Abstract
Background: Morbidity and mortality (M&M) meetings play a pivotal role in enhancing clinical practice and assessing surgical competencies. When organized effectively, these meetings provide valuable learning opportunities for surgical trainees. Our objective is to examine current perceptions of M&M meetings among practitioners by exploring common positive and negative attributes, and propose standardized modes of improvement.
Materials and Methods: A comprehensive literature search on morbidity and mortality meetings was conducted using Pubmed, Ovid MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials. Various combinations of keywords including “morbidity and mortality”, “surgical education”, and “surgical trainees” were utilized without imposing any search restrictions
Main outcomes: M&M meetings facilitate a conducive learning environment where surgeons of all experience levels can openly discuss critical medical errors. Emphasizing a blame-free atmosphere is crucial for effective problem-solving. Innovative approaches such as direct patient involvement and online platforms can enhance the efficacy of M&M meetings.
Conclusions: M&M meetings serve as vital conduits for transferring experiences and knowledge from seasoned surgeons to trainees. However, a culture of blame may impede transparency and undermine the educational value of these meetings.
Background
Morbidity and mortality meetings are commonly used as a surgical training tool [1]. Generally speak-ing, morbidity and mortality meetings should be held weekly or every two weeks during working hours, and last between 45 to 60 minutes [1-2]. Both surgical attendings and trainees are encouraged to attend morbidity and mortality meetings and other surgical or medical specialists are welcomed, espe-cially if they can provide a different point of view in the case discussion [1]. Moreover, the use of morbidity and mortality meetings offers a mode of evaluating and improving surgical competencies in both attendings and trainees [3;4].
Nevertheless, morbidity and mortality meetings can be a difficult environment for younger surgeons and trainees to report a medical error and avoid a feeling of blame. The possibility of analyzing and un-derstanding clinical cases under the supervision of a senior surgeon undoubtedly minimizes the chanc-es of repeating the same error, and offers a great learning opportunity; this ultimately increases the quality of delivered healthcare services and ameliorates patients safety.
Methods and Materials
An organized search of relevant literature was performed by two researchers using the following databases from inception: Pubmed, Ovid MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials. Retrieved literature was limited to the English language.
The terms “morbidity and mortality”, “morbidity and mortality meetings”, “surgical education”, “surgical trainees” were used in various combinations. No search restrictions were imposed. Compara-tive studies, multicenter studies, case reports, large and small case series were included. All papers se-lected for this literature review which specifically address the role of morbidity and mortality meetings in surgical education are reported in Table 1.
Results
Table 1 summarizes the main benefits and limitations of morbidity and mortality meetings. All the pa-pers analyzed elicit the importance of morbidity and mortality meetings. Morbidity and mortality meet-ings can improve surgical training, while some offer new ways of implementing specific meeting fea-tures to increase their effectiveness. At the same time, some papers criticize certain limitations of these meetings, especially towards younger surgeons or trainees.
However, these potential limitations are outweighed by the provision of practical solutions. A proper analysis and discussion of the relevant literature is developed below [4-18].
Summary of Outcomes
Morbidity and mortality meetings are a fundamental tool to discuss clinical cases and their relevant lit-erature between more and less trained surgeons.
To investigate it, Abu-Zidan et al submitted an anonymous questionnaire to a group of surgeons and trainees about morbidity and mortality meetings’
satisfaction and, based on the answers, they imple-mented the successive meetings. After 9 weeks, they repeated the questionnaire showing an improved literature knowledge and ability to discuss a clinical case. During morbidity and mortality meetings, trainees are required to perform presentations. In preparation for these presentations, the residents had to update their knowledge on the latest guidelines or literature. Thereafter, these trainess would be ex-posed to a “friendly” discussion with more experienced surgeons on the presented cases [4].
