When I was a resident, we had a weekly Morbidity and Mortality Conference.
That was the euphemism for what most called it, Death and Donuts.
That moniker was not meant to be disrespectful. It was merely an acknowledgement that death did happen at the hospital. High risk procedures were indeed risky.
And a normal part of learning, getting better, and promoting quality included routine, open, honest conversations about what went wrong. What could we learn from the outcome? What could we do better? How do we prevent such errors from happening again, if even avoidable?
The conversations were tough.
I remember a resident delivering his narrative.
The attending asked the resident. “Was your patient sleeping with your wife?”
The resident looked bewildered, not understanding what this had to do with the operative mishap.
The attending asked the resident the same question. “Was your patient sleeping with your wife?”
The resident still didn’t know what to say. He said “No. Of course not.”
The attending finished, “THEN WHY ARE YOU TRYING TO KILL HIM?”
Humiliation was often a part of the Death and Donuts experience.
When others heard about mistakes, they learned. They learned what to look for to prevent a mishap. They thought about patient safety. No doctor wanted to end up on center stage.
Unfortunately, humiliation makes it less likely a doctor will want to share his mistakes. Who wants to be humiliated?
I’m guessing the tone of Morbidity and Mortality Conferences has changed. I’m guessing they are less hostile. More about checking the boxes. I also know that some abuse such conferences to settle vendettas with competitors.
And donuts are no longer brought in by pharmaceutical reps.
What do you think?
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