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MEdIC Series: The Case of the M&M Shame Game

2017-12-02T23:38:54+00:00

Welcome to season 5, episode 3 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Drs. Tamara McColl, Teresa Chan, John Eicken, Sarah Luckett-Gatopoulos, Eve Purdy, Alkarim Velji, and Brent Thoma) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine!

This month, we present a case of a junior faculty member who is apprehensive about presenting at M&M Rounds after a recent “public shaming” of one of his fellow colleagues.

MEdIC: The Case of the M&M Shame Game

By Tamara McColl  MD, FRCPC

Stefan groaned as he emphatically closed his laptop and rested his head on the desk in the physician office.

“What’s this all about?!” chuckled Meredith. “You looking at your bank account statements?”

“No… worse,” sighed Stefan. “I’ve been scheduled to present M&M rounds in 2 months. After what happened with Ron’s case, I’ve just been feeling sick about the thought of having to present in front of our group. How do I spin my case in such a way that I avoid the disaster that ensued after his presentation?”

Stefan was relatively new to the department and had attended his first M&M session last month when Ron, a mid-career emergency physician, presented a fairly serious adverse clinical outcome in a patient he had treated. He had outlined a case in which a known drug seeker’s back pain was not thoroughly investigated and led to a missed spinal epidural abscess with subsequent neurologic deficits.

Stefan had attended the rounds and had thought to himself, “This is a great case. I could have easily missed this diagnosis as well. We’re all human and humans make mistakes. We often tend to downplay the symptoms of our frequent flyers and drug seekers.” He was waiting for a constructive discussion from the group and instead witnessed a scenario akin to a firing squad in which the senior physicians took their turns shooting bullets at their vulnerable colleague who had just unloaded the most uncomfortable details of a case he inevitably already lost sleep over.

Stefan had approached a few staff after rounds, voicing how painful it was to watch the public shaming of their fellow colleague. The general consensus was that “this is how it’s always been. This is what M&M Rounds are all about.”

 “So what are you going to do?” asked Meredith, looking genuinely concerned.

“I don’t know if there’s much I can do. I suppose I’ll prepare as well as I can and just roll with the punches when they inevitably come,” he replied with a note of apprehension. Stefan left the department still thinking about whether the case he chose will result in his own public humiliation and how his colleagues may regard him as less of a physician after it’s all over.

Discussion Questions

  1. As a new staff to the department, should Stefan speak up about his M&M concerns? How should he go about it?
  2. Realizing that the culture is a little outdated at his new site, how can Stefan initiate movement towards positive change and help champion a new process of M&M case review?
  3. How can we make M&M rounds less threatening so as to encourage faculty to present their difficult cases?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

Our 2 experts for this month’s case will be:

  • Dr. Lisa Calder (along with colleagues Drs. Edmund Kwok and Shawn Mondoux)
  • Dr. Jeremiah Schuur

On December 15th, 2017 we will post the curated commentary and expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. That said, we’d love to hear from you, so please comment!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

MEdIC Series: The Concept
Tamara McColl, MD FRCPC MEd(c)

Tamara McColl, MD FRCPC MEd(c)

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba
  • Aidan Baron

    Hi Tamara,

    Great series post and really interesting coming from a non-physician service delivery / more corporate background where individuals often don’t get the opportunity to present their own M&M cases (usually a senior manager delivers the case to an entire group / audience which might include the individual.)

    Theresa asked me to copy in a a few comments I’d made on twitter. Apologies for the very poor syntax.

    “Not just in medicine but in corporate and service delivery world:

    The person who made a mistake presents their OWN case and owns it.

    A little story:
    The most hurtful experience of my adult life was being caught off-guard and publicly shamed in front of 150 colleagues.
    It wasn’t just the embarrassment, it felt like I had been betrayed and abandoned by my managers and mentors.
    Soul crushing.

    I left soon afterwards.

    Next company had culture where we presented our own cases, OWNED the errors, and provided teaching points.
    it’s still humbling. And one feels vulnerable….
    But the debrief with mentors happens in private. The sharing of learning is public.

    I firmly believe that when you give people their own mistakes to present you hand them ownership, power, and an ability to save face.
    You humanise the error.
    And by contextualising it, others relate better to the scenario and are more likely to prevent it in future because it’s more relatable. There’s a huge difference between forcing a resident to present their case, and giving them the opportunity to own it, & deliver teaching”

    In respect to the above scenario and the negative culture of M&Ms in the medical establishment, perhaps what is needed is the exact opposite?
    Perhaps clinicians presentng their own cases at M&Ms should be accompanied at the lecturn by a faculty chair who can field/moderate/filter questions and whose presence signifies support and tangible defence of the person presenting; in a way, solidifying a just culture.?

    Some rambling thoughts.

    Aidan

    • Tamara McColl

      Thanks for sharing your experiences and thoughts Aidan!! The emphasis on learning is key! Does your company have an outline or rules for presenting cases? Is it well established that the environment will be safe and blame-free with a focus on learning to prevent the mistake from occurring again in future?

    • Todd Fraser

      At a place I used to work, we had 2 meetings a month – the Mea Culpa session and the FIGJAM session. They were exceptional learning opportunities for everyone who went, and you learned from both successes and mistakes. Everyone honestly took part, were supported and outcomes were documented. It was the best safety culture I’ve ever worked in.

      It’s really up to us to capture data about ourselves and learn from it. While there are options available online to do this (eg http://osler.community) it doesn’t really matter as long as we start to measure, and OWN our personal performance.

      • Tamara McColl

        Thanks for sharing your insights, Todd! I’d be interesting in learning more about the Mea Culpa and FIGJAM sessions. How were they structured? How were presenters chosen? How was psychological safety preserved?

        • Todd Fraser

          Thanks Tamara – remarkably unstructured. The culture of the unit was to share and embrace both positive and negative experiences. I was probably a bit too junior at the time to realise it, but it clearly reflects the core leadership values of the unit. Some people presented extraordinarily challenging personal experiences – but the unit supported them in doing so. It was impressive to say the least.

  • I’ve just been asked to oversee the Paeds portion of our hospital’s M&M meetings, and so I’m looking forward to learning from this conversation. I must admit I also find the M&M process (in general) rife with hierarchical complexities, blame and shame.

    One thing that makes me much more nervous than I would be in a simulation debrief, for example, is the fact that there are often a lot of strong personalities in the room, a lot of hidden agendas and it can be difficult to control the tone of the conversation when it involves such an enormous crowd. My brief experiences have been that there is often the best of intentions from the staff running the M&Ms themselves, but an off key comment from a self righteous senior at the moment when a junior doctor is at their most vulnerable can have lasting consequences.

    I also resent that it is often the most junior member of a team that is asked to present, and that while this might be perceived as valuable learning for them, the pressure this places them in and the vulnerabilities that they must embrace to stand before ‘the firing squad’, is not really acknowledged. Better I think to have teams present, with juniors helping prepare but also senior doctors involved in the presentation to help shield their juniors a little and also to make it clear that hospitals work in team based formats and as such the risk and the rewards are shared together.

    The world of simulation has put a lot of effort into understanding the principles of psychological safety, but I worry that M&Ms are still more heavily influenced by our ‘ancestral’ hierarchical culture and a subconscious need for the hospital as a whole to ‘out’ or ‘punish’ those who have been deemed to shame the institution.
    I have faith that it can be done well but I think it requires a remarkable amount of skill to do so. And deep down I wonder if these are the right formats to have such important learning conversations? I learn a lot from my mistakes, I learn a lot by asking more learned colleagues about their approach to the same problem, but if I was to choose the most effective space to reflect on an error, I’m pretty sure being in front of 50 colleagues wouldn’t be in my top 10 list.

    • Suneth Jayasekara

      Like Ben Symon, I am also involved in simulation education, and echo his thoughts about the effort we put into setting up a psychologically safe environment, and the fact that this is often not done for M&M meetings. In fact the risk to psychological safety would be much higher in M&M than in simulation, as the case is a real case, and often actual harm has occurred to the patient. I wonder if all M&M’s should be started off by a pre-brief, reinforcing the objective of the session as a learning conversation, and systems improvement. Also specifically stressing on the effects of hindsight bias in the people in the room, and acknowledging that there may have been many other factors at play that would have made it much more challenging in the real world, that when reviewing the case in retrospect.

