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Mastering M&M: A Practical Guide to Presenting Complications · Behind The Knife: The Surgery Podcast

• m&m pod - 3_31_26, 10.39 AM === [00:00:00] Hey everyone. Welcome back to Behind the Knife. This is Cody Patrick, Jason and Iman. And today we're gonna be talking to you about something that every surgical trainee will experience and remember for the rest of their career, which is presenting at Morbidity and Mortality Conference. No matter where you train, Eminem is one of those experiences where you can feel your heart rate creep just a little higher. When you walk into present, your name's on the slide case is queued up, and you know the discussion's gonna be thoughtful, detailed, and led by people who have seen everything. Yeah. Uh, and if you're a resident listening to this, you've probably remember your first m and m presentation, or you can, you can picture it or maybe you have nightmares about it. It's definitely a formative experience. So it's not just another case conference, it's one of the places where surgical identity gets shaped. It's how we talk about complications, how we learn from them, and how we treat each other, uh, throughout that process. And it is formative because Eminem is one of the defining professional rituals of surgery that's pretty unique to surgery. It's where we model accountability. It's where we publicly examine decisions under real [00:01:00] uncertainty, and it's where we demonstrate in a very explicit way how surgeons think. Our goal for today is simple. We want to give residents a roadmap for preparing high quality m and m presentations, presentations that actually facilitate learning for other trainees in the room, and that communicate very clearly to an experienced audience. We want to do it in a way that's practical, what to include, what to leave out, how to frame the case, and how to prepare yourself. We also intend for this episode to be useful for attendings who will assist a resident in preparing for the presentation, add to the discussion, and maybe even moderate the session. It's also important to clarify what we won't be diving into today. So this is the profound emotional weight of having a complication laid bare. M and m, this is arguably one of the most harrowing experiences we face in our profession, is a weight felt by residents and attendings alike. When a mistake happens and a patient suffers, the resulting guilt and self-doubt can be absolutely overwhelming. Often, just as you're starting to emerge from that [00:02:00] initial kind of post complication fog, that Eminem notification hits your inbox, you see it, your heart sinks. Staining before your peers. To dissect a complication is a uniquely miserable hurdle. So because these emotions deserve their own dedicated space, we're gonna let Steve Thornton, one of our exceptional BTK fellows. Look into this farther. He's curating a special series exploring the role of shame, specifically in surgery. So it's obviously a vital conversation and we're looking forward to that. So we are not gonna be covering that part of m and m today. Well said. Patrick, one quick note before we move on. The best m and m presentations often feel deceptively simple, and that's because the presenter did the hard work upfront deciding what, what, what matters, choosing what to emit and building a narrative that the room can actually hold in working memory. If you're listening to this and saying, man, I'm a busy resident. I don't have time for that level of prep. Well, the reality of the situation is you don't have time not to. Eminem is one of the few places where the whole department is focused on the same case, [00:03:00] and your preparation determines whether that attention turns into meaningful learning. Also, the, in a real sense, the way you present a complication shapes your own relationship to it. When you can describe the facts clearly and analyze them without shame, you build the kind of professional resilience that you're gonna need for a long career in surgery. One thing upfront is that it's important to ask for help early and in some places expected. Ask a senior resident who you look up to, to sanity check your timeline. Ask the chief to look at your slides, ask a fellow or attending what questions a room tends to ask. And you may even consider asking the moderator who selected the case if they had any particular interests or learning points in the case they want you to incorporate. Just like everything in surgery, prep for m and m is a team sport. Yeah. Iman and Cody, you guys. Who do you like to ask in advance when it comes to reviewing your, your presentations? Yeah, per personally, I always will reach out to the moderator first and get a [00:04:00] sense of what kind of questions they want to ask. You know, as a junior resident who may have presented more cases than I should have, I I had the, I think that that was one of the most valuable things I could do. The other thing I would do after that is just immediately reach out to the attending who I did the case with. And once you have that as a foundation, you can ask other residents to kind of help tweak things. But I think getting those two, um, is not just a is not just something you can do. It's something you should do. I totally agree with Ayman. I think you know it, the moderator probably selected the case for a particular reason, so trying to. Figure out the rationale for this selection and kind of what, from their standpoint, some of the key learning points may be related to