Book Review

A Complex Sorrow

N Engl J Med 1994; 330:294-295January 27, 1994

Article

A Complex Sorrow
By Marianne A. Paget; edited by Marjorie L. DeVault. 153 pp. Philadelphia, Temple University Press, 1993. $22.95. ISBN: 1-56639-041-9

One's first reaction to this unusual book is to reflect on the tragic loss, early in her career, of Dr. Marianne Paget. Medicine, social sciences, and the law had much to gain from her insights. Hers was a short but unique career. As a sociologist, she had begun studying an uncomfortable aspect of medicine -- our errors and mistakes. As a social scientist, she was exploring how doctors talk (or fail to talk) about their mistakes, how lawyers describe them in the courtroom, and how each affects patients and public policy.

Paget's premise was that clinical medicine is an “error-ridden activity.” Decisions in medicine are based, of necessity, on incomplete information, she noted. Physicians are “experts in a work that proceeds by trial and error. Error is fundamental in clinical medicine: it is neither uncommon nor unusual.” She believed that the failure of doctors to discuss mistakes led to potential distortions in thinking about clinical cases. She wanted to study the way in which mistakes were viewed in the legal context. She observed that lawyers use the term “negligence” in describing all medical mistakes, though the term carries with it the concept of the violation of a standard of medical practice that leads to grave injury. “How error is considered in legal disputes and how it is articulated in medical circles is vastly different,” she wrote, “and yet I hope to reveal both as forms of discourse about personal misfortune in patient care.” Paget viewed her work as phenomenological, not technical, because she believed that sociologists could not be detached observers, since they were required to observe and interpret findings as individuals living in the environment being studied.

Dr. Paget applied and was accepted to a law and social science program to explore how medical mistakes were legally constructed and how they affected malpractice insurance and public attitudes and policies. While attending courtroom trials in 1987, she began to have back pain, which over a period of six months was diagnosed as an injury and was later found to be inoperable cancer. The irony of her life's mirroring her work is at the heart of her observations. However, she noted that she never asked, “Why me?” but “Why not me?” -- given the frequency of errors. She called mistakes “complex sorrows of actions going wrong.”

Her work in doctor-patient communication is well described. She had an unusually creative concept that a study of communication could be produced as a play. It was staged successfully, to her great delight. Ironically, the female patient in the play was misdiagnosed as having depression when she actually had cancer. Paget's journal of her responses to advancing illness offers a powerful insight into the emotions surrounding imminent death. The valiant efforts of her support team are described by Marjorie DeVault. The team sustained her through the unsuccessful series of treatments and her death. It is a human story of “one of our own” who chose to face death bluntly and squarely. As her illness progressed Dr. Paget became obsessed with finishing this piece of work before her death. She coped with her illness by focusing on work. It is a model chosen by many physicians, who find that work provides a solace and compelling evidence of being alive and productive despite illness.

The book is a tribute to both Dr. Paget and her colleague, Dr. DeVault, who carried the work to completion. It is a book of special interest to physicians. Dr. Paget's ideas about mistakes in medicine cry out for further study. Her personal journey through illness in the context of her background in medical sociology is particularly useful for its insights for physicians.

Jimmy Holland, M.D.
Memorial Sloan-Kettering Cancer Center, New York, NY 10021