Nathanson et al. [1], supported by Kane et al. in a subsequent letter [2], call for mandatory standards of training for rare anaesthetic events and mandatory safety preparedness. Their implicit assumption is that, with more training, anaesthetists will become less error-prone, performance will improve and, therefore, outcomes from uncommon, life-threatening peri-operative events will also improve. I believe this assumption merits challenge.

Mandatory training for rare peri-operative events and safety preparedness is an integral part of anaesthesia training delivered through various methods including didactic sessions; formal and informal education; scientific meetings; literature review; and simulation laboratories. It is a key component of the curriculum for the Fellowship of the Royal College of Anaesthetists. Ongoing regular training and education in all aspects of anaesthesia is also a fundamental part of clinical practice. So perhaps it is more accurate to call for different training in the management of rare peri-operative events, begging the question ‘will this make things better?’

Time for ongoing training must be utilised wisely. Is it possible to show that suboptimal management of rare events can be ameliorated through participation in a revised and different mandatory training programme? This proof might be elusive, since a tendency towards failure to perform perfectly (especially at times of high stress, pressure, complexity and surprise) is a fundamental part of the human condition. What makes us human also makes us error-prone and while this may be modifiable it is fundamentally ineradicable and cannot be dissipated by the setting of an inhuman standard.

Introduced in 2009, ‘Never Events’ aimed to reduce preventable errors in healthcare. An editorial argued that labelling them as such was ineffective and highlighted the issues with negative framing [3]. Despite this, these events persist. Nathanson et al. liken fatal unrecognised oesophageal intubation to a never event, estimating its annual occurrence at < 1. As long as anaesthetists are humans, this number may never reach zero, no matter how much mandatory training we are required to complete.

Is it necessary to establish a new standard requiring training completion, with implicit sanctions for non-compliance? We adhere to both imposed professional standards, like those set by the General Medical Council, and moral and personal performance standards. It is contentious to suggest that implementation of a new explicit standard (and corresponding sanction) will bring about the desired improvement in human performance.

Nathanson et al. call for a paradigm shift, and I would echo this, albeit a different one. The seven completed National Audit Projects highlight deficiencies in human performance and suggest areas for improvement. An alternative approach could focus solely on successful anaesthetic management, promoting the sharing of best practices. Learning from our successes may offer more valuable lessons and provide incentives for future performance improvements, rather than penalties for shortcomings.

Before embarking on a medical career, I completed a degree in philosophy, during which I learnt about the theory of utilitarianism [4]. This has sometimes been described as achievement of the maximum amount of good for the largest number of individuals. If one were to apply this framework to the current argument – which is ‘what is the best and fairest way of optimising the performance of error-prone humans that deliver anaesthetic management to a patient population?’ – then one might end up considering carefully the fair use of incentives and, possibly, penalties to achieve the desired outcome. In such a utilitarian assessment, it is essential to consider the needs of our patients as a priority. Additionally, we should consider our own needs and morale, which may be affected adversely if we are misunderstood or treated unfairly.

Nathanson 等人 [1] 在随后的一封信中得到了 Kane 等人 [2] 的支持，呼吁制定罕见麻醉事件的强制性培训标准和强制性安全准备。他们隐含的假设是，随着培训的增加，麻醉师将变得不易出错，表现将得到改善，因此，不常见的、危及生命的围手术期事件的结果也会得到改善。我认为这个假设值得挑战。

罕见围手术期事件和安全准备的强制性培训是通过各种方法提供的麻醉培训的一个组成部分，包括教学课程;正规和非正规教育;科学会议;文献综述;和模拟实验室。它是皇家麻醉师学院奖学金课程的关键组成部分。麻醉各个方面的持续定期培训和教育也是临床实践的基本组成部分。因此，也许呼吁对罕见的围手术期事件进行不同的培训更准确，并提出一个问题“这会让事情变得更好吗？

必须明智地利用持续培训的时间。是否有可能证明可以通过参与修订和不同的强制性培训计划来改善罕见事件的次优管理？这个证明可能难以捉摸，因为无法完美表现的倾向（尤其是在高压力、压力、复杂性和意外的时候）是人类状况的基本组成部分。使我们成为人的东西也使我们容易出错，虽然这可能是可以改变的，但它从根本上是不可根除的，不能通过设定不人道的标准来消除。

“Never Events”于 2009 年推出，旨在减少医疗保健中可预防的错误。一篇社论认为，将它们贴上这样的标签是无效的，并强调了负面框架的问题 [3]。尽管如此，这些事件仍然存在。Nathanson 等人将致命的未被发现的食管插管比作从未发生过的事件，估计其每年的发生率为 < 1。只要麻醉师是人，这个数字可能永远不会达到零，无论我们需要完成多少强制性培训。

是否有必要建立一个要求完成培训的新标准，并对违规行为进行隐含的制裁？我们既遵守严格的专业标准（如综合医学委员会制定的标准），也遵守道德和个人绩效标准。认为实施新的明确标准（和相应的制裁）将带来预期的人类表现改善是有争议的。

Nathanson 等人呼吁范式转变，我会赞同这一点，尽管情况不同。已完成的 7 个国家审计项目突出了人类绩效的不足，并提出了需要改进的领域。另一种方法可以只关注成功的麻醉管理，促进最佳实践的分享。从我们的成功中学习可能会提供更有价值的经验教训，并为未来的绩效改进提供激励，而不是对缺点的惩罚。

在从事医学事业之前，我完成了哲学学位，在此期间我学习了功利主义理论 [4]。这有时被描述为最多的人实现最大的善行。如果将这个框架应用于当前的论点——即“优化为患者群体提供麻醉管理的容易出错的人的表现的最佳和最公平的方法是什么？”——那么人们最终可能会仔细考虑公平使用激励措施，甚至可能使用惩罚来达到预期的结果。在这种功利主义的评估中，必须优先考虑我们患者的需求。此外，我们应该考虑我们自己的需求和士气，如果我们被误解或不公平对待，可能会受到不利影响。