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Asking the hard questions

Asking the hard questions

by Maria Evans

“The purpose of the Morbidity and Mortality (M and M) Conference is to provide a safe venue for physicians in all levels of training to identify areas of improvement, and promote professionalism, with ethical integrity and transparency by use of a case study. The conference assesses all aspects of the care given to the patient, as well as provides feedback in quality improvement. The M and M Conference also provides a forum to to foster a climate of openness and discussion about medical errors.

“This conference also promotes leadership, research, and scholarly activity, and is a learning opportunity for clinical medical students and residents to assess their own core clinical competencies.” –Sample description of Morbidity and Mortality Conference from a large teaching hospital

One of the most vulnerable–and revealing–things I was exposed to in medical school and residency was the Morbidity and Mortality Conference, affectionately called “M and M.” In medical schools, these are often held in large lecture halls and are quite well attended. Pathologists and radiologists can never escape them, as it’s almost certain there will be radiology images, as well as gross and microscopic pathology, from the various diagnoses the “patient of the month” accumulated. I particularly remember Surgery M and M. It was held in the Surgery conference room, and there was one seat that was solely for the use of the Chief of Surgery–no one sat in that seat if he was absent, reminiscent of the Bishop’s Chair on the chancel. Woe betide some unfortunate new medical student or intern who inadvertently plopped his or her behind in that seat!

In this conference, no stone is left unturned, and the physician presenting the case (often a senior resident) is very much on the spot and feeling quite drained at the end. Every lab is scrutinized, every physical finding cogitated upon, and every possible outcome change at every step in the patient’s care is analyzed. The cases presented were not stories of modern medical miracles–they were almost certainly cases where the patient eventually died or ended up with some terrible outcome. But each step of the way, everyone involved with the care of that patient asks himself or herself two hard questions–“What would I have done differently if I had it to do over again at this point in the story of this patient?” and “How would it have changed the course of this patient or this patient’s quality of life?”

Really, mostly, in M and M, we find that the outcome probably wouldn’t have changed much for this patient–only the path to the outcome–but reflecting upon it might change something for the next patient. We do, however, find the humbling truth that we sometimes either delayed a diagnosis and cost the patient some degree of quality of life, or rushed to obtain a diagnosis in a frail patient that created a faster downward spiral in the patient’s course. I still remember a very poignant day when I saw the Chief of Surgery (yep, the same one who sat in the special chair) give a big sigh and exhale, “You know, I should never have taken him to surgery that day. I was wrong.” In the formative years of my training, M and M conference was a secular form of Ignatian spirituality–the examination of both conscience and of consciousness. Had I followed the norm of best practice for my specialty? Was I even aware what was developing at the time it was evolving? It was also striking to me that this needed to happen in a community setting–only going home and thinking about the cases on my own would not have been as beneficial. Revealing our vulnerability to a group engendered a sense of accountability to the patient.

In short, it’s about asking ourselves what we did wrong even when we are pretty sure what ultimately happened was right.

Advent is a good season for doing that, and in a different way than in Lent/Easter. Lent, for me, tends to be with a steeper cycle, with deeper mood swings–much as how the mood of the disciples must have been during the reception of Jesus to Jerusalem, followed by the trial, the passion, and the crucifixion–followed by the most sudden and unexpected emotions that must have accompanied the Resurrection. Advent is gentler for me–steady upward movement from deep darkness, and the birth of new things inside us occurring without much pomp or fanfare. It’s a good time to quietly ask the hard questions about our conscience and our consciousness in the dark spots in our lives. It’s a time to believe that the things being made new in us are being knit together with all the marvelous detail of the tiny fingernails and toenails on a newborn.

It can also be a time to address the topic of reconciliation. The December holidays are often a time when families can either rise to a new level of understanding of one another, or sink to the depths of their dysfunction. It’s a time for looking back at the things that had bad outcomes, and asking those same questions we always asked in M and M–“What would I do differently if I had it to do over again?” “How would I do it differently the next time a similar situation happened?” “How aware was I at the time?” “How can I be more aware next time?”

Advent seems to be a time that it’s easier to ask these questions in the light of quiet hope and expectation, without all the tumult of Lent. It’s the season for feeling quiet growth in the deep darkness, and understanding just how temporary the things that disquiet us really are–just as pregnant women endure the kicking, the indigestion caused by an active fetus, and the constant trips to the bathroom as their bladders get crowded out. Pregnant women know these things won’t last forever.

The beauty of M and M conference is it occurs at a time remote enough from when the events take place, the team can look back at it with more clarity and objectivity, and look forward with hope and anticipation. What things will emerge from our dark spaces this Advent that we can look back at a little more objectively, and then look forward with the same hope and anticipation?

Maria Evans, a surgical pathologist from Kirksville, MO, writes about the obscurities of life, medicine, faith, and the Episcopal Church on her blog, Kirkepiscatoid

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Maria L. Evans

Thanks for your comment. My fear, of course, is as the medico-legal climate gets stickier and stickier, there will be a day that it is too fearful to be doing M and M. But then I remember Advent is also a season of "hope amidst fear." I hope you have a blessed season also!

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BSnyder

Thanks very much for this - it's a wonderful post.

It's actually very heartening to think about the medical school M&M. It's incredibly hard for people to admit our mistakes - and of course mistakes in hospitals are sometimes a matter of life and death. It's a really difficult- but absolutely necessary - thing to face reality, and it's good to hear that it's happening in at least some small corner of the world. Especially now, when self-justification seems to be pretty much the standard order of the day everywhere. And especially in what might be the most difficult possible context.

And then, as you say, Advent is gentle in its way: a large dose of hope and expectation along with the "asking of the hard questions." It's a beautiful time of year; a blessed season to you.

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