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In this book proposal, Charles L. Bosk synthesizes 50 years of ethnographic research to consider a key question: Why have decades of patient safety initiatives to reduce preventable deaths and adverse safety events failed to make traction on either one? With his incomparable wit and dry humor, Bosk takes us through the changes to the medical system that accompany his own evolution from a doctoral student to accomplished professional. Bosk's last work prods us to think deeply about the nature of medical error, our attempts to fix it, and what it means to improve medical care. [ABSTRACT FROM AUTHOR]

A largely uncoordinated patient safety movement arose in response to the Institute of Medicine's 1999 report on patient safety, To Err Is Human. Two key outcomes have resulted from that movement: (a) new guidelines that enlarge requirements for documenting compliance with patient safety data and (b) a new obligation for health care organizations to create a "safety culture" based on the "science" of safety. The organizational title patient safety officer (PSO) designates a member of an emerging occupation charged with assuming these enlarged responsibilities. This article seeks, first, to describe the emergence of this new organizational role, the PSO; second, to identify the new tensions that task and mission inflation have created for PSOs; and third, to examine how PSOs manage the tensions between their increased core work task and their new professional mission as agents of organizational change. Drawing on interviews conducted with 32 PSOs, 127 nurses, and 36 physicians in 17 surgical departments across 5 states in the United States from 2012 to 2015, the authors find that PSOs most commonly resolve the tension between core work activity and professional mission by focusing on their task as agents of audit and compliance. The authors find, as well, that when PSOs attempt to use their expanded role as social reformers to change behaviors in surgery, they must overcome the resistance of frontline workers. They require cooperation from executives and surgeons to effect change. When this support is unavailable, PSOs lose their voice and may abandon efforts to improve safety. [ABSTRACT FROM AUTHOR]

Context Adults aged sixty-five and over account for a large fraction of all surgeries performed in the United States each year. While historical growth in rates of surgery in this population is commonly attributed to financial incentives and technological innovations, the shifts in thought that underpinned the spread of surgery among the U.S. elderly remain largely unexplored. We examined changing perspectives on aging over time in American surgery through two case studies: the expansion of general surgical procedures among older U.S. adults between 1945 and 1965, and the spread of coronary artery bypass grafting (CABG) among the U.S. elderly between 1975 and 1995. Methods For this article, we used close readings of historical journal articles, textbook excerpts, survey reports, and government documents related to surgery and aging. Findings Similar perspectives on aging informed the spread of both general surgical procedures among older adults after World War II and CABG in the elderly from the mid-1970s onward. In each case, surgeons argued against earlier views that surgery was contraindicated in old age using rhetoric that negated the relevance of age to medical decisions. Furthermore, surgeons elevated other types of information-such as the presence or absence of chronic diseases-to supplant age as an explanation for the high operative mortality rates seen among older patients. By stressing the modifiability of operative risk in the elderly, surgeons' arguments positioned old age itself as a new surgical 'frontier.' Conclusions Surgeons' arguments for the expansion of surgery among the U.S. elderly over time worked to negate the relevance of age to medical decisions and to portray the wider use of surgery in the elderly as uniformly beneficial. While potentially promoting broader access to surgical care, such perspectives may also have contributed to ongoing health policy challenges by normalizing surgery at any stage in the life-course, with implications for current patterns of surgical utilization and medical spending. [ABSTRACT FROM AUTHOR]

Abstract: We examine how a policy aimed at improving patient safety by limiting residents’ work hours brought with it an unintended and unexamined consequence: altered socialization due to modified rites of passage during residency that endangered the stereotypical “Surgical Personality” and created a potential rift between the occupational identities of surgical residents who train under duty hour regulations and those who trained before they were imposed. Through participant observation occurring between June 2008 and June 2010, in-depth interviews (n = 13), and focus groups (n = 2), we explore how surgical residents training in four U.S. hospitals think about the threats that the shift from unrestricted to restricted duty hours creates for their claims of competence and professionalism. We identify three types of resident responses: (1) neutralizing statements that deny any significant change to occupational identity has occurred; (2) embracing statements that express the belief that a changed and more balanced occupational identity is needed; and (3) apprehensive statements that expressed fear of an altered occupational identity and an anxiety about readiness for individual practice. [Copyright &y& Elsevier]

