By By Vietrez P. David-Abella, MD
SURGERY: M&M
posted 13-Jun-2015  ·  
1,135 views  ·   0 comments  ·  

Death never ceases to surprise, be it in a 75-year old with ascending cholangitis, or a 25-year old for elective hernia surgery. Death is that irreversible passing into the unknown, or to some, into nothingness. It may inspire awe or fear. At any rate, it marks the end of life as we know it.

One would think that physicians who regularly meet death would develop a steely resolve to remained untouched by the devastating effects it usually has on those who are left behind. But no, this is just one of the heartaches that we learn to live with, the downside to the profession.  And to be able to forge ahead as a healer, we learn to develop opposing and complementary attitudes toward it: compartmentalize our emotions to remain objective, but let our hearts be touched by each death, to retain our humanity.

Medical training has developed a mechanism to etch our patients' deaths or disabilities into our consciousness, and thus instill accountability: the Morbidity and Mortality Conference, shorthanded as M&M. As students we attended weekly M&M in each of the departments we rotated in. The senior resident (specialist-in-training) would present all the deaths and complicated cases for the week, while the consultants weighed in: what could have been done to prevent each death or complication. In the end, we were supposed to learn from our mistakes, that we may be able to avoid similar occurrences in the future.

Some residents became marked as "toxic," handling and presenting complicated and unusual cases. Although they were usually hammered during M&Ms, it was a commonly-held belief that it is better to be toxic during one's residency, and learn earlier, than to be toxic as a consultant.

As I moved up the training ladder, responsibilities increased in complexity. From being "retractor-on-duty" in the operating room and first-call for patient admissions and referrals (which meant seeing the patients, taking the history and physical examination, following up and relaying diagnostic results to consultants, evaluating referred patients, etc.), I was soon tasked to handle cases on my own, under the supervision of consultants. This meant evaluating patients under my service and prescribing treatment. Being a resident, I would have to clear all major decisions with the consultant-on-deck, who was essentially liable for all my actions.

Elective operations, or ones not emergency in nature, had to be presented at a pre-operative conference, where the consultants would usually agree on the proposed surgery, be it a routine gallbladder removal or a potentially-complicated removal of a colon cancer.  Then there's the M&M. While successes were hardly celebrated, and were merely added as statistic to operations done, deaths and complications were specially discussed.

The history and physical examination, diagnostic test results, and course in the wards were presented, the detail of which depended on the complexity of the case: the more complicated, the more minute the examination of medical data.  The conduct of the operation was described, as well as other post-operative events. If other services, such as medicine, pediatrics, or obstetrics-gynecology, were involved, they were invited to the M&M as well. Radiologists and pathologists had to be around to answer questions on an imaging interpretation or histopathologic result.

But after the whole medical exercise, there is only the physician and his conscience. Some physicians have actually stopped their clinical practice after a patient's death, paralyzed by the enormity of their responsibility for people's lives.

It helps for a budding clinician to realize early on that he or she is but the pen where the ink of greater forces, be it a Supreme Being for some, or random chances to others, flows through. The real responsibility lies in conscientiously evaluating patients: a thorough history and physical examination is said to enable one to arrive at the correct diagnosis in 90% of the time. The 10% would thus have to be filled up with carefully-chosen diagnostics, be it a "routine" complete blood count, or an expensive CT scan.

A revered consultant once gave us a simple criterion on whether to have a test done or not: would the result change your management? If you are just having the procedure done to make you feel good about the treatment, then the test is non-essential. The advice also makes sense in medical economics.

One must also keep in mind that 50% of a patient's healing comes from his or her faith in the physician as well, sometimes called a placebo effect, but recently recognized as part of mind-body connection. This is why this same revered consultant insisted that we residents dress up in a manner befitting our stature as MDs: white blazers required, not the scrub suit tops that we preferred. And that we establish physical connection early on, facilitated by the medical examination, and reinforced by a pat on the shoulder, or a touch to the hand, during follow up visits. Indeed, touch is a basic human need that strengthens, assures, comforts.

Despite physicians, many patients survive. For the ones who don't, we ask: Did I do everything to the best of my ability? Did I ask the help of my colleagues? Did I explain adequately to the family what happened? Because when the dust of the M&M has settled, it is really just us and our conscience.

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