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Forgive and Remember
Managing Medical Failure
By Charles L. Bosk
The University of Chicago PressCopyright © 2003 The University of Chicago
All rights reserved.
At 6:30 A.M., only a few physicians and staff walk the still-darkened corridors of Pacific Hospital. Within an hour, the hospital will pulse with activity: nurses will wheel medication carts and chart racks down the halls; technicians will draw patients' blood, orderlies will place patients on line for the various diagnostic and therapeutic procedures the hospital provides; vendors will hawk the morning newspaper; and teams of physicians and students will make rounds on their patients. In the predawn, however, there is no hint of the burst of activity to come. A lone houseofficer trudges down the hall. A few nurses from the night shift gather at their station, chat while charting the previous night's activity, and share a last cup of coffee before ending their day at the beginning of everyone else's. Only one small group of physicians is already engaged in the purposive and feverish activity that one associates with the hospital during the day. For them, the day is in full swing. This group of physicians moves from bleary-eyed patient to bleary-eyed patient while jotting down what work must be done that day. Their movements are swift and precise; no energy is wasted in extraneous chatter with patients or each other.
Who are these few physicians? Why are they up so early? They are members of the surgical housestaff of Pacific Hospital. The two or three days a week on which the services they are assigned to operate, these men and women begin rounds at 6:00 A.M. so that they can be scrubbed, capped, gowned, and ready to operate on their first patient at precisely 8:00 A.M. This starting time is important to them for a number of reasons. First, they know if they miss it they will be behind schedule all day. Although the twenty-minute difference between 8:00 A.M. and 8:20 A.M. is not great, it is often the difference between a hurried lunch and a twelve-hour fast. Moreover, this is not a quiet, meditative fast, but one during which the hungry houseofficer must remain standing; assist with or perform operative procedures; pass "ad hoc" quizzes on anatomy and the advisability of various treatment modalities; engage in witty repartee with his superordinate, the attending surgeon; or accept silently his role as butt of his superior's jokes. Second, houseofficers who are not ready on schedule appear to their superordinates as inefficient, lazy, or unreliable. As houseofficers well know, "attendings" do not suffer wasted time—or those who force them to waste it—gladly. A houseofficer's good name rests in part on his ability to keep events running on schedule.
For eighteen months, I was a participant-observer of the surgical training program of Pacific Hospital. Three interrelated problems captured my interest and attracted me to this field setting. First was a question of social control. On precisely what kinds of behavior does a houseofficer's good name rest? What kinds of actions discredit him? How are evaluations of competence constructed by superiors, how are these evaluations shared, and how consequential are they? To use the vocabulary of Everett C. Hughes (1971), I was interested in how a segment of the medical profession exercises its "license" and "mandate."
Second was the question of social support. The superordinate's task is a delicate one. He must control mistakes. Yet at the same time, if he wishes to train competent, independent, and (eventually) autonomous professionals, he must allow his subordinates enough room to make the honest errors of the inexperienced. To allow this requires a certain cold-blooded calculation on the part of the superordinate. On the one hand, he needs to restrain himself from taking charge of situations too quickly lest he damage a subordinate's confidence. On the other hand, he needs to know when to rescue a subordinate—and patient—lest a surgical accident shake the novice's belief in his abilities. So the superordinate has a dual problem: (1) he must control his subordinate's performance and make sure that errors are corrected and not repeated, and (2) he must allow his subordinates room to make errors or they will never learn the judgments and techniques necessary to perform properly. At all times we should remember that this give-and-take between ranks is more than a mere academic exercise; the clinical material for these lessons is another human being who has placed his life in the surgeon's hands. Surgical superordinates who are permissive run the risk of abusing the patient's trust, while those who are restrictive may retard or destroy the careers of fledgling surgeons. The forces that lead a superordinate to monitor his subordinates' behavior more closely or those that lead him to forego close supervision are therefore not trivial matters. Because the consequences of these different modes of control and support are so fateful, rationales must be provided for their employment. Studying the different modes of control and their rationales will allow us to understand how a group of professionals conceptualizes its privileges and responsibilities.
Third was the question of sustaining individual commitments, motivation, and action in the face of failure. How does the surgeon cope with the knowledge that his clumsiness, forgetfulness, or tardiness contributed to another's death and/or suffering? How does the individual surgeon accept this responsibility and yet not shrink from future action? All groups possess devices for making failure a normal and accountable feature of everyday life. Surgeons are no different from the rest of us in this respect; the difference lies in the consequences of a failure. We assume that where the possibility of such consequential failure exists on each and every occasion for action, there will be powerful, shared devices for coping with these failures. Again, this is not a trivial matter, for to understand and analyze these devices is tantamount to analyzing the structure of the profession's conscience: its sense of right and wrong, and its sense of how large the gray area between them is.