the case, uh, so that you can incorporate that into your presentation. And then one other pearl, just to build on what Iman said, if you rotated it off service and maybe you weren't necessarily involved in the patient's care when the complication itself actually developed, it's always good to talk to the chief resident who might be running that service after you. Uh, to get a good sense clinically of [00:05:00] what might have happened in the patient's rescue and, and their complication. Yeah. So, Cody and Iman, do you guys wanna know a little secret that Jason and I keep from you? We also ask colleagues and other specialists about the case in advance, or at least I do. Jason, do you talk to anyone else? Oh, yeah, absolutely. I'll, I'll, I mean, that's the best part about having good partners is you can, you know, go to 'em and, you know, kind of lay it all out there and process it. So, I talk about all my complications with, with my, you know, trusted partners. Exactly. It's good for processing mentally clarity, and there's always something that comes up. I'm, I'm shocked because. But a lot of these cases, you know, you feel awful. Something bad happened to a, a human being, and so you feel terrible and you look at it and you think about it in the way that you don't think about any other cases. And just when I think I have it all figured out, every angle figured out, my partner will be like, Hey, like what about this? Or just thinking about this. I'm like, oh man, what a great, you know, suggestion. And I think that's also just extraordinarily valuable for our conversation right now, which is how do we present at m and m? Well, you know, Jason and I, as, [00:06:00] as staff, like to say something about our cases too, right? And so we want to have our thoughts in line and so getting. Everyone's feedback is, is so important. And you know, historically, most Eminem conferences may have had a more punitive tone. It's kind of like the, the knee jerk reflex you hear at Eminem and it's like, oh man, this, this stinks. And that certainly can create a culture where people become guarded. It's my impression that the majority of institutions, but maybe not all, have largely moved away from some of that heated rhetoric and that kind of, that blame centric focus. You know, that dominated these, these surgical auditoriums in morning's past, and that's a good thing for sure. So modern Eminem, when well done, is something that's systems focused. It's educational, it's reflective, and it's structured in a way that we can learn from the inherent complexity of what we do as surgeons. And in my opinion, when it is well done, this is the single. Best learning opportunity that we have as surgeon, and that shift you're describing Patrick matters because [00:07:00] the resident presenting the case is not there to be on trial. Your job is not to defend yourself. Your job is simply to tell the story clearly what happened when it happened, what the team knew at the time, what decisions were made along the way, and some reflection of what could or should have been done differently that may have changed the outcome for the patient. Then the room derives meaning from it. The room identifies learning points, the room identifies systems issues and cognitive traps and potential technical considerations. And ideally the room does that in a way that makes everyone in the room better, including the next resident who's about to face the same decision in the operating room later that day. You know, I'd actually take it one step further. So for me, Eminem is about making sense out of uncertainty. You know, this job is full of imperfect information. You know, patients present late physiology evolves. The imaging's not always definitive. Consultants disagree, and you know that right decision is often only obvious in hindsight. Yeah. So m and [00:08:00] m is where we can slow the case down and ask what did we think was happening? What were we worried about? What signals did we prioritize? What signals did we ignore? And how do we navigate the trade-offs that were in front of us at the time? And what, if anything, could we or should we have done differently? Yeah. Yeah. I think it's important that the resident really focuses on telling this story and knows that the burden of interpretation and education is not entirely on them. So it's the facilitators and attendings in the room that really have a responsibility to do the analysis, to model the professionalism and humility associated with the case. And if the discussion becomes a gotcha, everyone loses. Um, if it becomes defensive, it really loses educational value. That modeling humility is, is such a huge thing. And, and m is not about blame. Uh, it's not about shaming and it's not about the presenter trying to prove that they did nothing wrong. That's not a very good way to approach it. And it's also not about pretending that nothing could have been [00:09:00] done differently. Again, as Jason said, you want to try to find, you know, what are, what are those pieces, uh, of that puzzle, uh, as you put it together, that could have been different and would've led to a different outcome. Yeah, it's about collective learning and it's about modeling accountability. One of my mentors early on told me very early in my training, you know, run towards your complications and, and that really stuck with me. I like that. So, you know, when m and m's done well, it reinforces what makes surgery particularly unique. You know, not all specialties do this. We're unique in that we, we strive