Insights on Residency Training

Ahmad Yousaf, MD, is the 2015-16 Ambulatory Chief Resident in Internal Medicine at Rutgers New Jersey Medical School.

He nervously shifted in his position in front of the audience of his peers. His voice was a little shaky, and the few words trying to escape his lips were chewed and swallowed. He was narrating a case in which a colleague’s sense of urgency, or rather, her lack thereof, likely negatively affected his patient. She sat in the front row with her head down, scared that the presentation might eventually lead to the revelation she was the one at fault. That would not be the case.

This is Morbidity and Mortality (M&M) conference. Most attendings and chiefs will tell you that it is, far and away, the most valuable educational experience in residency… and I agree. It is a conference in which there is objective iteration of a case in which a physician, team member, or system error occurred. Emphasis is on what could be done so that the error is never repeated. Sometimes, the issue is one that never affected a patient’s care but could have, in another scenario: a “near miss.”  Other times, the conference focuses on an error that directly affected the welfare of a patient and, rarely, resulted in or contributed to the death of a patient. Classically, M&M felt like a firing squad in which elders in the hierarchy of medicine picked apart residents who always seemed to make the most egregious gaffes when faced with a room full of people pointing their figurative rifles. There was a lot of sweating and stuttering and apprehension. Thankfully, things have changed across the medicine academic realm, and M&M has changed from a blame game and target practice to a time to reflect and develop.

Humans make mistakes, and doctors are human. Therefore, doctors will make mistakes. This paradigm must be acceptable for medical academia to have a culture that results in the production of competent and confident physicians. M&M conference is the teaching modality that makes an error… a mistake… a point of reflection and a motivator for improvement, not a finger-pointing blame game.

The presenter concluded his case presentation, and the room stayed quiet for a moment. The burden of that silence is immense. Somebody died, and one of us could have done a better job to try to prevent it. That burden often results in tears. Every doctor in the room knew what it feels like. We have all been there. We all have a personal M&M folder locked away in the recesses of our psyche that highlights our limitations, reminds us of the blunders we have made, and impels us to never make those mistakes again.

The boss in the back of the room broke the silence with a reflection after seeing the intern up front with tears in her eyes. “It is completely okay that you cry about the mistakes you have made when it negatively affects your patient. It means you care.”  I thought about those words of wisdom and appreciated how important it is to have a safe venue, especially during residency, to regret something you have done.  The conference concluded with a list of learning objectives everyone in the room should take to heart so that countless mistakes do not have to be made for the physicians in the room to gather insight. We succeed together, and we fail together. And then… back to the floors so you can do it better.

~Yousaf