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V ' IIX " ‘.:I I ‘_ Il' ‘L"‘I“ , l ‘1'; ALI". 11",”4y ~~«‘Vr3.*1-1‘.I"~- ..1 J 1" '_ J’u‘ ”I" N“\“I1d‘?u"£""fl 153‘?“ LIMIIJI‘JQ 41.155 LIBRAE. Y Michigan State UniVCfi-it‘l This is to certify that the thesis entitled The Unity of Mistakes: A Phenomenological Study of Medical Work presented by Marianne A. Paget has been accepted towards fulfillment of the requirements for Ph. D. degree in Sociology @Wzi 974%; Major professor Datewrfll/ /é,/ / 77 J 0-7 639 © 1978 MARIANNE A. PAGET ALL RI GHTS RESERVED THE UNITY OF MISTAKES: A PHENOMENOLOGICAL STUDY OF MEDICAL WORK BY Marianne A. Paget A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Sociology 1978 Q €//Q)) ABSTRACT THE UNITY OF MISTAKES: A PHENOMENOLOGICAL STUDY OF MEDICAL WORK BY Marianne A. Paget This study is an interpretation of interview data on medical mistakes. The interview data were acquired in the context of a longitudinal study of the training of physicians at the College of Human Medicine at Michigan State University. Residents and practicing physicians who had entered medical school some seven or eight years earlier were asked what they thought about and did when they made a medical mistake and what they thought about and did when they observed other physicians making mistakes. The responses to these questions are approached as 52535 requiring illumination. It is as if the author had come across historically remote documents, quite out- of-the-ordinary documents, which required rendering in the English language. This approach has been adopted because the author is interested in the subject's exper- ience of making mistakes in time as it unfolds. Marianne A. Paget The physicians interviewed reported that medical mistakes are inevitable, that is to say, that medical mistakes are an intrinsic feature of the work process of medicine. Quite commonly, however, reports about the inevitability of mistakes in medicine are regarded as excuses, apologies, or rationalizations of medical mis- conduct. Approaching the responses as tgxtg, then, per- mitted examining in detail discussions of the inevita- bility of mistakes. The study's focus is the diagnostic and therapeu- tic process. It is described as an error-ridden activity. And making mistakes in medical work is identified as a problem of acting in time. Three descriptive pictures of medical mistakes are constructed: first, the evolution of mistakes in clinical action; second, the identification of mistakes in the aftermath of action; and third, the complex sorrow of making mistakes. These descriptive pictures attempt to portray the subject's experience of becoming mistaken. The study begins with the common sense idea of an honest error. I ask: What constitutes the phenome- nology of an honest error? What is the work of such a phrase in discourse? An honest error disclaims blame. It suggests that someone is or, rather, was unwittingly wrong. However, a mistake is always an unwitting and unintended act. The adjective honest, the work of the Marianne A. Paget word honest, then serves to intensify and reemphasize the absence of guile. A statement like, "It was an honest mistake," captures an ambiguity in experience which is extended in the interpretation. It is used as a door, so to speak, opening onto other apprehensions of the mean- ing of making mistakes. While the focus of analysis is honest errors in clinical action, negligent acts are also examined. What distinguishes a negligent act from an honest error is ‘that a negligent act directly causes damage and repre— sents a derelection of professional duty. Negligent acts, however, are neither the most common errors in clinical action nor the most revealing of the character of clinical work. Making mistakes/being mistaken is identified as a distinct experience of being. It includes but is not defined by being at fault and includes but is not defined by being blamed. Making mistakes/being mistaken is also identified as a source of the organization of clinical work, clinical discourse, and clinical conduct in the arenas of medical work. How could anything originate out of its opposite? for example, truth out of error? or the will to truth out of the will to deception? or selfless deeds out of selfishness? or the pure and sunlike gaze of the sage out of lust? Such origins are impossible; whoever dreams of them is a fool, indeed worse; the things of highest value must have another, peculiar origin--they cannot be derived from this transitory, seductive, deceptive paltry world, from this turmoil of delusion and lust. Rather from the lap of Being, the intransitory, the hidden god, the 'thing-in-itself‘-—there must be their basis, and nowhere else. Nietzsche ii ACKNOWLEDGMENTS I want to thank a number of individuals for their assistance in the development of this study. Ronald W. Richards, the Director of the Office of Medical Education, Research and Development at Michigan State University in 1973-74, gave me both the research time and the resources necessary to begin a related project from which this study evolved. Arthur S. Elstein, when he became the Director of the Office of Medical Education, Research and Development in 1974, also extended this privilege. I have especially appreciated his strong support of my work. Ann G. Olmsted, who in 1967 asked me to join her study of the training of physicians in the College of Human Medicine, very graciously allowed me to develop data from that study in a new way. Bo Anderson was very helpful in the initial formulation of my ideas about medical work. Anthony J. Bowdler, M.D., with whom I have talked at irregular intervals about the training of physicians, was also very helpful. Peter Finkelstein, M.D., Nova M. Green, Peter Lyman, James B. McKee, Elianne Riska, Barrie Thorne, iii John Useem, and Peter 0. Ways, M.D., have all read and commented very helpfully on this study. I especially want to thank James B. McKee, the chairperson of my dissertation committee, and Peter Lyman for their strong support of my work and their sensitivity to its difficulty. I received excellent technical assistance from Judy Carley, Marty North, Janice L. Smith, and Kay Steensma. And Ann Cauley provided excellent editorial advice in the preparation of the final manuscript. iv I. II. III. IV. V. TABLE OF CONTENTS THE LANGUAGE OF MISTAKES . . . . . . Introduction . . . . . . . . Background and Method . . . . . . Data . . . . . . . . . . Plan of the Study. . . . . . . . LANGUAGE DEPARTURES. . . . . . . . Introduction . . . . . . . . The Literature on Occupations and Pro- fessions . . . . A Preliminary Sketch of the Diagnostic and Therapeutic Process . . . . . The Semantic Sense of Mistakes . . . Summary . . . . . . . . . . . THE CHARACTER OF CLINICAL ACTION . . . Introduction . . . . . . . . . The Data of Experience . . . . . . An Interpretation. . . . . . . . Knowledge and Action. . . . . . . Conclusion . . . . . . . . . . LANGUAGE OF INTENTION . . . . . . Reparation and the Irreparable . . . The Reconstruction of Action . . . . The Reconstruction of Experience. . . An Interpretation. . . . . . . . Conclusion . . . . . . . . . . THE COMPLEX SORROW OF CLINICAL WORK . . Introduction . . . . . . . The Experience of Mistakes: A Collec- tive Representation . . . . . . An Interpretation. . . . . . . . Page 16 2O 24 24 27 38 50 61 63 63 68 72 81 92 96 96 104 108 111 124 127 127 134 147 Page Mistakes as Complex Relations . . . . 147 Going-Bad; Going-Wrong . . . . . . 149 Being Mistaken . . . . . . . . . 152 Being at Fault . . . . . . . . 159 Negligence . . . . . . . . . . . 164 Conclusion . . . . . . . . . . . 171 VI. THE UNITY OF MISTAKES . . . . . . . . 176 Bearings-Markings. . . . . . . . . 176 Limits to an Analysis of Mistakes. . . 176 The Limitations of an Interpretation. . 179 The Being of Being Mistaken . . . . . 186 The Unity of Mistakes . . . . . . . 192 The Shape of Medical Work . . . . . . 196 APPENDIX . . . . . . . . . . . . . . 202 SELECTED BIBLIOGRAPHY . . . . . . . . . . 