Morbidity and Mortality Rounds

What follows are my views on the organization and conduct of morbidity and mortality rounds.

The principal reason to conduct M&M rounds is: To review an individual patient's poor outcome in detail with all members of the treating team and in this way try to determine what led to the poor outcome and discuss ways to prevent a similar event from happening again.

In cardiothoracic surgery, the outcomes to be discussed are principally mortality. To discuss all morbidities is not practical. It would be ideal to discuss major morbidities, although in a referral centre with a high volume of complex and ill patients, this may also be impractical. The surgeons may agree on a certain list of morbidities that they wish to present on a consistent basis. For example, deep mediastinal wound infections, ARDS, anastomotic leaks, or "massive" blood transfusion, etc. Discussing only mortalities allows for a more detailed discussion of fewer patients, rather than a superficial discussions on many patients.

It is important that M&M rounds concentrate on individual patients in significant detail. The presentation describes the unique events and circumstances that led to that patient's death. Subsequent discussion is around what could have been done differently, identifying things that could be changed or improved. Things that can be "changed and improved" may be about an individual or a system. Instituting solutions to problems identified may be complex and difficult so they can seldomly be completely addressed in an M&M forum. If the problems are significant enough, the division chair should take definitive steps to make effective changes at a later time.

As stated, M&M rounds should be about individual patients. Collection, presentation and discussion of data on groups of patients and their outcomes are to be addressed on a different occasion and in separate forum. This type of outcomes meeting does not replace or substitute for the M&M round, but in fact, should complement it.

Another very important component of the M&M conference is the attendance. Attendance of all surgeons in the division is essential. The division chair should lead by example is this regard. I believe that as many other physicians and surgeons should be involved. This includes medical students, residents and fellows, whose attendance should be mandatory. The forum should be open to any MD in the community interested in the patient or the discussion. This adds transparency. At a minimum, all the MDs involved in the patient's care should attend: surgeon, requesting consultant, primary care doctor, anesthetist, intensivist and any other consultants that were involved in the patient's care. The larger group and varied backgrounds should lead to a diversity of opinions and perspectives which, in theory, yields a more fruitful discussion.

In order to intelligently discuss the poor outcome of a patient, one must know as best as possible why the patient died. For this, an autopsy is essential and should always be requested in the event of a patient death. This also means that a pathologist with experience it thoracic diseases and autopsies is an integral part of the presentation and discussion at the M&M conference.

It may be argued that by having an open forum the discussion may be inhibited because of embarrassment or competing/conflicting political interests. In an open forum, people would be less likely to give honest opinions. Therefore, it may be argued that these conferences should be held "behind closed doors". I believe that a policy of openness and transparency is better and in the long run helps the credibility of a division. Furthermore, if a division is composed of competent and skillful surgeons, there should be no concern when discussing bad outcomes. They occur even in the best of hands. The point is what is to be done to try and prevent it from happening again.

The M&M conference should be held once per month in a large auditorium with audiovisual capabilities. Two hours should be allotted. One week before, a summary of the each case should be made available to all the consultants involved with the patient. This allows them to think about and review the case. The case is presented by the consultant surgeon and discussion takes place between the consultants only. Residents and fellows do not participate despite their attendance. This is a 'business' round and not a teaching round, although there can be much learned by everyone.

Finally, I would like to mention a similar type of conference that discusses "near misses". It is similar in spirit as the M&M round, yet the structure and conduct are different. Dr. Chaim Locker reminded me of the importance of this sort of discussion within a division. He used an airforce analogy when he told me that, although it is important to discuss the catastrophes, it is sometimes more useful to discuss the near-catastrophes.

The "near misses" conference can be held once per week and should involve only surgeons of the division aswell as residents and fellows. All should participate in the discussion. The meeting should be a no-holds-barred critique of cases. The discussions will tend emphasize aspects of the surgical care of the patient so participation by others is not critical.

To conclude, our actions as surgeons should be transparent when it comes to a poor patient outcome. This is the first step towards the critical assessment of what could have been done differently; and this will lead to changes that may prevent a death under similar circumstances. If we are competent and skillful, and then honest about our outcomes, our colleagues and patients will judge us fairly. We will also have their respect.