M & M

Today I had the pleasure of presenting at our weekly “M & M” conference. The “Morbidity and Mortality” conference is held every week in an effort to promote self-examination in the hopes of improving the quality of care. It’s sort of like a condensed version of Lent, only more public. We scrutinize all of our patients’ outcomes, and try to learn from the ones that don’t go right. It’s a noble thought but, especially in the surgery world, it has the tendency to become slightly contentious. In fact – back to the Lent comment for a moment – some have described it as a crucifixion.

It’s a difficult thing to stand up in front of all your peers and say, “I did this, and then that bad thing happened.” Today I told the story of a patient who died. He needed an operation. We gave him one. He had a heart attack and died. The implication is that it’s my fault.

I presented the case in detail, and had every aspect of it questioned. Can you imagine a room full of white coats scrutinizing every detail? Did he really need the OR? Did he need that particular operation? What could have been done differently? He died, after all, so surely SOMETHING could have been done. I did my best. In the end, there really wasn’t anything I could have done.

Still…as miserable as it was to relive that sad sequence, it’s a good exercise to look carefully at the past and evaluate it in the hopes of preventing a bad outcome the next time around. And what better thing can we do after a death than try to use it to the benefit of the next patient?

And they’ll always be a next one. At least I hope so.