204 vi CHAPTER I THE LANGUAGE OF MISTAKES Introduction There are special difficulties in attempting an interpretation of mistakes in medical work. Two kinds of contemporary issues tend to overwhelm discourse: a crisis in health care and a crisis in malpractice liti- gation. Malpractice, a term in use in legal discourse about bad medical practice, is context specific. The malpractice of medicine, in a legal context, has its origin in a request for compensation by a patient, or a patient's family, for unnecessary harm. Compensation in this setting requires evidence of bad medical practice on the part of a physician or several physicians. Unneces- sary harm, bad medical practice, and compensation, how- ever, are not identical issues. Rather, they are issues joined in legal proceedings which require establishing blame.1 1See Sidney Shindell, M.D., L.L.B., The Law in .Medical Practice (Pittsburgh: University of Pittsburgh Press, 1966); Elliot L. Sagall, M.D., and Barry C. Reed, IL.L.B., The Law and Clinical_Medicine (Philadelphia: .3. B. Lippincott Company, 1970); R. Crawford Morris, The precise tort for malpractice is negligence. Yet this is not the only tort for which physicians can .be sued. They are also commonly sued for assault and battery, breach of contract, and unauthorized autopsy. Negligence, however, is the only tort that specifically requires establishing a violation of professional stan- dards. This means that in most circumstances, collabora- tive medical testimony is required.2 Though some of the mistakes referred to in this study may suggest malpractice in a legal setting, I am not investigating mistakes in a legal setting. I am investigating them in the context of clinical medicine and among clinicians of medicine. My topic is far broader; it encompasses a far wider range of mistakes than the term malpractice suggests. This study does not discuss the crisis in the distribution of health care, a very important area of inquiry and analysis. The inequities in our health care are pervasive. These inequities do not arise denovo in medicine but reflect an indigenous system of social L.L.B., and Alan R. Moritz, A.M., Sc.D., M.D., Doctor and Patient and the Law (5th ed.; St. Louis: The C. V. Mosby Co., 1971). For a general introduction to the evolution of malpractice litigation, see D. S. Rubsamen, M.D., L.L.B., "The Evolution of Medical Malpractice Liti- gation in the United States," Canadian Medical Association Journal 113 (August 1975): 334-41. ZShindell, pp. 34-35. ire for. DEV 5*": 64V tlt n.- .‘ I l J. H “V inequality, especially a market economy which has trans- formed many human values into commodities. I am not investigating a phenomenon about which no one has ideas. We are, each of us, a colony housing life, as Lewis Thomas might put it, in contact with practitioners of medicine.3 Mistakes in medical work have significant implications for us all. Yet this topic should not be construed as a revelation of medical prac- titioners' mistakes. I approach the meaning of mistakes from the point of view of the person who makes them and the person who knows them as his or her own mistakes. I adopt an existential point of view. From this point of view, the mistakes of physicians bear a resemblance to your mistakes and my own mistakes, the mistakes each of us makes as a human being acting in time. Bging is an important concept. It should be understood not in a static sense of being an entity, but in a dynamic sense of being in-time, living in-time. Human beings live in-time. They, therefore, become beings rather than are beings.4 The mistakes of phy— sicians bear a resemblance to your mistakes and my own 3Lewis Thomas, The Lives of a Cell: Notes of a Biology Watcher (New York: The Viking Press, Inc., 1974). 4Rollo May, "Contributions of Existential Psycho- therapy," in Existence: A New Dimension in Psyghiatry and Psychology, ed. Rollo May (New York: Basic Books, Inc., 19583. p. 41. EV! I it at mistakes as sentient and aware individuals acting and living in-time. In this light, I examine especially two ordinary platitudes, "everybody makes mistakes" and "mistakes are inevitable," and try to grasp their hidden and inner significance in time as it unfolds. The term ”mistake" is used less often in clinical circles than a companion term "error." "Mistake" is used here, with reservations, just because it is a term employed in everyday life. Meaning is a difficult topic, and the meaning of medical mistakes is an especially difficult topic. Each of us has already a preconception of their meaning, an already formed idea of what medical mistakes signify. They signify that someone is at fault and worthy of blame, that is to say, that a person, a physician, is at fault and worthy of blame. I do not want to exclude these meanings, being at fault or being blameworthy; but I do want to identify them as meanings commonly associated rather than identical with the use of the term "mistake." It will be helpful to keep in mind the distinction between what a mistake denotes and what a mistake con- notes. A mistake denotes something wrong rather than right, something incorrect rather than correct, for example, a wrong act. Furthermore, a mistake is connected ‘with someone who has made it, with someone who is, there- fore, wrong. It refers to a person's misunderstanding or misinterpreting something. The term connotes being blameworthy and at fault. I will be exploring other connotations of the meaning of mistakes. Being wrong I will illuminate as a complex sorrow of clinical action. The ease with which we connect making a mistake with being blameworthy and at fault is indicative of a mode of thinking about knowledge and action of which I was not entirely aware when I undertook this study and which will take some time to disclose. Action in this study has a precise meaning. Action unfolds in—time. More specifically, in the context of clinical work, action unfolds as a response to something already wrong, a person's experience of illness. A clinician becomes involved in something already wrong. He or she acts in response to it. But when does a clinical act or sequence of acts become wrong? The opaque and relational nature of clinical action is examined as it becomes wrong. Action is opaque, capable of the unexpected and the entirely new. For this reason, it contains the attributes of risk and invention. Erving Goffman conceives of action in this way. He uses the metaphor of the high wire. "To be on the wire is life; the rest is waiting."5 Yet action is relational; it is 5Attributed to Karl Wallenda, cited by Erving Goff- man, "Where the Action Is," in Interaction Ritual: Egays on Face-to-Face Behavior (New York: Anchor Books, 1967), p. 149. is so cc W1". taken in relation to others. It also risks the world of others. The difficulty, then, with the metaphor of the high wire is that it captures action not as it risks the world of others but as a sensation or an entertainment. Only for the high wire artist is the wire a dramatic symbol of the risk of action. In Chapter III the nature of clinical action is examined as it risks a response in relation to others. There is a paradox in being wrong. Being wrong is a cognition which follows doing something. Doing something wrong is also a cognition. What precedes the cognition of doing something wrong? In other words, when does doing something wrong arise as a cognition in doing something about human illness? When is it appre- hended and apprehensible? I This study considers the-use-of—thought-in- action-in-time. I especially ask: how is it we know what is? Our knowledge of what is, in some instances, is knowledge of what already is, that is to say, knowl- edge of what has already happened.' A mistake follows an act and identifies the character of an act in its completion. It identifies its incorrectness or wrongness. .An act, on the other hand, is not wrong; it becomes wrong or goes wrong. The complex sorrow of clinical action is the sorrow of discovering that you and I are wrong, 50': is i. J i y dez 9.1;: V Luf Y'A sometimes, with respect to a person's very existence; it is the sorrow of discovering that you and I are already wrong. I began this study when I became aware of the anguish of clinical action and of the moral ambiguity of being a clinician, a person who acts, acts sometimes mistakenly, and who, therefore, lives within the exper- ience of being wrong. Being wrong is a distinct exper- ience of bgigg, of dwelling or abiding in being. It is different from the experience of being blameworthy and at fault, just as my experience of being wrong as a sub- ject is different from your awareness of my being wrong. Here, I am encumbered by a general lack of attention to problems of bgigg. Descriptions of the conduct of life are seldom invested with the full weight of existence.6 6See Theodore Thass-Thienemann's discussion of the etymology of being in The Interpretation of Lagguage, Vol. 1, Understandingthe Symbolic Meaningpof Language (New York: Jason Aronson, Inc., 1968), pp. 141-52. I quote here only one of a number of concepts of being: the I was of being. "Different from the present being I am, it is is the past I was, it was. It is another verb and another concept. It refers not to being, but to that which has been, that which does not exist anymore; thus, it refers to non—being. If we say there is no presence without a past implied, there is no I am without I was, which means, in other words, there is no 'being' 'witfiout the implication of 'non-being.’ The verbal symbols *which describe this 'I am' with the implication of the past ;point, in Germanic languages, (refer) to 'dwelling, abid- .tngy' to something that remains. The 'house' became the symbol of 'being' with the implication of 'has been.‘ In English, one can observe, even in present-day language, the tendency to make an equation between 'to dwell' and 'tc) live.' . . . The 'house of being' (Heidegger) unites fi '1. in‘ ac «C ~C ‘ \c h \ “Us ‘k w Background and Method This study is based on interviews with forty phy- sicians who, at the time that I was given support to transcribe their tapes, the academic year 1973-1974, were in residency training or in medical practice. These interviews were two or three hours long and were the fifth or sixth in a series of interviews with these phy- sicians who were participants in a longitudinal study of medical training initiated by Ann G. Olmsted in 1966. Her study is a lS-year study of five classes of medical students in the College of Human Medicine at Michigan State University.7 I joined her study in 1968.8 These interviews occurred as conversations on clinical work, clinical training, and patient care. Open-ended in format while systematic in the development and coverage of themes, they included a discussion of mistakes in medical work: both mistakes these physicians had made themselves and mistakes they had observed others past, present and future. One can still trace, in the dis- tant related languages, the original meaning of English was and were, German war, 'was,‘ and gewessen, 'been' with the noun wesen 'essence, being,'" p. 145. 7For a description of this study see Ann G. Olm- sted, "The Professional Socialization of Medical Students: Research Plan," September 30, 1969. 8See "A Brief Introduction to My Research Interests in Medicine," presented to the Office of Medical Education Research and Development, October 24, 1974, for a descrip- tion of the impact of this study on my thinking. making. The questions asked were: what do you think about and do when you make a mistake and what do you think about and do when you observe another physician making mistakes? My primary focus here is on the dis- cussions of mistakes, although entire interviews in which these discussions are embedded serve as a background for this emphasis. I also have as a background a much longer period of research contact with these physicians. Either Ann Olmsted or I interviewed these physicians and their peers once a year in medical school, at least once in residency training, and once in medical practice. In 1973, these physicians were the first to reach either advanced residency training or medical practice. In general, they were members of the first and second classes of the college. These discussions have been employed in an unusual manner. I have attempted to render them, to construct a reading of them as one would construct a reading of manu- scripts of deep human significance. This has been done, in the first instance, because I believe these discussions are deeply significant. In rendering them, I have treated them as Eggtg requiring illumination. I have approached them as a scholar would approach historically :nemote texts or as an archeologist would approach the remmants of another civilization. I have not assumed that their meaning is transparent because they are English 10 language "texts" and I am a native English speaker. I have assumed instead that our "common" language requires penetration; it imposes an order, as any language must, on the expression of experience. Our "common" language structures both my understanding of their experience and their capacity to articulate their experience. At best, after all, language is a vehicle of approximate meanings which must be clarified in context. At best, it captures something of the richness of what lies behind its use and is far more subtle, complex, and vital, that is, existence (ex-sistere which means literally to stand out, to emerge). I have tried to be sensitive to the limits of language, the uncommon nuances of common terms, the altered significance of spoken words as they sediment out in analogues, allusions, and metaphors and in the rhythms and inflections of speech. Although I have worked with these discussions as "texts," they are remnants of a more complex communication. The sounds of speech acts have been lost in written tran- scriptions. The silent languages Of gesture and expression are also gone, along with the vividness of persons speak- ing about their mistakes. These "texts" are artifacts of conversations which are themselves remnants of experience being pressed into words, sentences, and paragraphs, and I am engaged in an effort to retrieve a richer content. 11 My rendering of these "texts" is an act of inter- pretation. I have not assumed that it is either complete or that it is the only possible rendering. It is, how— ever, a full, or thick, rendering.9 I have used these "texts" on mistakes, first, to create a description of clinical medical work and, second, to create a description of clinicians at work. These "texts" contain an irreduc- ible substratum, a raw fact of reportage which is this: medical mistakes are inevitable. I have worked with this raw fact of reportage. I have asked, given these data, what is clinical work like and what is it like to be a person who does this kind of work, a person who is mis- taken. Interpretation is by its very nature an open effort and a personal act. I have been guided in my thinking about mistakes in medical work by the following ideas. First, the meaning of mistakes lies within human consciousness, yours and mine, because meaning is an issue of human consciousness, i.e., human awareness. I have examined the presumptions of my own thinking about mis- takes, especially regarding the problem of blame. Blame does not describe the meaning of mistakes; it transforms 9See especially Clifford Geertz, The Interpre- tation of Cultures (New York: Basic Books, Inc., 1973), pp. 3-30. See also Hans-Georg Gadamer, Truth and Method (New'York: The Seabury Press, 1975). the prc bet tux thi lat be} atl ta} th' the in H. 12 the meaning of mistakes. Blame is actually a social process which, in Chapter II, is described as a dialectic between persons. Second, meaning is culturally situated. I have thus attempted to remain aware of the press of the cul- tural tradition in which I am located which throws my thinking in particular directions. Instead of recapitu- lated surface thinking about mistakes, I have tried to go beyond it. And, in going beyond it, my interpretation attempts to extend our awareness of the meaning of mis- takes by exposing the presuppositions of much of our thinking about them. Language terms are themselves highly suggestive of what lies within immediate awareness and what lies at the periphery of awareness. A mistake, as suggested, denotes a wrong act. It is a compound word, mis-take: in Middle English, mistaken, from Old Norse, mistaka, ‘which means to £352 wrongly, for example, to take the wrong path or to go astray. Its synonym, error, in .Middle English is 25522, to wander about, from Old French errer, from Latin errEre, to go astray. According to Theodore Thass-Thienemann, errare developed out of the primary meaning to go astray into the moral implication to do wrong, to sin.10 10See especially his discussion of Oedipus' error in The Interpretation of Language, Vol. II, Undeggtanding the Uhconggious Meaning of Language (New York: Jason Aronson, Inc., 1968). pp. 94-97. 