This report centers on three themes: (1) How a professional group draws a boundary around itself and determines its own identity through the selection and rejection of recruits. (2) How superordinates attempt to control performance and how subordinates accept or avoid such controls in a professional training program. Of particular importance here is how norms of responsibility to patients and colleagues are articulated and how their violations are sanctioned. (3) How a professional copes with the existential problem of the limits of his skill and of his knowledge. In the course of things a surgeon's best efforts will sometimes fail and he must explain this failure to himself, his colleagues, and the family of his patient. We are interested in how the surgeon achieves accountability to each of these significant audiences and in what situations the surgeon fails to achieve this accountability. Taken together the three issues of membership in a professional group, social control of performance in that group, and shared patterns of explaining, understanding, and neutralizing failure and error are critical not only to our understanding of surgeons but indeed to all of the professions in modern American society.
These are, of course, not new issues; they have been much rehearsed in the sociology of medicine and the sociology of the professions. If these issues are not new, why engage them here? First, I want to recapture and refine the old Durkheimian insight that each occupational group possesses its own morality. I want to specify what for the surgeon is the "complex of ideas and sentiments, [the] ways of seeing and [of] feeling, [the] certain intellectual and moral framework distinctive of the entire group." As an occupational group, surgeons have a collective conscience. I shall make clear what it is, how it is formed, and what functions it serves. I then want to examine how this conscience serves the solidarity of the professional group and at what cost to the larger society. I want to know if any element in this "intellectual and moral framework" defines the essence of a profession in our society. Second, the occupational morality of the surgeon tells us much about how members of a profession interpret, act on, and defend their prerogative of social control. Any programmatic change which intends to make professionals more accountable to clients must of necessity start with a complex phenomenological understanding of what currently passes for accountability and how it is achieved. Field research such as this informs policy by grounding it in a firm understanding of how participants construct their social worlds. It is only from this concrete understanding of the present, practical order that any changes in the existing interactional politics of social control can be negotiated.
The Field Setting and Data Collection
The setting for this study of how surgeons detect, categorize, and sanction error is Pacific Hospital. Pacific Hospital is an elite medical institution affiliated with a major medical school and university. In both medicine and surgery, it has a luminous reputation and a grand tradition. Everywhere one looks, one is reminded of Pacific's special place in the medical universe. Portraits of distinguished faculty grace hallways and classrooms. Lecture rooms and entire wings of the hospital are named after past greats that Pacific claims as its own. In addition, Pacific sponsors several endowed lectures a year which are named for its most eminent embodiments of the clinician-researcher ideal. These lectures are given by current great names from other leading medical institutions. This practice underscores symbolically Pacific's great past, its current status, and its hopes for the future. Its reputation for excellence attracts the top talent to both Pacific's medical school and residency programs. By and large, these recruits are considering careers in academic medicine; they often have strong and well-defined research interests.
At one time, the splendor of Pacific's medical reputation was matched by its physical setting in what was once the "gilded" section of a large urban area. Most of the middleclass inhabitants of the neighborhood have long since moved away and their elegant mansions have been either leveled or subdivided into many small apartments. The area that surrounds Pacific is mostly lower-class black. This population generally uses the emergency room at Pacific as its primary mode of obtaining medical care. As a result, the surgical staff of Pacific sees many patients who are in extreme pain and/or who are the victims of traumas such as gunshot wounds, beatings, and stabbings. As a consequence, a good number of the surgical patients at Pacific meet their surgeons under conditions that are considerably less orderly than those for typical middle-class patients who are often referred after some diagnostic tests by their private physicians. As we shall see later, the nature of a patient's first meeting with the surgeon is often invoked to explain failure and/or error; however, for reasons I shall specify, such accounts are never accepted as legitimate excuses in themselves.
If the splendor of Pacific's neighborhood has faded, that of the hospital itself has not. Its central shell remains a magnificent Gothic structure with elaborate stonework, turrets, and gargoyles. Attached to the original building are several new wings of concrete and glass. The original square floor plan of the main building has with these additions become a bewildering maze of passageways, tunnels, and crosswalks linking old and new. The emergency room, the operating rooms, the surgical intensive care units, X ray, and the patient wards are all located on different floors in different parts of the hospital. Because of this, simply carrying out tasks in some logical order is often no mean feat.