      • Tamara McColl

        I really like that idea of the pre-brief, Suneth! Facilitating the session is key and reinforcing the central theme of learning from our cognitive biases and identifying the systems issues at play are a must! How does your centre structure M&M rounds?

        • Suneth

          Our centre is a new centre and most things are finding their feet. The meetings so far have been non-threatening (unlike in the case of the month!) Usually a third party presents the case. The person involved is usually present and can fill in the gaps if they choose. The facilitator steers the discussion away from individual criticism and more towards system issues and overall learning points. But I imagine at times this may get challenging for them. I’m curious about people owning their own case and presenting it themselves. I imagine this could be more powerful, but maybe has a higher risk of being unsafe?

          • Scott Schofield

            Hi Tamara,

            Nice to see you on here – I see you’ve moved away from Ottawa. I work with Suneth in Queensland and am involved in the PEM cases for our Emergency M&M process. There are a number of safe guards we try to maintain to encourage a safe learning environment:

            Time – Important to ‘let the dust settle’ after difficult cases. Often the individuals involved need their own time for reflection as well as time to address any significant issues at an individual/department/system level.

            Space – Having a third party review and present the case avoids some of the inherent bias of one presenting their own case.

            Structure – Our M&M group has agreed upon a terms of reference and general structure for presentations. This includes brief clinical summary, issues identified and organised in an Ishiwaka/fishbone diagram to prompt discussion around learning/action points.

            Supervision/Leadership – We are very fortunate to have a senior emergency physician colleague who chairs our meetings. It is a great resource for review of cases, guidance around approach to sensitive discussions, and advocacy of maintaining and preserving professional and respectful relationships at all times.

            I really like the idea of the pre-brief, if only to activity acknowledge the risk of personal criticism and put everyone on the same page in the book of safe learning, quality improvement and optimal patient outcomes.

          • Tamara McColl

            Great to hear from you Scott! And thanks for sharing your insights – excellent breakdown of the M&M process!

    • Tamara McColl

      Thanks for sharing your thoughts, Ben. How does your department choose M&M presenters? Is there a particular format you follow for the actual presentation?

      • At present it is usually someone associated with the case, but usually some time is left ‘for the dust to settle’, as Scott mentions. I can’t speak much about our unit as I’m relatively new to it but keen to learn from this discussion.

    • Todd Fraser

      There is nothing more powerful than a senior person openly sharing their mistakes, and demonstrating a willingness to own them.

      It is often said that cultural change will need to begin with the junior staff, as they are the future of our industry, but that’s folly. To truly change the safety culture in health, it will need to begin at the top. That’s confronting for many of us, but it’s a step we need to take.

      • A bit like how we try and teach ‘speaking up for safety’ by telling the juniors to speak up, rather than teaching the seniors to ask what other people are thinking. Even our solutions to systems problems seem to obey the hierarchy. Agree it’s more effective when it comes from top down, or at the very least when juniors are listened to while tempered with the experience of those more senior.

  • Gannon Sungar

    Great topic and some excellent discussion points. I think others have hit on the many of the main points. In my experience from running a number of M&M conferences, it is essential to create a culture focused on learning and not blame. A few ways to do this are:

    * Call it out directly. I used to start almost every conference with the below quote. It is succinct and, in my mind, sums up the “there but for the grace of god go I” approach that I take when sitting through a M&M conference.

    https://uploads.disquscdn.com/images/f46697c7738967853f91f65ceef07a8167eb42d10b9c04a2fd99ae4c0e817469.png

    * I believe a moderator is essential. To have someone not directly involved in the case who is able to facilitate discussion unloads the clinician presenter and can act as a shield to some extent if things start to tip towards the negative.

    * I agree that letting individuals presents their own cases is also hugely valuable. Not only does it give some control to the presenter, but it often humanizes the provider and gives depth of insight into the thought processes that may have led the case astray. Most importantly perhaps, is the intellectual humility it shows to stand up in front of your peers and present a case that could have gone better so that others may learn. From this point, I agree with Todd, critical to developing a positive M&M culture is involvement of senior members to present their cases, show their own humility, and let all recognize that the learning in this job is never-ending.

