and the M & M Meeting
Moshe Schein
A ‘big’ operation in a fit patient may be ‘small’
A ‘small’ operation in a sick patient may be ‘big’
A ‘big’ surgeon knows to tailor the operation and its trauma to the patient and his disease
“Again and again I find that there are few things so quickly forgotten by the surgical system as a dead patient.” (P.O. Nyström)
Let us hope that your patient survives his emergency abdominal operation and his postoperative course is uneventful. Unfortunately, the overall mortality of such procedures is still far from negligible and the morbidity rate is generally high. Now, after the storm has abated, it is the time to sit down and reflect on what went wrong.
As Francis D. Moore (1913–2001) said: “You want a surgical team that faces each error, each mishap, straight up, names it, and takes steps to prevent its recurrence.”
The Mortality & Morbidly Meeting
At any place where a group of surgeons is working it is crucial to conduct a regular M & M Meeting (MMM). This is the venue where you and your colleagues should objectively analyze and discuss – in retrospect – all the recent mortalities and complications.You are familiar with the cliché that “some surgeons learn from their own mistakes, some learn from those of others, and some never learn”. The aim of the MMM is to abolish the last entity.
Do you have a regular M & M meeting in your department? If you are associ- ated, as a resident or a qualified surgeon, with a teaching department in the USA, you must have a weekly MMM, because without a routine MMM the department’s residency program cannot be accredited. We know that in many corners around the world MMMs are not conducted; all blunders and failures are swept under the carpet. Elsewhere still, MMMs are conducted in name only, being used to present
“interesting cases” or the latest “success stories”. This is wrong. The MMM exists to analyze objectively your mistakes and complications, not to punish or humiliate anyone, but to educate and improve results. You do not want to repeat the same error twice. See to it that proper MMMs are conducted wherever you provide surgical care.
Optimal Format for the MMM
A routine hour should be dedicated to the MMM each week.
ALL interns, residents and surgeons should attend – regularly.
ALL complications and deaths that occurred in any patient treated by any member of the department should be presented.
“A complication is a complication” – irrespective of whether the outcome was a triumph or tragedy. All must be presented.
The MMM is a democratic forum. The boss’s blunder or that goof by the “local giant” is as “interesting”, if not more so, as that caused by a junior resident.
The resident-team that was involved with the case should present it. They should know all details and rehearse the presentation in advance.The patient’s chart and X-rays should be readily available. If you are the presenting resident, be objec- tive and neutral. Your task is to learn and facilitate the learning of others, not to defend or cover up for the involved surgeon; you are not his or her lawyer. Under- stand that the majority of those who are present are not stupid – they sense im- mediately when truth is deserted.
The Assessment of Complications
After the case has been presented, the person who presides over the meeting has to initiate and generate a discussion with the intent of arriving at a consensus.
An easy way to break the commonly prevailing and embarrassing silence is to point at one of the senior surgeons and ask “Dr. X, please tell us, had this patient been under your care from the beginning, would the outcome be the same?” This tech- nique usually manages to break the ice,prompting a sincere and complete response.
The questions to be answered during the discussion are:
Was it a “real complication”?Some surgeons may argue that blood loss, which required transfusion, is not a complication but a technical mishap, which simply
“can happen”.
Assess the cause: was it an error ofjudgmentor a technicalerror? Operating on a dying terminal cancer patient reflects poor judgment; having to re-operate for hemorrhage from the gallbladder’s bed marks a technical error – poor hemostasis at the first operation. The two types of errors are often combined and inseparable, the patient with acute bowel ischemia died because his operation was “too late”
(poor judgment) and the stoma, which was performed, has retracted, leaking into the peritoneal cavity (poor technique). Often it is impossible to define whether a “technical complication”(e.g.anastomotic leak) is caused by poor technique (tech- nical error) or patient-related factors,such as malnutrition or chronic steroid intake.
Another possibility is to look at the error as either an error of commission or omission. One either operates too late or not at all (omission) or operates too early or unnecessarily (commission). One either misses the injury or resects too little (omission) or does too much (commission). After the operation one either fails to re-operate for the abscess (omission) or operates unnecessarily when percutaneous drainage was possible (commission). Note that the surgical community considers errors of omission more gravely that those of commission; the latter are looked at with understanding: “we did all we could but we failed”.
Was there negligence? A certain rate of mistakes (hopefully low) is an integral part of any surgical practice as only those who never operate commit no errors,but negligence is deplorable. The operation was delayed because the responsible sur- geon did not want to be disturbed over the weekend or the surgeon operated under influence of alcohol; this is clearly “negligence”.When an individual surgeon repeats errors over and over again, a paradigm is exhibited, which in itself may constitute negligence.
Was the complication/death preventable or potentially preventable?We en- courage our residents to report the physiologic score of acute disease – APACHE II
(> Chap. 6) of the presented patient. Low pre-operative scores (e.g., below 10) mean
that the patient’s predicted operative mortality was very low, suggesting a prevent- able death such as anesthetic mishap. A very high score (>20) does not imply, how- ever, that the patient was unsalvageable. High-risk patients are those who require superb judgment and technical skills; these are the patients who do not tolerate even the smallest error.
