In his book When Breath Becomes Air, neurosurgeon Paul Kalanithi writes about the medical practice of holding a periodic morbidity & mortality conference.
We reviewed overnight events, new admissions, new scans, then went to see our patients before M&M, or morbidity and mortality conference, a regular meeting in which the neurosurgeons gathered to review mistakes that had been made and cases that had gone wrong.
The objectives of a well-run M&M conference are to learn from complications and errors, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications. Conferences are non-punitive and focus on the goal of improved patient care. The proceedings are generally kept confidential by law. M&M conferences occur with regular frequency, often weekly, biweekly or monthly, and highlight recent cases and identify areas of improvement for clinicians involved in the case. They are also important for identifying systems issues (e.g., outdated policies, changes in patient identification procedures, arithmetic errors, etc.) which affect patient care.
1. It is comforting to hear that the medical professionals we rely on are taking the time to review their mistakes and get better.
2. We could all learn from this.
Mistakes are not something to hide from, but something to embrace, discuss, and learn from.
Imagine if you had a regular M&M conference at your workplace?
What would that look like?
Who would be there?
How could your company or department benefit?
Imagine if our politicians were as methodical about recognizing and learning from their mistakes as our neurosurgeons?
Imagine if you took the time to sit down with yourself once month and do a personal M&M with the goal of improving your target outcomes (your relationship, work, a specific skill, fitness, etc.)?
The reason the M&M conference is so genius is because it creates sanctuary. Calling people out on their mistakes in an ad-hoc way can cause damage. But when we create a safe space to openly embrace mistakes, it's no longer personal. Context and environment matters.
To embrace our mistakes is to embrace our humanity.
P.S. When Breath Becomes Air is a profound and moving meditation on life, death, and meaning. Paul Kalanithi wrote the book in his final years of his short life (he died at 37 from lung cancer). His family and editors published the work after he died. I recommend it with vigor.
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