Saturday, May 4, 2013

What goes on at a real morbidity and mortality conference?

f you’ve read my reviews of the new medical TV show “Monday Mornings” [here, here and here], you’ll know I’ve been critical of many things about it. I was particularly disappointed with the way the show handled one of its central themes—the morbidity and mortality (M&M) conference.

I thought it might be useful to tell you how most real M&M conferences are run. M&M conferences generally take place at hospitals with residency training programs and are rather specific to surgical disciplines.

It is possible that they may be held in large non-teaching hospitals, but time constraints and the fact that direct attending surgeon to attending surgeon criticism in an open forum is difficult to do.

Unlike the TV version, real M&M conferences feature presentations by residents, not the attending staff. The resident who performed the operation prepares a summary of the case which these days is usually on PowerPoint. Pertinent history, physical exam findings, lab results and images are shown. A radiologist or pathologist may be on hand to help educate the attendees. The conduct of the surgical procedure and the patient's hospital course are described.

The resident is asked questions about the way the case was managed and what she knows about the disease process and the surgical literature. The resident may have prepared a brief review of recent papers on the subject.

The attending surgeon who was involved with the case might add some more details. At least one person asks a question that was already addressed in the presentation. An attending surgeon or two will describe a similar case they had 10 years ago that went wrong and state that now he does things a different way, never mind the evidence to the contrary.

Comments from other surgeons and the chairman are made. Often a consensus may be reached about whether or not the complication or death was preventable. The idea is that the discussion informs the whole department, and everyone does not have to make the same mistake. In theory, the complication might be averted the next time.

However, not all complications or deaths are due to errors. Sometimes despite everything being done correctly, outcomes are bad.

In the old days, residents were blamed for everything that went wrong. Public humiliation was common. A famous chairman allegedly once said to a resident who presented a case that resulted in a patient's death, “Why didn’t you just take a gun and shoot him?”

Although this is said to still happen in some hospitals, the conference is much more civil in most places.

Unlike the “Monday Mornings” version, M&M conference is not where attending surgeons are browbeaten, tricked or fired. Of course, the real conference is far less dramatic (most of the time).

There can be raised voices and sometimes arguments occur, but the focus of the conference is usually more on education and quality improvement.

It's too bad about the show. It could have done a lot of good if it tried to realistically portray how self-critical we are. Unfortunately, it went all Hollywood on us, like every other medical TV show.


Anonymous said...

After the round table discussion, each the deaths and serious complications are characterized as being the result of,

1. Error in diagnosis
2. Error in technique
3. Error in management
4. Patient's disease

There are no published minutes of the meeting and the discussion is "privileged" - not for repetition or discussion outside of the room.

LadySurgeon said...

The old school m&m still happens. I can tell you, just having finished residency last year. I spent many a Tuesday morning (when our m&m was) trying not to vomit as I worried how humiliated I was about to be. One attending in particular would just mumble "painful" the entire time while another would frequently say, "do you think you could possibly know more about this than I do? I've been doing surgery longer than you've been alive." Praise was rare, but I can still remember being told "good job" once and holding onto it for exactly one week, until the next humiliation

Skeptical Scalpel said...

Anon, good point. Some do keep minutes. I did. Because they were consider "peer review," the were not discoverable in court (allegedly).

Surgeon s, I am really sorry to hear that. I was hoping that type of behavior was a thing of the past. I am proud that I changed the culture of M&M conferences in three different hospitals during my career.

Anonymous said...

Skeptical Scalpel, can you tell us the name of the chairman who made the gunshot remark? (Or was it privileged?)

Anonymous said...

-would that some of us could afford
'Gordon's Guide to The Surgical Morbidity and Mortality Conference' [Paperback]
by Leo A. Gordon

Anonymous said...

"At least one person asks a question that was already addressed in the presentation." - Hilarious!

I love M&M as a cultural event, but deplore it as a learning tool. Each week residents walk away more influenced by anecdote, dogma, and personality than by evidence. For ninety minutes we pretend the internet, huge Cochrane reviews, and best practice guidelines don't exist.

My favorite refrain: Was this CT scan even necessary?
Always followed by: It was done before we were consulted.

artiger said...

I saw two different versions of M&M, one in med school and the other in residency (two different locations). As a student, I was buffered, but I was pretty horrified by a few attendings in particular, and how they seemed to enjoy roasting senior residents. Really, they were often laughing as they tore them to shreds.

My residency program was more one of quiet malignancy. No one got really yelled at, or ridiculed, but you were often made to feel quite small. I used to think that was even worse, but I can't fairly make that distinction since I was not a target in the first program I mentioned. And anyway, anytime you have to admit in front of the entire department how you (may have) screwed up, you're going to feel small. So it probably wasn't that bad. I did notice that quite often the attending of record of such complications would sometimes manage to be "busy" on those Friday mornings.

One last anecdotal story...As a fourth year, we had a death that was due to several different failures on the part of several of us on the team, including the chief resident. The chief read the case, and then proceeded to verbally list all the mistakes and omissions along with who committed the errors. Somehow he left his own mistakes out. The room was very quiet once he finished, but one particular attending went up to him afterward and told him never to pull that kind of chickensh!t ever again. And I don't think he did.

Skeptical Scalpel said...

I'd rather not say who commented about shooting the patient.

Gordon's book is great. It's a paperback and not that expensive.

Chris, of course we never ask for the CT. It's always the ED docs.

Artiger, I'm beginning to think the culture of humiliation is more prevelant than I thought. I wish I could survey a bunch of surgical residents.

Henna said...

Not that expensive? Gordon's book is evidently not in print because it goes for over $100 on Amazon.

Skeptical Scalpel said...

Henna, thanks for the update about Gordon's book. He reads my blog.

Maybe he'll see this. Let's hope he can get another printing of it. Although since I have a copy of it that's worth $100, maybe he should wait. :-)

NeuroTrumpet said...

You forgot to mention the free food. That was my favorite part of conferences during medical school. One can never have too many free bagels, danishes and coffee!

At my medical school institution, nobody ever seemed to grill the residents too harshly. The most lively--and sometimes heated--discussions were between attendings who disagreed with treatment approaches. As a student, this was excellent theater: we got to witness live, intelligent debates between highly knowledgeable faculty, all the while free from embarrassment, shame and guilt. Even the presenting resident enjoyed a momentary respite.

M&M conferences and resident lectures were therefore my favorite activities during 3rd and 4th year. All the benefits of learning without any of the stress. And we could eat!

Skeptical Scalpel said...

Yes, the free food. It's not longer funded by drug and equipment vendors though.

It sound like your M&M was run the right way.

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