13 I engaged, especially early in my thinking about this topic, in considerable analogical and associational thinking in an effort to get on the track of other modes of thinking about mistakes. An example will be helpful in clarifying this point. In ordinary language, we call some of our mistakes "honest mistakes." We say, for example, "it was an honest mistake." But what is it we mean here? In particular, what is it we mean by the adjective "honest"? The context in which we use such a phrase is very suggestive. In general, we mean to dis- claim being blameworthy while at the same time acknowledg- ing that we are wrong or rather were wrong. We are saying that we are unwittingly wrong. A mistake is always, how- ever, unwitting or unintended.ll The adjective "honest," therefore, serves to intensify and reemphasize the absence of guile. The phrase, "it was an honest mistake," captures an ambiguity which I want to extend. It is a door, so to speak, into other apprehensions of the meaning of mis- takes. Saying that "it was an honest mistake" not only disclaims blame but implies something else--the possibility of being both mistaken and unblameworthy. It implies, that is, that the phrase may have a real referent, real llIbid., p. 94. 14 here referring to something existentially real, i.e., real in human experience.12 Why use the term "mistake" at all? The term expresses personal involvement in something wrong. I want to examine this involvement very closely, especially the moral tensions of being involved in something which has happened wrong with respect to a person's life. I have adopted an actor's point of view. This is not a matter of empathy but an informed research strategy which attempts to disclose the integrity of an acting subject's experience.13 This is perhaps easier to do when such actors are strangers. Physicians are not strangers in the same sense that Kwakuitl shaman are. We have already at hand knowledge about their work. For this reason, we have much to unlearn as well as to learn for the first time, especially about what clinical medi- cine is like. I have also created a language, a network of terms and concepts, which makes my rendering possible. The reader will see the development of this language throughout; it refers to conduct and consciousness and 12See Rollo May's discussion of real, "The Origins and Significance of the Existential Movement in Psy- chology," in Existence, pp. 13-14. 13See Phenomenological Sociology: Issues and .Application, ed. George Psathas (New York: John Wiley & Sons, 1973), PP. 1-21. 15 contains terms like person, conscience, awareness, acting as if, and sorrow. It is a social psychological language or a language of existence created because the language in general use in sociological theory is too abstract and too impersonal to express or delineate tensions which arise in the here and now of lived-time. The term person is illustrative. It is used instead of the term £913 because I am interested in the sentient and aware being who acts, thinks, perceives, feels, and reflects in time. The term £913 does not depict a con- sciousness: thinking, acting, reflecting. It usually implies norms, attributes, or functions of an occupation.14 The public aspects, the observable aspects, of a person which can be noticed in action and discourse are rather like Erving Goffman's idea of "role." He employs the term in the dynamic sense of being a role player, a figure who plays a part on the stage.15 But I have chosen 14See for example Robert K. Merton's list of norms of the role of physician, "Some Preliminaries to a Socio- logy of Medical Education," in The Student Physician: Introductory Studies in the Sociology of Medical Education, ed. Robert K. Merton et al.‘TCambridge: Harvard University Press, 1957). See also Talcott Parsons' list of attributes of role, e.g., universalistic, functionally specific, achievement oriented, affectively neutral, The Social System (New York: The Free Press, 1951). 15Erving Goffman, The Presentation of Self in JEverydgy Life (Garden City, N. Y.: Doubleday Anchor Books, 1959); see also Erving Goffman, Encounters: Two Studies in the Sociology of Interaction (Indianapolis, Indiana: fflhe Bobbs-Merrill Company, Inc., 1961). 16 to call the public aspect of a physician, a persona, and have avoided using "role" in Goffman's sense, less because it is inaccurate than because it is tarnished with the cynicism of being a "staged" person. It also too quickly becomes infected with over-determinism, as though this figure really has a script rather than is improvising action.16 Although sometimes very hidden, every sociology has a psychology. Mine is an existential and phenomeno- logical psychology rather than a depth psychology. I am interested in problems in human consciousness rather than in problems of the unconscious, i.e., the phenomena of repression. Data I have tried to bring the reader as close as possible to the "texts" being interpreted because such data are rarely seen. And I ask something different of a reader: to follow both the data, what is being said and what it means, and my rendering of it. Two of the transcriptions of discussions about mistakes are remarkably rich. One appears in Chapter III, the other in Chapter IV. A series of "texts" about 16For a very important discussion of what a stage actor really knows, see Maurice Natanson, "Man as an .Actor," in Phenomenology of Will and Action, ed. Erwin vv. Strauss and Richard M. Griffith (Pittsburg, Pa.: Duquesne University Press, 1967) , pp. 201-20. 17 mistakes, presented in Chapter V, confirms these state- ments and expresses additional complexities. I have edited these "texts" in minor ways, deleting many speech distractors, the "hms" and "ahs" of ordinary discourse, in order to make them more readable. When necessary, I have taken precautions to assure the anonymity of the speakers. The form in which these data are displayed should not lead anyone to assume that they are somehow not real data. Their transformation into percentages, their clas- sification into types of errors, for example, errors of ignorance vs. errors of neglect, would serve no real purpose. Indeed, many issues of the interpretation of 17 What matters here is meaning would be obscured. whether the data refer to something real in human exper- ience and whether the mode of representation accurately depicts that reality. I have attempted to bring the reader to the very heart of the phenomena being inter- preted. A more complete representation of the data would have required audio. A still more complete repre- sentation would have required video. The inclusion of these interview transcriptions, or "texts," has another purpose also. They are intended 17Thomas J. Scheff has developed a classification of diagnostic errors. His purposes, however, are very different. See Thomas J. Scheff, "Decision Rules, Types 10f Error, and Their Consequences," Behavioral Science 8 (April 1963): 97-107. 18 as evidence of the inevitability of mistakes, i.e., evi- dence in the sense that these statements refer to some- thing existentially real. The inevitability of mistakes is sometimes denied in favor of an inquiry into the veracity of statements about mistakes. Eliot Freidson does this, for example, by transforming the inevitability of mistakes into an idea about them. The practitioner is prone to believe that mistakes are bound to be made by the very nature of clinical work, so that every practitioner at one time or another is vulnerable to reproach. This belief is used to excuse oneself and also to restraifiione from criticizing others and them from criticizing him. In looking at others' apparenp mistakes the physician is inclined to feel that "there, but for the grace of God, go I" and that "it may be my turn next." When he gets into trouble he expects colleagues to cultivate the same sense of charity and is inclined to feel that those who are not so charitable are dogmatic fanatics to be distrusted and avoided.18 (Emphasis mine.) "Prone to believe" effects a transformation in Eliot Freidson's conception of mistakes. Mistakes are an "idea" in the minds of clinicians, a "belief." This belief, he says, functions as an excuse, that is to say, it forms the basis of a charitable attitude, an attitude of restraint. What should be noticed is that his descrip- tion does not raise the possibility that mistakes are inevitable. Rather, their inevitability becomes an imputation of their inevitability, their existence, an imputation of their existence. 18Eliot Freidson, The Pgofession of Medicine (New York: Dodd, Mead 8 Company, 1970), p. 179. 