Welcome to our second blog. Today I want to tackle a subject that comes up during the later years of residency, although occasionally can creep up in your junior years. The famed morbidity and mortality conference. This is geared more towards our surgical colleagues. It is part of most if not all residency training programs in many shapes and forms. Its purpose is to present a case that resulted in a complication (morbidity or the death of the patient). Sometimes the complications are due to not recognizing an entity on time, a technical mistake performed at the time of surgery, not recognizing the complication after surgery, or even a complication unrelated to the procedure itself, but worth discussing as a group.
In terms of why it’s a relevant point of discussion for FMGs is that these conferences are a great way of getting your name “out there” with the rest of the residents and attendings that might have not worked with you in the past. It’s also a great opportunity to practice your presentation chops, i.e. your delivery style, your mastery of presentation software, and how you deal under pressure (getting grilled by your attendings).
It’s good to consider the presentation almost like a board examination, except YOU are presenting the case, but once the questions come in, your composure and way of answering them will leave either a great impression or a not so great one.
Every program does it differently with differing requirements in terms of number of slides, what will be discussed, number of cases, what level resident presents, etc. However, the structure is usually similar in most places: a resident presents the case, the complication, discusses the literature, and takes questions from the attendings present. The question that always comes up is: “what would you have done differently.” The correct answer varies.
Usually, you are informed of the need to present, or your service is supposed to present on a given day. As such, you are usually aware of when to present with more than a week’s notice.
First, make sure you are acquainted with the process in your training program. For example, are you supposed to email a list of cases and complications the week before? Is there an administrator that collects the cases, or an attending that coordinates the conference? Make sure you know all the details that way you are not caught off guard.
Don’t start preparing the night before. It does not matter how smart or good you are, it shows. You need time to go back to the chart, review the clinic notes, the imaging studies, and the operative reports, etc., in order to have all the pertinent information. As you are doing this, write down or type out the details of the case that way you do not have to go back to get information you have already collected. This will help you with the next recommendation: know the case inside and out.
After your initial review, talk to the attending. Many times, there are details about the case that were not discussed with you pre-, intra-, or postop. Something about the history, or the physical examination, or the imaging studies, for example. This also gives the attending a chance to know that their case is being presented. This is very important, because you want to make sure that the attending is present at the conference. Some attendings always go to conference, others only attend if their case is being presented. Make sure you let them know so they can plan on being there. They will help you at the time of the conference to answer questions that are “beyond your pay grade.” The attendings can also help you sometimes in guiding you for the pertinent literature.
Review the pertinent literature, especially if any of the attendings wrote a paper on the subject. Keep it to one or two papers. More papers tend to be very distracting and you WILL lose your audience. When you present a paper, keep it brief and to the point related to your case. The table with 40 lines and 30 columns is usually unnecessary, distracting, and a waste of time. Only cut and paste the important figures or tables. On the topic of visual aids…
Keep your slide presentation short. Relevant past medical/surgical history. Focused physical exam findings (belly case – belly exam only, vascular case – pulse exam, you get the drill). Avoid extraneous information (pretend it’s an oral board presentation). You should have the rest of the history written down or memorized, that way if they ask you something “random” (like the patient’s alcohol intake, their admission Creatinine), you will have this information available.
Make sure you have ALL pertinent images. Nowadays it is easy to go on your online PACS portal and simply copy and paste the picture of that CT, MRI, or Xray that shows the clinical finding you want to present. If unable to do this, at least take a picture of it with your phone and paste it into your talk. Avoid videos since these require a good command of computer software so it does not freeze in the middle of your talk (or not show up at all). Remember to crop out or black out the patient’s identifying information. It does not matter that all the residents and many attendings know who the patient might be. Your talk MUST be HIPAA compliant!
Once you finish your presentation, practice giving the talk to yourself. Practice reciting it in the car. Particularly the “literature review” points/stats. I recommend recording yourself (audio or video, your call) for a couple of reasons: you will notice how long it will take you to give the talk, you will notice which slides might be extraneous, and you will catch yourself saying ummmm, and other verbal ticks that you might want to throw out of your formal talk.
M&M is usually held in the morning. Early. Which means you’re rounding even earlier with your team (great). You want to give yourself enough time to do a couple of things before you just show up to the conference room to load up your slides.
Excuse yourself from rounds if necessary, go to the bathroom, check your teeth and do a power pose. What is a power pose? You will stand in front of the mirror, place your hands on your hips, put your chest out and pretend you are superwoman or superman for a solid minute. Believe it or not, this has been proven to work. If you need further proof other than my encouragement, please read Amy Cuddy’s book Presence (2018), you can also watch her very famous 2012 TED talk (here’s the link: https://youtu.be/Ks-_Mh1QhMc) for a shorter version. I highly recommend the book.
Once done with the power pose, head over to the conference room. Ideally, 10 minutes early, load your slides and make sure they all project. I recommend bringing in a portable drive, and as a backup email the talk to yourself, just in case.
Don’t rush through the presentation. Some attendings crave of signs of weakness before they pounce on you with questions. Just deliver it the way you practiced. If asked a technical question and you know the answer, take your time in answering (again, like the oral boards).
If you don’t know the answer, repeat the question out loud, admit your ignorance, but if you have an idea on how to do it, offer a few words. Otherwise, just say you don’t know and let someone else answer. If you are the junior resident in the room and you know the answer, you might want to hold off on raising your hand. You never want to show off on a more senior resident. However, if they ask you directly, feel free to answer.
Finally, some questions might seem mean spirited or downright nasty. Remember, you did not make the final decisions about how the case was managed. It was your attending’s call. Do NOT get defensive. Just accept the questions, feedback, and keep going. It is important to accept criticism in medicine, especially in surgery. So just like in The Godfather, remember, “it’s not personal, it’s business.”
I hope this short guide helps you with your first, or upcoming M&M conferences. The good thing about these is that just like learning operative technique, delivering these gets easier with experience. However, since we also believe the tenets of deliberate practice, if you get feedback from your co-residents or faculty, keep that in mind for the next one. So just like the M&M conference million-dollar question: what would YOU do differently for your next talk?