6:30 on a Tuesday morning in January, still pitch
black outside, and 65 people in white lab coats are
swarming into a conference room in the Hospital to
talk about a handful of the more troubling operations
performed by the Department of Surgery in the previous
week. The case review sheets lie in a scattered stack
on a narrow credenza near the doorway, sharing
the table surface with coffee, donuts, bagels and
chunks of fruit.
Modest socializing wells up among colleagues, but
the mood is all business as the participants file in
and quickly scan the sheets, all bearing the heading “Privileged
and Confidential.” The grid lists seven operations
that did not unfold as hoped. Three cases ended in
death. One of them will get the full treatment during
the next hour. The physicians involved have known for
a week that this review was coming and are prepared
to see their decisions thoroughly dissected before
their peers. They’ve taken seats side by side
in the second row.
their colleagues at academic medical centers
across the nation, Hopkins surgeons have gathered for
nearly 90 years to engage in sessions like these, called
morbidity and mortality conferences—known as
M and M meetings. Here, in tucked-away conference rooms
beyond public scrutiny, a tug-of-war between candor
and obfuscation plays out as physicians try to figure
out why certain cases ended badly. By going over each
disappointing outcome in excruciating detail, they’re
hoping to avoid similar pitfalls in the future.
Some surgeons believe an easygoing analysis of cases
that went awry encourages straighter answers and is
less threatening to physicians’ egos. Others
are convinced that stating openly where the blame belongs
works best. But blame tactics can make sessions feel
like hostile prosecution. And the fact is, not all
unforeseen results arise from technical errors: Disappointing
outcomes may also stem from decisions about whether
to operate at all, or from the nature of the patient’s
Still, no matter the cause, these discussions call
into question the judgment of even the finest practitioners
of modern medicine. And despite calculated efforts
to remove any blame-fixing, professional reputations
are on the line—and in a group setting.
“So let’s get started,” says Julie Freischlag from across the room at precisely 6:38.
As department chair, Freischlag has targeted this case
for special attention. She takes her seat near the
front of the small auditorium, determined to probe
not only for technical errors but to also learn whether
the decision to operate was justified.
With Freischlag’s nod to the podium, a petite
surgical resident with a distinctly Bulgarian accent
commences rattling off the most essential details of
today’s centerpiece case. The audience will learn
nothing of the patient’s race or religion or
social status; only the cascade of escalating clinical
issues that brought her to Hopkins.
|> Residents now serve as the chief presenters in surgical case reviews.
The 67-year-old woman arrived with complaints that
she had no mobility or sensation in her right leg.
Her left leg was little better. Both feet were cold.
But these symptoms only hinted at the mountain of underlying
challenges that first confronted physicians here.
“Severe coronary artery disease since 1988,” presenting
resident Christina Vassileva notes at the top of her
list. The condition began to impede blood flow to the
patient’s legs 18 years ago. When the circulation
problem became unmanageable through anticoagulation
therapies, surgeons created a new pathway for the blood
flow by bypassing two disruptive aneurysms in the arteries
that ran through her abdomen to her legs—a fix
that was reaching the end of its remedial lifespan
when she arrived at Hopkins. “Pulmo-nary hypertension,”Vassileva
continues ... “coronary
artery disease ... history of pneumonia ... extensive
deep vein thromboses ... hepatitis C from a transfusion
And then the kicker: The patient had been battling
inoperable liver cancer for several months. Even if
the symptoms that brought her here could be defeated,
the woman’s life could ultimately be extended
by only a few additional months.
With the underlying cancer condition trumping all
others, the dilemma came into sharp focus—how
much intervention should the physicians apply, given
its short-term value? If surgery was indicated, how
much quality of life could this woman gain amid the
inevitable trauma of extensively sliced tissues and
the time it would take to heal from the operation?
Even more ominous: Could a patient in her condition
survive at all? In short, was there more to be lost
than gained by attempting surgery?
the mid-January day when the woman first became
Bruce Perler’s patient, he spent considerable
time reviewing his grim choices in trying to offer
her some relief. At 55, Perler possesses the avuncular
manner that comforts worried patients and their families.
His understated self-confidence and thinning hairline
hint at the vast sea of clinical wisdom he’s
gathered during his 30 years in medicine. With a CV
thick with research distinctions and career accomplishments,
this is a specialist who’s long been a go-to
guy for a broad range of high-level consults in vascular
surgery. Department head Freischlag feels lucky to
have Perler as chief of the division that is her own
Shortly after the woman’s arrival, Perler’s
workup team found that she had no detectable pulses
at all in her right leg; the limb looked like a lost
cause. It was cold, immobile and incapable of sensation.
If left in place, the dying appendage loomed as an
imminent threat to this patient’s life. But the
major surgery required to remove the leg posed its
own considerable risks in someone with such complex
The distressing variables conspired against easy
answers. Might the physicians restore some circulation
to her legs by reducing the clots with high doses of
the blood-thinning drug heparin? Should they instead
attempt to remove the clots with minimally invasive
surgery? Or should they take the “easy” way
out by amputating one or both limbs? And, finally,
with mere months to live even in the best-case scenario,
how much would this patient gain with any of these
Meanwhile, the patient was anxious. Her blood pressure
was high. The pain in her legs was so intense that
it crippled her mental state, making it necessary for
her husband and two grown sons to act on her behalf
during doctor-patient decision-making.
