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005 APDS SPRING MEETING

sing the Morbidity and Mortality Conferenceo Teach and Assess the ACGME Generalompetencies

oel C. Rosenfeld, MD

t. Luke’s Hospital, Bethlehem, Pennsylvania

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URPOSE: The weekly Morbidity and Mortality (M&M)onference, a Residency Review Committee on Surgeryequired conference, is a hallmark of general surgery residencyraining. This conference has been used traditionally to teachnd assess the ACGME General Competencies of patient carend medical knowledge. The author’s department has changedhe format of their weekly M&M conference so that it enableshem to teach and assess residents also in terms of the ACGMEeneral Competencies of practice-based learning and improve-ent, professionalism, interpersonal and communication

kills, and systems-based practice.

ETHODS: Each Monday the chief resident on each teachingervice compiles a list of patient discharges and deaths for therevious week. Although all deaths are presented, only signifi-ant patient complications are selected for the following week’s

&M conference. This 2-week preparation period enables theesident, who was primarily involved in the care of the patient,o thoroughly review the case and prepare his/her presentation.t the conference, the resident presents the patient’s history andiscusses the complication or death, not only in terms of theatient care provided (traditional M&M model), but also itnalyzes the case in terms of health-care systems problems thatay have contributed to the patient’s morbidity and/or mor-

ality; patient safety issues; communication problems with theatient, family, or other health-care workers; and ethnic orthical issues related to the care provided. The case is theneviewed by faculty surgeons. Again, not only is the patient careritiqued, but also systems problems, communication prob-ems, and ethical dilemmas.

Each resident who presents a case at the M&M conferencelso completes a practice-based improvement log. This formnalyzes the patient’s outcome including factors leading to theomplication and/or mortality, opportunities for systems im-rovement, patient safety or communication problems, ethnicr ethical issues, what the resident would do different in his/her

orrespondence: Inquiries to Joel C. Rosenfeld, MD, MEd, Department of Surgery, St.

auke’s Hospital, 801 Ostrum Street, Bethlehem, PA 18015; fax: (610) 954-6450; e-mail:osenfj@slhn.org

CURRENT SURGERY • © 2005 by the Association of Program DirPublished by Elsevier Inc.

64

ractice, and references consulted for this case. These forms areeviewed with the resident by the Residency Director and be-ome part of the resident’s portfolio.

ONCLUSION: The restructuring of the M&M conferenceo that a case is analyzed with all ACGME General Competen-ies has made the M&M conference more interesting and hasmproved the educational aspects of the conference. Analyzingcase according to the various ACGME General Competenciesas provided another method to teach these competencies toheir residents and a tool to determine whether the residents areeeting the competencies. (Curr Surg 62:664-669. © 2005 by

he Association of Program Directors in Surgery.)

NTRODUCTION

he goals of professional education, whether it be medicine,aw, accounting, or education, are to teach future practitionersf the profession how to problem solve, how to continue toearn new methods or improve on present or older methodshile performing presently approved procedures, and how toevelop self-learning techniques so they can continue to de-elop professionally throughout their life. These goals are essen-ially the objectives of the ACGME Outcome Project and the 6eneral Competencies (patient care, medical knowledge prac-

ice-based learning and improvement, interpersonal and com-unication skills, professionalism, and systems-based practice).

f properly structured, the weekly morbidity and mortalityM&M) conference can help to fulfill these goals of professionalducation.

Traditionally the M&M conference has had as goals educa-ion, performance improvement, and risk management. Theonference has usually been centered on the ACGME Generalompetencies of patient care and medical knowledge. Practice-ased learning and improvement may have been addressed inerms of performance improvement. Various studies, however,ave questioned whether the M&M conference really makes aifference in terms of performance improvement.1,2 Depend-

ng on the atmosphere of the conference, errors and adverse

dvents may not be discussed openly.3 Also, unless a resident

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ctively reflects about a patient’s complication or death, he orhe may not learn from the case. We have modified the formatf our weekly M&M conference and developed a post-confer-nce resident exercise in which a resident submits a form ana-yzing a case he or she presented at the M&M conference. Thesehanges enabled us to use the weekly M&M conference to teachnd assess residents in terms of various aspects of the ACGMEompetencies.

ETHODS

he changes in the M&M format include the following. Eachonday the chief resident on each teaching service submits a

ist of patient discharges and deaths from the previous week.omplications are listed for each patient. All deaths are auto-atically selected for review at the following week’s M&M

onference. Only significant patient complications as deter-ined by the chief of surgery and/or the residency director are

elected. The resident, who was primarily responsible for theare of the patient whose case was selected for presentation, haspproximately 2 weeks to prepare a presentation. The almost-week interval between a patient’s discharge and the presenta-ion of the case at the M&M conference enables the residentrimarily responsible for the patient to reflect on the care pro-ided and to adequately prepare the case for presentation. Theuthors expect the resident to discuss the case with the respon-ible attending surgeon. The resident develops a Power PointMicrosoft Corporation, Redmond, Washington) presentationummarizing the hospital course with pertinent laboratorytudies and x-rays.

