Occupational rituals in patient management.

The social practices surrounding diagnosis and management decisions are analyzed from a sociological perspective as occupational rituals. These rituals are part of rounds and conferences, and they assist physicians in managing uncertainty, making treatment decisions, and evaluating outcomes. Physicians use eight key strategies to manage uncertainty: hedged assertions, probability reasoning, a focus on uncertainty as a research problem, requests for consultations, Socratic teaching, deciding not to decide, gallows humor, and hyperrealism. Clinical experience and scientific evidence are used in treatment decisions. The manner in which decisions are made at rounds allows physicians to dramatize the seriousness with which they take their responsibilities to patients. Two major rituals for evaluating outcomes of treatment decisions, grand rounds and the mortality and morbidity conference, provide a forum for dramatizing success and failure, respectively. Occupational rituals allow physicians to discuss their problems. The capacity of modern medicine to process clinical data threatens to obviate these rituals.