Pacific is now approximately a 450-bed structure. Of those beds, 200 are allocated by the Admitting Office to general medicine and 193 to surgery. The remainder is for inpatient psychiatric services. Of the 193 beds allocated to the surgical services, approximately 120 are reserved for the surgical subspecialties such as neurosurgery, orthopedics, ENT (Ear, Nose, and Throat), plastics, cardiac and thoracic, and vascular. This leaves 75 beds or so for all four general surgery services which are the subject of this report. At Pacific, the general surgery services perform operations ranging in complexity from removal of hemorrhoids to esophagojejunostomies [an operation which binds the esophagus to the upper intestinal tract]. The general surgery services train housestaff to manage what are considered "normal, typical," surgical problems, and at the same time the services perform procedures which would not normally be undertaken elsewhere because of a patient's compromised condition, the lack of available support technology, or the presumptive lower level of competence and confidence of surgeons in other less elite institutions. The general surgery services have two classes of patients: those referred from colleagues at Pacific or elsewhere because of the unusually complex nature of their problems, and those who entered through the emergency room. I did not observe that the two different types of patients received differential types of care. Attending surgeons in charge of services stress that they need an appropriate mix of both patients with complex and routine problems so that they can keep themselves challenged and at the same time give their housestaff adequate experience.
During the time of my observations, each of the four general surgery services performed an average of 24.5 major operations and 10.2 minor operations per week. The weekly mortality and morbidity rate, that is, the rate of death and complications, was 5.1. Our task here is not to evaluate whether this rate is high or low, but rather to explain what this rate means to two groups of participants, attending surgeons and surgical housestaff. In fact, one of our first tasks is to see what relationship, if any, exists between the morbidity and mortality rate—or the official rate of error—and the surgeon's construction of what an error is and what its seriousness is. A major focus of this inquiry, then, is the social processes invoked to construct these rates and the meaning these rates have for actors in this environment. In this context, it is interesting to note that each week the Department of Surgery at Pacific Hospital posts a list of deaths and complications by service, thereby distributing knowledge of misadventure very freely within its ranks.
I made observations on two different surgical services: first the Able and then the Baker (names and identifying characteristics have been altered). These two different services were chosen by the logic of the constant comparative method (Glaser and Strauss 1967). The general surgical services at Pacific Hospital varied in their approach to surgical work along a continuum, the poles of which were low clinical-high research orientation and high clinical-low research orientation. Able represented the high research end of the continuum, Baker the high clinical. The formal division of labor on each service was identical. At the top of the hierarchy were attending physicians, all of whom were full-time faculty of Pacific Medical College whose practices were limited to the patients on their service. At Pacific all patients were considered the private patients of the attendings whose service they were on: there were no surgical patients who were considered the housestaff's responsibility alone. In a strict legal sense, the attending surgeon was responsible for what happened to patients under his care. It was the attending who decided when to operate and what operation to perform. The attending surgeon was clearly the superordinate on the service. He was the final authority in any disagreements with housestaff; only the attending could give orders binding on every member of the service. Both the Able and the Baker Service had two attendings, each of whom had the final say for his patients. Attendings on a service might disagree with each other about patient care procedures, but each recognized the right of the other to treat his patients as he saw fit and proper.
On each service beneath the two attendings was a chief or senior resident. This resident was responsible for the day-to-day management of patients. He saw to it that the treatment plans of the attending for patients were carried out. The smooth running of the service—making sure that diagnostic tests occur on schedule, that patients do not run into any unexpected troubles, and that all work is done properly—is the chief or senior resident's responsibility. Essentially, he functioned as an attending in the attending's absence; his major task was to anticipate and treat problems before they occurred and to keep the attending informed of these actions. Beneath this level of authority are second- and third-year residents whose precise responsibilities are difficult to state. They must make sure the orders of the chief or senior resident are carried out. They lack responsibility for the entire service but have great responsibility for individual patients. Keeping medications straight, staying up to date on chart work, making certain the patient follows his postoperative regimen (usually walking and expanding the lungs to prevent pneumonia), and maintaining smooth working relations with nurses all seem to be part of this resident's responsibility.
Excerpted from Forgive and Remember by Charles L. Bosk. Copyright © 2003 The University of Chicago. Excerpted by permission of The University of Chicago Press.
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