for transparency, self-critique, and continuous improvement. That's a great point, Jason. So now that we understand the context and purpose of Eminem and kind of how it's evolved, the next question becomes, which cases actually belong at m and m? Yeah. Uh, before we wanna jump in that, I think we should take just one second and think about how bonkers it is and, and that we do this at M Andm that stand up there in front of all of our colleagues and say, Hey, this is what went [00:10:00] wrong. I can't think of another another profession. That does this. I mean, it's a profound thing to do, to stand up there and, and own it and, and to learn from it. And again, that's why we're here today to talk about the importance of it. But it's just, if you really think about it, it's something special. And you think about like the, like I think about my, when I was in training, you know, the, the, the staff surgeons and my mentors that are really respected, you know, they weren't the guys that hid from their mistakes. They weren't the ones that had no complications. You know, they, they were the ones that looked at straight in the face and, and owned it and learned from it. It's very much a bonding experience. I mean, especially as a resident and especially as a junior resident when you're presenting your first Eminem, at least when when I presented my first few, you get overwhelming support from everybody, and I think it's just, it makes you really feel like you're a surgery resident in a sort of odd way, but it really helps you deal with the complication and. Get closer to your fears in the process. 'cause it's something everyone experiences and I think [00:11:00] something that, and Steve, Steven May talk about this later. Something that we may not know how to handle as without this Yeah. We're, we're gonna come back to that. It's cathartic in, in a lot of ways. Yeah. So, Patrick, how do you tell your residents, or how do you, um, at, at your institution, uh, decide what's an appropriate MM. Yeah, I think this is really important, right? Because we keep, we kind of said, oh, hey, m and m's, this m and m's, that it can be great. And we've kind of, to some degree it's like this positive, very positive uh, way We framed it so far, and that is. If done well, right, if done well. And so I know there's places that maybe don't do it as well as they could, and that's a, uh, something that can always be improved on in every institution can improve and iterate. And I know a lot of places like Duke and Michigan and, and other places have gone over time, iterated and iterating keep trying to improve on the process. And that comes back to Jason, your question of appropriate cases. So. These cases could be unexpected outcomes. They could be preventable [00:12:00] harm deviations from standard practice or even near misses and, and certainly all these cases have some clear educational value. And it educational value doesn't necessarily mean that the patient had a catastrophic outcome. Sometimes the most important cases are the ones where you barely avoided them because they revealed the same underlined. Uh, issues that, that other folks are, are bound to come across and some institutions have even, uh, well may even review big wins. So maybe a case that could have gone terribly wrong, uh, but didn't. Yeah, we instituted that and I think that was, uh, into our m and m, uh, where we do, uh, a case that was a near miss or a big win. Um, and I think it's really interesting way of going about it, you know, at kind of a higher level, I think residents should think about cases that, you know, challenge assumptions, you know, cases that expose systems and efficiencies, cases that reveal cognitive biases where, you know, the team's mental model. Didn't really match what the patient's physiology was actually [00:13:00] doing. Those are cases that really kind of move the whole group forward because they teach, you know, pattern recognition and decision making and, and not just the technical details. And, you know, I think we, you know, well said that, you know, when, when we were kind of young in a training, I dreaded m and m you know, because, you know, it was scary. But now at this point in my career, I think it's. Probably my favorite conference that we have, and it's the one that I really learn the most from. You can see what other people do in difficult situations and get that pattern recognition. So when you're in that same situation, you know, next time you, you have that kind of in, in your toolbox. Yeah. From a logistical standpoint, each institution has their own way of flagging or listing or choosing cases. And many have developed formal systems especially with an eye towards these, you know, choosing cases equitably and to optimize education. 