Mention Morbidity and Mortality Conference to most surgeons and watch flickers of painful memories play across their features. Many surgeons view these weekly hospital meetings – where one’s surgical errors are dissected before peers and superiors – as humiliating ordeals where participants may spend more time defending their actions than learning from their mistakes.
However, Los Angeles-based Cedars-Sinai’s Department of Surgery has transformed its weekly Morbidity and Mortality Conferences into an innovative educational study curriculum – the M & M Matrix. This progressive approach for reviewing surgical errors provides a forum where complications are discussed, analyzed, summarized into teaching points, and disseminated via e-mail to residents and participating attending staff, who are subsequently tested on the material.
According to Cedars-Sinai’s Associate Director of Surgical Education Leo A. Gordon, MD, FACS, Cedars-Sinai’s M & M Matrix is a significant departure from the old conferences, which were characterized by heated oral discourse. “In hospitals across the country, Morbidity and Mortality Conferences often result in tempers flaring and fingers pointing – and the lessons are often left at the door,” he said. “In Cedars-Sinai’s conferences, we take a systematic look at three different surgical complications, summarize the points, set them in print, and distribute them to residents and participating attending staff as study guides on which they will be tested.”
Dr. Gordon offered a hypothetical example of a 19-year-old male who develops a pulmonary embolism after undergoing surgery for multiple gunshot wounds to his pelvis. “The M & M Matrix on this case would be called ‘Pulmonary Embolism Following Surgical Procedures for Trauma,’” said Dr. Gordon. “At the conference, the moderator would lead a methodical discussion on how and why this complication occurred. The subsequent study matrix would include a summary of the discussion along with current medical references specific to the complication.”
According to Dr. Gordon, the complication-focused curriculum is a much more effective way to teach than the older “normal recovery” model.
“The M & M Matrix is an evolving concept in resident education, in which the first exposure to a surgical procedure is a complication, rather than a normal recovery,” he said. “This ‘tracing backward’ from a surgical complication to normal physiology and surgical recovery makes a profound impression on young surgeons. It has been shown that surgeons who are exposed to errors early in their careers are less likely to make them later.”
And this, according to Gordon, was the impetus for implementing the M & M Matrix educational model. “In 1999, the national Institute of Medicine released ‘To Err Is Human: Building a Safer Health System’ that addressed the subject of medical errors,” he said. “The M & M Matrix is a paradigm for identifying and assessing medical errors and changing medical behavior. We are excited about its potential use for resident education, certification, re-certification, issues of competence, and continuing medical education.”
According to Achilles A. Demetriou, MD, PhD, chairman of Cedars-Sinai’s department of Surgery, "The M&M Matrix is the perfect mechanism for transforming the valuable lessons of the Morbidity and Mortality Conference into an active and ongoing program of medical education.”