Who was responsible? The MMM is not a court (> Fig. 52.1). Culpability is not the issue,but at the end of the presentation it should be clear to all present how things might have been done better. Blame is to be avoided at all costs (except in the most extreme cases, and then the MMM is not the forum to deal with them) because any system that aims to apportion blame as part of the quality control processes will fail;
the truth will be hidden and confrontation avoided. Such is human nature. The sad truth, however, is that in many instances complications and mortality are caused by
“system failure”– which in purely surgical terms means that the hospital is a
“s***hole” with a malfunctioning chain of command, organization, supervision, education and morals. For example, the old man was gasping unattended 6 hours in the emergency room before you were called to assess his acute abdomen.You de- cided on an emergency laparotomy but no operating room was available for 2 hours.
Because the orderlies went for dinner another half-an-hour was lost until you de- cided to fetch the patient yourself. Only then did you realize that the antibiotics and intravenous fluids you ordered had not been given. A clueless anesthetist then struggles with the intubation producing prolonged hypoxia… and so on and so on… how much damage can an old man take? System failures are much more com- mon than you think, just look around your own environment…
Was the standard of care met? As you surely know, the “standard of care”
means different things to different people. (“The good thing about standard of care is that there are so many to choose from”.) It has a spectrum, which should be well represented and assessed by a group of well-informed practicing surgeons. Take, for example, a case of perforated sigmoid diverticulitis with local peritonitis
(> Chap.26); any operation ranging from a Hartmann’s procedure (the conservative
surgeon) to a sigmoid resection with anastomosis (the modern surgeon) would fall within the accepted standard of care. Primary closure of the perforation would not.
Easy to assess – “anyone who would attempt closing the perforation please raise your hand”. No hand is raised; the responsible surgeon is left lonely to understand that what he did is not acceptable and is outside the practiced standard in his com- munity. The responsible surgeon may, however, present published literature to support that what he did is acceptable elsewhere. Local surgeons may, however, be dogmatic and wrong!
Evidence-based surgery. At the end of the presentation the resident should present literature to pinpoint the “state of the art” and the associated controversies, emphasizing “what could have been done,and should be done when we see a similar case in the future”.
The surgeon in whose patient the complication arose.At the end of the discus- sion the most senior surgeon involved in the care of the concerned patient should offer a statement. He may chose to present additional evidence from the published literature to show that what was done is acceptable elsewhere.The most graceful way
Fig. 52.1. “You killed the patient!”
to deal with the situation is to discuss the case scenario frankly and humbly admit any mistakes one may have made. If you had another chance with the same patient how would you manage him? By standing up and confessing you gain the respect of all present.When you lie, cover-up and refuse to accept the verdict of the gathering, you evoke silent contempt and distain, (or perhaps sympathy from obsessive liars).
So stand up and fess up!
Conclusions and Corrective Measures
Finally the person in the chair has to conclude – was there an error? Was the standard of care met? And what are the future recommendations and the corrective measures? If you are that chairman,and you may be some day,don’t be wishy-washy.
Be objective and definitive, for the audience is not stupid. Essentially, in any depart- ment of surgery the face of the MMM, its objectivity and practical value, reflects the face of the department’s chairman or director.
Financial Morbidity
In this day and age of growing costs and limited resources we must not ignore the financial morbidity – the excessive spending on unnecessary procedures, even if they were not associated with an immediately visible physical morbidity
(> Fig. 52.2). When discussing the case, ask the presenter to justify the Swan-Ganz
catheter that has been inserted, or the reason antibiotics were continued for 7 days, or why the patient was “observed” in the SICU after an uneventful laparotomy?
A useful educational exercise is to randomly present a detailed summary of the hospital bill of a presented patient. If you are confronted with what your patient’s care, your superfluous acts, and the complications you created actually cost in dollars or euros, you may become a more careful surgeon.
The SURGINET
An ideal and objective MMM as featured above is not conducted in many places because of local sociopolitical constraints. If this is the case in your neck of the woods,it may be damaging to your own surgical education; how would you know what is right or wrong? Books and journals are useful but cannot replace a thorough analysis of specific cases by a group of learned surgeons. Well, if you have a PC and e-mail access you can subscribe to SURGINET, an international forum of surgeons, who would openly and objectively discuss any case or complication you present to
Fig. 52.2. “How much money can he bill for sending this guy to his grave?”
Fig. 52.3. “SURGINET – please help me!”
them (> Fig. 52.3). Should you want to take part in this “international MMM” send an e-mail message to Dr. Tom Gilas of Toronto, tgilas@sympatico.ca, or to one of the editors of this book: mschein1@mindspring.com.
Conclusions
As you know, there are many ways to skin a cat, and it is easy to be a smart-ass looking at things through the “retroscope”. Our sick patients and the events leading to the MMM are very complex. But behind this chaos there is always an instructive truth which should be and can be disclosed and announced. As Winston Churchill said, success is “the ability to go from failure to failure without losing your enthusiasm”.
“It is usually the second mistake in response to the first mistake that does the patient in.” (Clifford K. Meador)
“The two unforgivable sins of surgery. The first great error in surgery is to operate unnecessarily; the second,to undertake an operation for which the surgeon is not sufficiently skilled technically.” (Max Thorek, 1880–1960)
We hope you enjoyed our little book. Let us wish you farewell using this memorable quotation from Winston Churchill’s broadcast (1949) to the people of conquered Europe.
“Good night then: Sleep to gather strength for the morning. For the morning will come. Brightly will it shine on the brave and the true, kindly on all who suffer for the cause, glorious upon the tombs of heroes. Thus will shine the dawn.”
You – the emergency surgeons – are the heroes of medicine. For you the dawn will shine!
The Editors
