An adverse patient outcome—particularly one that results in death—is the hardest part of being a physician. It is also a reality that almost every physician confronts.
As weighty as such an event may be, it also presents a powerful opportunity for professional growth and reflection. In certain circumstances—typically deaths resulting from medical errors and unforeseen complications—a resident physician may be required to present on an adverse outcome, in front of faculty and peers, at a morbidity and mortality conference (M&M).
AMA Wire® spoke with Christina Duzyj Buniak, MD, MPH, assistant professor of obstetrics, gynecology and reproductive sciences in the maternal-fetal medicine division at Rutgers University Robert Wood Johnson Medical School. Having presented M&M conferences as a resident and attended them as a student and faculty member, she offered insight on what residents should know going into their first one.
It’s not about blame and shame. “We have a pretty robust performance-improvement process to go through root-cause analysis to determine if there was an individual-level error or a systems-level error,” Dr. Duzyj Buniak said. “The goal of the M&M now is to find the systems-level errors and to have a global education for individual providers who have those gaps in knowledge. So it’s not finger-pointing at the person ultimately managing those situations.”
Don’t take pushback personally. “Obstetrics is a place where sometimes there is hard science and sometimes there is anecdotal medicine,” she said. “My role, especially being a subspecialist in maternal-fetal medicine, is to question the gray and provide the solid evidence in terms of what could have gone differently. There’s also a need to support the decisions made in areas of gray, while asking, ‘How did you think through that in the absence of good available evidence?’ We are trying to redirect the algorithm when there isn’t solid evidence. That’s really important.”
Consequences aren’t always punitive. “Physicians put a lot onto themselves after an event,” Dr. Duzyj Buniak said. “Efforts to provide support may sometimes be seen as remediation. From personal experience, I had two adverse events occur back to back. Following those, there was a suggestion that I needed to be taken off clinical services to recover. In the moment, that felt like remediation when really it was a form of support. … The second-victim phenomenon is real. Simply slapping somebody’s hand, who is already grieving from what they just went through, is not in anyone’s best interest.”
Everyone has been in your situation. “The thing that made me more nervous than [presenting] my first M&M was being a medical student and watching my first M&M,” she said. “I realized that in the not-too-distant future, that would be me up there having to defend decisions that I didn’t always have control over. When you’re a trainee presenting a case in M&M, you are presenting management decisions that were made that maybe you didn’t make yourself and that feels very threatening.”
There is value of acknowledging failure. “There are patients that I have in my head that will always be with me. For one reason or another, they are the guiding beacons in what I learned. Their faces are in front of me. I carry those, both my success and my failures, and my guiding principles of what to do better next time.”