The traditional Surgical Morbidity and Mortality Conference that I remember so well from my residency days has changed. Not everything has changed, however. Usually the most senior resident involved still presents the case along with a discussion of the operation performed and the complication. There is invariably a discussion of the central question, “What should have been done differently?” Residents still occasionally get nervous before presenting a case as I did years ago, and there is still the occasional disagreement over how a surgical issue was handled. But there are subtle differences notable in the M&M discussions of today.
Rather than focusing on who did something wrong, there is today more often a focus on the “systems issues” in the case. In other words, if a pneumothorax was missed after a central line placement, the discussion today is much more commonly focused on the systems that should have been in place to ensure that such an abnormality was noted and acted upon. In years past, the focus was squarely on identifying which resident shirked his or her responsibility to review the film.
This current “blame-free” environment is the hallmark of a “learning organization” that aims to use the review process to improve performance. Mistakes are viewed as opportunities for learning and improving the system. And the nonpunitive analysis goes a long way toward improving morale among the residents and certainly encourages teamwork and identification of mechanisms to avoid errors within a hospital or service. These are all good things. But I worry that perhaps there is a tendency to go too far with avoiding individual responsibility.
Sometimes it is easy to talk about things “just happening” in large medical systems of today. Many surgeons are accustomed to dictating operative reports in the passive voice. For example, I find myself routinely stating, “the patient was prepped and draped,” “an incision was made,” and “exposure was obtained.” All these statements suggest that things happened and, perhaps “mistakes were made,” but there is little attribution to a specific actor. Unfortunately, it can be easy to also talk about patient care in a similarly abstract manner in which it is hard to identify who did what to whom.
The central question, I believe, is whether this new focus on the system and the team is ultimately better for patient care. We do want all members of the operating room team, for example, to feel responsible for speaking up when something does not seem right. We want every person involved in a patient’s care to feel comfortable with stopping an incorrect intervention. Surgeons, in particular, should not be upset by having the medical student question which side of the patient is being operated upon. Hierarchy should never stand in the way of speaking up to avoid an error being made. Nevertheless, we must not completely eliminate the sense of personal responsibility that each individual caregiver should feel toward ensuring the well-being of the patient.
In 1937, Chicago surgeon Max Thorek, M.D., wrote a pioneering book entitled, Surgical Errors and Safeguards. Dr. Thorek wrote, “While it is human to err, it is inhuman not to try, if possible, to protect those who entrust their lives into our hands from avoidable failures and danger.” I believe that this philosophy continues to be embodied in the Surgical M&M conference.
One of the central components of the M&M discussion has not changed. After all of the discussion about systems and corporate responsibility, I believe that the most common statement that I have heard from the treating surgeon is, “My error was that I should have done ... ” Although some observers might see this ascription of the individual role of the surgeon to be anachronistic, I believe that it captures the reality of the situation that even though patients are operated upon by teams, it is most commonly an individual relationship with a specific surgeon that has prompted the patient to go ahead with the surgery. We must not lose sight of the importance of that individual relationship and the responsibility that the individual surgeon has in influencing patient choice. In many ways, although the tenor of the Surgical M&M conference has changed the old question of “What could I have done differently?” remains of central importance to ensuring that surgeons take responsibility for their patients’ well-being.
Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.