When my friend suggests dinner, I beg off.
“Finishing M&M, not in the mood,” I explain with a sad emoji.
“One of those,” she sympathises.
When I first encountered the acronym for the morbidity and mortality meeting, I thought it ironic that one of the bitterest reckonings in medicine shared the name of the sweet treat of my youth.
I first began attending M&Ms as a medical student, squeezing into the back of the room to listen to senior doctors dissect various harms patients had incurred. Back then I was just a wide-eyed observer keen to understand the moving parts of a huge system. Fast forward a few decades and I have attended hundreds of these meetings.
Morbidity and mortality meetings in medicine are a century old.
In the 1930s surgeons, physicians and anaesthetists would meet to discuss cases and conclude with a vote if the death was preventable. Imagine the contest of ideas (and egos) in that gathering.
Today the format and aim of the M&M is still surprisingly unclear. While deaths must be recorded, the meeting itself is not compulsory.
It is variously regarded as an educational opportunity, a tool for quality improvement, and a forum for identifying outliers. It may also serve to restrain hubris, interrogate standards and force system changes, the last especially relevant in shifting from the traditional “blame-and-shame” approach to a collaborative one.
No clinician enjoys being in the crosshairs of an M&M. It is a delicate matter to raise problems without judgment, acknowledge the benefit of hindsight and focus on the future instead of litigating the past. When conducted from a place of psychological safety, curiosity and empathy, the process can be useful for setting standards.
But I can’t help noticing that the more M&Ms I attend, the worse I feel on my way out.
First, I am sceptical about the definition of morbidity as determined by doctors. Mortality means only one thing but morbidity is open to interpretation – and it is well recognised that doctors frequently underestimate the patient experience.
I met a chemotherapy patient with such profuse diarrhoea and weakness who received help so late that he became bedbound. Morphine had him hallucinating, waving to “all those people” on the ceiling. His poor wife was distressed and terrified – and yet, the medical notes recorded his condition as stable because he wasn’t getting worse. The use of such narrow medical standards worried other providers, including his nurse, but, if his doctors didn’t flag his morbidity as serious, chances are no one else would.
This is how non-fatal events can be downplayed instead of receiving systematic exploration to ensure they are not repeated.
The truth is that any patient sick enough to be tabled at an M&M has encountered a whole range of providers from whom it is important to hear. To review the case from the perspective of doctors alone is to miss the full story and, potentially, attract groupthink. But modern medicine with its siloed nature renders impossible the kind of communal deliberations needed to achieve holistic care.
In my view, the most troubling absence at M&M meetings is the patient or family voice. Admittedly, the object of the meeting is to untangle medical errors in a safe space but to altogether exclude the patient experience or filter it through the eyes of doctors is to do patients a disservice.
The most powerful way of reflecting on our omissions and commissions is to hear how they affected the patient. “It was the worst experience of my life, and I really thought Dad was going to die” lands differently than “the patient’s daughter was a bit upset”.
“I kept calling, got passed around, and have never felt more alone” is more damning than “unfortunately, the patient couldn’t reach us”.
But unless patients demand accountability (by resorting to a complaint, if they can be bothered), the magnitude of their troubles can go unheeded. M&Ms need a better way of incorporating the patient voice even if the patient is not in the room.
These meetings are intended to help doctors reflect on what we could have done better and simultaneously advocate for a healthcare system that is our ally. But it’s hard not to carry a heavy conscience when the pattern of errors is familiar. A lack of communication between providers, a failure to listen to the patient, a surfeit of confidence, a dearth of humility.
The M&M meeting is an opportunity to get things right the next time. But without skilful and impartial moderation, the process can turn into a mere checkbox exercise, which may well leave patients wondering how this could ever achieve systemic change in a healthcare system that is always distracted by some crisis.
Walking away from some of the most depressing M&M meetings, I dream of an outcome that says to the affected people: “We reflected on your case. Here is how it made us feel and this is what we learned. In the future, this is what we will do differently.”
Whenever there is morbidity and mortality, rarely do patients or families seek retribution. Indeed, their uniform wish is that “this doesn’t happen to anyone else”. I suspect most never find out.
Mostly, I love my job but there are days when I dread the thought of attending another M&M. But I know it’s important to go back because we owe it to our patients, past and future.
Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death