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. [ABSTRACT FROM PUBLISHER]

Context: Current efforts to improve the cost-effectiveness of health care focus on assessing accurately the value of technologically complex, costly medical treatments for individual patients and society. These efforts universally acknowledge that the determination of such value should incorporate information regarding the risks posed by a given treatment for an individual, but they typically overlook the implications for medical decision making that inhere in how notions of risk are understood and used in contemporary medical discourse. To gain perspective on how the hazards of surgery have been defined and redefined in medical thought, we examine changes over time in notions of risk related to operative care. Methods: We reviewed historical writings on risk assessment and patient selection for surgical procedures published between 1957 and 1997 and conducted informal interviews with experts. To examine changes attributable to advances in research on risk assessment, we focused on the period surrounding the 1977 publication of an influential surgical risk-stratification index. Findings: Writings before 1977 demonstrate a summative, global approach to patients as 'good' or 'poor' risks, without quantifying the likelihood of specific postoperative events. Beginning in the early 1980s, assessments of operative risk increasingly emphasized quantitative estimates of the probability of dysfunction of a specific organ system after surgery. This new approach to establishing surgical risk was consistent with concurrent trends in other domains of medicine. In particular, it emphasized a more 'scientific,' standardized approach to medical decision making over an earlier focus on individual physicians' judgment and professional authority. Conclusions: Recent writings on operative risk reflect a viewpoint that is more specific and, at the same time, more generic and fragmented than earlier approaches. By permitting the separation of multiple component hazards implicit in surgical interventions, such a viewpoint may encourage a distinct, permissive standard for surgical interventions that conflicts with larger policy efforts to promote cost-effective decision making by physicians and patients. [ABSTRACT FROM AUTHOR]

Understanding how and why programs work-not simply whether they work-is crucial. Good theory is indispensable to advancing the science of improvement. We argue for the usefulness of ex post theorization of programs. We propose an approach, located within the broad family of theory-oriented methods, for developing ex post theories of interventional programs. We use this approach to develop an ex post theory of the Michigan Intensive Care Unit (ICU) project, which attracted international attention by successfully reducing rates of central venous catheter bloodstream infections (CVC-BSIs). The procedure used to develop the ex post theory was (1) identify program leaders' initial theory of change and learning from running the program; (2) enhance this with new information in the form of theoretical contributions from social scientists; (3) synthesize prior and new information to produce an updated theory. The Michigan project achieved its effects by (1) generating isomorphic pressures for ICUs to join the program and conform to its requirements; (2) creating a densely networked community with strong horizontal links that exerted normative pressures on members; (3) reframing CVC-BSIs as a social problem and addressing it through a professional movement combining 'grassroots' features with a vertically integrating program structure; (4) using several interventions that functioned in different ways to shape a culture of commitment to doing better in practice; (5) harnessing data on infection rates as a disciplinary force; and (6) using 'hard edges.' Updating program theory in the light of experience from program implementation is essential to improving programs' generalizability and transferability, although it is not a substitute for concurrent evaluative fieldwork. Future iterations of programs based on the Michigan project, and improvement science more generally, may benefit from the updated theory present here. [ABSTRACT FROM AUTHOR]

Rereading Renée C. Fox's "A Sociological Perspective on Organ Transplantation and Hemodialysis," published in 1970, one is likely to be struck more by continuity than by change. The most pressing of the social, policy, and ethical concerns that Fox raised remain problematic fifty years later. We still struggle with scientific and clinical uncertainty, with the boundary between experimentation and therapy, and with the cost of organ replacement therapies and disparities in how they are allocated. We still have an imperfect understanding of transplant immune responses. We still debate when a potential donor "actually" dies, and we still seem to think better empirical criteria could harmonize the diverse religious, cultural, and socioeconomic values of patients, providers, third‐party payers, and policy‐makers. Organ transplantation was for Fox both a particular case unfolding in time and an entryway for discussing the difficult moral questions presented by many new medical technologies in a context of high demand and limited resources. [ABSTRACT FROM AUTHOR]