'cause no one wants to feel. Targeted, uh, at their, at their own institution. But regardless of how it's done, it is incumbent upon trainees and the staff to submit [00:14:00] appropriate cases. So you never wanna try to hide a case. It's only draw more attention to yourself. Like Jason said, you wanna run towards your complications, not away from 'em. And I wanna normalize something when your case gets selected. It's stressful even for confident residents, even for senior residents, and even for attendance. That stress is normal because you care. Instead of viewing it as a punishment, it's helpful to try and view it as an opportunity to demonstrate professionalism. Where professionalism here means that you did the work, you know the details, you present the story. Clearly, you're honest about uncertainty, and you're willing to learn publicly. Yeah. Going back to what Jason said, again, I like that so much. Run towards your complications. So if you're secretly hoping that your case doesn't get picked, that's probably the exact case that needs the most discussion. Not 'cause you're in trouble or did something wrong because, because your comfort. Is a signal that there's something meaningful to learn for yourself. And then if you're looking at it meaningfully for yourself, that means others are gonna learn from it too. So everyone on this podcast has learned an enormous [00:15:00] amount, I'm sure, and even Iman and Cody, your young careers from presenting and uh, or discussing your own cases. Yep. Yeah, totally agree. And as I was more of a junior resident, I am was increasingly guilty of having my, uh, hand up and hoping that that case that got listed that I was a part of, uh, did not get chosen. Uh, but as I've. Kind of matured throughout my training, although I'm still, you know, only a few years in, uh, I totally welcome the opportunity to present cases, uh, that I've been a part of and always look forward to learning from others. Okay, so you have a case now. What, let's talk about how to tell the story and how to present a great case for m and m. Yeah, it's the meat of this podcast, right? We want people to present. Well, okay, so most institutions have a slide template. Not every institution actually uses PowerPoint. I think most do to some degree, some more sparingly than others. But regardless of a format, a strong m and m presentation shares the same structure. And really you can think of it as a narrative with [00:16:00] important anchors. And so you can start with a one sentence headline, the true headline. It should tell the audience immediately what happened, why we're here to talk about it, for example. You might have a post-op day two hemorrhage after laparoscopic, right colectomy requiring re-operation or delayed recognition of anastomotic leak after sigmoid colectomy. So clearly those headlines set the expectations and it tells the room what they're listening for, what they need to key in on. That's great, Patrick. And then from there you build a clean and chronological narrative, and that chronology drives comprehension for the rest of the room that wasn't taking care of that patient or a part of that case. And the way residents get in trouble with m and m is not because the case was too complex, it's because the story was hard to follow for the audience. So anchor your narrative with timestamps and time intervals. David mission, time of the operation, post day one, time of first fever, time of first CT scan, time of Reconsult, time of escalation, and so on and so on. Yeah. Now with that said, though, you [00:17:00] definitely wanna avoid irrelevant details. I think this is where especially junior residents stumble the most. It's so important. It's probably in fact the most important recommendation from this podcast in regards to structuring. Your presentation, it's certainly tempting to tell the entire hospital, of course, like it's a discharge summary, but the audience doesn't need that. They don't need to hear every lab or every system abnormality. They need the facts that explain the decision points. And again, frame the educational narrative, an educational narrative that you're gonna choose. So you wanna keep it clean, you wanna keep it tight. You wanna create a truthful but deliberately curated presentation. Yeah, I would say you wanna have a structure in your mind. So, for me, non-negotiables are, you know, pertinent background. You have a clear timeline with key decision points, present objective data. The outcome and what you would or would not have done differently the next time. You know, if you can't identify the key decision points, the room can't analyze 'em, they're [00:18:00] gonna get lost and they're really gonna take nothing away. The key is that people are able to have a, this as a meaningful learning conference. I remember the first time that I presented at Eminem, our moderator was one of the more experienced moderators, and when I called him beforehand, he told me that I have three minutes to present my case, and the rest of the time will be used for discussion. So his, his advice to me and the practical pearl that I've used since is that the more concise your presentation, the more valuable the discussion will be because you give the entire room time and space to think. Personally, you should know the whole patient course. You should know the final pathology. You should know that detailed summary, and you should know the final culture results, what happened after discharge. But you don't have to present all of it upfront, present what's important, and if anything else is necessary, people will ask. In terms of visuals, imaging is, is very powerful. You know, having that CT scan up there with those key images, if you have the ability to kind of scroll through [00:19:00] the CT scan and you know, let people see what you were seeing at the time, that's very helpful. If you can't do that, at least have representative screenshots of key slices and it really helps the audience. Understand what your thought process was and what you were seeing. I'd say that a lot of institutions also have the radiologist presence too, and so ideally they can be keyed in, in advance to the key images, you know, which dates and which, which, uh, specific. Pathology is looking for on those images to ensure that that presentation