Charles L. Bosk

Reality check for checklists

This paper was published as The Lancet, 2009, 374 (9688), pp. 444-445. It is available from http://www.sciencedirect.com/science/journal/01406736. DOI: 10.1016/S0140-6736(09)61440-9

Between two worlds: Medical student perceptions of humor and slang in the hospital setting

AbstractOBJECTIVE: Residents frequently use humor and slang at the expense of patients on the clinical wards. We studied how medical students react to and interpret the “appropriateness” of derogatory and cynical humor and slang in a clinical setting. DESIGN: Semistructured, in-depth interviews. SETTING: Informal meeting spaces. PARTICIPANTS: Thirty-three medical students. MEASUREMENTS: Qualitative content analysis of interview transcriptions. MAIN RESULTS: Students’ descriptions of the humorous stories and their responses reveal that students are able to take the perspective of both outsiders and insiders in the medical culture. Students’ responses to these stories show that they can identify the outsider’s perspective both by seeing themselves in the outsider’s role and by identifying with patients. Students can also see the insider’s perspective, in that they identify with residents’ frustrations and disappointments and therefore try to explain why residents use this kind of humor. Their participation in the humor and slang—often with reservations—further reveals their ability to identify with the perspective of an insider. CONCLUSIONS: Medical students describe a number of conflicting reactions to hospital humor that may enhance and exacerbate tensions that are already an inevitable part of training for many students. This phenomenon requires greater attention by medical educators.

Bureaucracies of Mass Deception: Institutional Review Boards and the Ethics of Ethnographic Research

Ethnographers have long been unhappy with the review of their research proposals by institutional review boards (IRBs). In this article, we offer a sociological view of the problems associated with prospective IRB review of ethnographic research. Compared with researchers in other fields, social scientists have been less willing to accommodate themselves to IRB oversight; we identify the reasons for this reluctance, and in an effort to promote such accommodation, we suggest several steps to reduce the frustration associated with IRB review of ethnographic research. We conclude by encouraging ethnographers to be alert to the ways the procedural and bureaucratic demands of IRBs can displace their efforts to solve the serious ethical dilemmas posed by ethnography.

A Comparison of 2 Surgical Site Infection Monitoring Systems

IMPORTANCE Surgical site infection (SSI) has emerged as the leading publicly reported surgical outcome and is tied to payment determinations. Many hospitals monitor SSIs using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), in addition to mandatory participation (for most states) in the Centers for Disease Control and Preventions National Healthcare Safety Network (NHSN), which has resulted in duplication of effort and incongruent data. OBJECTIVE To identify discrepancies in the implementation of the NHSN and the ACS NSQIP at hospitals that may be affecting the respective SSI rates. DESIGN, SETTING, AND PARTICIPANTS A pilot sample of hospitals that participate in both the NHSN and the ACS NSQIP. INTERVENTIONS For each hospital, observed rates and risk-adjusted observed to expected ratios for year 2012 colon SSIs were collected from both programs. The implementation methods of both programs were identified, including telephone interviews with infection preventionists who collect data for the NHSN at each hospital. MAIN OUTCOMES AND MEASURES Collection methods and colon SSI rates for the NHSN at each hospital were compared with those of the ACS NSQIP. RESULTS Of 16 hospitals, 11 were teaching hospitals with at least 500 beds. The mean observed colon SSI rates were dissimilar between the 2 programs, 5.7% (range, 2.0%-14.5%) for the NHSN vs 13.5% (range, 4.6%-26.7%) for the ACS NSQIP. The mean difference between the NHSN and the ACS NSQIP was 8.3% (range, 1.6%-18.8%), with the ACS NSQIP rate always higher. The correlation between the observed to expected ratios for the 2 programs was nonsignificant (Pearson product moment correlation, ρ = 0.4465; P = .08). The NHSN collection methods were dissimilar among interviewed hospitals. An SSI managed as an outpatient case would usually be missed under the current NHSN practices. CONCLUSIONS AND RELEVANCE Colon SSI rates from the NHSN and the ACS NSQIP cannot be used interchangeably to evaluate hospital performance and determine reimbursement. Hospitals should not use the ACS NSQIP colon SSI rates for the NHSN reports because that would likely result in the hospital being an outlier for performance. It is imperative to reconcile SSI monitoring, develop consistent definitions, and establish one reliable method. The current state hinders hospital improvement efforts by adding unnecessary confusion to the already complex arena of perioperative improvement.

Learning through observation: the role of ethnography in improving critical care.

Purpose of reviewTo determine the conditions under which ethnographic research is a useful tool for reflexive self-learning and enhanced performance in critical care units. Recent findingsThe focus of studies using qualitative methods to investigate the organization of work in critical care units largely remains the investigation of the stresses and strains for staff, patients, and families managing communication at the end of life. A more recent focus of research has been on safety and quality improvement. Iterative feedback between researchers and clinicians is likely a useful tool for self-reflexive learning and change. SummaryQualitative researchers have long been involved in the study of critical care. There is a new emphasis on using ethnographic methods as a tool for behavioural change through the process of iterative feedback.

