In “Forgive and Remember: Managing Medical Failure Charles Bosk discusses and shows the reading a world seldom seen by many and that is the culture of surgical training. The first publication of this book was in the 1970’s and has been updated by addressing the ways in which medical errors were looked at hand handled. His main thesis of the book discusses the types of errors and what kind of responses is given to medical errors in surgery. Bosk tries to give meaning to the social environment in which students of surgery learn on the job and are developed from other beginners who are fine tuning their skills to become competent surgeons.
He pays very close interest in what values are used while gaining this skill, especially that the teachers are often far from perfect themselves and that the role of their personality may play a large part. The author shows four typical errors surgeons make, technical, judgmental, normative, and quasi-normative. Using many examples from his field study the conducted Bosk explains how failure is recognized, managed, controlled and denied. This perspective study with its excellent bibliography and good methodology is a valuable contribution to medical sociology.
Its arrival at a time when such issues as unnecessary surgery is being debated in professional and public arenas makes this book a must read for medical students as well as the lay person who might be facing surgery. The technical and judgmental errors relate to the trainees experience and theoretical knowledge. The technical is usually the least shameful for surgeons. Poor stitching is something that through experience will get better with time and practice. Judgmental errors can be acting or not acting at the right time such as when you should or should not operate.
The only way one can actually see if it was the right choice is usually after the surgery, it should be noted that statistical odds are used to argue in this situation to decide if it should be done or not. It was interesting to know that attending physicians and not trainees are known to make these kinds of errors more often. The normative and quasi-normal errors relate to an interpretation of the norms of the group and especially the codes of conduct of the senior attending surgeons. These are vital to a surgical trainee’s career.
Bosk describes how seemingly unregulated, sometimes odd and unfair these might be. Normative errors are more often made by subordinates and involve breaches in informing individuals of what will be happening or what they can expect that show an interpersonal problem with patients and nurses. These types of behaviors from training surgeons make it difficult for them as well as other trainees. Quasi-normative errors involve deviating from the ways perhaps a senior attending physician would handle things.
The rise of evidence based medicine has perhaps changed what Bosk calls clinical expertise that is to go against the evidence in medicine and favor one’s own opinion is unusual and often the subordinates can arrive at the correct course of action as well as the attending physician can. Bosk makes the observation that the seemingly more minor infractions of technique actually harmed patients, but barely touch the trainee’s reputation. The normative errors seldom hurt patients but on the other hand could be very damaging for residents in the training environment.
In describing the social controls applied with the group, Bosk describes three types informal-internal, formal-internal and formal external. He mentions that most are the first type which is peer monitoring each other or several members recounting stories of things gone very wrong. There are very few formal reviews except for death and dying discussions. Even the promotion decisions were made without a clear standard: the senior physicians would meet to discuss who would continue and who will not through a general agreement.
In the most disturbing case, where his revised edition notes is that he had suppressed the gender of the doctor in question, the sole woman trainee is described as unable to communicate with peers and patients and also technically awkward. In addition to this there was concern that this trainee might be mentally ill and should not be trusted around patients without a psychiatric evaluation. No examples are given to support these serious claims and the trainee was dismissed disappearing from the community.
Bosk added that she avoided him too and had little basis upon which to form an opinion. It was troubling that none of her peers reached out to her if this was true. Now it is routine that a peer will come to a supervisor out of concern for the well-being of another trainee. Bosk did follow-up and found that the trainee went on to practice in emergency medicine and died early, but does not give much information on whether the first indication of her mental health and ability were true or not. But I would say that perhaps that the first was wrong because of her success in another field.
Two areas that have grown since Bosk’s book is attitudes towards patient autonomy and cultural differences Bosk describes the “mixture of incredulity, compassion, and disgust” that attending physicians have towards patients who delay surgery or didn’t “cooperate” because of religious reasons, poverty or lack of insurance. He describes one of his experiences, where one of the senior attending physicians made personally insulting remarks to all members of the operating room staff based on their cultural differences to try and get a reaction from them.
The words he used were very appalling and insulting to those of Jewish, Korean, and African American origin. In medicine one should try to understand these differences and respect them and try to not provide a different level of treatment based on their cultural or religious beliefs, but instead work with the patient to gain the best possible solution. Bosk’s book provides a framework that remains quite useful in understanding the variety and response to errors that are made in surgical and in medical training.
He underlines the subjective nature of the response to all sorts of errors, which are made and evaluated by imperfect human beings. The book is less up to date in the areas of patient rights, informed consent, gender issues and cultural competence in the medical profession when dealing with society. Bosk’s ethnography of surgeons in training was first developed as a dissertation in sociology at the University of Chicago with the help of many of his mentors such as Fred Strodtbeck, Charles Bidwell, Barry Swartz, and Odin Anderson, along with Renee Fox at the University of Pennsylvania and Harold Bershady.
The first edition is held as a classic in medical sociology and in sociology in general. The book shows the vulnerability of the medical practice and training of the profession. Medicine is known as a risky business. Thousands of patients die each year in America from preventable adverse events. Bosk looks from the perspective of his own involvement in the uprising error movement and its national policy talking about increasing patient safety and from acquiring a larger scope on bioethics.
This ethnography provides a picture of personal anxiety as well as sociological questions. Bosk’s discussions on fuzzy boundaries of his sociological categories of errors of technique, judgment, and normative and quasi-normative errors tell it like it is for those in the field. Bosk is critical of his first edition, but gives a new look into the general sociology, medical sociology, professional sociology and professional debate for bioethics in the medical field.
Bosk gives a strong conclusion that medicine punishes its lesser skilled members by excluding them from privileged professional ranks, but that this punishment isn’t something that will protect the general public. Another important issue addressed is the distinction between professional self controls taking into account the absence of “corporate” control over physicians. Bosk argues that successful training programs produce an increase awareness of professional self control and that post graduate training of physicians “is above all things a ethical training.
” The author gives in the conclusion a very complete appendix to his methodologies that shows the use of qualitative methods in a medical setting. I recommend the book very highly and to me filled in many questions that I had concerning medical ethics. I hope this will follow me in my chosen career path as well as in my personal life.
Reference: Bosk, C. L. Forgive and Remember: Managing Medical Failure. Chicago: University of Chicago Press, (2003).
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