stays crisp. So pre, uh, you know, preparing in advance with everyone, including the radiologist, is a good move. One of my favorite things about a good old VA case that gets presented at Eminem though is the. The manual video with video on the screen, iPhone of the scroll through the CT scan in good old CPRS, although I hear that's going away relatively soon with Cerner. Let's run through the don'ts because these are traps. So during Eminem conference, don't editorialize, don't apologize. Don't assign blame. [00:20:00] Don't bury key information. And lastly, don't over speculate. Yeah. So what you're talking about is this is an art form, right? I mean, this is really an art form. Presenting a complex case, choosing the most important points to draw out educational value in a, in a way that facilitates that discussion while maintaining, you know, absolute truth and clarity is a, it's tough. It's tough, but you see people do it well and it's a, it's, it's, it's a beautiful thing. So. You know, you want to include those cold, hard facts. And I think from a stylistic standpoint, you want to have that healthy dose of introspection right? As you're standing up there and humility kind of really speaking in a way and, and, and your body language in a way that shows those things. And you can earnestly, ideally describe how you could have done better. And this is, this comes with the idea of falling on the sword, right? And I wouldn't say that it, it is appropriate. [00:21:00] To fall on the sword, but you don't wanna overdo it, right? So if you transected the common bile duct, you should fall on that sword, right? But if you had a, an asto leak in a malnourished patient, you know, then a pre albumin of six on chemotherapy, you know, you don't need to make a scene in paling yourself up there, you know, uh, in that circumstance. So, so key differences and, and important style points. Those are awesome points, Patrick. A few other style points. You don't need to walk through every operative step of the index case or the take back unless it's actually relevant for the case. When you're describing a case, you should be describing as if you're describing on your oral boards exam, using the key steps, key maneuvers, uh, that get you through that operation. And then from there, if the complication's technical, you'll need operative detail. For instance, if you're discussing that an anastomotic leak, knowing how the anastomosis was formed, whether it be stapled or hand sew, what the staple size or load or the type of suture water, those are essential details, but details about how the fascial [00:22:00] was closed is not, yeah, keep it, keep it simple. Keep it simple. Keep it. Yeah. I think a practical, you know, trick for doing that is narrate it like you're, you're handing the case to someone who wasn't there. If a neutral listener can't answer what happened next, why did the team do that? Then your narrative needs more structure, not necessarily more detail. Yeah, so a simple checklist you could use is, can I state the complication in one sentence? Another good kind of check mark is, can I point to two or three moments? Those anchors we talked about earlier where the trajectory could have changed if a different decision was made. You know, those are extremely important, and if you have those pieces to the puzzle. Uh, you're gonna be about 80, 90% of the way there in terms of a good presentation. And remember, when you're choosing what to put on the slides, you're not deciding what's true. You're deciding what's useful for learning and for the people that is in the room, uh, during the m and m presentation, the full chart is the full chart. Your slides are the teaching tool [00:23:00] by which everyone in the room can learn. Yeah. Guess what? So every presentation that you see where someone puts on 900 words on a single slide and you're like. You know, drift off and start looking at your phone. That's the, the same thing applies to Eminem. So your, your, your slides should be well styled. You know, we talked about a timeline or you could choose whatever you'd like, but don't put, you know, 10 bullet points on the slide of, of heavy text that, that, that'll cause everyone's eyes to glaze over too. It's just same for any presentation. And, and when it comes to the analysis, 'cause you are probably gonna include at least that one slide on the analysis or at least a statement on that. It's, it's probably good and, and certainly in your mind in advance to explicitly separate an individual decision versus some system conditions because we all work in complex systems and a lot of these complications are, may not be directly the result of a surgeon making a certain decision and maybe a systems-based issue. And so being able to clearly state that helps frame that educational discussion [00:24:00] and lead to more productive back and forth between the audience when the case is discussed. About the system itself, because guess what? Everyone who's in that room, they also work in the same system and oftentimes have the same frustrations. Yeah, and you should not be worried that bringing up system issues sounds like making excuses. You can say, here's the decision we made and these are the conditions we were working with. That framing is honest and mature, and at least at our institution, important because the system issues you bring up. Go right back to the attendings, and often things change. Don't underestimate the value of asking the room for their own mental models or thresholds for making different