Book Review: Forgive and Remember: Managing Medical Failure, 2nd edition
Authors: Robin Williamson
Journal: Journal of the Royal Society of Medicine (2004)

The first edition of Charles Bosk's book appeared in 1979 as `the definitive study of the training and lives of young surgeons' (I quote from the back cover of the new paperback edition). At that time Bosk was a young graduate student in sociology who spent 18 months `embedded' in the surgical residency of a teaching hospital in the western United States. He became an acute and generally sympathetic observer of those struggling simultaneously to learn and practise surgery. Like a journalist on the battlefield—and his description of the surgical tribe at `Pacific Hospital' has a distinct whiff of grapeshot—he experienced the classical dilemma of when to stay silent and when to intervene, if only to remind the house staff about a task overlooked.

In reading this provocative book I set myself three questions: how thoroughly has it been updated, how relevant will it be to a readership of doctors and those with a general interest in healthcare (as opposed to `narrative ethicists' and `cultural ethnographers') and how parochial is the subject matter? I too was attached to the surgical department of a famous American hospital during the mid-1970s (as a research fellow), and I recognize some of the character types and clinical scenarios portrayed. Prolonged immersion in his field work allowed Bosk some pungent insights into the relationship between trainees and trainers. In the intervening quarter of a century he has progressed to become a professor of sociology and medical ethics. His stimulus to revisit the field was provided by fresh invitations both to lecture on the subject and to join a working party on humanizing bioethics. He has not returned to Pacific, however, and there are essentially no new data in the book, merely a reflection on his youthful research. This second edition is expanded by a preface, an additional appendix (amended not resected) and an epilogue, but the central core of the book is unchanged. So, alas, is the bibliography, which dates from the early 1970s and before.

`Putting on the hair shirt' was a frequent activity at the teaching hospital. Forget medieval monks wearing prickly underclothes as a private reminder of sins. The hair shirt at Pacific meant public confession of errors in the hope of expiation. Bosk's central thesis is that errors of a technical or judgmental nature—clinical mistakes freely admitted—could be forgiven, whereas normative and quasi-normative errors could not be. A normative error was one in which a surgeon was deemed to have failed in the conscientious discharge of his duties. While normative errors represented a breach of generally accepted standards of performance, quasi-normative errors were specific to the individual service. By failing to follow the particular protocol of his own team, the subordinate appeared insubordinate to his superordinate (to borrow the author's words if not his phraseology). In each case, covering up the mistake worsened the crime. The `attendings' (consultants in British terminology) could ostensibly do little wrong, although they too would publicly admit their mistakes at Grand Rounds. Bosk himself now dons a hair shirt by `coming clean' on two omissions in the first edition.

These two omissions are of interest because they appear to be a major justification for producing a second edition, as if the author wants to set the record straight (and perhaps allow himself more comfortable underwear). In the first case he disguised the female gender of `Jones', the one surgical resident who was regarded as a complete failure and whose surgical career was accordingly aborted. The reason for disguise was that the rarity of her position as a woman resident might have allowed her to be identified; he has since come to regret this humane deception. Her commission of all four types of error was labelled psychiatric at the time, but Bosk now attributes it to exclusion from the locker room, where her male colleagues would relax, converse and let off steam. He then proceeds to suggest that she was a victim of sexual harassment, without providing a jot of evidence to support the charge. The argument is that, because she went on to do well in another field of medicine, the original assessment of her surgical potential was not just biased but wrong. Several alternative explanations occur to me. The second omission concerns `Dr Arthur', an attending who emerges from the first edition as an opinionated bore but is now characterized as an objectionable bigot to boot.

The second question that I posed was whether this book would be of interest to non-sociologists. My answer is a qualified yes. A surgeon myself, I tended to sympathize with the animals under the microscope, but I am bound to admit that the author is merciful in his criticisms of the species Homo chirurgicalis. Less easy to digest are words such as epistemologic and dramaturgic, which had me looking in vain for a glossary. In the 1970s it seems that the subject of his work fascinated fellow guests at cocktail parties, but interest in the arcane world of surgeons has probably diminished in the modern egalitarian era; in Britain at least, surgeons have been knocked off whatever pedestal they previously occupied.

How well does this work translate for those working outside the United States? I have to say that Bosk makes few concessions to those unaccustomed to the American way of surgery; once again, a glossary would have been useful. Other surgeons in the English-speaking world would certainly have had a different vocabulary, but I dare say that their fundamental attitudes towards patients and junior staff may have been similar in the 1970s. The author admits that things have changed since then, although he indicates that other tyrannies have taken the place of the god-like attending. His work remains an interesting glimpse into a peculiar hierarchical world that has become partly obsolete with the march of time.