19 Freidson's description is also suffused with the rhetoric of blame. Speaking from the point of view of a particular physician (that is to say, any? or all phy- sicians?), he comments as follows: In most cases he is prone to feel that he is above reproach, that he did his best and cannot be held responsible for untoward results. "It could have happened to anyone!" or "How could I have known?" are commonly used remarks. In relatively few cases he personally concedes error; these he punishes himself for, but even so he must find them excusable in some way--"a bad break," "just one of those th1ngs." Self-criticism is more likely to be observable than other forms of criticism for it is often verbalized in order to get reassurance from friendly colleagues. By conceding error to friends who will not themselves criticize one gains Egg cathartic benefit of confession while avoiding £29 price of penance.19 (Emphasis mine.) Phrases like "these he punishes himself for," "verbalized in order to get reassurance," "the cathartic benefit of confession," and "avoiding the price of penance" identify the rhetoric of blame.20 19Ibid., p. 179. 20These are Eliot Freidson's most polemical state— ments about mistakes. In his most recent book Doctoring Together, A Study of Professional Social Control (New York: Elsevier, 1975?, his’description is less pejorative. "Nonetheless, it is possible to say with great confidence that most physicians agree that everyone makes mistakes simply by virtue of the fact of working. Insofar as it is a human being rather than a machine performing some func- tion, 'mistakes will happen,‘ as the common saying goes. Being human, the physician could not be perfect. In this sense, some number or proportion of mistakes was excusable and did not constitute deviation from a technical rule. Some physicians would not even call this group mistakes, and few were ashamed of them. They were normal mistakes. In contrast, there were mistakes that were in some sense inexcusable, of which the individual was ashamed. These ‘were deviant mistakes," p. 128. 20 I start in another place. I do not regard the inevitability of mistakes as an idea but as an existential reality. I ask instead, given the inevitability of mis- takes, what is medical work like and what is it like to be a person who does this kind of work? These "texts" then are evidence of the inevita- bility, the reality, of mistakes. They display the phe- nomenon in its full complexity and detail. Although all of the physicians in this study described mistakes, not all of their discussions have been included. The dis- cussions excluded are by no means different, though they are briefer. Data, in any case, on the inevitability of mistakes are quite common; but the problem is not pro- viding data on mistakes--the problem is understanding their meaning. All of these discussions of mistakes provide the grounds for my interpretation. Mistakes are regarded not as excuses but as signs of purposeful conduct going awry. Plan of the Study In the chapters which follow, medical work is de- scribed as a process of discovery and response, of risked action and error. I call it an error-ridden activity. My description of medical work as an error—ridden actithy is not at all like contemporary sociological descriptions. Clinical work is not usually described as an error-ridden activity. In fact, it is rarely described 21 at all. Instead, it is characterized abstractly as a profession, an applied science, a field of expertise, or a technical activity. Chapter II reviews the literature on the sociology of work and focuses especially on the meaning of work as a human activity, as something which is done by sentient individuals. I examine the divergence of my conception of work, as activity, from the sociological conception of work, as occupation. The chapter then begins a description of medical work emphasizing the diagnostic and therapeutic process. Finally, the literature on mistakes is reviewed. Chapter III creates a language of description with terms like thinking and acting, acting as if, and the dramaturgy of acting as if. This descriptive lan— guage is intended to create a picture-in-motion of work and of persons at work. I am interested in depicting movements and transition in conduct in time. My topic, mistakes, is itself dynamic, intimately bound up with time as it unfolds. The picture presented, then, is not like a portrait or a still life. Rather, it is like edited film footage, a visual and animated representation of medical work. Chapter IV creates yet a second descriptive lan- guage called a language of intention. Terms like intention, attention, care, and regret are used to 22 describe mistakes not in action as it happens, but in action as it is reexamined in retrospect. The identifi- cation of an error is shaped by an inquiry which attempts to get to the point of understanding what has gone wrong and correct it. Yet some errors are not correctable. My description of the reconstruction of action in retro- spect focuses on regret. Chapter V develops an interpretation of mistakes as complex sorrows, an interpretation taken from the inside of action. It is a phenomenology at the psycho- logical level. It is I who create the phenomenology of the mistakes of physicians. This is, of course, what interpretation implies. It is they who give me the grounds for my interpretation. Chapter V also considers the problem of negligence, and I argue that it is neither the most common "mistake" (here I reach the borders of semantic sense) nor the most revealing of the character of clinical work. Irreparable and unavoidable mistakes are more revealing of the character of medical work. Chapter VI returns to an early theme-~making mistakes as a problem of being. Making mistakes includes but is not defined by being at fault and includes but is not defined by the experience of being blamed. This chapter also examines the limitations of the interpre- tation and of the data. Finally, I consider the ways in 'which being mistaken shape the organization of clinical work. 23 A recurrent theme of my description of medical work is that it is a process of discovery: medical work is discovered in action. Discovered, as a term, is not like seeing or observing. Patients do not wear their illnesses as they wear apparel. One apprehends, one infers, one tests, one experiments, one tracks, one follows the course of events in order to disclose the nature of illness and affect it. This study is always implicitly about language and how it shapes our awareness. In attempting to create several descriptive languages, I have departed considerably from sociological practice. I have tried to invoke nuance, imagery, complexity, movement, feeling, and paradox. Without losing analytic precision, I have also attempted to shift a pervasive and false vision of clinical medi- cine, a vision which is in large part connected with a language of variables, categories, and tables. Socio- logists have develOped a particularly barren language. In doing so, we have not so much achieved insight into the human world as emptied it of its meaning, richness, and depth. CHAPTER II LANGUAGE DEPARTURES Introduction In this chapter and the next, medical work is described as an error-ridden activity, a core referent from which an interpretation of mistakes radiates. For some time, I had been using a cumbersome phrase, practice of knowledge, to describe medical work, a phrase which is far less telling and clear. Calling medical work an error-ridden activity is intended to suggest that the work is an inaccurate activity practiced with consider- able unpredictability and risk. Especially, it is intended to suggest that the essential activity of medical work, the diagnostic and therapeutic process, is error-ridden. (Medical work is a general term which encompasses a range of related activities and social relations. Clinical medicine is a still more general term.) Later in the chapter, the diagnostic and thera- jpeutic process is described in a preliminary way. Here it is important to focus on the anamolous nature of my 24 25 description of medical work as an error—ridden activity. My use of the term activity is specialized. Activity expresses movement and transition; the diagnostic and therapeutic process intersects the movement of human ill- ness. It unfolds in response to it. Activity is a term, then, which expresses this depth structure: motion, movement, transition, and transformation. Language either captures this depth structure or it fails to do so. Error-ridden is utilized in neither a statistical nor a pejorative sense; rather, it is used descriptively. It is intended to suggest that mistakes are an indigenous feature of the diagnostic and therapeutic process as it unfolds. A clinician's description of medical work does not emphasize the error-ridden nature of the diagnostic and therapeutic process; instead, it stresses the pro- gressive refinement and modification of the process. Philip Tumulty, for example, in referring to clinical diagnosis, says the following: It should be remembered that a clinical diagnosis is not a one shot affair, and as the physician's observations and study of a patient's illness advances, this list of pertinent facts will have to be revised repeatedly. Data considered of little or no import today may become oflprime significance as new developments occur. (Emphasis mine.) 1Philip A. Tumulty, M.D., The Effective Clinician: .His Methods and Approach to Diagnosis and Care (Phila- delphia: W. B. Saunders Company, 1973), p. 191. 