Virtue Ethics in a Value-driven World: Medical Errors and the Albatross

I was rehashing a case, lamenting a poor surgical outcome. The complication was a rare one, unpredictable, and not particularly preventable. The system didn’t fail me—the equipment was clean, correct, and I had excellent support staff. Still, I perseverated on what I could have done differently. Although perhaps this was more emotional than rational, I had a gnawing feeling that if I were just a bit better, or had been more careful, it all wouldn’t have ended this way.

Yet, to believe that how things turn out is wholly or even mostly under my control is hubris. It may not be the typical version of hubris we conceive—of an overarching pride and overconfidence—but it is nonetheless prideful to believe that we, as surgeons, primarily control any patient’s destiny. And, as I reflected further, I realized that this belief developed early in my medical training.

I remember my first surgical morbidity and mortality (M&M) conference. Residents presented the cases, and although I am certain there were other educational points made, I left that and many more M&M conferences with one take-home message: Patients bore the mark of surgeons’ imperfections, and the best surgeons were those who were so perfect that the only marks they left behind were well-healed incisions in smiling patients.

In many institutions, M&M has been reborn as a quality improvement conference. I am doubtful that this is truly a rethinking, and at times it seems little more than a superficial rebranding. The data on preventable medical errors over the past 20 years certainly called for our attention [4]. But rather than creating a comprehensive quality improvement conference evaluating the system errors, M&M was refashioned to meet this new requirement with the morbidity or mortality now classified as an error. The most notable change is that at the end of the case presentation, the presenter is tasked with classifying the type of error made (such as, a system or diagnostic error). The rebranded M&M is essentially a case presentation rather than a focus on the systems that promulgate the errors. And, importantly, shaming—the antithesis of a true quality improvement exercise—still often occurs in the M&M conference. Then, having heard of the worst surgical results of the past few months, attendees scatter back to their clinical responsibilities.

I believe that we are ethically obligated to end M&M, at least as it now exists. This conference, as currently employed, harms (or at least fails to protect) patients because it focuses overmuch on individual surgeons’ actions rather than encouraging a culture of safety. It also harms those who practice surgery—which can’t be good for patients, either—as it represents a kind of idolatry to an impossible standard of perfection, and in so doing, potentiates physician burnout by emphasizing, month after month, that we are never good enough. As physicians, we have a moral obligation to not only care for our patients but also to care for ourselves, and M&M is antithetical to that goal.

Some might argue that M&M highlights some part of the sacred responsibility of being a surgeon. That the focus on injury and death reminds us of the high stakes for which we play, and that the pressure of presenting at M&M is small compared with the stakes of surgery itself. They might argue that if we don’t own our failures, we don’t deserve our successes.

There is some appeal to this argument, but it is wrong. We don’t need a conference to convince us that our jobs are important, and anyone who takes this job lightly won’t be convinced by sitting in a room for an hour a month. If the M&M conference is designed to help us improve our orthopaedic game, it needs to be designed with that end goal in mind. I think it should begin by focusing on keeping surgeons in the game after they’ve had serious complications, and the quality improvement functions should be shifted into a true quality improvement conference that is organized to help care teams learn the most from every complication or system failure.

Are we ethically required to discontinue M&M as an education format given the concerns that it may increase burnout by demanding perfection? No. To the contrary, I believe we are ethically required not to discontinue M&M but to rethink it as a resilience support group.

M&M is most harmful because it wastes an opportunity for burnout prevention and resilience training, when surgeons are acknowledging their vulnerability, and instead it frequently worsens the feeling of burnout. In an interview, Dr. Charles Bosk (the author of Forgive and Remember: Managing Medical Failure) argued in support of M&M as the “current epidemic of burnout among physicians and nurses is a consequence of there being too few safe spaces for discussing the affective dimensions of working in environment that requires time-pressured decision-making under conditions of unresolvable uncertainty” [3].

I agree with Dr. Bosk that M&M should serve primarily a psychosocial role rather than being reinvented as a quality improvement conference or serving as a venue for public flagellation. But how would this work? It likely would be institution dependent. But I have seen it done well. At the 2022 American Orthopaedic Foot and Ankle Winter Meeting, we hosted the inaugural “Albatross Award.” The albatross as a metaphor of inescapable burden comes from the poem The Rime of the Ancient Mariner [2]. At the meeting, the Albatross Award was conceived as a forum to share “clinically challenging scenarios, one in which an initial surgery leads to another to another … to another. Like an albatross circling and circling, years may pass before the patient successfully “lands” [1].

The forum was not recorded, participation was voluntary, and all reporting of patients’ stories was HIPAA-compliant. Early-, mid-, and late-career surgeons stood at the podium and presented, in 5 minutes or less, the cases that had haunted them, some over decades. Scholars, fellows, and attendings communed over the universality of complications, as the presenters discussed not only what had gone wrong, but also what—if anything—they wished they had done differently. The complexities and challenges of surgical practice were made clear, as was the seriousness of the complications and the inherent privilege in practice. My most deeply held, take-home message was that all surgeons (even the most famous) have cases they regret, and they still don’t always get it right, even if (or perhaps especially when) it seems that they did everything they could have done.

The value of normalizing the challenges of practice to trainees may be even greater. A landmark study in 2006 showed that self-perceived errors among internal medicine residents occurred commonly, and led both to decreased quality of life and increased burnout [5]. Despite this being both inevitable and generally well known, it’s not much talked about [6].

M&M could be a space where inevitable mistakes could be shared or at least normalized. It would also be a place where the unpredictability of clinical outcomes—both good and bad—would be emphasized. Although I wish medicine were a bit more like engineering, whereby negative outputs generally have an explanation, the reality is much murkier. Many patients do well who, theoretically, shouldn’t; sadly, the reverse is equally true.

I propose restructuring M&M by having cases submitted by anyone willing to present, and a committee could be created to pick cases and help run the sessions. Each case would be presented by an individual who was involved, and inclusion of surgical learners, advanced practice providers, nurses, and other support staff would depend upon the practice environment. After case presentation, a senior physician or an M&M committee member would then ask the group how they would classify the case according to three large boxes: (1) individual error (such as, I didn’t fix the fibula to length, resulting in a malunion), (2) system error (for example, the ER didn’t give the antibiotics, then the pharmacy didn’t convert the medication to a floor status, and the resident didn’t realize it wasn’t given in a septic arthritis patient), and (3) acts of God/nature (for instance, all steps were taken, but the patient had a postoperative myocardial infarction). Since a large subset of the complications that get presented at M&M fall into the second bucket—system error—those should be referred on to a separate setting where genuine quality improvement processes are used, presumably a hospital-wide committee that draws together involved departments and entities to perform root-cause analyses in a context that seeks to learn rather than blame. These exist, and they should be expanded, and kept in tight contact with individual departments’ M&M reports.

The most important component of this reimagined M&M would be creating an environment that rarely exists in medicine today—a time where a community gathers and discusses both the clinical and ethical challenges of this work. How one day we act with brilliant results and other days that same action has disastrous outcomes. One of my colleagues often says surgeons are always replaying our worst case and our last case. Rethinking M&M as an opportunity for us to share our worst stories would help contextualize them, even as we share the goal of trying to avoid complications the next time around.