The case analysis and presentation is broader than the previ-us case discussions under the old format. When the residentresents the case, he/she discusses the case not only in terms ofhe patient care provided but also analyzes health-care systemsroblems that may have contributed to the patient’s morbiditynd/or mortality; patient safety concerns; communicationroblems involving the patient, the patient’s family, or otherealth-care workers; and ethical or ethnic cultural issues relatedo the care provided. The resident also presents a brief literatureeview. The M&M conference moderator or a previously se-ected faculty surgeon, again from the same discipline but notnvolved in the case, then reviews the case. Not only is theatient’s care critiqued but also systems problems, communica-ion problems, and possible ethical dilemmas. The case is thenpened for discussion by the attending surgeon and the audi-nce.

Each resident who presents a case at the weekly M&M confer-nce also completes a practice-based improvement log (Fig. 1).his form was adapted and modified from a form developed by theepartment of Surgery at Southern Illinois University School ofedicine. This form analyzes the patient’s outcome including fac-

ors contributing to the complication and/or mortality; opportu-ities for systems improvement; and opportunities for enhancingatient safety, ethical and cultural issues involved in the case, and

hat the resident would do different in his or her practice in the i

URRENT SURGERY • Volume 62/Number 6 • November/December 20

uture as a result of this experience. The resident also lists referenceshat he or she consulted for the case. This form becomes part of theesident’s portfolio and is reviewed with the resident by the resi-ency director at periodic evaluation sessions.

ISCUSSION

he weekly M&M conference is a hallmark of general surgeryesidency programs. This conference fulfills the Residency Reviewommittee on Surgery requirement for a weekly forum in which

omplications and deaths are reviewed. This weekly conferencenvolving faculty, residents, and medical students is the “premierducational conference in most surgery departments.”4 It has beenalled “the golden hour of surgical education.”5 The M&M con-erence as a cultural ritual plays a significant role in the maturationnd acculturation of residents into the “society of surgeons.”6,7

The M&M conference enables surgeons and residents to discussdverse events. The goal of the conference is for surgeons to im-rove their knowledge by learning from the complications pre-ented so they can prevent similar problems from occurring in theuture. It is accomplished through the basic format of the M&Monference in which adverse events are discussed collegially in anpen setting with analysis and critique provided by multiple ex-erts.2,8

The M&M conference has been reviewed extensively in theedical literature. Although there have been papers analyzing its

ducational effectiveness in terms of quality improvement and pa-ient safety,9,10 only a few papers relate the M&M conference toeaching and assessing the ACGME General Competencies. Wil-iams and Dunnington,11 from the Southern Illinois Universitychool of Medicine, described the use of their practice-based im-rovement form completed by residents for the M&M conference.his form primarily dealt with the competencies of practice-based

mprovement and systems-based practice. Ziegelstein and Fie-ach12 from the Johns Hopkins Bayview Medical Center reportedsing a weekly inpatient morbidity and mortality morning reporto teach medical residents how to use errors to improve systems ofare. Rubinfeld et al13 from Henry Ford Hospital reported using aWeb-enabled” M&M conference to facilitate the learning of res-dents in terms of systems-based practice.

Traditionally, the M&M conference of the author, like mosturgery department M&M conferences, just discussed the pa-ient’s hospitalization—the competencies of patient care andedical knowledge. Methods to improve the care provided—

ractice-based learning and improvement—were also reviewed.his new format enables surgeons to discuss more than just

urgical judgment and surgical technique. System flaws, patientafety concerns, communication problems, and professionalismssues are also discussed.

The goal of this M&M conference is education. The confer-nce is conducted in a nonintimidating, nonjudgmental, andonpunitive manner. We have a separate performance im-rovement committee to deal with peer-review problems. Theositive learning environment of the M&M conference has

mproved the surgical educational program. At the conference

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IGURE 1. Practice-Based Improvement Log.

66 CURRENT SURGERY • Volume 62/Number 6 • November/December 2005

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URRENT SURGERY • Volume 62/Number 6 • November/December 2005 667

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here is a broader educational experience for both residents andaculty. More than just the surgical care rendered is discussed.ecause of the educational milieu of the conference withoutlame and shame, there has been an increased discussion ofdverse events and near misses—potential errors. This openiscussion of adverse events coupled with increased awarenessf the importance of systems-thinking has led to increased ad-

FIGURE

erse event and near-miss reporting by the residents and faculty

68 CURRENT

ttending surgeons of the author’s facility. Hopefully, it willnhance patient safety.