Perler met with the family and found everyone reasonable,
intelligent—and realistic. It might be necessary
to remove at least one of the woman’s legs, he
told them, but before considering the trauma of an
amputation, he wanted to try heparin to see if that
might improve the circulation. Everyone agreed the
primary goal was to reduce the patient’s pain.
The family seemed to accept that the woman’s
maturing cancer would soon take her life.
modern M and M conference dates back to the
early 20th century, when a Harvard surgeon at Massachusetts
General Hospital developed what he called an “end
result system” to gauge surgical performance
and outcomes. His idea was that if surgeons were expected
to share information with colleagues about how patients
fared after being operated on, they could subject themselves
as a profession to correction and scrutiny. The idea
soon caught on at other academic medical centers, and
Hopkins apparently adopted the tradition in the 1920s.
|> Former department chair John Cameron religiously participates in these sessions.
Over the generations, M and M protocols at Hopkins
have invariably changed as successive department chairs
have given the sessions their own stamp. During the
legendary 18 years (1985–
2003) when John Cameron was at the helm, for instance,
the sessions proceeded in Socratic fashion, with Cameron
quizzing surgeons on the details of their cases. Though
these oral exams could sometimes feel embarrassingly
direct to those on the receiving end, Cameron devotees
contend that his command of practice and literature
made the weekly grillings educational.
When Julie Freischlag assumed the chairmanship of
Surgery in 2003, she introduced several new ideas.
The function of moderator would rotate among division
chiefs or the department chair, residents would present
the cases, and key cases would be subjected to “evidence-based
analysis”—summing up outcomes in previous
patients with similar diagnoses as reported in the
literature. And, of course, all cases would continue
to be scrutinized for their core rationale: Did the
procedures help or harm?
hours after Perler put his patient on
heparin treatment to improve circulation in her legs,
the medication had failed to bring relief. Quite the
reverse: The woman’s pain had accelerated so
acutely that her family requested urgent intervention.
Perler agreed, but was forced by a professional commitment
out of town to delegate the operation. He chose one
of his most skilled surgeons, seasoned vascular ace
Glen Roseborough, for what promised to be a difficult
procedure—operating to restore some circulation
to the patient’s legs to help her out of her
Roseborough brought all the right skills to the equation.
A Canadian-trained practitioner, he had completed his
residency at Hopkins and amassed a formidable record
in vascular surgery. With 15 years of medical experience
by the age of 40—seven of them in vascular surgery—Roseborough
had developed a commanding authority in some of the
very specialties this patient would most require, including
minimally invasive surgical techniques, thoracoabdominal
aneurysm surgery and limb salvage surgery.
The initial plan was to remove the massive clots
that had formed inside the aged arterial grafts within
the woman’s abdomen. But as Roseborough and surgical
resident Christina Vassileva homed in on the graft
sites, they soon found their first big surprise: The
arterial tissues adjoining the grafts had dilated into
aneurysms the size of golf balls. Thick with scarring
complications, the ballooned tissues promised to dramatically
slow the procedure.
Only now did the surgeons get their first clear look
at the extent of the blockage in the right leg. The
clot was a chronic thrombus extending all the way through
the upper right leg and down to the knee. The left
side wasn’t much better. The planned reconstruction
time suddenly graduated from the expected 90 minutes
to more than six hours. Still, when the two surgeons
finally closed the incisions, the operation appeared
to provide the patient with relief. The new grafts
had returned the blood flow to her legs.
Informing the family that the procedure had gone
well, Roseborough transferred the woman to the ICU.
Soon after midnight, however, when he was finally ready
to leave the unit, the picture had changed dramatically.
As the fatigued surgeon prepared to head home, he learned
that the woman’s vital signs had plummeted, her
heart had slipped into a dangerous rhythm and her pressure
had dropped. Soon she was bleeding from the site of
the surgical incision, from IV sites and from her nose.
Roseborough then learned the patient had developed
another ominous complication, “compartment syndrome.” Her
abdomen had become distended with fluid, causing intra-abdominal
pressure that made her kidneys collapse and then stop
Alarmed, Roseborough ordered the patient returned
to the OR, where he and a vascular fellow commenced
an urgent search for the culprit behind the sudden
decline. Had the aggressive heparin therapy affected
the patient’s ability to clot? Had the grafts
failed? Had one of Roseborough’s vascular probes
punctured a sensitive vessel?
