m & m

At lunch last week, we had M&M. I am not talking about the tasty candy that melts in your mouth and not in your hands. Morbidity and Mortality is a conference where physicians discuss a recent case, usually one that went wrong on some level. The comment we often whisper to each other as we hear the story of the patient’s worsening hospital course is: “I wonder what the autopsy showed.” The patients presented usually have died by the time they make it to M&M.

The point of these conferences is for physicians to learn painful lessons from other physicians. Often they are good ones. Subtle things that would not necessarily catch your attention, but given a constellation of other subtle findings can lead to—voila—a diagnosis or different management plan.

It is never fun to present these cases. You are explaining to other physicians how someone under your care deteriorated or died. These conferences are to medicine what the confessional is to reality television, or perhaps the reunion wrap-up show. The action stops and we dissect what occurred. They take place in a sanctum where only other medical professionals are permitted.

Usually, we scour labs results, exam notes, x-rays, vitals, everything in the evidence to figure out what could have reasonably been done differently. The ‘defending’ physician points to the evidence to support why they did what they did. A tenuous position, since they already know the outcome, but they are not arguing they did the ‘right’ thing, only that it was a reasonable course. And usually, it was a reasonable course, just not a perfect one. These are not cases of malpractice. These are complex cases where tough decisions are made. Not for the weak of heart.

By way of example, fifteen years ago I was in Paris with my sister, who would wait for the Metro standing very close to the edge of the platform. When I am in an unfamiliar city, let alone country, I am always paranoid: Observing who is around, noting easy exits, potential dangers. When she would stand that close to the edge, I would feel queasy, imagining her losing her balance or being pushed before an oncoming train. What made this worse was imagining trying to grab her as she was regaining her balance, only to put her off balance again and her falling onto the tracks possibly because of my intervention.

These patients are all already falling when they come to us. We try to bring them back, but sometimes they end up hitting the tracks. These conferences are about trying to figure out what we can do differently the next time the situation occurs.