Wednesday, September 3, 2014

Improving the M&M conference

"Surgical pathology works more than 80 hours per week, has no regard for your gender or your life situation, and can be devious and sneaky in its presentation."

The following is a guest post by Dr. Leo Gordon, a surgeon from Los Angeles.

A recent paper in Annals of Surgery found that 24% of graduating surgical residents "were unable to recognize early signs of complications." One possible solution is a redesign of the morbidity and mortality (M&M) conference .

I have spent a significant part of my professional life in an effort—at this point it is a crusade—to change the nature of the M&M conference. For 11 years, I moderated 495 conferences, 1485 presentations, and 30 written examinations based on the error and complication-reducing points raised during the discussions.

If properly implemented, a redesigned M&M conference can satisfy the ACGME core competencies, the suggestions of the Institute of Medicine, and the public's demand for a reduction in medical errors.

What I have dubbed the "M&M Matrix" converts the weekly conference into a vibrant educational effort and creates a constantly updated patient safety curriculum for the resident and attending staff.

If the M&M Matrix is such a valuable idea, why hasn’t it been widely adopted?

Here are the reasons:

1. Implementing the M&M Matrix is a ton of work.

Setting up this program and changing the culture of a traditional conference requires acceptance at all levels of the department. It is a week-long effort, not a one-shot Tuesday morning flirtation with surgical education. To pull this off, someone is going to have to be paid, which is a stumbling block. The residents have to buy into this program. It is more work for them, but think of the benefits of the cautious analysis of a complication. Most departments look at the concept, realize how much work it will take, and revert to the traditional conference.

2. The M&M Matrix requires a moderator with specific talents.

Effective moderation of this conference requires a certain set of skills that not every attending surgeon possesses. The moderator has to select educationally valuable complications to discuss. The moderator has to…well…moderate the conference, focus on worthwhile comments, recognize the difference between a legitimate statement and the sweet reverie of surgical anecdote, and do it in a respectful manner. The moderator has to summarize the conference in a HIPAA compliant manner, distribute the teaching points, and construct an examination based on the conference.

3. The M&M Matrix relies on a structure of classic surgical education, a structure suffering advanced erosion.

I am entering my 36th year of practice. My view of surgical education is inconsistent with work-hour restrictions, life-style considerations, hand-offs, and current methods of patient care. I view the discipline of surgery as an effort to eradicate surgical pathology. Surgical pathology works more than 80 hours per week, has no regard for your gender or your life situation and can be devious and sneaky in its presentation. The method of assessing the effects of surgical pathology should be just as rigorous. I hate to fall back on a military analogy, but the M&M conference should be a boot-camp or basic training for the real war.

4. There is no statistical proof that the M&M Matrix decreases the incidence of complications.

The academics and statisticians have got me here!

How do you get inside the head of a senior resident as he is digging out the left colon in a tough diverticulitis case and show that in that fecund mind, because of this educational format, the resident is thinking:

"Gee, we discussed a lacerated ureter a few months ago. Remember the techniques of assessing the ureter that we discussed at the Matrix Conference? Didn't the outline we got and the test questions suggest that we should identify the ureter above and below and make sure we stay close to the colon?"

How does one quantify that a complication was avoided because of an educational effort?

These four reasons for lack of wider adoption can be overcome by a thoughtful analysis of the benefits of a redesigned conference. Given the current problems confronting surgical education, I believe that the idea will be re-evaluated and will eventually be adopted.

Time will be increasingly valuable in upcoming 60-hour work week. The hour allotted for the analysis of surgical complications has to be leveraged into a durable learning experience.

The incoming president of the American College of Surgeons, Dr. Andrew Warshaw, has chosen Dr. Ernest Codman as the subject of his presidential address. Dr. Codman invented the M&M conference. He conceived and implemented it, and in so doing improved surgical care. I hope that Dr. Warshaw’s remarks will spark a renewed interest in a re-design of the M&M conference.

I have a viable plan. Now I need the support to implement this plan. Perhaps I can complete Dr. Codman’s work!

If you have an opinion about the M&M Matrix, please comment below or contact the author—LeoGordonMD at


artiger said...

I think Dr. Gordon is spot on. I remember M&M as something that was almost universally feared. While some anxiety is probably appropriate, it shouldn't have been a license for some attendings to verbally abuse a junior.

Then again, I can also remember some feeling of relief and positive reinforcement from other staff, such as when I read a case of a CBD injury. As I read my narrative of misreading the cholagiogram, and passed around the film, my chief, to my immense relief, stated "I'm not sure that I would have correctly read this cholangiogram either". That taught me to be humble and honest in the face of a complication, rather than attempt to hide it or blame someone else.

Name, blame, and shame is supposed to be out. Teachable moment is supposed to be in.

Skeptical Scalpel said...

Artiger, I'm with you. The days of the punitive M&M conference are over.

Anonymous said...

I think Dr. Gordon has understated the root cause of slow adoption of the M&M Matrix when he said "To pull this off, someone is going to have to be paid, which is a stumbling block."
It is not a stumbling block, it is a total barrier to adoption, necessary but not sufficient to achieve adoption.
Only in monasteries do monks work for free. It is prerequisite that the institutions pay for improving quality and safety (both of which require education, btw), rather than ask practitioners to improve quality and safety in their spare time, between cases, etc.

Since most physicians work for hospitals now, we are left with the reality that management has to make the significant economic commitment necessary - it will not be easy because the public will not see immediate palpable benefits from such moves.

The ever-present "satisfaction questionnaires" will have to be abandoned as a measure of excellence - patients cannot be expected to evaluate such activities or understand their value.

So I'm positing that what's needed is change at a social and political level to enable Dr. Gordon's and others' excellent methodologies to be implemented. As long as safety, quality, and medical education are considered as anything but foundational to good medicine, nothing will change.

I am an anesthesiologist, a data analyst (Ph.D.), and am now studying patient safety (no degree yet).

Skeptical Scalpel said...

Anon, good points. Societal and political changes take time. I don't see them happening soon. There's also the issue of academic surgeons not getting any credit for teaching. The only thing that counts toward promotion is publishing papers.

RuggerMD said...

I always have felt that our M&M conferences were the main reason my complications are low.
I really paid attention and took in everything that was said in M&M.
Learning from others mistakes is a good thing to do.
Now, I weigh the risks and benefits of the decisions I am making and M&M experiences are part of that.

Skeptical Scalpel said...

I agree. Learning from others' mistakes (and your own) is the essence of a good M&M.

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