system is at fault for imbuing such fear, even in
> > educated individuals. I would classify it as Inadequate Training, and
> > the root cause of the inadequate training is the untoward fear of
> > radiation, even in those who are providing the training.
> 
> IF it were the system, then there would be very few physicians out
> there making "correct", "appropriate" decisions. I think that to
> always blame the system for the failure of an individual, is a
> serious miscarriage of justice. Sometimes we have to hold the
> individual accountable, and stop blaming society for the "world's
> ills." While in some cases, in a specific situation, management and
> training can always be cited as a Root Cause. But they are not always
> . just most of the time. In this case, are there any statistical
> correlations demonstrating that the other physicians who were in this
> physician's graduating class .. also have the same beliefs, same
> radiophobia, etc.? I doubt that there can be any correlation
> validated. SO, can we blame inadequate training in this case? I say
> not.
> 
> >  And those who
> > write and provide the training are directly influenced by the
> > radiophobic groups that set the standards that are so low it is easy to
> > scare everybody. It is not until that root cause is addressed that you
> > will have any chance of providing adequate training and influencing
> > decisions and behavior up the line.
> 
> Again, I suggest that this is a serious over-simplification. I
> believe that for the most part, physicians provide adequate and more
> often than not, valid decisions when it comes to issues as discussed
> in the original post. To blame all physicians lousy decisions based
> on training .. I think we're going to far.
> 
> ------------------
> Sandy Perle
> Technical Director
> ICN Dosimetry Division
> Costa Mesa, CA 92626
> Office: (800) 548-5100 x2306
> Fax:    (714) 668-3149
> 
> mailto:sandyfl@ix.netcom.com
> mailto:sperle@icnpharm.com
> 
> Personal Homepages:
> http://www.geocities.com/CapeCanaveral/1205 (primary)
> http://www.netcom.com/~sandyfl/home.html (secondary)
> 
> "The object of opening the mind as of opening
> the mouth is to close it again on something solid"
>               - G. K. Chesterton -

I totally agree with Sandy's analysis. In my first sentence I state that
"addressing the surface cause" by which I mean that the individual in
question has to bear the responsibility for his actions. There is no
doubt that he should be severely censured by the medical review board
for that state. 

After addressing the surface cause, I feel it is also imperative to look
at the setting in which it occurred. You actually raise an important
question. I think it is very sad that the public, also including those
involved in this instance, did not have the general knowledge that a
small dose is nothing to be concerned about. You see the situation as it
is; I ask why doesn't the public have the necessary awareness, and what
has to be done to change that. 

In an even larger scheme, it has to do with the scientific illiteracy of
most of the people in this country, and the acceptance of pseudoscience.
There is a fascinating article in this month's Reed College magazine by
Prof. Robert Kaplan, Biology, winner of the national teaching award. It
is about the battle still going on today of evolution vs creationism. If
we are still arguing that issue, it doesn't seem that much progress has
been made in educating the public to what the scientific method is
about.

I'm putting on my asbestos suit, so flame away!

Michael Kay, ScD, CHMM
mikekay@teleport.com