26 As Tumulty suggests, a clinician's description emphasizes the development of his observations, i.e., the repeated revisions of his observations through time and the development of the phenomenon of illness. Calling medical work an error-ridden activity, then, attempts to depict it as it develops in time and suggests that its practice is continuously problematic. My use of the term ggpk is also specialized. ngk, in this study, does not refer to occupation, a way of being occupied in a social structure, nor to a par- ticular kind of occupation, a profession, for example. Work, here, is a term of embodiment: it refers to doing .something with one's mind-body. Work is also a purpose- ful activity which unfolds: it is a practice.2 Clinical work is a practice of responding to the experience of 2See an especially clear discussion of work as a practice by Peter Berger, "Some General Observations on the Problem of Work, " in The Human Shape of Work: Studies in the Sociology of Occupations, ed. Peter Berger (New York: The Macmillan Company, 1964), pp. 211- 41. "To be human and to work appear as inextricably intertwined notions. To work means to modify the world as it is found. Only through such modification can the world be ‘made into an arena for human conduct, human meaning, human society or, for that matter, human existence in any sense of the word," pp. 211-12. See also Karl Marx and iFrederick Engels, The German Ideology Parts I and III, ed. with an Introduction by R. Pascal (New York: Inter- national Publishers, 1947). "The chief defect of all rmaterialism up to now (including Feuerbach's) is that the (object, reality, what we apprehend through our senses, is 'understood only in the form of the object or contempla- ‘tion; but not as sensuous human activity, as practice; not subjectively,” p. 197, "Thesis on Feuerbach." 27 illness. As a practice, its context is a relation encounter between persons about the afflictions of the human body and the human spirit. It is grounded here in a relational encounter from which it typically departs and to which it typically returns. My description of medical work is at odds with many contemporary descriptions because such descriptions refer to medicine as an occupation or a profession rather than to medicine as a purposeful activity. It is also at odds with many contemporary descriptions because they refer to medicine as a field of expertise, an applied science, or a technical skill. A review of the literature on occupations and work, with special attention to its abstractness, follows. Then, the essential activity of medical work, the diagnos- tic and therapeutic process, is described in a preliminary way. Finally, the far briefer literature on mistakes is examined. The Literatpge on Occupations and’ProfeSSions The literature on clinical medicine is character- istically abstract. Medicine is not described as an activity, as something being done, but is summarized as a ;profession, an applied science, a technical skill, or a field of specialized knowledge, categories which are ‘unlikely to provoke an imagery of trial and error, of 28 action and risk, or uncertainty. For example: "Medicine is of all the established professions based on fairly precise and detailed scientific knowledge, and it entails considerably less uncertainty than other technical occu- pations."3 The frame of reference here is comparative. Medicine is being compared to other occupations: "fairly precise and detailed scientific knowledge," "considerably less uncertainty than," "of all the professions." The difficulty is just this comparative focus. Fairly precise and detailed scientific knowledge in relation to what? Considerably less uncertainty than which occupations? Which professions? These terms are suitable in a classification of occupations in a social structure, but not in a description of the conduct of medical work. Instead, they substitute for a description of the conduct of medical work. Two papers have established the focus of the study of work for several decades: Talcott Parsons, "The Professions and Social Structure,"4 (1939) and T. H. Marshall's "The Recent History of Professionalism 3Freidson, The Profession, p. 162. 4Talcott Parsons, "The Professions and Social Structure," in Essays in Sociological Theory (rev. ed.; New York: The Free Press, 1954). 29 in Relation to Social Structure and Social Policy,"5 (1939). Although this entire inquiry can be traced to Emile Durkheim's The Division of Labor in Society,6 both these papers are concerned with mapping the social structures of industrialized societies, with the role of professions in industrial societies, and with the changing characteristics of professions. Their frame of reference is necessarily abstract. They are not about what persons are doing but how they are occupied and, even more abstractly, how the ways in which they are occupied are changing under the impact of industriali— zation. The extant literature on the professions, including medicine, follows out the logic of this inquiry into the development of industrial societies. Topics range from the professionalization of occupations in industrial society,7 to the organizations of 5T. H. Marshall, "The Recent History of Profes- sionalism in Relation to Social Structure and Social Policy," in Sociology at the Crossroads (London: Heine- mann, 1969) . a 6See especially the 1902 preface to the second edition, "Some Notes on Occupational Groups," The Divisigp of Labor in Society, trans. George Simpson (New York: The Free Press, 1964), pp. 1-31. See also R. H. Tawney, $22 Acguisitive Society (New York: Harcourt, Brace & World, Inc., 1920). 7Nelson Foote, "The Professionalization of Labor iJIZDetroit," American Sociolpgical Review 58 (January 1953): 371-80; Harold'L. Wilensky, "The Professionalization of Everyone?" The American: Sociological Reyiew 70 (September 1964): 137-58; Everett C. Hughes, "The Professions in Society," in The Sociological Eye: Selected Papers, 30 professions,8 the use and abuse of professional authority,9 and the professionalization of society.10 vol. II (Chicago: Aldine-Atherton, 1971), pp. 364-73; Wilbert E. Moore, The Professions: Roles and Rules (New York: Russell Sage Foundation, 1970); Howard M. Vollmer and Donald L. Mills, eds., Professionalization (Englewood Cliffs, N.J.: Prentice-Hall, Inc., 19667. 8See especially Eliot Freidson, "Professions and the Occupations Principle," in Professions and Their Prospects, ed. Eliot Freidson (Beverly Hills: Sage Publi- cations, 1973), pp. 19-38 for a review of the issue of authority and autonomy. See also Gloria V. Engel and Richard H. Hall, "The Growing Industrialization of the Pro- fessions," in Professions, pp. 75-88; Eliot Freidson, Egg- fessional Dominance: The Social Structure of Medical Care (New York: Atherton, 1970); Freidson, The Profession; Freidson, Doctoripg; William Kornhauser, Soientist in Industr (Berkley: University of California Press, 1962); Rue Buc er and Joan Stelling, "Characteristics of Profes- sional Organizations," Journal of Healthggpd Social Behavior 10 (March 1969): 3-15; Everett C. Hughes "Psychology: Science and/or Profession," in Men and Their Work (Glencoe, 111.: The Free Press, 1959), PP. 139-44. 