The article reflects on the life and career of the late medical sociologist Eliot Freidson of New York University. The author discusses Freidson's influence on the study and teaching of the sociology of medicine. Books authored by Freidson include "The Profession of Medicine," "Doctoring Together: A Study in Professional Social Control," and "Professionalism: the Third Logic." Freidson's personal and professional history is described, including his family life and education. The author discusses Freidson's main topics of study, including the physician and patient relationship, medical ethics, and professionalization in medicine.

This section comments on the article, Ethics Creep: Governing Social Science Research in the Name of Ethics, by Kevin D. Haggerty, which appeared in the Winter 2004 issue of Qualitative Sociology. According to the author, meeting the requirements to pass Institutional Review Board (IRB) muster seems to him a simple matter, even if an unwelcome chore, a matter of knowing what the regulations require and then providing exactly that. He does not see the requirement of prospective review as a threat to some overblown interpretation of his own or of his colleagues' first amendment right to association or speech. He does not see the requirement of prospective review as the greatest threat to social science. Prospective review strikes him as generally one more inane bureaucratic requirement in one more bureaucratic set of procedures, ill-suited to accomplish the goals that it is intended to serve. Prospective review, flawed a process as it is, does not strike him as one social scientists should resist. The author states that the article on ethics creep appears to him to be not so much an example of the danger of mission creep in the research review process. Rather, it seems to be an example of what happens when social scientists do not take an active role in shaping the way regulations are interpreted and applied.

Discusses how bioethics works in the pharmaceutical industry. Narration of mistreatment experienced by George, an employee in a pharmaceutical company; Influence of money on scholarly work and medical advice; Discussion of the ethical problem faced by Eli Lilly & Co. in the late 1990's.

Examines the dominance of bioethics in medical centers in the United States. Development of bioethics as an applied discipline; Impact of the conflict between applied philosophers and theorists on the development of bioethics; Role of social scientists in the practice of bioethics.

This paper utilizes the case of the Zaddik in the Hasidic movement to discuss routinization in terms of the movement's doctrinal basis and thus extends Max Weber's generalizations about charisma. The Zaddik was a highly personal type of leader whose authority is based on his ability to make contact with the feminine element of God, which is immanent but hidden in the world, and is demonstrated by his ability to gather disciples. The Lurianic Kabbala's myth of creation provides a way of recognizing similarities and organizing differences among Hasidim. The problems of the leaders on how to read their message and authority into the past to forge a sense of history for their followers, and how to read that same message into the future to provide the promise of salvation, have been highlighted. In the history of Judaism, there is a fairly constant tension between the ethical and exemplary dimensions of action. This tension expresses itself as a tension between two alternative conceptions of God as a transcendent lawgiver and God as a spirit immanent in all creation. The nature of the Zaddik's role and then the cultural legitimation for it have been examined.

This paper employs a cybernetic model of a religious symbol system to explain the competition among Rabbinists, Hasidim, and Messianists in the Jewish communities of eighteenth-century Poland. Hasidism's ability to attract adherents is explained by the great flexibility of its constitutive belief, ‘communion with God’ when compared with Rabbinic Torah or the Messianic belief in the ‘lifting of sparks.’ This flexibility is traced through all levels of the cybernetic hierarchy. [ABSTRACT FROM AUTHOR]

The article presents a report on the science of safety. Topics discussed include rising health-care costs associated with the emergence of the medical-industrial complex, the institutional goal of lowering health-care costs, and hidden cost of acute care as preventable adverse events. Also being discussed are the recommendations of the U.S. Institute of Medicine (IOM) for improving patient safety.