There has also been an increased appreciation and awarenessy residents and faculty of the importance of communicatingffectively with patients and other health-care workers. Culturalifferences affecting the way some patients approach theirealth care have been reviewed.

ntinued)

The conference has also improved the overall educational

SURGERY • Volume 62/Number 6 • November/December 2005

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rogram of the residency of the author’s facility by demonstrat-ng deficiencies in the curriculum. Weaknesses, not only inarious aspects of medical knowledge and patient care, but alson other areas such as ethics and communication skills withatients, families, and colleagues have been unmasked. Lec-ures, symposia, and interactive resident exercises have beenmplemented to correct deficiencies. The M&M conference haslso stimulated research opportunities by residents and facultyn terms of ways to correct problems presented at this confer-nce. These projects have resulted in presentations and publi-ations by the residents.

Attendance at the M&M conference by faculty surgeons andther physicians (radiologists, gastroenterologists) has in-reased. Evaluation forms based on a 5-point Likert scale com-leted by residents, faculty surgeons, and other physicians haveemonstrated greater satisfaction with the conference since the

ntroduction of the new format.Completion of the post-M&M practice-based improvement

og again enables the resident to reflect on his/her patient’sospital course and the complication. The form helps the resi-ent to contemplate what he/she would do different in theuture to prevent a similar adverse event. This form also enableshe program director to assess the thought processes of theesident in terms of the competencies, because the form querieshe resident of whether there were any opportunities for systemmprovement or enhancing patient safety and whether thereere any ethical or cultural issues involved in the case.

ONCLUSION

he restructuring of the author’s M&M conference so that aase is analyzed with all ACGME General Competencies hasade the M&M conference more interesting and has improved

he educational aspects of the conference. The discussion ofystems problems, patient safety issues, and communicationifficulties that may have led to a patient’s poor outcome as wells ethical and/or cultural issues in patient care has improved theverall educational program of the residency at the author’sacility. The M&M conference and the post-conference resi-ent exercise provide the author with a method to teach theCGME General Competencies to the residents and a tool tossess whether the residents understand and are meeting these

ompetencies.

URRENT SURGERY • Volume 62/Number 6 • November/December 20

EFERENCES

1. Harbison S, Regehr G. Faculty and resident opinions re-garding the role of morbidity and mortality conference.Am J Surg. 1999;177:136-139.

2. Risucci DA, Sullivan T, DiRusso S, Savino JA. Assessingeducational validity of the morbidity and mortality con-ference: a pilot study. Curr Surg. 2003;60:204-209.

3. Orlander JD, Barber TW, Fincke BG. The morbidity andmortality conference: the delicate nature of learning fromerror. Acad Med. 2002;77:1001-1006.

4. Sachdeva AK, Blair PG. Educating surgery residents inpatient safety. Surg Clin N Am. 2004;84:1669-1698.

5. Gordon LA. Gordon’s Guide to the Surgical Morbidity andMortality Conference. Philadelphia, PA: Hanley & Belfus;1994.

6. Gawande A. Complications: A Surgeon’s Notes on an Imper-fect Science. New York: Henry Holt; 2002.

7. Bosk CL. Forgive and Remember: Managing Medical Fail-ure. Chicago, IL: Chicago University Press; 1979.

8. Murayama KM, Derossis AM, Da Rosa DA, ShermanHB, Fryer JP. A critical evaluation of the morbidity andmortality conference. Am J Surg. 2002;183:246-250.

9. Russell J. Patient Safety and GME curricula: function fol-lows form. ACGME Bull. Aug. 2004;11-12.

0. Pierluissi E, Fischer MA, Campbell AR, Landefeld CS.Discussion of medical errors in morbidity and mortalityconferences. JAMA. 2003;290:2838-2842.

1. Williams RG, Dunnington GL. Accreditation Councilfor Graduate Medical Education Core Competencies Ini-tiative: the road to implementation in the surgical special-ties. Surg Clin N Am. 2004;84:1621-1646.

2. Ziegelstein RC, Fiebach NH. “The Mirror” and “TheVillage”: a new method for teaching practice-based learn-ing and improvement and systems-based practice. AcadMed. 2004;79(1):83-88.

3. Rubinfeld IS, Shepard A, Woodward A, Yoshida A. Useof a Web-enabled morbidity and mortality conferenceto increase systems learning. ACGME Bull. Nov. 2004;

12-14.

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