Forgive and Remember: Managing Medical Failure (review)

This year marks the twenty-fifth anniversary of the publication of Forgive and Remember: Managing Medical Failure,Charles Bosk's vivid ethnography of surgeons in training, developed first as a dissertation in sociology at the University of Chicago with the guidance of generous mentors — Fred Strodtbeck, Charles Bidwell, Barry Swartz, and Odin Andersen, as well as Renée Fox at the University of Pennsylvania and Harold Bershady. The success of the first edition, widely regarded as a classic in medical sociology and in sociology in general — the field notes are simply wonderful as are the sociological interpretations — is being celebrated by the University of Chicago Press with the publication of a second edition. Bosk has written a new preface, "A Sociologist Puts on the Hair Shirt," and added an amended appendix, "An Ethnographer's Apology, a Bioethicist's Lament — The Surgeon and the Sociologist Revisited."

As a teacher of medical sociology, I have long been in conversation with Forgive and Remember,either around the seminar table or in the lecture hall, and have assigned Forgive and Rememberto nearly two decades of Harvard undergraduates. They have read avidly, often imagining themselves as Bosk's characters, the surgical residents of Able or Baker service. Insights from the seminar table ended up at the family dinner table — and as Bosk hoped, made the latent manifest; "the dirty professional secrets" astonished surgical families in particular — " wearing the hair shirt" — " where did you hear about that?!" Many students were exposed to the emotional underbelly of medical practice and training by family and friends through Bosk-triggered conversations about errors and responsibility, learning more about raw medicine than they did shadowing their favorite pediatrician in a summer internship designed to expose them to real medicine.

I had similar affectively intense conversations with physicians in rural California in the 1980s when I asked, "What is the hardest thing about practicing medicine?" Physicians talked about medical failure, physician incompetence, and specialty turf battles. Reading Forgive and Rememberin 1981 led me to pursue Bosk-generated queries. Seemingly mundane discourses on professional competence masked political emotionality and intense specialty rivalries. Bosk's conceptual project on quasi-normative errors surfaced repeatedly in this starkly different setting, without the elegant structure of academic medicine and a surgical training hierarchy (see Good 1985, 1995; Good et al. 2004; Ruopp et al. in press).

Forgive and Remember,second edition, was read by a deeply savvy cohort of students living in an era of heightened awareness of diverse environments of risk and trust (after Anthony Giddens 1990) and the documenting of widespread medical errors by the IOM Report, To Err Is Human. (Kohn et al. 2000). Medicine is acknowledged as a risky business beyond the risk-management team's control; 98,000 or 48,000 or perhaps only 32,000 hospital patients die each year in America from preventable adverse events, the figure depending on whose data set is examined. Even as Bosk revisits his ethnography from the perspective of his own involvement in this recent error movement and its national policy talk about increasing patient safety, and from his acquired bioethics lens and that of his bioethics social science conversationalists querying the ethics of ethnographic representations of "the other" (e.g. the residents and attending surgeons — indeed Bosk's admission of de-gendering the initial ethnography is a slick correction) — the student cohort reading the "blue" Forgive and Remember,second edition relish the ethnography and its emotional power. The ethnography provokes personal anxiety as well as sociological questions, as among past cohorts. All this vivid ethnographic reading has led some students to flee a medical career and to turn to social science, law, or biotechnology. Others believe ethnography has taught them what needs fixing in medicine. Many fuss over the failure of government to enact aggressive tort reform and hypothesize corrective action. They puzzle over what systems approaches would lead to greatest risk reduction; the industrial cureappeals at least at this...