Lecoanet et al conducted a survey on both surgical and medical morbidity and mortality meetings and found several benefits. Notably, both junior and senior doctors felt their knowledge was being updated. These meetings and discussions also propagated an increase in inter-unit teamwork and collaboration; which ultimately contributes towards healthcare quality and patient safety. The “non
blaming” environ-ment was recognised as being one of the most important features of morbidity and mortality meetings. Older surgeons found the meetings more educational than trainees, but both agreed on the value in medical and surgical education. The only problem identified with these meetings was the lack of a con-sistent structure in presenting the cases [5].
Berhanetsehay et al. presented similar satisfactory results in their survey. They proposed a structured questionnaire with an open-ended question at the end to all physicians following at least two meetings. Participants agreed upon the educational role of morbidity and mortality meetings, however they noti-ced a low implementation and follow up of the core points discussed during the meetings. Similarly, as Lecoanet [5] already demonstrated, a structured format and a standardized case presentation provided a better perception of the educational role of morbidity and mortality meetings [6].
Kauffmann et al. offered a different perspective on surgical education; wherein the morbidity and mor-tality meetings were conducted to meet the Accreditation Council for Graduate Medical Education [ACGME] general competencies. They reviewed all the previous 21 months of morbidity and mortality meetings. In particular, the authors studied if there was any patient care improvement after the meet-ings. The authors also studied if the six general competences of the ACGME were specifically and ex-plicitly addressed. Discussing clinical cases and their outcomes provided a personal and professional improvement opportunity. This improvement can be tracked objectively when checked against the core points of the ACGME general competencies. In the end, the proper use of morbidity and mortality meetings appeared to improve surgical training by equipping surgeons with the skills and knowledge to recognize and manage errors [7]
At the same time, Orlander et al., while agreeing with the main teaching purposes of morbidity and mortality meetings, show that often “tough issues” are either not faced during the meetings, or are faced in such an inappropriate way that the participants may avoid “tough issues” out of fear of public humil-iation. This may happen for several reasons: for example, fears of legal action or loss of respect. How-ever, the authors emphasized that it is of utmost importance that medical errors are addressed appropri-ately; as learning from these errors will contribute towards improving the standard of care in similar future scenarios. In fact, the authors proposed a model for morbidity and mortality meetings, which they believe would help reduce this potential stray from an educational path. The inevitability of medi-cal errors should be a core concept when conducting morbidity and mortality meetings [8].
Kocabayoglu et al. reported their experience on morbidity and mortality meetings over a two-year peri-od in a liver transplantation unit. All of the meetings had a similar structure and involved all healthcare providers involved in liver transplantations. Both faculty and residents agreed on the fundamental role that morbidity and mortality meetings have in surgical education, especially regarding high complexity patients. Nevertheless, they highlighted the importance of maintaining the focus of morbidity and mortality meetings on structural and systematic problems, and to consistently provide means of im-provement in a blame-free environment [9].
Harbison et al. provided an interesting comparison between surgical residents and faculty. They ran-domly selected both faculty members and surgical residents to submit a survey about morbidity and mortality meetings with follow up every two weeks up to twelve weeks later; at the end of the survey, they also included an open-ended question to gather a direct opinion.
Their survey demonstrated that respondents agreed on the educational purpose of morbidity and mortality meetings and their im-portance in serving as appropriate quality checks in surgical units. However, the authors showed that residents found morbidity and mortality meetings less effective in surgical education; and they suggest-ed an improvement was needed to reduce defensiveness and blame [10].
Focusing more on morbidity and mortality meetings’ discussion topics and their perception, Gore [11] presents a two-part survey where part A focused on specifics about morbidity and mortality meetings and part B on audience perception. Part A offered a good standardization of a morbidity and mortality meeting: the participants discussed mistaken diagnoses, evaluated radiographs and autopsy reports and in almost half of the meetings, a non-surgical specialist was attending [1]. Part B reported on the per- ception of the attending members at the morbidity and mortality meetings. All the attending members agreed on the teaching role of morbidity and mortality meetings, especially when based on evidence-based medicine and when diagnostic tools such as radiographs and pathology findings were discussed. Interestingly, none of them reported the concealment of any medical information, even those errors that could have been possibly incriminating [11].
