When he first saw the email, just after finishing rounds in the surgical intensive care unit, Dr. Joseph Schlesinger began to panic. A government staffer was writing to inform him that he’d made “a fatal error.”
Standing at the nurses’ pod, surrounded by patients in various states of post-surgical woe, he wondered what he should do next. Life-sustaining machines whirred around him, residents discussed prognoses — but he heard nothing. “It was like I was in a vacuum,” said Schlesinger, an assistant professor of anesthesiology and critical care medicine at Vanderbilt University and a staff physician at the Veterans Affairs medical center in Nashville. None of the cases in front of him needed his immediate attention, and so he left to address the crisis in his inbox.