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Forgive and remember revisited
The American Journal of Surgery 194 (2007) 1–2
Editorial opinion
Forgive and remember revisited Robert E. Condon, M.D.* Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Ave., Milwaukee, WI 53226, USA Department of Surgery, University of Washington, 1959 NE Pacific St., Seattle, WA 98195, USA Manuscript received September 3, 2006; revised manuscript September 10, 2006
In 1979, the sociologist, Dr Charles L. Bosk, published the results of an important study in a major teaching hospital of behavior by surgical residents and attendings [1]. The focus of Bosk’s inquiry was the identification and management of error. His epitome of the manner in which surgical error is managed became the title of his book, Forgive and Remember. Errors are forgiven if they are remembered and not repeated. Many directors of surgical residencies were so impressed with the insights Bosk had provided that, in the 1980s, they enthusiastically recommended Forgive and Remember to their colleagues and to their residents. Some, including myself, bought copies of the book to present to their residents to help guide them in successful behavior during the residency. Over time, however, the initial wide awareness of the pertinent messages contained in Forgive and Remember has diminished. While some Program Directors continue to recommend the book to their residents, many others do not. And, my current inquiries among residents in a number of programs indicate that Forgive and Remember is not being widely read. The recently published 2nd edition [2] adds a discussion of, among other things, the new safety culture in medicine. Forgive and Remember should be read, in my view, by every surgical resident and attending surgeon. Bosk identified a number of principles that guide conduct of both attending surgeons and surgical residents, as well as the rules of successful resident behavior on a surgical teaching service. His discussion is as pertinent today as it was when published more than 25 years ago. Some things never change. Interest among both attending surgeons and surgical residents in the continuing utility of Forgive and Remember, may be kindled by contemplating some of its insights: (1) Surgical residencies function on the basis of full, immediate and honest disclosure by residents to
* Corresponding author. 2722 86th Ave. NE. Clyde Hill WA 980041653. Tel./fax: ⫹1-425-453-7860. E-mail address: [email protected]
(2)
(3)
(4)
(5) (6) (7)
(8)
(9)
(10)
(11) (12)
(13)
(14)
0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.09.037
attendings of all relevant events. Among behaviors expected of residents, by far the most important is “no surprises.” Following established procedures, ie, “going by the book” even when failure occurs, protects residents from an adverse judgment by attendings. Personal preferences of attendings are rules of conduct for residents since attendings define reality for residents. If residents disagree with attendings, there is little they can do; when opinions differ, clinical experience overrides scientific evidence. Supervision by attendings is expected by residents; when it does not occur, residents feel abandoned. All requests by residents for help from attendings are legitimate. Technical errors are expected, but should be rare; such errors are forgiven if speedily noticed, reported and corrected, and then not repeated. An error in judgment has occurred whenever a treatment strategy fails to produce a successful clinical result; the sources of judgmental error are overly heroic operations, failure to operate when clearly indicated, and failure to establish treatment plans for chronic problems. Judgmental errors by residents also are forgiven if quickly reported and not repeated; they are viewed by attendings as indicating a need for further training. Failure by a resident to behave as attendings expect (“normative error”) usually is not forgiven but is punished. Calling the attending when unsure is always the safer strategy for residents. Inability to get along with nurses is viewed by attendings as a failure by the resident to do their expected job. Inability of a resident to secure cooperation and needed permissions of patients and their families is also viewed as a failure of expected behavior. Expected behavior that is unique to an attending, that may even be “eccentric,” must be provided by residents assigned to that attending’s service; fail-
2
R.E. Condon / The American Journal of Surgery 194 (2007) 1–2
ure in this regard (“quasi-normative” error) may result in a judgment that the resident is insufficiently reliable. (15) The resident who answers questions from the attending with a complete and accurate response wins trust; vague answers lead attendings to assume laziness or incompetence. (16) Attending rounds are an exercise in which the attending pokes around to be certain that residents are behaving as expected. If all seems well, the attending teaches; if not, the attending intensely questions residents, seeking errors. Such increased monitor-
ing is a warning to residents that their performance is unsatisfactory. A resident who absorbs and guides personal behavior in accord with the messages in Forgive and Remember stimulates attendings to teach more and criticize less, providing a reward for the effort. References [1] Bosk CL. Forgive and Remember: Managing Medical Failure. Chicago: University of Chicago Press; 1979. [2] Bosk CL. Forgive and Remember: Managing Medical Failure. 2nd ed. Chicago: University of Chicago Press; 2003.
