One in 3 Americans dies in hospitals 1; this number has likely risen precipitously during the COVID-19 pandemic. These in-hospital deaths are often reviewed and discussed among physicians at morbidity and mortality conferences (MMCs). The COVID-19 pandemic has forced many medical centers to shelve such conferences entirely because of both social distancing and the need to maintain focus on clinical care. However, there has never been a more important moment in recent history to provide clinicians with opportunities to reflect and commune with and support each other. Creating an environment in which clinicians can be human will require restructuring the MMC to provide a space for reflection and, ultimately, lead to defining a new purpose and charge for the MMC. In this article, we provide 3 recommendations for getting started on this critical work.
Historical Evolution and Role of the MMC
The MMC is one of the legacy traditions of the medical profession and serves as an ideal mechanism to improve medical care within the context of a patient’s story and that patient’s interaction with the local institutional ecosystem and the larger health system. This forum has evolved into its current format, which serves 2 major roles: education and quality improvement. 2–4 However, a second evolution is needed to humanize the MMC in the wake of the COVID-19 pandemic. In addition to a platform for education and quality improvement, clinicians need a space where they can reflect on lives lost and spirits broken. This is particularly true when they are facing a disease with an uncertain natural history, limited treatment options, and a high risk of transmission to frontline clinicians.
Development of the MMC concept has been attributed to the surgeon Ernest Amory Codman at Massachusetts General Hospital in the early 20th century. 2 Codman maintained a list of his patients and their outcomes as a means to learn about and then educate his colleagues on best practices in surgical management. In 1983, the Accreditation Council for Graduate Medical Education made MMCs a mandatory component of training program certification, leading to their almost universal adoption. 3
The heightened focus on medical errors and patient safety over the last decade led to an evolutionary period for MMCs. 3,4 This modern charge of the MMC is reflected in the current literature on process improvement in MMCs, which is primarily focused on incorporating standards and regulations aimed at quality improvement and better patient outcomes. (See Table 1 for a summary of recent MMC research. 4–10) This is also a period when the scope of the MMC moved from individual errors to systemwide failures. Because the structure of MMCs is highly variable, studies have advocated for the standardization of roles of different members of the MMC, such as the moderators and discussants, and routine collection of outcomes at MMCs. 6,7 Such structured implementation of standardized MMCs may even help improve patient outcomes. 4 By organizing specific roles and standardized measures, hospitals will have information they can use to improve their practices and protocols. As part of these modifications, it is critical to ensure that MMCs are peer reviewed and protected so that physicians and other medical staff members can raise concerns without fear of retaliation.
An aspect of MMCs that has been little explored to date, although vital to medicine, is addressing the humanistic side of medical care in the conference. Medical care can exact a heavy toll on clinicians, especially when an adverse event occurs. Wall et al focused on modifying MMCs to help increase opportunities and provide safe spaces for health care providers to discuss ethical dilemmas that may come up during medical care. 10 By discussing ethical dilemmas, medical staff can learn from one another and better define their professional and personal obligations and values while placing the patient’s health and interests first. 10 This important aspect of MMCs should not be neglected. If we forget to address the values and reactions of our medical staff, they will gradually lose their connection to human life and experience, which will ultimately affect patient outcomes.
The Next Phase of the MMC’s Evolution
Create space to be human
As the field of medicine becomes increasingly corporate in structure and mission, the importance of staff’s mental well-being has not kept up with other metrics. 11,12 However, this metric is critically important because our emotions and well-being are interconnected with the patients’ emotions and outcomes.
Physicians connect to patients as fellow human beings who laugh and cry or get mad or elated, all in the context of illness. The need for us to remain human is not only vital to patient care but also to our own well-being and avoidance of burnout. Physicians and other medical staff face repeated traumas from the lives lost during their care. Yet, physicians often lack space in medicine to be human. 12 In the absence of an established institutional platform, many clinicians turn to social media to share intimate patient experiences. While social media are important outlets, these avenues may not be the most appropriate for sensitive clinical discussions. Many clinicians feel a pressing need not just to count, but to honor the dead. Therefore, it is important to create a space where the medical staff can be candid about the results of their actions and then—hopefully—grieve, learn, teach, and, ultimately, heal. 12
Restructure MMCs to provide space for reflection
Medical staff members need to be given the time and a way to understand their feelings about the lives lost and possible mistakes that may have been involved in these outcomes. This is a difficult process to standardize because each individual grieves differently. While some may want to share their thoughts by talking, others may prefer to journal or actively reflect, while others may find more peace in engaging in an activity. The MMC could be reformed (or a separate activity instituted) to allot independent time every 6 months or so for each staff member to dedicate to an activity of their choosing. This time and space would enable staff to reflect on and respect the lives of the patients they had lost during that period. One approach is a session that would start off with a short briefing for the group of participants. Participants would then separate to work on their activities alone and then come back together to reflect in small groups. Another possibility is including a reflective session in each conference, which would incorporate human elements into existing MMCs. Whether that space should be a part of MMCs can be debated, but whether that space should exist cannot.
Define a new purpose and charge for the MMC
During the loss and isolation brought by the pandemic, a call to action to reform MMCs appears challenging and perhaps superfluous, yet it is what our colleagues in medicine and our patients need most. As medical providers are risking their lives to heal and patients are scared, a space for reflection and revitalization reminds health care workers of their motivation and provides hope. Moreover, by intentionally allotting time for health care workers to reflect, which should ward off burnout and indifference, patients will ultimately benefit. Clinicians have much to learn from each other when dealing with the widespread and long-term effects of this unprecedented pandemic. By reforming the MMC, we not only give the providers a reflection space but also a reliable avenue for sharing knowledge about and experiences in treating patients affected by COVID-19. Both providers and patients need this reform now more than ever.
Our primary recommendations are, first, to create space to be human and for reflection within the MMC and to define a new humanistic charge for this forum, one reflecting humanistic principles such as compassion, empathy, and respect. The MMC, generally the conference with the broadest reach, has historically been effective in changing institutional culture as evidenced by its role in the patient safety movement. Participants in a more human-centric MMC may ask questions such as, “How did we comfort the patient’s family following the patient’s death?” “Did we succeed in helping the deceased fulfill any final hopes and dreams?” and “What was the personal impact of a patient’s adverse outcomes on the well-being of the health care staff involved?” Second, these humanistic principles should be incorporated into shorter and more focused gatherings, either by simply urging providers to take time to reflect together after their shift or by holding an online session for health care workers who have time off. Third, an MMC focused entirely on the human aspects of medical care should be periodically arranged; this type of MMC would provide an outlet for storytelling, artistic expression, and reflection.
Humanizing the MMC—a core symposium in clinical medicine around the world—could be the first step in revitalizing the eroding spirit at the heart of medicine as essential during peace as during a pandemic. Many clinicians are struggling to make sense of the human cost during this crisis, and such reform would be an important step toward clinicians reclaiming a deeply personal place in this pandemic.
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