Forgive and Remember: Managing Medical Failure

by Charles L. Bosk

On its initial publication, Forgive and Remember emerged as the definitive study of the training and lives of young surgeons. Now with an extensive new preface, epilogue, and appendix by the author, reflecting on the changes that have taken place since the book's original publication, this updated second edition of Charles L. Bosk's classic study is as timely as ever.

Genres: Medicine, Nonfiction, Sociology, Medical, Science, History, Education

301 pages, Paperback

First published February 1, 1979

Reviews

[Emma Hawkins · Rating 4 out of 5]

I read this for school. I’ve read other enthographies in the past but this was the first one to really move me. I think this book is a work of art! Flawed, but owns up to his mistakes.

[Kelly · Rating 4 out of 5]

This was definitely an interesting look at how mistakes are handled in surgery. I didn’t always agree with the author’s conclusions, in part due to coming from a different field with different assumptions (he’s a sociologist and my training is in psychology, which have very different methods of collecting data and ways of interpreting it) but I still found them really illuminating to read. Also, some of the book is out of date (it was originally published in the 70s), but the second edition was published in 2003, and it includes very thoughtful reflections on how medicine has changed (particularly with regard to the twin growth of both managed care and bioethics) and things the author might have done differently. The book is worth reading almost for those parts (mostly the appendices) alone.

[Leslie · Rating 4 out of 5]

This book is an ethnographic study of social control in surgical residency programs. It presents a typology of error (technical, judgmental, normative, and quasi-normative) that provided the foundation for subsequent studies of medical error. It also suggests that the primary function of surgical training is moral training, because normative and quasi-normative errors are treated as moral and are the primary basis of subsequent sorting and exclusion from the ranks - of elite groups, or of surgical groups altogether.

[Melsene G · Rating 4 out of 5]

If you want to understand the social controls inside a surgery unit-you will find this book very interesting. The biggest issue is that it was written in 1979, soooo long ago and healthcare has undergone a transformation since then. However, the author does add an epilogue and appendix updating his original work-don't skip that part.

My take away is that social control by the Attending surgeon has two components: technical errors and normative errors of residents, interns and training docs. In other words, technical errors by a resident were accepted-the resident needs more training, but not following orders and falling in line with the Attendings rules, this was unforgivable-and could end the career of a would be surgeon.

The author is a sociologist-and was in his early 20s when he did his field research. I'm not sure how much of this still goes on in today's surgery units, but people are people and I'm sure as much as things change, they stay the same due to human nature.

[Nathan Douthit · Rating 5 out of 5]

I loved this one. Some very helpful principles and ideas for working through how doctors approach error, and the process of medical education in dealing with error. Definitely worth a read if in any medical education, may be more profound if in surgical education.

[Elizabeth · Rating 2 out of 5]

This book is a study of the socialization and teaching of surgical students and residents by attendings in an elite academic medical center. More specifically, it examines how mistakes are dealt with. There are four types of errors in this analysis: technical, judgmental, normative, and quasi-normative. Technical errors are actual mistakes in technique. Judgmental errors are mistakes in diagnosis and treatment in regard to actual medical care. In general, these mistakes are guarded against by proper levels of supervision and can be fixed if they are recognized quickly. Subordinates are not punished or criticized too harshly for these mistakes as long as they admit to them and learn from them. Normative and quasi-normative errors are not taken in the same light. Normative errors occur when an attending believes a subordinate has not performed his role properly. Basically, the subordinate has not followed the correct rules or processes. Quasi-normative errors are the same except the rules are attending or unit specific. For example, one surgeon may not allow paper tape on his patients. These errors indicate to an attending that the subordinate does not have proper respect for rank. Whereas technical and judgmental errors can be corrected by education and practice, normative and quasi-normative errors indicate a level of unteachability in subordinates.
The importance of rank expressed in this book was surprising. Even the way the doctors enter a patient’s room is based on rank. Such rigidity of rank preserves the authority of the attedings and even the chief resident. The subordinates are always accountable to someone, whereas the attendings have only marginal accountability to their colleagues. Bosk discusses the Mortality and Morbidity Conference during which the doctors explain their unexpected failures. However, the other doctors at this conference rarely criticize the failure very much. Simply the act of humbling one’s self by admitting failure seems to mitigate any culpability. While this professional humility may be enough in most cases to prevent the mistake from happening again, it is perhaps troubling that there is no higher accountability than one’s colleagues who in turn will be judged in the same forum. Thus, there may be incentive to be lenient. Another problem with the monitoring system of doctors is that once attendings decide that a resident will not continue in a program because he is not competent to treat patients, they are absolved of any responsibility. Yet this person is already a doctor and often goes on to practice medicine elsewhere. One argument that attendings make in the book is that some subordinates are not high enough caliber to be at an elite academic medical center. These attendings are concerned about their legacy through their students. However, it is not entirely apparent why lower caliber students should be more acceptable at one hospital than another.
What is perhaps most interesting in this book is the fact that the attendings value clinical experience over scientific knowledge. This ability of attendings to choose a course of treatment based on what they have seen rather than what they have learned or read is what separates subordinates from superordinates. Sometimes subordinates find these methods arbitrary and frustrating. This emphasis on clinical experience directly contradicts the current movement for evidence-based medicine. I wonder, if the doctors were interviewed today, if they would value their own judgment so highly over scientific evidence. Furthermore, does placing such a value on evidence based medicine exacerbate the problem of dehumanizing the patient because the patient is then treated by a system of protocols? In other words, scientific knowledge treats the disease; clinical experience treats the patient. Yet it is unclear which is better or how they should be combined.

