By Jeanne Braun

President, Braun Strategies, a division of the Capacity Group NY, LLC—an EPIC Company

As a risk management professional, it’s difficult to turn off my safety radar simply because I’m on vacation.

This year, I decided to experience the San Fermín Festival in Pamplona, Spain, more commonly referred to as “the running of the bulls.” As a New Yorker, my exposure had been limited to hyped-up television coverage of the run and hurried profiles of those poor, unfortunate ones gored by the bulls. For most people, this is adequate, but in my world, this was on the long list of things to do before I lost interest or kicked the bucket.

No, I did not actually run with the bulls, opting for a safe and reserved spot on a lovely balcony overlooking the street. Equally exhilarating and terrifying, the overall experience reinforced many things I already knew and understood about safety and risk management. But more about that later.

The San Fermín Festival is held every year in July. Thousands of people from around the world descend on a small town in northern Spain and enjoy the food, sangria, live music, and nightly fireworks of the festival. The running of the bulls takes place almost every morning during the festival, and there is a bullfight every night. People dress in the ceremonial white outfit with a red scarf and a red sash, a nice contrast to the grand old historical buildings that line the streets of Pamplona. But the run is the focal point.

As part of the ceremony, three gun shots are fired. Along the theme of “get ready, get set, go!” each shot is separated by about 10 seconds. The first shot is the “get ready” warning. The second shot gives the runners a head start on their route, and the third lets them know the bulls are on the way.

The gun shots begin. Standing on a balcony just 10 feet above the street, my adrenaline starts pumping and everyone starts cheering. Looking down, I observe that the street was freshly washed by the town’s sanitation department and the cobblestones were moist and slippery. The runners started jogging a bit, casually, waiting for the bulls to catch up. Most had their heads facing sideways or backwards over their shoulders, trying to catch a glimpse of the bulls behind them.

Suddenly, two young men slipped, fell hard, and were unable to get out of the way of the crowd or the bulls. Other runners started tripping and falling over them. Some were experienced runners, even marathoners, but that made no difference when you’re in a sea of people running from 16 bulls, each the size and weight of a small car. Fear overtook the runners as they pushed and shoved others to the sides. Some were seriously injured.

Many of the runners are repeaters. They run every year and plan their strategy way in advance. Most are not. One lovely gal I met on the trip decided impulsively that she was going to run the following morning.

About late 40s, Ellen (name changed) and I had seemed to have a lot in common. An experienced traveler with a bucket list, she worked in an executive-level position with a growing financial firm and lived by the “work hard, play hard” mantra to which many of us alpha females subscribe.

She felt confident. It seemed like fun when we were watching it from the balcony. Several people in our group completed the run and survived. Why couldn’t she?

I caught up with Ellen the next day. Limping somewhat and pretending not be in pain, she wasn’t too proud to admit that she made a terrible decision, that she could have been seriously hurt and hadn’t conducted enough research to figure out what she was getting herself into.

I wasn’t aware of this, but apparently when the crowd and bulls empty out into the bull arena it’s sort of a free-for-all. To avoid getting gored, one must either outrun the bulls or jump over a six-foot fence. With tears in her eyes, Ellen relayed the terror of trying to climb over a fence with a bull just a few feet behind her. With the full force of adrenaline and fear, she climbed up the fence, but being out of shape, got stuck on the top with one leg dangling on either side. It was every man for himself, so no one was around to help push her to safety. Eventually, she jumped and limped her way back to the hotel.

Ellen’s overconfidence and lack of experience was the basis for her poor judgment, and while, luckily, she came through with her body parts intact, it could have ended tragically.

Overconfidence in Healthcare

So, how does this relate to healthcare risk management?

Can overconfidence and poor judgment lead to bad outcomes in patient care? I wondered.

A small share of doctors (11%) purportedly account for about 25% of complications, according to ongoing analyses of Medicare data. The issue of patient safety always has been a top priority, but landed in the spotlight when the Institute of Medicine published its “To Err is Human” report in 1999. Research reveals that performing a procedure with great frequency reduces the potential for bad outcomes or complications.

In fact, healthcare reimbursement now is tied to performance, a roundabout way of incentivizing healthcare providers to specialize in what they do. Knowing what procedures to avoid is a little like avoiding a confrontation with a bull.

I spoke with Michael Brisman, MD, a Harvard-trained neurosurgeon practicing in New York. Brisman is president of Neurosurgical Group, PC (NSPC), where he oversees a well-respected practice of more than 20 neurosurgeons and relationships with about six hospitals. According to Brisman, doctors who specialize in an area are the least likely to encounter problems due to lack of experience.

“When hospitals or physicians attempt to perform procedures in which they have little experience, it’s a red flag. It’s important to properly credential physicians per their training and background and resist the urge to treat a patient that needs a higher level of care,” he said. “Delaying a transfer can seriously harm a patient and may result in more complications, and possibly death.”

Stress as a Loss Factor

I also spoke with Poonam Alaigh, MD, a national healthcare leader and expert with an extensive background in healthcare risk management. She has seen firsthand how training, supervision, and drills are crucial to the patient care experience. We spoke briefly about the San Fermín Festival and my observations about the healthcare industry.

“Risk management in a hospital setting requires 100% commitment from every staff member and every physician and has to be core to how we deliver care, not an afterthought. Most hospitals are committed to doing it well. However, bad outcomes do occur,” she said. “Sometimes, they are due to inexperience, but there are a wide host of factors that contribute to a patient injury. Protocols and care plans attempt to identify every possible scenario, but even so, problems that you didn’t anticipate can happen.”

A review of the 2015 Medical Professional Liability report issued by Conning, Inc., reflects an entire section devoted to physician stress as a loss factor in the medical professional liability industry. It speculates about physicians finding themselves increasingly overextended and under stress and wonders if this results in more malpractice claims. The report authors cite a survey commissioned by The Physicians Foundation, where 20,000 physicians were interviewed in 2015. More than 80% of physicians were either overextended or at full capacity. (The report is available for purchase at:

In Over Their Heads

I contacted Robert Elliott, managing partner at Bartlett LLP in Mineola, NY. He is a former risk manager and nurse, and has much to add about medical malpractice overall.

We talked about Ellen, the now-repentant runner at San Fermín, and how her overconfidence could be played out in a healthcare setting.

“We have, unfortunately, seen a number of claims related to providers treating patients where they were in over their heads,” Elliott noted. “Generally, it’s an emergency situation and everyone is trying to do the right thing. Sometimes, claims occur because the hospital should be transferring the patient to another facility and there are delays in making that decision. Yes, it could be poor judgment, lack of experience, not enough planning, or a combination of all of the above.”

We agreed that Ellen’s overconfidence neatly parallels events transpiring in healthcare facilities every day. We also discussed the fear factor, how the lack of preparation can derail the situation simply because you are caught off guard, quite like a bull charging you from behind.

With the ever-increasing focus on quality of care, healthcare professionals at every level can transfer some of the lessons learned from my vacation. Running with the bulls is exhilarating — but sometimes the best view, in risky situations, is from the balcony.


• Jeanne Braun, President, Braun Strategies, a division of the Capacity Group NY, LLC — an EPIC Company, Lake Success, NY. Phone: (516) 277-8368. Email: