Journey into the Zen of M and M

Leo A. Gordon, MD, FACS
Associate Director of Surgical Education
Cedars-Sinai Medical Center, Los Angeles, CA

Surgical Residents, prior to your last morbidity and mortality (M and M) case presentation:

Did the moderator of the conference review your presentation?
Did the responsible attending surgeon review the case with you to make sure it was factually correct?
Did you or the moderator arrange for the subspecialist involved with the case to be present?
Were the responsible radiologist and anesthesiologist notified that the case was to be presented?
Did you follow a standard format for presentation graphics?
Did you make sure that any references you were using were recent and appropriate?
Did you review your presentation to make sure that you knew what went wrong and how you might avoid this complication in the future?
Did you classify the case in advance of the conference?
Did you conclude your presentation with a list of the essential points that you and your team learned from managing the complication?
Did you broadcast what you learned to your fellow residents?

If you answered “no” to any one of the above questions, you have not yet begun your journey into the “Zen of M and M.”

During M and M conferences—instead of focusing on information that might help you as you begin your surgical practice— it’s more likely that you’ve entertained the following thoughts:

"Rivera just got toasted. I think I'm next."

"If Morgan had a ten blade he would have cut out Curtis' eyeballs."

“I would have thought Dr. Flieber would be here to defend himself."

"You'd think with PACS the days of ‘the films were not available’ would be over."

"Nothing changes."

And finally:

“What now?”

The crowded surgical curriculum, core competency requirements, and work-hour restrictions have conspired to create an educational gold rush for your time. Despite faculty retreats, focus groups, break-out sessions, and consultants, we are all still saddled with a mere 24-hour day.

Since most didactic lectures, inservice preparation and literature-oriented journal club activities are now readily available on the Internet. Therefore, you must reexamine the time-benefit ratio of each of your morbidity and mortality conferences.

As the future of American surgery, you all have a unique and timely opportunity to change the nature of your morbidity and mortality conference. You also have a chance to change the culture of the conference. In so doing, you have the opportunity to become a safe and competent surgeon.

There is no other conference, conclave, or meeting on the surgical schedule that has more history, personal appeal, and potential educational benefit than the traditional surgical morbidity and mortality conference.

Most M and M conferences are hamstrung by tradition. Many of these sessions are poorly moderated, and preparation is often uneven. But the biggest deficit is the illogical nature of the conference itself.

The assembled wisdom of a department hashes out an issue in an open and spirited fashion. Tempers may flare! Issues are raised! Neck veins distend!

Then………………………..nothing!

Somewhere in that educational ether is the basis for a safe and productive approach to surgical pathology. But, when the dust settles, there is nothing left. That is, there is no mechanism for memorializing these lessons and there is no dedicated moderator to make the discussions organized and meaningful.

You, as surgical residents, have the opportunity to correct the deficiencies of the traditional M and M. But you need guidance to move toward that goal of creating a vital, interesting, and educationally valuable conference.

You need a reliable mechanism for organizing and for moderating the morbidity and mortality conference if you are to become the surgeon you want to be. Before you begin your journey, you need a template that is going to sustain the lessons learned. You need the M+M Matrix.

The matrix concept is based on an unassailable fact of surgery.

Patients are safer when the surgeon is smarter and a surgeon gets smarter by reviewing surgical complications in an educationally valuable manner.

The matrix program achieves the level of organization and coherence necessary for an effective educational effort. It requires time spent planning and refining all elements of the morbidity and mortality conference.

Surgical programs must adopt the M+M matrix philosophy:
The conference is a week long educational effort, but the matrix exists before, during, and after the conference.

Here’s how the matrix works.

1. Before the matrix conference

The matrix moderator is a dedicated member of the department and is an individual who does not regard this task as a burdensome administrative afterthought. The surgeon serving as moderator is familiar with the matrix concept and is funded, supported, and encouraged by a departmental commitment to an objective and educational patient safety effort.