  • Heather Murray

    Resource suggestions for M+M:
    Lisa Calder from Ottawa has done some great work on this – structuring an ideal M+M session around cognitive errors and system errors rather than a focus on “more training” – aka shame/blame. Here is a guide:
    http://www.emottawa.ca/assets_secure/MM_Rounds/CalderMM-Rounds-Guide-2012.pdf
    And here is the paper that described it:
    https://www.ncbi.nlm.nih.gov/pubmed/24628757

  • V A

    I’m a surgical resident in the US- and I actually think that a change in perspective would be useful here. Yes, overly harsh and critical M&Ms are not constructive. However, something I loved about surgery is that ever since the days of Dr. Codman, all of us must answer for our mistakes. In many fields in medicine, terrible outcomes occur and are brushed under rug, the same in many community hospitals around the country. But in academic medical centers, M&M forces at least some level of honesty and responsibility by doctors for the decisions that they make.

    When I am up there, answering for the decisions I have made, it is often not comfortable, and no it’s not a safe space. And it shouldn’t be. The process isn’t about my comfort or feeling better about a mistake, it’s about providing better care for our patients. We should feel uncomfortable and challenged- after all, how do you think the patient and their family feel? The hypothetical scenario in this case isn’t discussed, but in the first example given a man may well be paralyzed for life. The lessons learned in M&M are ones that will never leave you.

    I would suggest that in this case, Meredith refocus Stefan on a few key factors.

    1) At M&M mistakes are often sorted into 2 groups: knowledge errors and moral failings. Not knowing that a patient in respiratory failure after a gastrectomy often has a GI leak is a knowledge error. Not getting up in the middle of the night to manage that patient and instead trying to do it over the phone is a moral one. The former mistake is forgivable- we all have knowledge gaps. The latter is not, and often attracts the so-called “firing squad”. It is thus better at M&M to rapidly admit to knowledge and decision-making failures rather than be called on moral failings after denying the knowledge ones.

    2) Remember at all times that this process is about becoming a better doctor, and making better decisions for patients. Do research, literature reviews, and everything you can to use this incident to make a better decision next time.

  • This is a really important discussion point (like so many in this series)

    At the heart of this case is culture. Clearly these cases need to create a dilemma in order to create debate but I wonder if it is truly the case that ALL the senior clinicians lack insight into the behaviour. My experience it that it is one or two who don’t attend all meetings, and that when they do their senior colleagues are not always present, so that ‘bad behaviour’ is never persistently recognised or challenged.

    I am afraid I have little advice for Stefan if it really is the case that every month is like a firing squad, creating a counter-movement with no senior support in these circumstances is going to be exceptionally difficult!

    I suppose if this was the case he could start the process being setting the ground rules for the meeting. This is something that my colleague, Dr. Gareth Lewis, is clear about at the beginning of all of our Critically Careful Forums. A clear statement of intent that this is, “a learning forum, which is non-judgemental, is is designed to allow people to discuss and describe the challenges they have faced without fear of personal admonishment”. This starts everything single meeting (we have been going for well over a couple of years) and makes it difficult now for anyone to ‘badly behave’. This process is aided by the fact that the senior presence at the meeting is very consistent so sets again a culture for the meeting that would be difficult for others to come in and disrupt.

    An approach for Stefan may be to find a senior colleague who understands the need for a non-critical approach and co-present the M&M with this person. the senior could chair the discussion with a number of pre-pared questions which elucidate learning without allowing deviation towards victimisation. If you can break the chain of bad habits just once then a movement is likely to start at subsequent meetings as word will hopefully spread that the learning was more effective.

    In relation to some of the other comments about simulation it is interesting that the critically careful forum tends to be run by those who enjoy simulation debrief and education. I am not sure if this is a personality type effect or a debrief training effect – perhaps a bit of both!

    All the best – Damian
    The Critically Careful Forum: http://adc.bmj.com/content/101/Suppl_1/A135.1.info

  • CC

    Our M and Ms (sadly) aren’t a forum for learning. I voluntarily attend as a Clinical Nurse and am dumbfounded by the naked power plays and criticism of those absent from meeting. Seriously, my local Scout Parent Group Meetings were run with more structure and decorum.
    Often, details of the case will be absent or incorrect. Minutes not reflective of discussion AND not readily available to all staff involved. The occasional well run case review is only reason I attend- Can be very valuable way to learn.