Surgeons have a time-honored institution of reflection, learning, and responsibility in the Morbidity & Mortality conference. The M&M is unique in the medical profession and we should look critically at efforts by hospitals and bureaucracies to change its character and its purpose.
A story in this issue (“Little overlap between surgical M&M and AHRQ” on adverse events, p. xx) covers a published study () of the ways in which surgeon-reported M&M cases do (but mostly, do not) overlap with those captured in the ubiquitous Patient Safety Indicators (PSIs).
I am reminded once again of the long road we have traveled from the M&M conference of my student and resident days in the 1970s to today’s version of this event.
At our institution, the M&M has evolved over the years to serve not only an educational venue from which all in attendance learn from the misadventures of others and (hopefully) avoid similar errors in the future, but also as a component of the institution’s overall patient safety and quality improvement program. The authors point out the inherent difference between the clinician-generated M&M cases, which may possess selection bias in the cases they identify as complications, and the strictly defined PSIs that are captured from an administrative database and often include cases overlooked by the clinicians as not relevant to the surgical M&M process.
Both kinds of data are valuable, but for surgeons, the M&M is the one venue where they can focus in the company of their colleagues on those instances where the best intentions go off the rails: erroneous decisions, faulty assessments, and unanticipated complications.
The surgical M&M conference traces its origins to the admirable practice of early 20th century Boston surgeon Ernest Codman, who tracked the treatment outcome of all of his patients on “End Result Cards” for at least a year with the goal of identifying errors to improve the care of his future patients. He established the first M&M conference at Harvard and was one of the founders of the American College of Surgeons and the forerunner of the Joint Commission. His idea that surgeon and hospital outcomes should be made public so that patients could make an informed choice about where and from whom to seek care was, however, vigorously resisted by Harvard and Dr. Codman lost his privileges there.
I would offer that the M&M conference and the PSIs are apples and oranges: both good, but different. Each serves a different purpose. But too much integration of the PSI into the M&M format could end up creating a formulaic adverse events conference that answers to bureaucratic needs of the hospital, but loses some of its value as a forum for learning.
It is worth reflecting on how and why the traditional M&M has such value to surgeons.
To begin with, the quality of the leadership matters. A good leader knows how to avoid blaming, shaming, or embarrassing the presenter, who likely feels bad enough about the complication without being tortured about it. The goal is that all salient factors that contributed to the complication are elicited and that everyone present comes away from the conference armed with alternative ways to prevent a repeat of the same complication.
As a resident I learned more at the Saturday morning M&M than I did at any other conference. I was there every Saturday morning almost without fail for 15 years as a medical student, resident, and faculty member. There I learned not only how to avoid errors and benefit from the accumulated wisdom of many gray hairs in the audience, but also how to present an embarrassing complication both honestly and even with some self-deprecating humor.
Chief residents such as Don Trunkey, Brent Eastman, and Theodore Schrock were gifted in being accountable for mistakes while simultaneously deflecting ire with some well-chosen props. I remember one vivid example: Ted Schrock stepping up to the podium to present a “case gone bad” while holding a garbage-can lid in front of his chest like a shield, ready to defend himself. I don’t remember the case, but the picture is still etched in my mind 45 years later.
Our chairman, Dr. J. Englebert Dunphy, was a master at zeroing in on the critical errors in decision-making or operative conduct that had led to a poor outcome. When the presenter was honest and well-meaning but lacking in sophisticated insight, Dr. Dunphy would calmly ask probing questions that guided the resident to understand why a complication had occurred and how it might have been avoided. If the complication was exceptionally egregious, or the resident was not forthright or was evasive in his “mea culpa,” Dr. Dunphy would turn to one of his staunch faculty allies in the front row and inquire, “Brodie, what do you think about that?” to which Brodie Stephens would typically reply, “Bert, I thought we were here to CURE disease, not CAUSE it!” (To add some colorful football lore to the story, Howard Brodie Stephens was the All-American end who caught a 53-yard pass from “Brick” Muller in the 1921 Rose Bowl victory of Cal Berkeley over Ohio State, the Pacific Coast Conference’s last win against a Big Ten team until 1953.)
Certain resident shortcomings were sure to raise Dr. Dunphy’s ire. These included failing to take responsibility for your mistake and attempting to blame the error on someone else or on another discipline or not adequately supervising an intern or junior resident if you were the chief resident. The latter crime was the subject of one of the most clever and resourceful chief resident M&M presentations of all time, that of past ACS President Brent Eastman as his final presentation from his vascular surgery rotation, the last of his chief year. This one took some moxie, considerable preparation, and the involvement of colleagues near and far. Brent enlisted his good friend and later distinguished cardiac surgeon Dr. Larry Cohn, then junior faculty at Harvard, to find a list of Dr. Dunphy’s complications while he was a resident in Boston in the 1930s. Although records were no longer available, Dr. Cohn mentioned the issue to Dr. Hartwell Harrison, who had been chief resident at the Peter Bent Brigham Hospital when Dr. Dunphy was a junior resident. Dr. Harrison remembered a case that Dr. Dunphy had performed in the outpatient clinic without supervision in which he encountered uncontrolled bleeding.
Armed with the perfect case to present, Brent coached Dr. Edwin (Jack) Wylie to be his “plant” in the audience. At M&M, Brent sheepishly admitted that the case he had to present was that of an unsupervised junior resident who incurred uncontrolled bleeding in the outpatient setting. On cue, Dr. Wylie asked, “Who the hell WAS that resident?” Dr. Eastman then shuffled through his papers to find the correct sheet and announced, “Dr. John E. Dunphy, Peter Bent Brigham Hospital, 1937.” The room exploded in uproarious laughter, joined heartily by Dr. Dunphy.
That was then, and this is now. I can’t envision such a spectacle ever occurring these days. The M&M conference of 2018 has become far more standardized and endowed with greater scientific rigor. Its evolution has likely made M&M more precise and valuable as an educational tool for surgeons to learn from the mistakes of others, but of course, it has lost an element of surprise and hilarity that kept all of us sleep-deprived residents awake and alert. The lessons learned from the traditional M&M lasted this surgeon’s lifetime, and we should consider preserving some of the give-and-take, admission of failure, and reflection that made the M&M so unforgettable.