9Especially, Talcott Parsons, The Social System (New York: The Free Press, 1951), chapter 10; Amitai Etzioni, ed., The Semi Professions Egg TheirQrganization (New York: The Free Press, 1969); Freidson, Professional; Freidson, $29 Profession; Freidson, "Professions and the Occupations Principle," in Professions; Eliot Freidson and Buford Rhea, "Knowledge and Judgment in Professional Evalu- ations,” Administration Science Quarterly 10 (June 1965): 107-24; Eliot Freidson and Buford Rhea, 'Processes of Con- trol in a Company of Equals," Social Problems 11 (Fall 1963): 119-31. Eliot Freidson's ouvre is an extremely important critique of the abuse of professional authority. Terrence Johnson, Professiops and Power (London: The Mac- millan Press, 1972); A. M. Carr-Saunders and P. A. Wilson, The Professions (Cambridge: Oxford University Press, 1933). For a historical account of the political activity of the Anemican Medical Association, see Richard Harris, A Sacred Trust (Baltimore, Maryland: Penguin Books, Inc., 1969). 10Paul Halmos, The Personal Service Society (New York: Schocken Books, 1970); Paul Halmos, "Sociology and the Personal Service Professions," in Professions, pp. 291- 306. 31 A lengthy and unresolved discussion of the essential characteristics of professions has permeated the entire tradition of thinking since some stable semantic referent is required in order to classify occu- 11 None has emerged. Although pations as professions. several characteristics are regularly cited, expertise, codes of ethics, control of the terms of work, for example, these characteristics are subject to disagreement because they are arbitrary, intended for particular research purposes, and because they are implicitly evaluative, they confer status. Profession is not a neutral nor scientific concept. It is an honorific title in use in discourse about some kinds of work.12 A web of suffixes entangles this long tradition of inquiry about industrial societies and subtly alters the content of the discussion. Of these suffixes, profes- sionalization, professionism, and professionalism are the 11William J. Goode, "Encroachment, Charlatanism, and the Professions," American Sociological Review 25 (February 1960): 902-14; Eliot Freidson, The Profession, chapter 4; Everett C. Hughes, "Profession-57"i in The Pro- fessions_in America, ed. Kenneth S. Lynn (Boston: Houghton .fiifflin Company, 1965), pp. 1-14; Terrence J. Johnson, Egg- fessions, chapter 2; Morris L. Cogan, "Toward a Definition of a Profession," Harvard Education Review 23 (Winter 1953): 33-50; Howard M. Vollmer and Donald L. Mills, eds., "Editors Introduction," in Professionalization, pp. v-ix. 12See especially Howard S. Becker's discussion of profession as a folk concept, "The Nature of a Profession," Sociological Work: Method and Substance (Chicago: Aldine Publishing Company, 1970), pp. 87-103. 32 most common. Professionalization refers to the process by which an occupation acquires professional status as well as to the process of becoming a professional. Profes- sionism refers to the ethical orientation, or what is sometimes called "the service ideal" of a profession, and also to the ideology of a profession, its professional claims. And professionalism defines the professionism of a person.13 A problem of definition always lingers, how— ever, as the core meaning of profession remains unclear. The categorization of occupations for comparative purposes is not at all like the description of the conduct of work, that is, what people are doing. Nor is the description of work, what people are doing, in comparative terms like a description of work in its own terms. The essential activities of work also require description. Eliot Freidson, whose long and important contribution to the study of medicine is frequently cited, argues by contrast: In order to illuminate all professions by the close examination of one, however, it is necessary to remain at a level of abstraction that prevents con- fusing the unique with the general. This means that one's guiding concepts may not stem from the peculiarities of the concrete profession one is studying. It means that one must in some sense stand apart from and outside of the specific pro- fession one is studying. . . . Thus, in order to study medicine in such a way as to clarify and extend our understanding of professions in general, 13Even these definitions are unstable. Compare Ii.‘Vollmer and D. Mills, Professionalization, pp. vii-viii. 33 one must not adopt medicine's own concept of its mission, its skill and its science. Since pro- fessions are collective human enterprises as well as vehicles for special knowledge, belief, and skill, sociology can focus on their common organization as groups quite apart from their different concepts, providing the general concepts by which they may be made individually comparable.14 (Emphasis mine.) The particularity of medicine, however, is its complex relation to the life process and especially to personal suffering. Its unique contribution to the con- struction of the human world lies here. Yet Freidson fails to describe it for methodological reasons. He argues instead that medicine should be described in general terms, terms which make it comparable to other occupations. In his most recent book, Doctoring Together, he fails even to mention illness as the basis of the relationship between physicians and patients, confining himself instead to the description of a physician as an expert, or a merchant, or a bureaucrat.15 A small and unassimilated ethnographic literature exists on the activities of occupations rather than the status of occupations in a social structure.16 Although 14Freidson, The Profession, p. xix. 15Freidson, Doctoring, pp. 44-48, 87-98. 16See, for example, ethnographic descriptions of work relations, Fred David, "The Cab Driver and His Fare: Facets of a Fleeting Relationship," TheIAmerican Journal of Sociology 65 (September 1959): 158-65; James M. Henslin, 'mTfust and the Cab Driver," in Sociology of Everyday Life, ed. Marcello Truzzi (Englewood Cliffs, N.J.: 'Prentice- Hall, Inc., 1968), pp. 138-58. 34 it is descriptively rich, this literature is intrinsically anamolous because the terms of ethnographic description are not articulated as "categories" in the comparative study of work as an occupation. Ethnographic descriptions do not aim at abstract comparisons of work as an occu- pation, but at concrete descriptions of different kinds of work in their own terms. Studs Terkel's moving account of the kaleidoscope of human activities, Working, illus- trates both the complexity and diversity of work as a human activity and the difficulty of constructing a scheme classifying it.17 His own scheme is very modest, no more than a Table of Contents: Book One, "Working on the Land," farmer, miner, heavy equipment operator; Book Two, "Com- munications," receptionist, switchboard operator, pro- fessor of communications, etc.18 In the instance of medicine, a number of studies, some of which are ethnographic, illustrate not the expert knowledge of physicians but their uncertainty and ignorance,19 not their technical competence but their l7Studs Terkel, Working: Pepple Talk About What They Do All Day and How They Feel About What They Do (New York: Pantheon Books, 1972). 18Ibid., pp. xxv-xxx. 19For example, Renée Fox, "Training for Uncer- tainty,” in The Student Physician, ed. Robert K. Merton, et a1. (Cambridge: Harvard University Press, 1957), pp. 207-41; Renée Fox, Experiment Perilous (Glencoe, Ill.: The Free Press, 1959); Renée Fox and Judith Swasez, 35 20 not their professionalism but their moral equivocation, mercantilism, not their ethical conduct but their in- humanity.21 These studies lie around as the odds and ends of an otherwise "orderly" subject matter. Renée Fox's studies of physicians at work are particularly noteworthy because they describe clinical uncertainty as well as clinical expertise. In an early paper on the training of physicians, she identified two basic medical uncertainties: first, the uncertainty which results from incomplete mastery of available knowledge; and second, the uncertainty which results from the limi— tations of current medical knowledge.22 The Courage to Fail: A Social View of Organ Transplants gpd Dialysis (Chicago: The University of Chicago Press, 1974); Julius Roth, Timetables (New York: The Bobbs- Merrill Company, Inc.). 