The Unity of Mistakes, Marianne A. Paget, Philadelphia, Pa: Temple University Press. 2004. 183 pages; softcover, $19.95.
The author, a sociologist whose promising life was cut short by cancer, subtitled this book "A Phenomenological Interpretation of Medical Work." As Joan Cassell points out in her excellent foreword, Paget was exploring the trial-and-error process involved in practicing medicine. In this work, she was not analyzing "Medicine" as a profession, a discipline, or an industry with its attendant claims of authority, rather, she was studying "the immediacy of physicians' experiences" as they treated patients successfully and unsuccessfully. In this work, Paget was focusing on errors made by (or experienced by) physicians and their patients.
Between 1967 and 1976, Paget was involved in a study of the training of physicians at Michigan State University, in the course of which she interviewed physicians, including practicing and hospital attending physicians as well as residents. The present work is an analysis of the interview data she collected during that study. In the text, much of the interview material is presented verbatim, with all of the pauses, interjections, and backtracking that occur in informal conversation. Her personal experiences as a cancer patient are reflected in her later book, A Complex Sorrow: Reflections on Cancer and an Abbreviated Life (Philadelphia: Temple University Press; 1993).
In the first chapter, "The Language of Mistakes," the author gives us a valuable briefing on the art of interviewing for research purposes. She describes the book as an interpretation of interview data about mistakes in medical work. She found, among other things, that physicians (like everyone else) have a recognizable set of language conventions for dealing with errors. Common comments were that "Mistakes are inevitable" and that mistakes are an intrinsic feature of medical work. She included 2 questions in each interview, "What do you think about and do when you make a mistake?" and "What do you do and think about when you observe another physician making a mistake?" (page 9). She analyzed the background of the responses to these questions.
Chapter Two, "Language Departures," deals with the sociology of work. In it, Paget explores the divergence of her personal conception of work as activity from the sociological conception of work as occupation. Her description of the medical record, and the effects of its 2 principal types, the source-oriented record and the problem-oriented record, are masterly. She explores the meaning of "clinical intervention." This reviewer disagrees with Dr Paget's comment that the word, intervention, implies actively having an effect. Intervening and intervention can occur without producing any observable or measurable effect except for changing the circumstances surrounding the act of intervention.
The rather confusing third chapter, "Acting-as-If," could as well have been entitled "The Relativity, Unpredictability and Inevitability of Mistakes." The author further explores the unfolding of clinical work in dialectic fashion, calling the process "acting-as-if." The concept suggests the "rule out" process, although Paget does not use this term. In the chapter on the semantic sense of mistakes, Paget explores such topics as excusable mistakes, reparable mistakes, and unconscious mistakes, including slips of the tongue or pen.
In her summary of the next chapter, the author says that she has "pressed on into the experience of making mistakes because it lies at the heart of the [research] project and because I believe it is a source of many of the social forms that organize the work: the conferences, the autopsies, the audios, the professional reviews, the curb-side consultations, the ubiquitous and relentless talk about medical problems, and also the duplicity in the work" (page 95). Here indeed is a light-bulb insight that brings us back to earth from the rarified realm of phenomenology.
Paget expands on this theme, emphasizing the view that the study of medical mistakes, as she conducts it, is not judgmental and punitive, but is a search for improvement in medical practice. She asserts that patients should not "defer judgment on their care or the care of members of their families. Their aim is and ought to be preserving the possibilities of the best care they can acquire" (page 139). Her comments on the inner logic of mistakes are memorable. She holds that it suggests, not blame, but sets of alternative practices-better or worse, effective or ineffective.
This challenging little (183 pages) book is not everybody's cup of tea. Its existential approach to what most people view as potential real-world emergencies affecting their chances of life or death may make the author's arguments hard to follow, depending on where the reader is anchored. Nonetheless, while it is not a comfortable summer-beach read, its impact on familiar, comfortable patterns of thinking about medical mistakes makes it worth the effort.
Jean Gayton Caroll, PhD
Editor