Learning Points

It seems to be the same whether it happens in the United States or Kenya.

You step in front of a group of your peers and consultants/attendings.  The Power Point is queued to your presentation.  You look around the room.  All the necessary characters are present - the medical student or intern who sleeps through ALL the lectures.  The consultant/attending who brings his computer/i Phone to everything is already tapping away.  The attending who hasn't picked up a book or journal in 20 years is ready with some jaunty comment. 

So, you take a deep breath and begin.  And afterwards, you wait for the onslaught of questions that you KNOW will come.  It is the sword of Damacles above your head, the day of judgement in the medical community.  It is the M&M Conference. 

M&M - or Morbidity and Mortality Conference - is something that most hospitals with educational programs (residency programs) hold periodically to review case of patients in which the outcome or care was poor or unfavorable.  The goals of M&M are to learn from patient complication or medical errors, so that medical professionals can prevent future bad outcomes.  These conferences are confidential and focus on improving patient care, physician judgement or hospital protocols. 

Apparently M&M Conferences have long been a part of the medical education.  In the early 1900s, Dr. Ernest Codman at Mass General Hospital in Boston lost his hospital privileges after suggesting that surgeon competence be formally evaluated.  However, his ideas contributed to the development of a case reporting system that designated culpability for poor outcomes.  This system was adapted by the American College of Surgeons in 1916.  In 1983, the requirement that all residency programs hold routine M&M Conferences was issued.

Well.  That seems honorable right?  Physicans getting together and talking, in order to learn through mistakes.

HA! M&M Conferences are the scurge of every resident on earth!  Here's a few reasons why:

1. The person who presents the case is responsible for all things done, not done, or done poorly for the patient during the hospitalization. 
Problem: Behind every patient is a team of multiple interns/residents and consultant/attendings.

2. Sometimes the person presenting the case has never even met the patient that he/she is presenting!

Problem: Obvious.  But it's a good case, so you take one for the team.

3. The consultant/attending is never in attendance to support you on the case, or if they are, they forget they were involved with the case and ask disparaging questions.

Problem: Refer to number 1

4. There are always at least 1-2 hecklers in the audience. The heckler is someone who - because of their vast medical training - feels it is necessary to point out all your mental deficiences by asking such questions as, "Did you compare the patient's rectal temperature to his oral temperature?"  and "Did you check a sodium: chloride ratio?" OR "Does the patient have a history of recent space travel."
Problem: The heckler's questions are always polite and well-posed, they are not-relevent are, in fact, retarded.  They add stress because you are not allowed to say, "Who cares?!"  Instead, you must muster such diplomatic responses as: "No." or "That's a good question, but I don't recall that being in the case file."

5. You have to tell "what you learned."    

Problem 1:  Sometimes the learning point of a case is vague and not helpful to the audience.  It is also unfair to the presenter.  For example,  "You should have diagnosed X condition sooner."  How is that a learning point?  I should be smarter?  Why should I have diagnosed it sooner?  Was it because obvious symptoms were ignored?  More often, here in Kenya, it is a combination of the patient presents late, there are too few nurses to care for so many patients and labs/imaging can take 24 hours or longer.  This is really about constructive criticism - and doctors are not very good at that.  "You should do better," is not constructive criticism.  Sometimes it is as simple as changing to: "If you have a patient with A, B, C, consider X." 
One memory from my residency:  I remember taking care of a patient who was 24 weeks with triplets who was hospitalized for preterm labor.  One night on my watch, early in my second year of residency, she went into labor and delivered.  The attending later said that the deaths of all three babies were on my shoulders because I should have diagnosed her labor sooner.  I've never regained the respect that I lost for that attending.  For those of us who are in a position to teach, be careful with your words - they can create long-lasting memories.

Problem 2: Do you even need to have a learning point?  I say no.  Sometimes there are poor outcomes - not because anybody did anything wrong - but because there are risks with surgery, there are limitations to testing and medicines does still have boundaries.  These cases are still worthwhile as teaching tools - not every M&M needs to feel like a meeting with the firing squad.

6. Sometimes the M&M involves other specialties.
Problem:  You may have to rush to "claim" the case before the rival specialty gets it or you may have to present it in retaliation.  If the case has a particularly bad outcome and people are upset, it would be beneficial if were the other "team's" fault.

All in all, M&M Conference was and is a great tool for learning and improving patient care.  But it can also be one of the most hated parts of medical training where the focus becomes to defer blame to other specialties or to gloss over mistakes.  The product of M&M conference is dictated largely by the environment in which it is hosted.  Perhaps with an enviorment of purpose and objectivity, without finger pointing or self-elevation, these conferences can foster the type of learning and reform that is still needed in medicine.