Similarly, Falcone et al [12] provided a two-year survey on morbidity and mortality meetings held by senior surgical residents, showing a general stability in reporting adverse events. Like Kauffmann [7], they considered morbidity and mortality meetings a great way to implement and verify the six general competencies of the American Council for Graduate Medical Education, with particular focus on prac- tice-based learning and improvement. Although they explained some incoherent results such as the de-creased reporting of adverse events in pediatric surgery; they also noticed some underreporting of non-fatal adverse events– probably related to a fear of reporting or not acknowledging adverse events. Meanwhile, the survey providds an insight into what was considered an adverse event, which differed across different surgical specialties. Finally, they offered some tips to improve a standard surgical mor-bidity and mortality meeting. These include providing feedback to the senior-most resident to check and increase the quality of the meetings, providing all surgical residents with a summary of major and nonmajor adverse events, and fostering an atmosphere of collaboration to create a safe space for expe- rienced surgeons and surgical residents to freely discuss the clinical cases without fear of judgement or blame [12].
Besides the involvement of other medical specialists during morbidity and mortality meetings, Myren et al. propose a new morbidity and mortality format where patients themselves attended the meetings.
They noticed, supported by recent literature, how involving the patients in daily practice improves the perceived quality of care, although it may be difficult on a daily basis due to the
typical busy doctors’ schedule. This different approach offered new technical difficulties as compared to a standard morbidi-ty and mortality meeting, such as rescheduling working hours in order to manage an appropriate time for the meetings, especially if there are other specialties consultant involved. Yet more promisingly, they offered the possibility to interact directly with the patient when the case was discussed, establish-ing a better partnership between doctors and patients. However, some healthcare professionals raised concerns about the openness of the discussion in specific cases and the actual value of the learning pro-cess. At the same time, patients reported an improved communication with healthcare professionals and a better understanding of the adverse events themselves, which was previously impossible to under-stand during hospital admission due to stress, pain/ painkillers, or anesthesia. Some patients, finally, decided to participate in these novel morbidity and mortality meetings in order to increase the learning for healthcare providers, and simultaneously reduce the possibility of error repetition. [13].
The changes brought forth by the recent COVID-19 pandemic offered a new way to approach morbidi-ty and mortality meetings through specific online tools. The re- assignment of healthcare providers worldwide towards combating the pandemic, decreased the focus on training programs and meetings. Both Myren [14] and Gallo [15] published surveys studying these changes and submitted innovative ways to implement surgical training during that particular period.
After the positive results in 2021 [13], Myren et al. [14] tried adding a patient perspective during online morbidity and mortality meetings. They followed a similar questionnaire in their previous paper [13], adding new key points such as
non-verbal communication and an online tool to be evaluated. They rec-orded five morbidity and mortality meetings held by a consultant concerning adverse events of varying gravity. Although they all confirmed the positive results achieved in patients attending in-person mor-bidity and mortality meetings such as a benefit in doctor/patient communication and relationships; they reported the online meetings caused a worse understanding of patients and healthcare workers due to a lack of non-verbal communication. Non-verbal communication appeared to play a fundamental role in understanding patients’ perspectives of the situation, so healthcare providers had to rely mainly on ver-bal communication to interact with the patients, which created a general insecurity from healthcare pro-viders about not being completely understood. However, patients still reported all the positive attributes of in-person morbidity and mortality meetings, with an added comfort in learning and mastering a new online tool. One even perceived an increased interest from doctors due to more personal questions in order to clarify patient’s perspectives and doctors’ explanations [14].
At the same time, Gallo et al. present a national three-part survey on how much the COVID19 pandem-ic affected surgical residents’ training [15]. Based on the various surveys already published in interna-tional literature, they selected 430 surgical trainees to answer the survey, which was divided into three distinct parts: the first part gathered information about general demographics and the typical activities held before the pandemic, the second part focused on the changes elicited in clinical/surgical education-al activities, while the third part evaluated the activities that were maintained during the pandemic. The authors clearly reported a decreased amount of surgical, research and didactic activities due to a reduced number of surgeries, COVID19 restrictions and reassignment of surgical residents in medical wards to face the emergency. Considering the educational shift during the swave, only 65% of residents had the possibility to study and learn in their specialty field of choice, while the others had to partially or fully focus on learning about COVID19.