Residents submit their cases to the matrix moderator, using a standard format for the submissions:

complications
problem cases
cases of special interest to any resident on the team
a service list

The moderator selects three cases based on several criteria.

Are the cases of educational value?

Are the cases of interest to the attending staff as well as to the resident staff?

Are the complications unusual or infrequent?

The residents outline the case in a Powerpoint® format and they meet with the moderator to focus on the main issues of the case:

What is the complication?
How could the complication be avoided?
How could the complication have been detected earlier?
How is the complication to be categorized?

This effort to streamline the presentations before the conference allows the audience time to focus on the central issues of the case.

The moderator personally invites a knowledgeable member of the appropriate subspecialty in order to avoid the dissemination of outdated or incorrect information.

2. During the matrix conference

A matrix conference is a moderated conference.

Only a strictly moderated conference can achieve the zen of the matrix.

The moderator’s job is to stay on the case at hand and to deter the all-to-frequent detour into surgical mythology, unsupported opinion, and personal rumination. Additionally, the moderator is the arbiter of all comments, discussions, and criticisms.

Anonymity is maintained, because attending attribution is a sure-fire method for derailing the conference. After all, personality has the potential to trump pathology.

The presenting resident ends each presentation with a list of “matrix points,” which consist of the essential error- and complication-reducing points gleaned from a review of the case and from the discussion.

3. After the matrix conference

The conference does not end when the conference ends.

The work of the moderator continues after adjournment. As such, the moderator builds on the matrix points by elaborating on the essential error and complication-reducing methods and issues that were discussed. These educational trigger points are then prepared and distributed to the resident staff and to the attending staff. As as result of the moderator’s work, a library of matrix points--an anthology of patient safety issues that arose from the discussions--evolves.

Unlike the issues tossed about in a traditional morbidity and mortality conference, the matrix points do not exist in a vacuum. Under the leadership of a faculty committed to the matrix concept, these points are woven into the daily fabric of the educational program. They rear their heads on rounds, in the operating theater, and the emergency department and they form the basis of written examinations administered at regular intervals throughout the academic year. At the end of the year, a matrix summary is published.

American surgery has a potent patient safety education tool. That tool is hidden and restricted in a tradition-bound conference. Surgical curriculum innovation must begin at the morbidity and mortality conference. It is up to you, resident educators and department chairs, to understand this need for advancement and to implement this critical change.

Surgical residents,

Your curriculum and conferences are useless unless you have an unswerving personal commitment to get smarter and better every single day. Incorporating the matrix concept into your program develops your presentation and organizational skills–skills essential to a safe and productive surgical practice.

The matrix concept provides you with a valuable opportunity to use surgical complications as a powerful teaching tool. The matrix transforms the chaos of the traditional morbidity and mortality conference into an educational dynamo.

I wish you luck as you embark on this transition.

Work hard.

Stay on point.

You will achieve:

The Zen of M and M

Residents,

If you are interested in learning more about the M+M Matrix and implementing the M+M Matrix in your program, please read:

Gordon LA: Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix. The Agency for Healthcare Research and Quality website. Internet (http://webmm.ahrq.gov). Accessed September 2007.
Gordon LA. Cut to the Chase – 100 Matrix Pearls for Doctors. Shrewsbury, UK: TFM Publishing Ltd; 2006.
Gordon LA. Can Cedars-Sinai’s M+M Matrix Save Surgical Education? Bull Am Coll Surg. 2004; 89(6)16-20.
Gordon LA. Gordon's Guide to the Surgical Morbidity and Mortality Conference. Philadelphia: Hanley & Belfus, Inc; 1994.

Or:

Contact:
Leo A. Gordon, MD, FACS
Associate Director of Surgical Education
Cedars-Sinai Medical Center
Los Angeles, California
Leo.Gordon@cshs.org
310-423-5262

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Online June 1, 2011