Why Johns Hopkins let the cameras in


PORTIONS OF A Mortality and Morbidity Conference (M&M;) of the Department of Surgery at the Johns Hopkins Hospital recently were aired on "Hopkins 24/7" on ABC-TV. Traditionally, M&Ms;, as they are called, are confidential.

M&Ms; are aimed at reviewing unsuccessful outcomes for the purpose of improving subsequent patient care. They are carried out with only doctors and nurses present because only in such an atmosphere can discussions be open and productive.

The hospital agreed to break with this tradition because of the publicity surrounding the recent Institute of Medicine report of the alarming frequency of unnecessary deaths and complications in U.S. hospitals. By allowing the public to observe what goes on in an M&M;, we hoped to show one of the principal ways we have of safeguarding patient care.

The hospital holds a weekly surgery M&M; conference; all junior and attending surgeons are expected to attend. Facts about each death or complication that occurred during the previous week are presented by a junior surgeon who assisted in the care of the patient. The patient's identity is not revealed. The surgeon responsible for the patient -- the "attending" surgeon -- discusses what happened and why.

Other surgeons, whose collective expertise and experience is substantial, offer their opinions. Specialists from various surgical disciplines participate. For example, a plastic surgeon might contribute insights with respect to wound healing.

Often the patient's death is deemed unavoidable, such as from terminal cancer, or if a trauma victim from a motor vehicle accident arrived at the hospital with irreversible injuries. In some instances, however, alternative means of diagnosing or treating the patient may have been possible. Attending surgeons openly discuss similar patients they might have handled differently, or offer information from recent clinical studies that might have altered the outcome.

The in-depth discussions at an M&M; aim to identify root causes of unsuccessful surgical outcomes and suggest alternatives to improve future outcomes. Considerations include diagnostic tests performed before surgery, the timing of surgical intervention, type of operation performed and post-operative care.

Discussion can often enable a consensus to emerge regarding cause and effect and, more importantly, identify opportunities for improvement. Immediate changes in policy and practice often occur, a life-saving benefit for future patients. The conference is carried out, not to assign blame, but in the spirit of suggesting alternative ways of handling such a patient to decrease the likelihood of death or a serious complication.

The M&M; is not a new invention. Its origins probably can be traced to the early 1900s, when a Boston physician, Dr. Ernest Amory Codman, suggested that all surgeons have the results of their operative procedures scrutinized by only physicians with the most favorable results performing the procedures.

This created great controversy. Codman was shunned and ridiculed by many of his colleagues for such a suggestion. He was ultimately instrumental in influencing standards for professional accreditation and care of patients in hospitals. Such standards are concerned with patient safety and the continuing education of those taking care of patients.

Over the past decade, the practice of "evidence-based medicine," or the use of information from highly controlled studies to plan the best treatment for a patient, has emerged as a goal toward which all physicians strive. Even if a physician attends professional conferences every year and regularly reads medical journals, the proliferation of new medical knowledge is such that it is extremely difficult for a physician to stay current. Attending an M&M; is one of the many ways to do this.

The leaders at the Johns Hopkins Hospital felt it appropriate to have an M&M; aired on national television so that the American public could witness the scrutiny each unsuccessful outcome undergoes, with the sole purpose of improving patient care.

While we were willing to participate in this one-time filming of an M&M; for educational purposes, it is appropriate that such conferences take place in a confidential environment where physicians can speak freely concerning deaths and complications. This encourages an atmosphere of learning rather than blame.

In addition to an M&M;, other administrative mechanisms are used to monitor and evaluate physician performance on a regular basis in order to safeguard patient care.

Just as an M&M; is used to educate professionals, it is our goal to help educate the public about measures taken to ensure the excellence and safety of patient care in American hospitals.

Dr. John L. Cameron is chief of surgery at the Johns Hopkins Hospital, and the Alfred Blalock professor and chairman of the Department of Surgery at the Johns Hopkins University School of Medicine.

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