Wednesday, January 7, 2015

Book review: Forgive and Remember - Managing Medical Failure

Hero also likes to use Forgive and Remember: Managing Medical Failure as a pillow.
“…residency training is designed as a moral education, the purpose of which is to teach young doctors the standards of practice.” Charles Bosk, 1979

We take for granted the fact that ethics is taught in medical schools, but it certainly isn’t taught in all veterinary schools – although there is movement afoot to improve, standardise and introduce the teaching of veterinary ethics.
So it was interesting to read Charles Bosk’s landmark account of (human) surgical resident training, in which he argues that technical training is largely secondary to moral training.

Forgive and Remember: Managing Medical Failure takes its title from a mantra of surgical teachers. Errors are not in vain if we learn from them.

“Benefits of the error are believed to outweigh the costs. One individual suffers, but legions of patients yet unseen have the lesson gleaned from this error passed onto them”.

That may be so, but as Bosk points out, “…the costs of technical failure never shrink to zero, and it is the patient who always pays”.

Bosk, a sociologist, spent 18 months embedded in the surgery team at a large teaching hospital in the US. In the 1970s. Before ethics committees were common (he didn’t even obtain ethics approval for his study) and before ethics was formally taught in most med schools.

The book was a revelation at the time, highlighting the challenges of training young surgeons. The following passage is one that any vet who has taught students surgery can relate to:

“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 level of 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.”

Forgive and Remember gave people insights into the challenges of being a doctor and the limits of clinical decision making.

“Medical decision making is a probabilistic enterprise. Presented with a patient with a set of symptoms, the physician makes a diagnosis and then decides on an intervention. Only rarely is it the case in which the physician can say “this patient has x and we must do y”. Even when it is certain that a patient has x, this does not dictate what should be done since the treatment of choice will vary according to the severity of x, the patient’s age, the physician’s skill, and the technology available at any given hospital. Moreover, there are some disorders for which there is significant disagreement among equally learned colleagues over what the treatment of choice should be. Finally it is not always clear that a patient has x since there are any number of disorders with similar symptoms. Whatever may be the nature and depth of his uncertainty, the physician is usually forced by the patient’s condition to act before the uncertainty is resolved. In this situation, the phyician’s action is dictated by what he knows at the time.”
“Clinical results, not scientific reasoning, determine how correct judgement is.”
It was one of the first books to lift the cone of silence around morbidity and mortality meetings.

And it offered an argument about why the character of surgeons, and other professionals, is often attacked in the event of an error.

“The physician does not promise to cure. The lawyer does not promise to win the case. The most that either can promise is to help as best he can and in a fashion consistent with the highest standards of the community. Now, in most professional-client relationships, the client has a great deal at stake. In fact, so much hangs in the balance that suspicion of the professional’s motives and the appropriateness of his conduct is always a possibility.”
It describes a world in which technical errors are more acceptable, and more likely to be forgiven, than normative errors (failing to discharge one’s obligations conscientiously), and quasi-normative errors (failing to meet the particular standards of an individual clinician, with their own protocols and values that they and they alone subscribe to).

When I wasn't reading it, Hero was sleeping on it.
Although the world Forgive and Remember describes is dated – it would be a rare hospital where surgeons where allowed to make life and death decisions without consultation, or get away with treating subordinates in a blatantly sexist or racist manner (Dr Cox and Kelso from Scrubs would fit right in), it’s an amazing account of the way surgeons are taught how to BE a surgeon. Not so much the technical skills, but moral standards.

This is a book with two key narratives. The focus of the first is on the surgeons. But in the second, the author shifts his analysis to his own role – revealing his own bias and the impact of his own observing on the team. Not insignificant. He wasn’t just a fly on the wall. At times he was scrubbed in, retracting, joking in the locker room.

He details major limitations to objective analysis (some would argue that that isn’t even possible), including his own sense of obligation for being included, and the ethical issue of whether to intervene where his input might have changed an outcome.

Just as a misjudgement about where to place a scalpel can alter surgical outcomes, so too can judgements about what to include and how to identify participants in an ethnographic account. In an amended appendix, written decades after the first edition, he reveals (confesses?) to changing a detail in order to protect someone’s identity – a supposedly simple change that has huge implications for how the text is read and the influence it has (I don’t want to spoil it for anyone who will read the book).

It isn’t exactly a light read but a fantastic read for anyone interested in surgery, sociology, observational studies, clinical decision making, ethics, errors and medical history. 

Bosk CL (2003) Forgive and Remember: Managing Medical Failure. Second edition. Chicago: University of Chicago Press.