The article focuses on the issue of bioethics in the context of the stem cell research. The issue involves the support of the U.S. government on the research through budget allocation that can finance the therapeutic application of stem cells in the field of medicine. One of its concerns highlight the moral campaign on stem cell research without any association to the issue of abortion in the United States. An overview of the advantages and disadvantages of the advancement of the stem cell research in relation to public welfare is offered.

Comments on the study entitled 'North American Bioethics and Medical Humanities Training Program Survey,' by the American Society for Bioethics and Humanities. Percentage of growth in the bioethics training programs in the 1990s; Factors which contributed to the growth; Demographics of the graduate degree in bioethics.

The authors discuss the vision of Le Corbusier, a high-modernist architect, philosopher, and urban planner, on urban life. They state that a new kind of urban life would be situated within and enabled by a new utopian landscape of design by Le Corbusier through the planned arrangement of separate spaces for working, living, and commerce. They mention that the urban environment envisioned by Le Corbusier reflected a desire to make city life capable of being systematically observed and regulated.

The authors comment on a study published in "The New England Journal of Medicine" regarding the Michigan Keystone intensive care unit (ICU) programme. An evidence-based intervention in 103 ICUs in the programme had resulted in a reduction in catheter-related blood stream infection rates. The authors propose that checklist deployment without an appreciation of how and why they work is a potential threat to patients as well as to quality care. They also claim that attributing the reduction of infection solely to the use of checklists is a crucial mistake.

Background: Implementing quality improvement in hospitals requires a multifaceted commitment from leaders, including financial, material, and personnel resources. However, little is known about the interactional resources needed for project implementation. The aim of this analysis was to identify the types of interactional support hospital teams sought in a surgical quality improvement project. Methods: Hospital site visits were conducted using a combination of observations, interviews, and focus groups to explore the implementation of a surgical quality improvement project. Twenty-six site visits were conducted between October 2012 and August 2014 at a total of 16 hospitals that agreed to participate. All interviews were recorded, transcribed, and coded for themes using inductive analysis. Results: We interviewed 321 respondents and conducted an additional 28 focus groups. Respondents reported needing the following types of interactional support during implementation of quality improvement interventions: a critical outside perspective on their implementation progress; (2) opportunities to learn from peers, especially around clinical innovations; and (3) external validation to help establish visibility for and commitment to the project. Conclusions: Quality improvement in hospitals is both a clinical endeavor and a social endeavor. Our findings show that teams often desire interactional resources as they implement quality improvement initiatives. In-person site visits can provide these resources while also activating emotional energy for teams, which builds momentum and sustainability for quality improvement work. Implications: Policymakers and quality improvement leaders will benefit from developing strategies to maximize interactional learning and feedback for quality improvement teams. Further research should investigate the most effective methods for meeting these needs. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM PUBLISHER]

Abstract: This article identifies the role played by a series of medical scandals in the UK, occurring from the mid-1990s onwards, in ending a collegial model of self-regulation of the medical profession that had endured for 150 years. The state’s original motive in endorsing professional self-regulation was to resolve the principal–agent problem inherent in the doctor–patient relationship. The profession, in return for its self-regulating privileges, undertook to act as a reliable guarantor for the competence and conduct of each of its members. Though sufficient to ensure that most doctors were “good”, the collegial model adopted by the profession left it fatally vulnerable to the problem of “bad apples”: those unwilling, incapable or indifferent to delivering on their professional commitments and who betrayed the trust of both patients and peers. Weak administrative systems in the NHS failed to compensate for the defects of the collegium in controlling these individuals. The scandals both provoked and legitimised erosion of the profession’s self-regulatory power. Though its vulnerability to bad apples had been present since the founding of the 19th century profession, it was the convergence of social and political conditions at a particular historical moment that transformed the scandals into an unstoppable imperative for reform. Huge public anger, the voice permitted to a coalition of critics, shifts in social attitudes, the opportunity presented for imposing standards for accountability, and the increasing ascendancy of pro-interventionist managerialist and political agendas from the early 1990s onwards were all implicated in the response made to scandals and the shape the reforms took. Scandals need to be understood not as simple determinants of change, but as one performative element in a constellation of socially contingent forces and contexts. The new rebalancing of the “countervailing powers” has dislodged the profession as the senior partner in the regulation of doctors, but may introduce new risks. [Copyright &y& Elsevier]

