Forgive and Remember: Managing Medical Failure (review)

In Forgive and Remember: Managing Medical FailureCharles Bosk describes and demystifies the previously hidden culture of surgical training by focusing on the ways in which errors were addressed in the 1970s. The revised edition corrects some crucial omissions he made when originally publishing his analysis. His thesis regarding types of errors and the response to them still seems quite fresh today, even to another relative outsider such as myself — a female internist with a humanities background trained in the 1990s. However, certain advances in medical practice and changes in the social context in which patients and doctors meet do cause some reconsideration both of his theses and of his omissions. His point that his thesis is still completely apt and yet also outdated is oddly correct on both counts.

Bosk tried to understand the social milieu in which students of surgery learn on the job and are developed from tightly supervised novices gaining their skills into competent, independent surgeons. He was particularly interested in what values are used to assist in this growth, especially acknowledging that the teachers are often far from perfect themselves and that the role of their personalities may be enormous. He delineates four types of errors — technical, judgmental, normative, and quasi-normative.

The technical and judgmental errors relate to the trainees' experience and theoretical knowledge; possibly shockingly for lay people, the technical error is often the least shameful. Poor stitchery, for instance, is simply a mark of inexperience that will improve with time and practice. Atul Gawande, in his recent book of essays Complications,describes theway interns learn to place central venous catheters similarly — these errors are easily forgiven yet remembered to make sure they do not recur repeatedly and will give way with practice to competence, though they can be traumatic for the trainee and patient alike. (Intriguingly, I can find no evidence that Gawande, the surgeon, and Bosk, the sociologist, are aware of the other's work, though they traverse similar ground. Gawande, a surgeon himself, is rightfully more interested in the ways to cut down on error than on what they mean to his peers and supervisors.) Judgmental errors consist of acting or not acting at the right moment — operating when one shouldn't or not operating when one should. Often the outcome, rather than an absolute standard, decides whether the judgment was correct, though statistical odds are often used to argue for or against proceeding. Attending physicians, rather than trainees, are more often known to make these kinds of errors.

The normative and quasi-normative errors relate to an interpretation of the norms of the group and specifically codes of conduct of the senior attending surgeons. These are vital to a surgical trainee's career. Bosk describes how seemingly arbitrary, whimsical, and unfair these are. Normative errors are more often made by subordinates and involve breaches in informing superordinates of all unfolding events, as well as interpersonal difficulties with patients and nurses. In my own training residents making these sorts of errors were characterized as "wild" or "egomaniacal" and were perceived as making life more difficult for themselves and other trainees. For example, my supervising resident could instruct me to attempt a central line on a second side in a severely ill patient without getting a chest x-ray to be sure the lung had not been punctured by our failed attempt. Then, when the subsequent x-ray revealed bilateral pneumothoraces (collapsed lungs), she could report this rapidly to our attending surgeon and go on the following year to become my chief resident, though I knew as an intern that we should not proceed in this way (by the book) — a significant judgmental error handled with extreme attention to normative behavior.

Quasi-normative errors involve deviating from the ways particular senior attending physicians liked things done, whether based on evidence or not. Fortunately quasi-normative errors seem to have diminished quite a bit; my residents may good-naturedly tease me about what I...