Forgive and Remember by Charles Bosk is an ethnography of surgeons. A sociology graduate student at UChicago followed around general surgeons on two services at UChicago Medical Center for 18 months, gained their trust, and got an inside view of how surgeons recognize and deal with errors. Importantly, he puts forth a clear picture of how surgical education functions and what surgeons think makes a good trainee. The book is not a guide on how to become a good surgeon; it is empirical rather than normative. Rather, the ideas are “good to think with” and suggest a way to look at the world of surgical education and make sense of all the hierarchy (attendings >> chief resident > resident > intern > student), rituals (morbidity and mortality conference), and indignities (scut work, getting pimped, holding the retractor). The point is, these practices all have a purpose. They could probably be made better, but dismissing them outright is simple-minded. Aspiring surgeons need to make the best of what the current state of training gives them.
Though the book (Bosk’s PhD dissertation; he is now professor of medical sociology at Penn) was written 30 years ago, there are many aspects of surgical training that, according to the epilogue of the second edition, remain the same today. Many scenes depicted in the book were very easy for me to imagine after having shadowed surgeons an academic medical center for a week last winter. The differences between now and then are only a matter of degree: the environment is less hostile, trainees are more diverse (read: a female is not uncommon), there are work-hour restrictions, and, because of managed care and practice guidelines, attendings have a little less than absolute authority.
After the jump: a summary of points that stood out to me (why surgery is special, what the typical surgical personality is, what the four forms of errors are, how trainees are evaluated).
Key features of surgery as a specialty
- Precise and definitive nature of surgical intervention
- Expectations: specific for success
- Actions: anatomically precise, invasive, radical
- Outcomes: visible and relatively fast
- More accountability and more to account for
- Expectations legitimate action and action explains outcome. The only acceptable reason to subject a patient to the high risk/trauma of surgery is an expectation of success (cure/palliate). As a corollary, the intervention is then seen as responsible for the outcome.
- Links the physician’s action and patient’s condition more intimately than other specialties.
- In medicine, interventions are often nonspecific. Thus, failure often attributed to inevitable pathophysiology rather than to treatment.
- In psychiatry, goals are diffuse and treatment is imprecise. Thus, failure of psychatrist’s actions not linked to response of patient.
- Consider comparison of failure: Surgeon operates on 83 yo with gallbladder problems, patient dies soon after; can surgeon claim patient died of old age? Colleagues ask, what did you do? Internist treats 83 yo with gallbladder problems with medication, patient dies soon after; can internist claim patient died of old age? Colleagues ask, what happened?
Why do surgeons go to work so much earlier than other physicians?
At 6:30am, 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… These men and women begin rounds at 6:00am so that they can be scrubbed, capped, gowned, and ready to operate on their first patient at precisely 8:00am
- More things to do: A 20 minute difference often means the difference between a hurried lunch and a twelve-hour fast, during which the hungry houseofficer is physically, intellectually, and emotionally strained (remain standing, assist with or perform operative procedures, pass ad hoc quizzes on anatomy and the advisability of different treatment modalities, engage in witty repartee with the attending or silently be the butt of the attending’s jokes)
- Culture: houseofficers not ready on schedule appear inefficient, lazy, and unreliable
- Info: A nephrologist told me that many medical specialties, but not surgery, depend on the lab results of the day, which are not available until mid morning.
The surgical personality
Much of the satisfaction of surgery derived from individual physicians going beyond what was expected to achieve unexpected success. Self-sacrifice, a distaste for any calcuation of cost and benefit, a willingness to run long odds on the patient’s behalf– all of these characterized the surgical personality. The ethos was anti-bureaucratic, anti-rules, and, if need be, anti-rational, especially if rationality were measured in terms of cost-benefit ratios, expectancies, and likely outcomes. Any limitation of effort, any expressions of doubt, any hesitation before action, any anxiety about success–all these were seen as alien to the true surgeon.
- Action ethic, dedication, self-confidence
- There is more to literature on the “surgical personality” to be reviewed that has to wait for a future post.
Until he is confident and secure, any good surgeon dreams about his operations. He reoperates, taking stitches in and out, revising his approach. He does this, too, for clinical situations. He rethinks how each patient was managed… You need this kind of attention to detail, absolute dedication, and personal honesty to be a good surgeon.
Four forms of error
The central thesis of the book is that “in surgical education, technical norms are subordinated to moral ones.” The following are ways that surgeons interpret errors (not that they are the four types of errors).
- Technical errors (techniques imperfectly performed)
- Judgmental errors (incorrect strategy of treatment chosen)
- Normative errors (failure to discharge normal role obligations conscientiously: e.g. not telling the attending of a change in patient status, inability to work agreeably with nurses, inability to secure the cooperation of patients and family)
- Quasi-normative errors (failure to follow attending-specific procedures and rules)
When technical and judgmental errors are 1) speedily noticed, reported, and treated, and 2) not frequently made by the same person, they do not damage the trainee’s claim to competence. Error is perceived by superordinate as a teachable moment, occurred only due to the maker’s inexperience, and signals only a momentary lapse. Trainees learn that everyone makes mistakes and consequences can be mitigated. Their biggest fear is repeating mistakes and not learning from them.
On the other hand, normative and quasi-normative errors signal a character deficiency. These violate the expectations of your role as a physician (obligations to patient), as a trainee (obligations to superordinates), or as a professional (obligations to colleagues, nurses, and other staff). These are serious errors because moral deficiencies are difficult to change. (Even though quasi-normative rules are idiosyncratic/arbitrary, quasi-normative error signals insubordination and hubris.)
Interestingly, Bosk claims that normative errors are easier to detect.
Subordinates are constantly revealing their moral worth to superiors in a variety of manners: by their degree of attentiveness as they hold retractors, by their affect as they discuss clinical problems, by their rapport with patients, and by their resourcefulness in getting things done.
Holding the retractor is what every third-year student does. Retractors are also known as idiotsticks, because holding them takes little skill. However, inattentiveness while doing such a task signals indifference to becoming a surgeon. Conversely, attentiveness signals an appreciation for the art and a respect for the attending.
Surgeons cited the three A’s (availability, affability, and ability) in the order of their rank importance for trainees.
The ultimate point is that when evaluating students, technical ability is subordinate to perceived moral worth.
The question for surgical trainees of the future, as colorectal surgeon Lauren Kosinski points out, is what ‘availability’ means in the face of the tension between new 80-hour work week restrictions and the expectations of older generation surgeons.