Domestic Animals and Disease

First, I have a comment/question. With the exception of the chapter on livestock and germs, I’m not really sure why we were assigned this book. That chapter was interesting and pertinent. The rest of the book, while informative, did not seem so pertinent to the goals of this course. Especially since this book is more than twice the length of many of the other books we read this semester that were very important subject matter, it seems strange that this extraordinarily longer book would be the least on topic.

Second, recall the anecdote about the man whose wife got furious because he was having sex with the sheep (195-196). Diamond continues after that and says:

“This incident sounds bizarrely one-of-a-kind and of no possible broader significance. In fact, it illustrates an enormous subject of great importance: human diseases of animal origins. Very few of us love sheep in the carnal sense that this patient did. But most of us platonically love our pet animals, such as our dogs and cats…Some of us adults, and even more of our children, pick up infectious diseases from our pets. Usually they remain no more than a nuisance, but a few have evolved into something far more serious. (196)

This, as he says, “illustrates an enormous subject of great importance”. This topic and passage, as well as some of the comments he makes on later pages, brought to mind two specific things.

The first is the issue of getting sick from our pets. I remember a while back seeing things on TV about how sleeping with our pets will make us sick. I found an Article about the issue which brings up most of the points of it. Also here is the link to the pdf of the cdc report. The second thing it made me think of is the movie "Contagion". For anyone who was at all interested in his description of epidemics or in epidemics in general, it is a really great movie for showing how diseases spread.

Doctors and Hospitals or the Army and soldiers

Forgive and Remember Charles Bosk discusses the reasons so many medical mistakes are made in hospitals throughout the U.S. Some 98,000 people a year die in the U.s. due to preventable error or misdiagnosis and many live only to have to deal with and pay for additional medical complications. Bosk discusses the roles residents and learning staff have in these errors. I am left wondering how these mistakes could be minimized. Of course experienced doctors could provide more supervision during the learning process, but the first few years of a doctor’s career are just that, a learning process. Without having a hands on experience and learning semi- independently how would these learning health care providers ever really learn? Bosk describes the level of observation and guidance attending provide their young staff and how mistakes are often corrected before things get worse.

So long as you learn, there doesn’t seem to be too much trouble that follows a medical mistake, unless rank is crossed. Bosk’s description of the different types of mistakes which are reasonable and simply not allowed; his description made me think of hospitals as being somewhat military like in how it is run. There are four types of error which he claims occur: technical, judgmental, normative, and quasi-normative. Those in which a medical provider does no respect rank are seen as the gravest. As long as one admits ones mistakes to ones superior and submits to an inferior role, punishments seem to be minimal.

One of the most disturbing aspects Bosk mentioned was relocation as a punishment. It isn’t exactly a punishment to poorly qualified or trained doctors, so much as a way to prevent these low quality professional from reflecting on their superiors. You don’t just remove a pedophile from one church to save it’s good name, he is removed from the order itself, and so it should be with doctors, in my opinion. Careless providers should not simply be moved to hospitals which  expect less and in which patients may be less able to advocate for themselves, the expectations of doctors should just be standardized everywhere. Doctors should all be good practitioners. 

hygiene

In his book, “Better: A Surgeon’s Notes on Performance,” Atul Gawande does a great job at explaining the three “core requirements for success in medicine.”  The three requirements are diligence, “doing right,” and ingenuity. He explains that the field of medicine can only work if a doctor or nurse follows these three requirements. 

 I feel like something that has not been discussed much, but that I thought was particularly notable was the issue of hygiene.  I was shocked to find out how much energy is spent making sure medical staff keeps up appropriate hygiene in the hospital.  With the large rate of infection in hospitals, I feel like this should be a no-brainer.  Since infection is such a huge risk factor in hospitals, one would think that the whole staff would be just as diligent about antiseptic in the main hospital floors as they are in the operating room.  I was shocked to know that this was not the case.  Yes, it is true that doctors are only human, however they are humans that the rest of us trust to take care of us when we are sick or injured, and therefore they have a responsibility to prevent infection from spreading how ever they can, even if that includes obsessively washing and sterilizing their hands.  

What Constitutes a Mistake?

