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A new program at Cedars-Sinai Medical Center in Los Angeles has transformed its weekly morbidity and mortality conferences into an innovative educational study curriculum for reviewing surgical errors, which its creator says, "will do for error and complication reduction in America what the Flexner report of 1910 did for medical education."
The program, called the M+M Matrix, was developed by Leo A. Gordon, MD, FACS, associate director of surgical education. He describes it as a complication-oriented method of surgical review based on the teaching points of a weekly conference. "It is a day-by-day, week-by-week, month-by-month program that extends the great lessons of this essential conference throughout the year and year after year."
The theory behind the program is simple: "If a surgical resident early in his career is exposed to a surgical error or complication in an educationally meaningful manner, that resident will be less likely to engender that error or complication in his career, and if he does, he will be in a better position to identify and treat it," Gordon says.
The morbidity and mortality conference, even in its traditional form, is unique in the medical world, Gordon asserts. "I’ve been a general surgeon for 23 years, and since the first day of my internship, I’ve been fascinated by them," he recalls. "It is a meeting in which problems of the previous week are discussed in an open manner among all members of staff who attend. It’s very special; you can’t equate it with peer review meetings or QI meetings."
Instead of sitting in your office and thinking about the most significant error of the week, you get 50 of your colleagues to talk about it, Gordon continues. "It’s very sobering; you have a very identifiable actor. If things go wrong, it may be due to what you did and how."
Gordon was so fascinated with the process he wrote a book about it, aimed at interns, called Gordon’s Guide to the Surgical Morbidity & Mortality Conference (Hanley & Belface). With that fascination, however, came a keen insight into the flaws of the process. "The theory behind these conferences is education, but the great failing is that the great lessons presented die at the door," he observes. "The meeting starts at 8 a.m., passions rise, voices rise, great surgical debates are framed, the logic is laid out, and at 8:59, it ends — that’s it. There has never been a method for codifying and perpetually and continually disseminating the great lessons of the most important hour of the surgical week."
The M+M Matrix is grounded in problem-based learning, Gordon explains. "It outlines the complication-oriented points in a generic manner — no patients’ names, no surgeons’ names, no identifying data. You’re there to analyze, to instruct the next generation, in an effort to aid them in avoiding such complications in the future. You don’t care whose error it is," he notes.
The process unfolds continually, week in and week out. Thursday morning is the day of the weekly conference. During the conference and at the end, the coordinator formulates an M+M Matrix. "This is a support structure for education: complication-oriented teaching points," Gordon explains. They are written down and distributed the next day via e-mail to resident staff and attending staff. "A lot of people outside our medical staff also subscribe," he notes.
On Saturday and Sunday, time is spent selecting exam questions. Every four months, the resident staff (required) and attending staff (voluntary) take a written exam of 25 multiple-choice questions based solely on teaching points of the conference. Next to every question is the date of the conference and the point that was made.
The moderator also spends this time writing what has become the most popular element of the program: The M+M Monday memo. "This is divided into two parts," Gordon says. "One is an op-ed piece, in which I report on the last conference. In addition, I answer e-mail questions that have been sent to me from participants." This is a means of extending the conference, he explains. "It is shared with all subscribers, but no names are used."
In addition to writing the Monday memo, Gordon reviews a list of potential cases for the Thursday meeting. "I select the cases based on educational value, staff interest, and frequency," he explains. "A bored audience is one that won’t show up. How many pulmonary emboli after trauma can you go through?" On Tuesdays, he receives from the residents short summaries of the cases, and reviews them for accuracy. On Wednesdays, Gordon meets with the presenting residents to review the cases and ensure the presentations will be valuable to the audience.
This process continues month by month, with the exams being held every four months. In addition, each July there is an orientation for new residents; in October, there is a board review for graduating residents; and in June, a year-end review is held.
According to Gordon, the greatest benefit of the program is that "It prevents the error before it occurs by engendering a complication-oriented approach to surgical practice." He calls it "a preemptive strike for the next generation of surgeons." Other error-reduction programs take place after the fact, while this one occurs before, he notes.
Gordon says his program is directly in line with mainstream thought. "If you look at the [Institute of Medicine] Report’s five recommendations about surgery, the M+M Matrix fulfills each one of them," he asserts. "It’s American surgery’s answer, line by line."
He also predicts the program will help spur surgical recruitment among medical students, which is in serious decline. "In March, for the first time ever, all the available slots did not fill," Gordon says. "This can become the premier medical educational tool. If you take a med student and put him in the audience of an up-and-running program, it becomes a powerful recruitment tool for surgery. Talk about creating a role model. . ."
Because the program launched in June 2001, it is too early to track error reduction, Gordon says. "We do have a complete track record of what we have discussed," he notes. "I think it will take three to four years, but you must admit, if you throw away all the statistics and just look at the concept of grooming a surgeon with an eye on error and complication, this should lead to a decrease in errors."
For more information, contact: Leo A. Gordon, MD, FACS, Associate Director of Surgical Education, Cedars-Sinai Medical Center, 8635 W. 3rd, Los Angeles, CA 90048. Telephone: (310) 659-9603.