[Gary A. DePaul · Rating 5 out of 5]

I've read the first and second edition. The introduction to the second edition gives more depth into the culture of the cadre of physicians and the culture of their expertise. I've referenced Bosk's four types of clinical errors in my introduction of one of my forthcoming books.

This is a must-read for anyone planning to enter the medical profession.

[Hari Brandl · Rating 3 out of 5]

I reasonably good read, if a little self-important: the language is slightly more formal than it need be. The author also ignores some important avenues for addressing errors, both technical and normative. Back in "the day" doctors at every level could get away with harassment and abusive behavior as well as with errors. Nurses had little status in hospitals. I was a nurse for more than 40 year in hospitals in several parts of the world and I have seen the status of nursing change, though it has been a long, slow battle. Studies in the nursing literature, at least, have documented correlation between the interrelationships among house staff/attendings and patient outcomes. With the focus on risk management, and the improvements in nursing education (the expansion of roles in nursing has grown vastly since Dr. Bosk's original study) there are "Obstructionist Physician" programs wherein abusive/sexist/racist/incompetent physicians at every level can be reported and dealt with. Trusted nurses can also complain directly to doctors and/or administrators they work with about lapses in technique and behavior we observe. And there are even anonymous tip lines and hospital ombudsmen that are utilized by staff, patients and their families to shed light on problems that may lead to poor outcomes and/or lawsuits.

[Jon Zelner · Rating 4 out of 5]

I'm a sociologist who loves the sociology of health and illness (i.e., social epidemiology/health demography) but hates medical sociology as a general rule (doctor/patient interaction studies, etc.) But Bosk won me over with this book. Unlike most of us, he actually pays attention to his writing, which is crisp and engaging. And his study is illuminating - he stays away from the perils of obviousology that often doom ethnographies and produced something I'll be happy to have on my bookshelf for the long-term.

[L L · Rating 4 out of 5]

I was delighted to discover that one of the judging criteria (atleast according to Wikipedia http://en.wikipedia.org/wiki/Ethnography) of an ethnography is “aesthetic merit”. While this book is not primarily aesthetic, it is a well-written and compelling scholarly work. It is an ethnography of surgeons-in-training, with a focus on medical error—which errors are considered normative and forgiven, and which errors are not. Bosk also reflects on his research methodology and choices.

[Kathy · Rating 4 out of 5]

I took a class with the author about 6 years ago, so it was interesting to finally read something he wrote.

It is impressive that Bosk was able to so thoroughly integrate himself into the surgical "in-group." The book provides a thorough analysis of error and its ramifications, and is further expanded in its depth by Bosk's reflections on his work in the epilogue.

[Shoshana · Rating 3 out of 5]

This book is a bit dry and, having been written in the 70's, sexist (the doctors and patients in the research examples seem to only ever be males), but it is a very interesting and educational account of the training of surgeons.

[Nirav · Rating 5 out of 5]

The sociology of how physicians manage medical error

[Piper · Rating 4 out of 5]

For those of you who want to pursue a career in surgery, you should read this.