It's Complicated: Doctors (and everyone else) learning to live with mistakes.
In many (but not all) hospitals, the physicians on staff attend the “Morbidity and Mortality Reports” conference. This is usually a weekly or monthly conference. One member from each service, usually a fairly junior physician, takes turns reading the statistics for their service’s patients since the last conference. With the detached emotion of a local radio reporter reading a small town police blotter, the chosen doctor starts by saying how many patients they had treated and how many procedures they had done, thus establishing the denominator. Next they list how many of those patients had complications (i.e. the Morbidity), followed by the number of patients who had died (i.e. the Mortality). It is usually a rather dour affair which at many programs goes by the sugary moniker, “M&M”.
A moderator runs the meeting. This might be a hospital administrator or the chief of a division, or maybe a different moderator on a rotating basis. Now depending on the institution and the time constraints the moderator peruses the list and decides which of the M&M’s get more explanation. Some may take a few words of clarification. Others require a deep dive. Surprisingly not all of the Mortalities are very interesting and barely get a mention. Some people just die in hospitals. Nuff said. But complications? Especially ones that result in documentable harm to the patient? Now that’s where there’s usually some ‘splainin’ to do.
It’s a conference brimming with potential failures. So many so that many hospitals came up with a system for how to report the complications. For my residency we identified the complication, whether or not an error occurred, what type of error it was, and if no error occurred then why did the complication happen? Now, already you can see a disconnect between my brain and the very language of this conference. All M&M’s regardless of the institution would avoid words like “failure”. The word “complication” was fairly unavoidable in a conference to discuss complications, but we doctors hate to fail at anything. Of course in life everyone makes mistakes. Mistakes are not failures.
Although sometimes it’s just a question of how in detail you examine it. We might say that a complication is not a failure or that the person at fault is not a failure. But in our analysis we might pinpoint the cause of the complication, and that can definitely have implications of failure. I love the catchphrase “granular”. How granular do we get when looking for cause? If we dissect the problem down to its building blocks, we usually find the failure. “Technical Failure”, “Failure of Judgment”, “Failure of Situational Awareness”, etc. They may not have those exact titles in the final analysis, but that’s what they are. Still, though, that’s looking at the molecular level. From 30,000 feet complications are much less personal. They consist of systems and root causes much more than one person’s failure.
Doctors have to have some of that water-off-a-duck’s-back imperviousness to complications. They happen to every healthcare provider. If you haven’t had any complications, you haven’t treated enough patients. Now some doctors just had an innate ability to toss a complication into the “been there, done that” file. Others would dwell on any complication for weeks, even months…or years. Guess which type I was, don’t worry, I’ll give you two tries. I know some older physicians who can list off their own complications like the old-timer in an action movie ticking off all of the battle scars on his body, each with their own story. I know others who would practice in a very peculiar and particular way with absolute almost obsessive consistency, solely because of a complication they had years ago. Who’s outlook was better? Is it better to register a complication and just move on or to adjust everything in your practice in reaction to the last complication you had? As with almost everything in life, the answer lies somewhere in between. Learn from your mistake without letting them consume or cripple you; never forget that your errors have had real consequences, some of them dire, on your patient. All doctors lie somewhere on the spectrum between casual disregard and crushing self-reproach. And this behavior is certainly not limited to doctors to be sure.
The key, regardless of where on the scale you lie, is not letting the complication define you as a failure. A complication should inform you, caution you, and yes in some cases haunt you. But they should not define you. As I continue on my journey, I know that one of my failures has been failing to live by this concept. I identified with every mistake, error, complication…every failure. Can I fix this? My therapist says yes. Have I? TBD.
Hey I told you a lot of the genesis for this blog was the result of the demons inside my head. But I’m pretty darn sure I’m not the only one who does this. Do you carry a mistake with you? Do you let it guide you as experience and insight should? Or does it anchor you to the past, a constant reminder of your shortcomings? Are you the sum of your complications? Relax. Have some M & M’s. They’re tasty and gone in a few seconds. Just don’t binge eat them.
M & M’s. Mistakes & Memories. They melt into doubts, not in your plans.