However, where available, the use of remote teaching, such as case reports in morbidity and mortality meetings, and virtual simulators for surgical practice proved to be fundamental to keep providing education towards surgical trainees, although 33% of the participants described a complete interruption in surgical training activities. Regarding the results of this survey, positive feedback arose from surgical trainees in using new devices such as virtual learning or virtual simulators and implementing the standard in person class or morbidity and mortality meeting with online attendance. Many of these practices still remain implemented in post pandemic surgical didactic programs [15].
Finally, Epstein [16], Bakhshi [17] and Vreugdenburg [18] focused on the impact of morbidity and mortality meetings in surgical education and patient safety. Epstein et al. [16] provided a literature re-view about the difference between morbidity and mortality meetings and quality assurance conferences and their importance as educational tools. While morbidity and mortality meetings are developed to evaluate clinical cases in order to optimize the successive decisions of healthcare professionals; quality assurance conferences are mandated by hospitals to identify and correct systematic faults, gathering all of the information on a single process and analyzing its structural biases and mistakes. Following this definition, quality assurance conferences are able to fix and prevent a medical error by adjusting the hospital system and patient journeys. These changes are typically effected via a proto-col or a particular instrument. Morbidity and mortality meetings, on the other hand, rely on analyzing clinical cases with the relevant literature to evaluate possible medical errors, proving much more useful in surgical training. These meetings are also mandatory for the American Council for Graduate Medi-cal Education in every surgical training program nationwide. As Epstein found in the literature, there is a lack of a standardized format or cadence of morbidity and mortality meetings. There is an even greater lack of standardized protocols for monitoring implementations after the discussions.
However, it is commonly accepted that they offer an invaluable opportunity for younger trainees to dis-cuss a case with experienced surgeons, and to learn how to handle a medical error. Apart from the sin-gle meeting, Epstein also evaluated the benefit of a retrospective and prospective collection of data for morbidity and mortality meetings, creating a database for data collection in order to provide the single center or unit experience about an adverse event and how a diagnosis and treatment were determined [16].
Bakhshi et al [17] published a literature review about the lack of standardization of morbidity and mor-tality meetings. They underlined how important mandatory morbidity and mortality meetings were, for increasing patient safety and improving surgical training. At the same time, they noticed how the lack of an international protocol reduced the effectiveness of the meetings, and potentially led to the over-sight of certain fundamental parts of clinical case discussion or literature revision. They reported that in their center, morbidity and mortality meetings are mandatory for surgical units. However they experi-enced several mistakes during the submission of a case for these meetings, such as delays in the sub-mission or data affected by a recall bias. In order to overcome these problems, they established an online platform accessible to all surgery units to record all clinical cases that could be discussed in a morbidity and mortality meeting. Since morbidity is far more frequent than mortality, they started re- cording mortality cases only. In the first eight months, 73 cases were analyzed, discussed and signed off by the Head of the Department. As stated before, morbidity and mortality meetings are fundamental in surgical training and are typically conducted by younger surgeons or trainees. An online register may be useful to avoid recall bias and help the trainee in the literature review preparation for the meet-ing [17].
Vreugdenburg et al. [18] reviewed the literature on morbidity and mortality meetings, searching for fac-tors that positively or negatively impact the effectivity of the meetings and their educational purpose. After the primary selection and control by an independent review group, they selected 22 studies, 19 of which identified enablers or barriers. Positive traits included a clear format in structuring and present-ing the clinical case; the appropriate invitation of other specialties’ consultants or the use of online tools; focusing on a central theme including close-calls and near-misses in a blame-free environment; propos-ing recommendations at the end of the meetings which should be implemented and verified after a cer-tain amount of weeks; and a detailed record of previous morbidity and mortality meetings. Negative attributes included the lack of research or academic preparation on the topics presented; an inconstant attendance at these meetings; a negative perception of morbidity and mortality meetings from their at-tendants; and logistical issues in creating the event or inviting the right healthcare providers for the meeting to begin with. Combining these enabling factors and avoiding these barriers can help to in-crease the efficiency of morbidity and mortality meetings, in order to obtain both a better quality of sur-gical training and a better improvement in patient safety overall [18].