Editorial opinion
Forgive and remember revisited Robert E. Condon, M.D.* Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Ave., Milwaukee, WI 53226, USA Department of Surgery, University of Washington, 1959 NE Pacific St., Seattle, WA 98195, USA Manuscript received September 3, 2006; revised manuscript September 10, 2006
In 1979, the sociologist, Dr Charles L. Bosk, published the results of an important study in a major teaching hospital of behavior by surgical residents and attendings [1]. The focus of Bosk’s inquiry was the identification and management of error. His epitome of the manner in which surgical error is managed became the title of his book, Forgive and Remember. Errors are forgiven if they are remembered and not repeated. Many directors of surgical residencies were so impressed with the insights Bosk had provided that, in the 1980s, they enthusiastically recommended Forgive and Remember to their colleagues and to their residents. Some, including myself, bought copies of the book to present to their residents to help guide them in successful behavior during the residency. Over time, however, the initial wide awareness of the pertinent messages contained in Forgive and Remember has diminished. While some Program Directors continue to recommend the book to their residents, many others do not. And, my current inquiries among residents in a number of programs indicate that Forgive and Remember is not being widely read. The recently published 2nd edition [2] adds a discussion of, among other things, the new safety culture in medicine. Forgive and Remember should be read, in my view, by every surgical resident and attending surgeon. Bosk identified a number of principles that guide conduct of both attending surgeons and surgical residents, as well as the rules of successful resident behavior on a surgical teaching service. His discussion is as pertinent today as it was when published more than 25 years ago. Some things never change. Interest among both attending surgeons and surgical residents in the continuing utility of Forgive and Remember, may be kindled by contemplating some of its insights: (1) Surgical residencies function on the basis of full, immediate and honest disclosure by residents to
* Corresponding author. 2722 86th Ave. NE. Clyde Hill WA 980041653. Tel./fax: ⫹1-425-453-7860. E-mail address: [email protected]
(2)
(3)
(4)
(5) (6) (7)
(8)
(9)
(10)
(11) (12)
(13)
(14)
0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.09.037
attendings of all relevant events. Among behaviors expected of residents, by far the most important is “no surprises.” Following established procedures, ie, “going by the book” even when failure occurs, protects residents from an adverse judgment by attendings. Personal preferences of attendings are rules of conduct for residents since attendings define reality for residents. If residents disagree with attendings, there is little they can do; when opinions differ, clinical experience overrides scientific evidence. Supervision by attendings is expected by residents; when it does not occur, residents feel abandoned. All requests by residents for help from attendings are legitimate. Technical errors are expected, but should be rare; such errors are forgiven if speedily noticed, reported and corrected, and then not repeated. An error in judgment has occurred whenever a treatment strategy fails to produce a successful clinical result; the sources of judgmental error are overly heroic operations, failure to operate when clearly indicated, and failure to establish treatment plans for chronic problems. Judgmental errors by residents also are forgiven if quickly reported and not repeated; they are viewed by attendings as indicating a need for further training. Failure by a resident to behave as attendings expect (“normative error”) usually is not forgiven but is punished. Calling the attending when unsure is always the safer strategy for residents. Inability to get along with nurses is viewed by attendings as a failure by the resident to do their expected job. Inability of a resident to secure cooperation and needed permissions of patients and their families is also viewed as a failure of expected behavior. Expected behavior that is unique to an attending, that may even be “eccentric,” must be provided by residents assigned to that attending’s service; fail-
2
R.E. Condon / The American Journal of Surgery 194 (2007) 1–2
ure in this regard (“quasi-normative” error) may result in a judgment that the resident is insufficiently reliable. (15) The resident who answers questions from the attending with a complete and accurate response wins trust; vague answers lead attendings to assume laziness or incompetence. (16) Attending rounds are an exercise in which the attending pokes around to be certain that residents are behaving as expected. If all seems well, the attending teaches; if not, the attending intensely questions residents, seeking errors. Such increased monitor-
ing is a warning to residents that their performance is unsatisfactory. A resident who absorbs and guides personal behavior in accord with the messages in Forgive and Remember stimulates attendings to teach more and criticize less, providing a reward for the effort. References [1] Bosk CL. Forgive and Remember: Managing Medical Failure. Chicago: University of Chicago Press; 1979. [2] Bosk CL. Forgive and Remember: Managing Medical Failure. 2nd ed. Chicago: University of Chicago Press; 2003.