Sociologists, philosophers, and historians of science tend to focus their attention on the production of knowledge. More recently, scholars have begun to investigate more fully the structures and processes that impede the production of knowledge. This article draws on interviews conducted with 41 academic researchers to present a phenomenological examination of 'forbidden knowledge'-a phrase that refers to knowledge considered too sensitive, dangerous, or taboo to produce. Forbidden knowledge has traditionally been understood as a set of formal controls on what ought not be known. We argue that the social processes that create forbidden knowledge are embedded in the everyday practices of working scientists. The narrative legacies of past controversies in science are of particular importance, as they serve as a tool that working scientists use to justify, construct, and hide their acceptance of forbidden knowledge. As a result, the precise contents of forbidden knowledge are fluid, fuzzy, essentially contested, specialty specific, locally created, and enforced. [ABSTRACT FROM AUTHOR]

OBJECTIVE: 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. [ABSTRACT FROM AUTHOR]

Medical educators worry that the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty-hour rules (DHR) have encouraged a 'shift work' mentality among residents and eroded their professionalism by forcing them either to abandon patients when they have worked for eighty hours or lie about the number of hours worked. In this qualitative study, we explore how medical and surgical residents perceive and respond to DHR by examining the 'local' organizational culture in which their work is embedded. In 2008, we conducted three months of ethnographic observation of internal medicine and general surgery residents as they went about their everyday work in two hospitals affiliated with the same training program, as well as in-depth interviews with seventeen residents. Field notes and interview transcripts were analyzed for perceptions and behaviors in regard to beginning and leaving work, reporting duty hours, and expressing opinions about DHR. The respondents did not exhibit a 'shift work' mentality in relation to their work. We found that residents: (1) occasionally stay in the hospital in order to complete patient care tasks even when, according to the clock, they are required to leave, because the organizational culture stresses performing work thoroughly, (2) do not blindly embrace noncompliance with DHR but are thoughtful about the tradeoffs inherent in the regulations, and (3) express nuanced and complex reasons for erroneously reporting duty hours, suggesting that reporting hours worked is not a simple issue of lying or truth telling. Concerns about DHR and the erosion of resident professionalism resulting from the development of a 'shift work' mentality likely have been overstated. Instead, the influence of DHR on professionalism is more complex than the conventional wisdom suggests and requires additional assessment. [ABSTRACT FROM AUTHOR]

It is no surprise that bioethics and sociology developed an adversarial relationship: bioethicists value the clear descriptions of ethically charged situations provided by social scientists, but doubt the ability of those trained in social science to logically derive and discern ‘the good’. For their part, social scientists – experts in observing and collecting data about the way the world is– find bioethicists ignorant of the ways elegantly crafted solutions to ethical problems get altered when incarnated in varied social and cultural settings. This discipline-centred self-affirmation can be a satisfying exercise, but it offers nothing to the project of promoting more moral medicine and health care. The articles collected in this volume demonstrate the value of collaboration between social scientists and bioethicists. Focusing on four themes found in recent sociological research in bioethics – ethics of research, the creation of moral boundaries, bioethics and social policy, and the bioethical imagination – this anthology offers practical models of co-operative work where the strengths of each discipline are brought together to advance our understanding of bioethical issues and to show the way toward just and effective social policy. [ABSTRACT FROM AUTHOR]

Presents a study that explores critical care nurses' beliefs, motivations and experiences regarding end of life care. Method use to conduct study; Results of study; Discussion of study.