          When I first picked up Charles Bosk's Forgive and Remember, I thought that it would be a straightforward book about mistakes made in the medical field and how they are dealt with. However, I think that the biggest thing that I've taken away from this book so far is that what exactly constitutes a mistake is a highly contested and complex idea that depends on many factors. In fact, Bosk argues that residency training is primarily "a moral education, the purpose of which is to teach young doctors the standards of practice" (xvi). In other words, before doctors can truly be held accountable for determining what is right and what is wrong in medical practice, they must go through a grueling several years of preparation.
          This seems counterintuitive because in many other aspects of life people seem to have an innate sense of what is right and what is wrong. Why should surgery be any different? I think that Bosk's answer to this lies in the complex and technical nature of surgery, as well as in the inherent uncertainty present in any form of medical practice. Unlike other aspects of life where right and wrong may be as clear as black and white, there is a huge gray area in medicine and especially surgery that makes it very difficult to tell when an unforgivable error has occurred. It might seem obvious to an outsider that if a patient dies than a mistake has occurred on the part of the surgeons, but sometimes doctors can do everything right and a patient still dies. Similarly, sometimes doctors can get away with making a lot of mistakes as long as they still have a positive patient outcome. This is a very pressing problem because it is impossible to learn from your mistakes if you don't even know that they occurred.
          Bosk tries to tackle the problem that doctor's face of determining when a mistake has occurred by classifying mistakes into 4 categories: technical, judgmental, normative and quasi-normative. Technical and judgmental mistakes are thought to be inevitable and occur because the resident is inexperienced and doesn't know any better yet. Normative mistakes on the other hand, "involve the violation of universal rules that hold across surgical services" (xx-xxi). Similarly, Bosk defines quasi-normative mistakes as "involv[ing] rules specific to individual attendings and their services" (xxi). Both normative and quasi-normative mistakes are "treated as breaches by a morally accountable agent and as occasion for corrective remedies" (xix). On the surface this seems straightforward enough, but as Bosk goes on to explain, whether a mistake is classified as technical, judgmental, normative, or quasi-normative depends on a dizzying array of factors including "who the attending was, who the resident was, how smoothly things were going on the service when the mistake surfaced, how a request for information was managed, what time of year it was when the mistake occurred", etc. (xx).
          To me, this highlights the central problem of this book: if judging mistakes is so arbitrary, how can we really know when something unforgivable has occurred versus when an innocent and unavoidable mishap has occurred? And how does this uncertainty effect patients and doctors alike?

Group Mentality in Surgery

Charles L. Bosk’s book Forgive and Remember: Managing Medical Failure is an in depth ethnography that investigates the little known world of surgeons. The book differs greatly from How Doctors Think, and I think that this example is a better way to understand how working as a medical unit may affect the care of people admitted to a hospital. Although some may be shocked at how impersonal they may be with their patients, I think that knowing these aspects of surgeons can ultimately improve how surgeons perform.

Bosk takes Durkheim’s sociological approach in order to understand the morality of an entire group. Rather than approaching each surgeon individually, they are viewed as a collective who make mistakes and learn together and adhere to strict social dynamics within their group. The social interaction skills unlike Groopman’s book are not with the patients but with one another. This may because there is a difference between diagnosing patients, where there is forced patient-doctor interaction, and being skilled at operation, which is helped by your surgical team. Surgeons ultimately need to listen to each other in order to stay informed about patients and to learn. As highlighted in the section on error, rank, and responsibility, it appears that making a technical error (like an infection from surgery) can be more excusable than normative errors (error in assuming role). If a normative error is made, it is a miscommunication, perhaps between attending and house staff that is preventable, which may be why it faces more scrutiny.

As other posts mention, the solidarity of the surgeons may come at the expense of a patient. Although I would never want to be the guinea pig of an intern, I think that the book is correct in quoting a surgeon who says “the way you learn as an intern is by being put on the spot and coming through it” (53). Through reading this book, I can understand how technical errors are seen as permissible rather than normative errors. Even in Groopman’s book, doctors cannot be perfect on the first try, it takes years of practice to understand how to diagnose and treat patients. However, you can try to control how the housestaff, nurses, interns, and attendings work with one another to be a better team and efficiently help patients. What I enjoy about this book is that so much emphasis is placed on surgeons as a unit and how they operate as a team. When the science isn’t always exact and people are unsure of the best way to operate on a patient, the bond between a skilled attending and an inexperienced intern is a key element to success. Perhaps in changing the culture of surgical teams, we can improve the way surgeons practice and perform.