Strength and Limitations of this study
This review underscores the significance of morbidity and mortality (M&M) meetings in surgical edu-cation. Drawing upon available data and literature, these meetings, which involve presentations and discussions with expert surgeons and other medical professionals, offer diverse modalities to enhance the knowledge and competencies of surgical trainees. By facilitating a comprehensive analysis of adverse events, M&M meetings enable trainees to learn from mistakes and implement strategies to prevent recurrence [16; 18].
Furthermore, the adaptability of M&M meetings to remote teaching sessions is noteworthy, with online databases dedicated to documenting patient morbidity and mortality, thus facilitating comprehensive evaluations and discussions
[17-18]. Additionally, involving patients or their relatives in these meet-ings fosters a supportive environment conducive to improving doctor-patient relationships and promot-ing understanding of the impact of adverse events on patients’ lives [13-14].
However, challenges such as the lack of transparency during case presentations due to legal concerns and inadequate preparation may hinder the effectiveness of M&M meetings [8-10]. Nonetheless, fos-tering a non-punitive atmosphere and acknowledging the possibility of medical errors can mitigate these challenges and enhance the educational value for surgical trainees [8-10].
The primary limitation of this review lies in the reliance on subjective data, predominantly from sur-veys, which poses challenges in objectively assessing the impact of M&M meetings on surgical train-ing. Despite this limitation, the reviewed literature offers insights and recommendations, such as struc-tured protocols and meetings, to optimize the effectiveness of M&M meetings [16-18].
Conclusions
Morbidity and mortality (M&M) meetings stand out as a pivotal resource in enriching surgical training, especially within a structured environment that promotes open dialogue and cultivates a blame-free cul-ture. These meetings offer a promising avenue for refining the education of young surgeons, honing surgical skills, and advancing patient care practices. As such, integrating M&M meetings into our prac- tice could yield substantial benefits. Moving forward, there is a need for prospective studies to delve deeper into the impact of this educational tool on the behaviors and development of young surgeons at the outset of their careers
Table 1: Main improvements and limitations using M&M meetings for surgical education
Author | Year | Improvements | Limitations |
Abu Zidan | 2001 | Significant improvement in surgical training | NA |
Lecoanet | 2016 | Significant improvement in surgical training | NA |
Berhanetsehay | 2020 | Improvement in surgical training | Low application of core point discussed during M&M meetings |
Kauffmann | 2011 | Improvement in surgical training | NA |
Orlander | 2002 | Improvement in surgical training | Not facing though issues |
Kocabayoglu | 2016 | Improvement in surgical training and detecting errors | Need for a structured approach of meetings and follow up |
Harbison | 1999 | Improvement in surgical training | Less effective for residents, high amount of shame and blame |
Gore | 2006 | Improvement in surgical training especially if based on EBM | Higher feeling of failure reported among younger residents |
Falcone | 2012 | Stable reporting of adverse events | Undereporting minor adverse events from senior residents |
Myren | 2021 | Sharing M&M meetings with patients | Openness to discuss clinical cases and proper learning value |
Myren | 2022 | Same improvements as in face to face meetings | Lack of non verbal communication |
Gallo | 2022 | Online M&M meetings were a fundamental learning tool during COVID-19 pandemic | NA |
Epstein | 2012 | Significant improvement in surgical training | NA |
Bakhshi | 2021 | Improvement in surgical training using online database to record and discuss clinical cases | NA |
Vreugdenburg | 2018 | Improvement in surgical training adapting different formats | NA |
