Ophthalmic morbidity and mortality conferences may have value
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This column is the latest article in the ongoing series “I wish I hadn’t done that.” Past submissions can be read here.
At the recent American Society of Cataract and Refractive Surgery meeting in San Diego, we were pleased to debut the first ever “I wish I hadn’t done that” session.
The event panel consisted of myself, along with Drs. David Chang, Amar Agarwal, Bobby Osher, Michael Snyder and Martin Dirisamer. We delivered our remarks to a packed house, with standing room only in the auditorium. I have never been prouder to be a part of any session, even though the actual content of the course was a 90-minute exposé of some of our most embarrassing mistakes.
Traveling back from the conference, I was reminded that morbidity and mortality (M&M) conferences used to be quite common in the fields of general medicine and surgery. Bad outcomes were dissected in a public forum and examined critically.
I have never heard of ophthalmic M&M conferences, although perhaps they exist somewhere. Nevertheless, in ophthalmology, as in other fields, there must be some value in examining our performance and looking specifically for errors. This is contrary to our natural psychological tendency to seek out excuses and justifications for our behavior and our preference for hiding bad outcomes, particularly from our peers and immediate colleagues.
The logic of the M&M conference dictates that any bad outcome should be scrutinized for mistakes, not just by the treating physician but in a collaborative setting. In our ASCRS session, although all the presenters had specially prepared their remarks, the audience pointed out additional mistakes that the panelists themselves had not identified.
We are probably poorer as ophthalmologists for the lack of some M&M type forum in which we can all collaborate. It may be possible to institute such a thing at a university or academic hospital in which departments can act collectively. In the setting in which most ophthalmologists find themselves (private practice), however, it is less obvious how to participate in such a thing. Perhaps in this modern day of Zoom teleconferences, an online version of an M&M conference could be considered. Entry and viewership could be regulated with password protection, and it might facilitate a type of participatory learning that keeps us grounded in the reality of our fallibility and the importance of leaning on each other for growth.
- For more information:
- Jack S. Parker, MD, PhD, of Parker Cornea in Vestavia Hills, Alabama, can be reached at jack.parker@gmail.com.
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