Studying ethics as policy: The naming and framing of moral problems in genetic research

This article reports on a study of an ethics policy developed by a startup genomics company at the time it gained all commercial rights to a populationbased biobank in northern Sweden. Work in the anthropology of policy has been used as inspiration to study throughto identify how the policy took shape, to follow it through to the networks in which it took on social life, and finally to probe its social implications, in particular among the people for whom and on whom it was supposed to work. It is argued that as ethics takes the form of policy work, it tends to be so preoccupied with presenting solutions that it overlooks critical understanding and assessment of problems. It is suggested that anthropology might play a complementary role to the policy work of ethics by reintroducing otherwise marginalized moral voices and positions.This article reports on a study of an ethics policy developed by a startup genomics company at the time it gained all commercial rights to a populationbased biobank in northern Sweden. Work in the anthropology of policy has been used as inspiration to study throughto identify how the policy took shape, to follow it through to the networks in which it took on social life, and finally to probe its social implications, in particular among the people for whom and on whom it was supposed to work. It is argued that as ethics takes the form of policy work, it tends to be so preoccupied with presenting solutions that it overlooks critical understanding and assessment of problems. It is suggested that anthropology might play a complementary role to the policy work of ethics by reintroducing otherwise marginalized moral voices and positions.

Training for Efficiency: Work, Time, and Systems-Based Practice in Medical Residency

Medical residency is a period of intense socialization with a heavy workload. Previous sociological studies have identified efficiency as a practical skill necessary for success. However, many contextual features of the training environment have undergone dramatic change since these studies were conducted. What are the consequences of these changes for the socialization of residents to time management and the development of a professional identity? Based on observations of and interviews with internal medicine residents at three training programs, we find that efficiency is both a social norm and strategy that residents employ to manage a workload for which the demand for work exceeds the supply of time available to accomplish it. We found that residents struggle to be efficient in the face of seemingly intractable “systems” problems. Residents work around these problems, and in doing so develop a tolerance for organizational vulnerabilities.

Learning from mistakes in clinical practice guidelines: the case of perioperative β-blockade

For more than two decades, the role of β-blockers in preventing cardiac complications after surgery has been among the most hotly contested and controversial topics in medical practice. Based on two small randomised trials published in the late 1990s,1 ,2 leading physicians and experts in patient safety embraced preoperative β-blocker initiation as a therapeutic victory for high-risk surgical patients: an apparently simple and effective treatment that promised, for the first time, to prevent life-threatening postoperative cardiac events. Yet nearly as soon as preoperative β-blocker initiation had come to be seen as a ‘best practice’, its status was cast into doubt. New randomised trials published between 2005 and 2008 failed to confirm promising early findings and highlighted the potential for harm with β-blocker overuse.3–6 Recommendations that had previously urged widespread preoperative β-blocker initiation among high-risk patients7 ,8 were softened or reversed.9 ,10 Debates over whether or not β-blockers were safe for surgical patients displaced discussions on how to promote their use on a large scale. On one level, what may be most remarkable about the rise and fall of preoperative β-blocker guidelines is how unremarkable it seems. Preoperative β-blockade is only one of several recent examples in which expert endorsements of promising therapies changed markedly when new evidence highlighted potential harms that had been overlooked by these endorsements. Yet the β-blocker story differs in important ways from canonical examples of reversals in recommendations for medical practice. Prominent retellings of how expert recommendations changed regarding hormone replacement therapy (HRT) for women after menopause, for example, have emphasised the pitfalls of relying on non-randomised studies rather than randomised controlled trials in defining benefits and harms of therapies.11 ,12 In contrast, preoperative β-blocker initiation was elevated rapidly to the status of a best practice specifically …

Bioethics, Raw and Cooked: Extraordinary Conflict and Everyday Practice

This article explains the emergence, growth, and institutional anchoring of bioethics in both policy and clinical arenas. Under the heading of principlism, bioethics developed a public language for resolving disputes that allowed it to transform disputes involving sacred matters into profane work routines. At the same time, having principlism as a common language for solving practical disputes allowed “ethics work” in health care to be separated from moral theorizing as a practical activity. Two issues—the right to die and the protection of research subjects—serve to illustrate the process through which bioethics established a large institutional footprint in health care.

Assessing the effects of the 2003 resident duty hours reform on internal medicine board scores.

Purpose To determine whether the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty hours reform affected medical knowledge as reflected by written board scores for internal medicine (IM) residents. Method The authors conducted a retrospective cohort analysis of postgraduate year 1 (PGY-1) Internal Medicine residents who started training before and after the 2003 duty hour reform using a merged data set of American Board of Internal Medicine (ABIM) Board examination and the National Board of Medical Examiners (NMBE) United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge test scores. Specifically, using four regression models, the authors compared IM residents beginning PGY-1 training in 2000 and completing training unexposed to the 2003 duty hours reform (PGY-1 2000 cohort, n = 5,475) to PGY-1 cohorts starting in 2001 through 2005 (n = 28,008), all with some exposure to the reform. Results The mean ABIM board score for the unexposed PGY-1 2000 cohort (n = 5,475) was 491, SD = 85. Adjusting for demographics, program, and USMLE Step 2 exam score, the mean differences (95% CI) in ABIM board scores between the PGY-1 2001, 2002, 2003, 2004 and 2005 cohorts minus the PGY-1 2000 cohort were −5.43 (−7.63, −3.23), −3.44 (−5.65, −1.24), 2.58 (0.36, 4.79), 11.10 (8.88, 13.33) and 11.28 (8.98, 13.58) points respectively. None of these differences exceeded one-fifth of an SD in ABIM board scores. Conclusions The duty hours reforms of 2003 did not meaningfully affect medical knowledge as measured by scores on the ABIM board examinations.