20For example, Fred David, "Uncertainty in Medical Prognosis, Clinical and Functional," American Journal of Sociology 66 (July 1960): 41-47; David Sudnow, Passing On: The Social Organization of Dying (New Jersey: Prentice- Hall, 1967); Julius Roth, 7fSome Contingencies of the Moral Evaluation and Control of Clientele: The Case of the Hopeful Emergency Service," American Journal of Sociology 77 (March 1972): 839-56; Donald Light, “Psychiatry and Suicide: The Management of a Mistake," American Journal of Sociology 77 (March 1972): 821-38; Freidson, Doctoripg, especially chapters 7, ll, 12, 13, 14. 1Marcia Millman, The Unkindest Cut: Life in the Backrooms of Medicine (New York: William Morrow & Company, Inc., 1977); H. R. Lewis and M. E. Lewis, The Medical Offenders (New York: Simon and Schuster, 1970). 22Fox, "Training For," p. 208. 36 She has continued to explore problems of uncer- tainty in her studies of practicing research physicians. In her ethnography of Ward F-Second, an experimental metabolic unit, uncertainties in both diagnostic and therapeutic work were endemic.23 These uncertainties were one of a number of sources of stress to both research physicians and their patients. For example, the phy- sicians of this research-therapy unit were constantly faced with the limitations of current medical knowledge in the treatment of complex disorders, and their patients were often treated at a highly empirical level. Her most recent book, The Courage to Fail, describes the evolution of the experimental frontiers of hemodialysis, kidney transplantation, cardiac replacement, and the use of a mechanical heart along with the sharp tensions of developing extremely hazardous and new pro- cedures in the treatment of patients with catastrophic illnesses.24 While her studies have consistently depicted clinical uncertainties and many other problematic features of the practice of medicine, her work has had little impact on the abstract portrayal of medical work as a profession, a field of expertise, an applied science, or a technical activity. 23Fox, Experiment. 24Fox, The Courage. 37 Donald Light has commented very succinctly on much of the sociological literature on the professions including medicine: If expertise and error lie at the heart of the pro- fessions, most sociologists write from the periphery. Sociological literature concentrates on gross structure, such as professional organization, licensing, relations to complex organizations and government, and external organization of work as exemplified in the structure of a hospital. Although these features are important for handling disputes over competence and mistakes, that perspec- tive is not given them. . . . Instead of being seen as problematic, technical competence is assumed. Reviewing over 850 books and articles on professions, Wilbert Moore (1970) found no reason to devote much space to this perspective. "Expertise and error" as a core idea of "profession" is much more telling than expertise, ethical conduct, or control of the terms of work. It is also, of course, much more accurate. At the same time, the phrase is difficult to utilize because it is so ambiguous. It requires a great deal of precise analysis--expert in relation to what? erroneous in relation to what?--just the kind of close work which is unnecessary in a compar- ative study. In summary, the sociological literature is bound by an image of work as occupation, i.e., a way of being occupied in a social structure. Furthermore, the comparative focus of the literature makes it difficult to establish a description of work on other terms. In 25Light, pp. 821-22. the in the a: ignora social dces n that p as a t abstra Abstra Deiica ridien ticula: ti“ o: 3:51 tr; the Ce: theraPe sentat: of t' he :l‘Ple 38 the instance of medicine, the very categories in use make the articulation of medical uncertainty, medical ignorance, and medical mismanagement improbable. Occupation, as a way of being occupied in a social structure, is also often a static concept. It does not readily connect with a dynamic description of what people are doing in working or with the use of work as a term of embodiment and effort. Both the kind of abstraction and the content of the dominant sociological abstraction of work are at odds with the description of medical work as an error-ridden activity. A Preliminary Sketch of the Diagnostic and Therapeutic Process A characterization of medical work as an error- ridden activity is also abstract. Like profession, Egchnical activity, or applied knowledge, error-ridden a_¢tivity depicts the terrain of clinical work in a par- ticular manner. It has the advantage of being an abstrac- tion of activity, of movement and transition, development and transformation. In addition, it is an abstraction of the central activity of medical work, the diagnostic and therapeutic process. The phrase is intended as a repre- sentation, a short hand. What matters here is the nature of the illumination achieved; just how much, with this Simple expression, is explained. 39 Chapter III animates my description of medical ivork; I emphasize clinical action as it presses into the linknown. Here the diagnostic and therapeutic process is J:rofessions, work, and mistakes suggests that my ciifis-hscription of clinical medicine as an error-ridden El<:=!tivity is a radical departure from both common socio- logical understanding and the wider cultural context. I: ]have begun a description of medical work, emphasizing especially the diagnostic and therapeutic process. c1'lepter III continues this description and enlarges 62 upon it by emphasizing the meaning of clinical action. Then, Chapter IV creates a picture of clinical work from the point of view of reconstruction of the act. CHAPTER III THE CHARACTER OF CLINICAL ACTION Introduction The phrases "mistakes are inevitable" and "every- lbody makes mistakes" are condensations of experience, laighly edited reports of the evolution of human activity. firhese phrases carry a code because they are universal Jrepresentations of experience. Although they suggest riearly the same meaning, they differ in their style of E>ortraying meaning. "Mistakes are inevitable" is more remote and Ipmanderous than "everybody makes mistakes." It leaves 11¢: trace of the evolution of activity or of an acting Eitabject. Mistakes are, i.e., they exist at all times Eilrmd in all places. It is as though they have their own ifzilxed realm independent of the persons who make them, 5‘ reified manner of speaking which is all too common. By contrast, "everybody makes mistakes" is more active 6‘1311d clear. It catches hold of a human subject, "every- lz><=>ected nor new to the physicians being interviewed, S ince they had been asked at least. once before when ‘tllhese physicians were fourth-year medical students. S<>me variation occurred in the ways in which these two Questions were asked as they were fitted to the occasion and content of the preceding discussion. Joan Stelling and Rue Bucher in their study "‘E?ocabularies of Realism in Professional Socialization"~ 65 report a great deal of awkwardness among the physicians they interviewed in answering their inquiries about mistakes.l And they assume that such awkwardness indi- cates that the physicians they were interviewing lacked the concept of mistake in their frame of reference, that is to say, that the very idea of mistake is a lay rather than a professional idea. Their position is paradoxical, however, for even while some of the residents they inter- ‘viewed used the term "mistake" with facility, they assume that the word was not in their frame of reference. Part of the difficulty with the Stelling/Bucher analysis is that the term "mistake" is charged with aassociations which may create awkwardness: blame, mal- ;practice, guilt, harm, anxiety, regret. Another part <>f the difficulty is that the term's meaning must be :rxegotiated and distinguished from the concept of failure. ZIFt must be understood both as a word being employed to .J?JE5 medical mistakes in William A. Nolen, M.D., The Making SELEE: a Surgeon (New York: Random House, 1968), especially 531;). 71-81. Also see his description of errors in his Own care as a patient in William A. Nolen, M.D., Surgeon EZEEgider the Knife (New York: Coward, McCann & Geoghegan, Inc., 1976), especially pp. 70-73, 112-25. Also see JC- shua S. Horn, M.D., Away with All Pests: An English égliggrgeon in People's China: 1954-1969, Introduction by Modern Reader, 1971), pp. 54-58.