Medical Judgment

Charles L Bosk’s Forgive and Remember: Managing Medical Failure has been an interesting read thus far. As a participant observer of the surgical training program at Pacific Hospital, Bosk provides insight into the ways in which doctors interact with each other, how they cope with the physical and mental difficulties that come along with being a medical professional, and the manners in which they go about teaching their stressful and selective trade to others. He highlights how doctors handle instances in which errors, both large and small, are made.

I am enjoying the different perspective Bosk’s book provides when compared to Groopman’s in How Doctors Think. Bosk is a sociologist and has the perspective of an outsider looking in, whereas Groopman is a doctor and draws primarily from his experience as a medical professional. This is an issue that I think of whenever I read sociological studies, as I am not sure which source provides more accurate information. On one hand, Groopman and others who study and write about their own professions, social positions, nationalities, and other subjects, have lived and breathed their subjects for years if not their entire lives, and therefore may have more information about them. Nevertheless, an outsider has the potential to be more objective about a study, as he or she likely does not have personal or emotional ties to the group and may notice things through observation that someone accustomed to the situation may take for granted.

Bosk’s discussion of how doctors develop and maintain a good reputation ties in well with what we discussed in both classes last week. Bosk’s study is very relevant to the question of how much we can truly trust the decisions made by doctors, as well as the most important attributes we want to see in a good doctor. I was particularly interested in what Bosk says about judgmental errors in his chapter Error, Rank and Responsibility, as the issue of judgment is so incredibly important to anyone in a position to make decisions that affect others. Bosk quotes several doctors who make tough decisions about patients who could be saved by surgeries, though the risks were extremely high. This reminded me of an article that I read for a sociology class on deviance and social control, which I took last semester about a doctor who gave critical patients toxic doses of morphine after Hurricane Katrina in order to allow time for patients who were more likely to survive if they got treatment (Strained By Katrina http://www.nytimes.com/2009/08/30/magazine/30doctors.html?scp=1&sq=strained%20by%20katrina&st=cse). This is obviously an extreme example about which we could discuss the ethical issues for days, but similar to the doctors in Bosk’s book, this doctor made a judgment call and then had to deal with the consequences of that later on. I am excited for the discussion of this book in class, as the example that it provides are much more extreme than those provided by our other readings and I feel many people will have strong opinions on the matter.

Mistakes

When reading Charles Bosk's Forgive and Remember, I was struck with the type of errors that occurred at the hospital. I understand that for a technical error as long as you do not repeat a mistake, it is almost seen as okay. It disturbs me to see how some patients are like a test dummy to the interns and the housestaff. It is by chance that one person might get a housestaff that is inexperienced and another receives someone who has learned from their mistakes. I just do not think that it is fair that the person who has to pay for the errors is the patient. They have to pay the added cost to the medical bill because of additional procedures to rectify the error. Nevertheless, I find it reassuring that as long as the attending is alerted to the error after it occurred, they have a higher chance of reverting the error.

I also find it reassuring to see how attendings really want to be informed about the new developments of what occurred to the patient even if it is at the wee hours in the morning. This shows that they are on top of things and it not only the housestaff and interns running the show. It shocked me to realize that once an attending sent a resident to perform his first colonostomy alone, claiming he will come back but never returning. It is terrifying to realize that resident was left to perform surgery on a patient without being sure what he was doing and was left to ask the nurses technical questions about the procedure like how big should the incision be and how much bowel should he exteriorize. Even though for this case the resident performed the procedure well, the next time complications may occur because he may have made a mistake due to inexperience and the nurses may not be as helpful to guide him through the procedure.

While human subjects are good for learning how to practice medicine on, I believe that it should not be okay to make any mistake. I understand that at first the housestaff is scared of making a mistake, which might be an extra stress on them when they evaluate a patient. I believe that the feeling regarding committing a mistake should be similar to this fear throughout their medical career. Bosk points out that without these mistakes, housestaff may not learn how to fix these mistakes in the future. He mentions that making a mistake on one person may help all the others in the future. This is sound logic, however, considering I may be the patient in the future that may will have to pay for the consequences of the mistake done by the housestaff I wish that one time mistakes are not seen as okay but still feared to caution them against reckless mistakes.