Now, as Roseborough and the vascular fellow opened
the patient’s abdomen to relieve the pressure,
they found the grafts still strong, with no vessels
ruptured. They found no blood pooling in her abdomen,
a perversely bad sign: It meant there was nothing they
could repair, nothing they could do to reverse this
patient’s decline. The woman’s heart was
beating erratically as they closed her, and her blood
pressure dropped again suddenly. Immediately, the surgeons
started her on units of fresh frozen plasma, but her
vital signs refused to stabilize. At 3:17 a.m. on January
19, the woman went into cardiac arrest and died.
went wrong with this case? As the conferring
surgeons prepare to unravel that puzzle, Freischlag
turns first to Perler. From his central position in
the auditorium, Perler cuts to the chase about the
one pivotal decision that most haunts him: From the
outset, was the decision to save both of the patient’s
legs ill-advised? “My gut feeling,” he
says, “is that sometimes you have to lose a leg
to save a life.”
Seated immediately to Perler’s left, surgeon
Roseborough cites his frustrations with the aneurysms
in her groin. The damaged grafts had unduly prolonged
the clot-removal procedure—a heavy tax on any
patient’s system, but more so on such a compromised
Freischlag goes back to the woman’s downward
spiral after the second operation and turns to one
of the most skilled trauma experts in the room, Edward
Cornwell. Cornwell addresses what he considers the
case’s core dilemma. “Every instinct of
our training,” he says, “is to save limbs
whenever we can.” This woman’s many physical
problems posed cruel obstacles to that plan, Cornwell
admits, but the idea of amputating both her legs and
forcing her to face her final months in life as a double
amputee would be unappealing to any caring surgeon.
As others chime in, it becomes clear that, faced
with similar dilemmas, the rest of the surgeons in
the room would have made the same choices as Perler
and Roseborough. But if they come up against a case
like this in the future, surrounded by such a collection
of complex questions about operational procedures,
they will now be prepared. They will have heard their
peers discussing the pitfalls, one by one.
But Freischlag has one more question: How do the
operational decisions made by the surgeons in this
case stack up against other cases with issues like
these? To make sure these M and M discussions aren’t
restricted solely to anecdotes and opinions from colleagues,
the department chair has recently introduced a process
called “evidence-based analysis,” in which
the presenters search the literature to find outcomes
data for similar patients.
department chair Julie Freischlag has
The lights are dimmed and surgical resident Vassileva
unveils a slide presentation about the clinical history
of patients with occluded arteries similar to the case
The bottom line of the evidence suggests that such
patients who receive new grafts do better over time
than those who don’t. But it also suggests that
the graft sites themselves are prone to deteriorate
from continued atherosclerosis that can combine with
hypertension to produce thinning of the tissue combined
with excess growth—developments that create a “perfect
storm” of factors that could produce precisely
the sort of aneurysms that complicated the operation
that has just been discussed.
entire presentation has unfolded in about 38
minutes. But what can this gathering of busy surgeons
do with the information they have just shared? Do they
come away as better practitioners? Will future patients
M and M conferences today might well play a more
crucial role than ever before. With Johns Hopkins determined
to become a leader in the national quest to help caregivers
learn from their disappointing cases, these candid
discussions offer a forum for helping physicians to
avoid pitfalls. Still, well-known patient safety experts
like Hopkins critical care specialist Peter Pronovost
feel that M and M conferences are ripe for upgrades.
The talks are structured with a limited vision, he
says, chiefly because only physicians are typically
invited to take part.
“What about the way nurses see the problem?” Pronovost
asks. “What about the OR tech people, the administrators?
By inviting everyone who touches the process into the
room, the M and Ms could go a lot further as an educational
In Freischlag’s M and M conferences, a number
of nurses, nurse practitioners and OR techs do sit
in, but few other departments, according to a recent
Pronovost survey, open up their meetings.
Surgeon Glen Roseborough wonders, meanwhile, if Hopkins’ M
and M process might benefit with a more aggressive
approach. “I think this was a very tame M and
M,” he says of his own case. The most quality-compulsive
surgeons, he believes, are attracted to the rigor of
high standards. Seeing those standards applied both
in practice and review can perpetually help people
like him improve their game. Like many of his colleagues,
Roseborough is proud of his ability to self-prosecute
and frustrated when others won’t do the same.
Still, Roseborough can’t think of how he would
have approached his own case differently, even with
the benefit of hindsight. For him, he says, such cases “beg
the question: What are we supposed to do for someone
like this? Is there a correct level of intervention
we should be exercising with a terminally ill patient?”
As a product of Canada’s nationalized health
system who also once served within the United Kingdom’s
similar structure, Roseborough has long been impressed
with how the American medical culture is geared to
go to unusual lengths for every patient. “In
the UK,” he says, “a case like this would
have been handled with a morphine drip and a hearty ‘cheerio.’”
Bruce Perler also ruminates about the session. Sitting
in his office two weeks after hearing his case second-guessed,
he’s philosophical. “This case really
was that kind of end-of-life circumstance because of
all the malignancy issues,” he says. “We
faced a series of bad options, and it was a matter
of trying to pick the least unattractive.”
As for his feelings about subjecting his decision-making
to the scrutiny of a roomful of peers and subordinates—let
alone his chair, Perler has no doubts. “I want
their review,” he says, “but the most important
opinion is the one from the person I meet in the mirror
each morning. It’s about my conscience.”