decisions. You know, like, you know, Patrick, what's your threshold for bringing up a loop ostomy, or doing an ED thoracotomy or shooting an IOC or whatever that thing is. You'll find that senior surgeons often have different thresholds for, you know, CT ICU transfer, when to take a patient, back when not to. Calling a friend asking for help put, placing a drain or not placing a drain. [00:25:00] Eminem is one of the best venues to kind of dissect those thresholds and hear how others do it, and you start calibrating your own thresholds for these, you know, various decisions. And you, again, you know, keep it simple. If your slide looks like a discharge summary, it's, it's way too dense. I can't, can't agree with that more. Yeah. And the last point here is that your tone really makes a difference. Having a neutral factual tone invites better discussion. If you sound too defensive, the room will get tense. And if you sound too vague, the room can't help and it takes away from discussion. If you sound overly self-critical, the room ends up reassuring you instead of learning from the case. And like Dr. Geoff said, you do not always need to follow on the sword. So you've told the story. Now comes the part where the case turns into learning, which is the analysis. So at most institutions, there's an assigned moderator for each Eminem. Like we said before, talk to them beforehand. Their goal is not to surprise you. They [00:26:00] usually have a set of teaching themes they want to emphasize, and if you align on those themes, the discussion is more focused and less stressful. Having that in your mind. Also helps you anticipate what the room may ask and where you might need a clearer slide slide or a clearer timeline. So when presenting the contributing factors, use a structured approach. A simple framework to consider patient factors, disease factors, system factors like we talked about earlier, cognitive factors and technical factors. Patient factors might be things like comorbidities, physiology, frailty, communication barriers. Disease factors might be severity, atypical presentation. Rapid decompensation system factors may be issues related to handoffs, to staffing, to access to in timeliness of imaging, delays in consultation, or unclear ownership of a decision. Yeah, I think the cognitive factors are huge. 'cause some of that stuff you just mentioned, Cody is, is totally sensible, right. A patient's comorbidities for example. But the cognitive factors are [00:27:00] something we don't talk about quite as much in surgery. They play a huge role though in the decisions we make. A few like anchoring, which is when you stick with the adverse diagnosis or premature closure when. You're deciding that you figured it out and you stop reassessment of a patient, or even availability bias, where you weigh heavily more heavily than you should. Something that you recently saw. All these different types of cognitive factors fit into that Swiss cheese type model. And if you pay attention over the years of, of M, and I'm sure Jason, you can attest to this too, there are cases where it's like a big oopsie. Right and an unfortunate one, but most of these align with that Swiss cheese model. A few things happen, or sometimes even more than a few where, uh, the Swiss cheese model prevails and a rare or potentially devastating complication. Happens. And, and a lot of those, part of those pieces then often have a cognitive [00:28:00] factor in it baked into these other patient factor system factors, et cetera. But Jason, I don't dunno if you have any thoughts on that. I I I I'm usually struck by kind of how it's, it's you, it's rarely one thing. No, definitely, definitely. And that's where that kind of pattern recognition comes in, because these are things that you're not gonna find in a, in a textbook, you know? These, these patient courses, patients have complex physiology and there's, there's things that are outside of control. What's available in your hospital, um, what you're on divert for. You know, those, those things that are really outside of your control. So it, it's looking at that whole system and how the, yeah, certainly. Your actions, but also just the nature of the disease, the system you're working in, how all those things interplay to patient outcomes. And you'll start, the more you see different things play out differently, you're gonna start to form that pattern recognition and it really is gonna help you be a better [00:29:00] clinician and a better surgeon. So, you know, along those lines, you know, I, I think it's, it's critical to avoid that hindsight bias, right? With the benefit of hindsight. You can always say what should have or should have not been done, but that's not the educational question for Eminem. You know, the question is, you know, given what you knew at the time, what options were reasonable, what information didn't you have, what signals were there but you missed, and what would've made it easier for the team and the system to choose a different path and potentially have a different outcome? Yeah, totally. And you need to present those alternatives objectively. If there are reasonable alternative strategies, whether it be a different imaging modality, a different threshold, uh, for considering a re-operation versus a drain placement. Choosing a different set of antibiotics or dis disposing the patient to a, a different level of care. Lay them out clearly without judgment and let the audience kind of [00:30:00] stimulate discussion around that and when it's appropriate, incorporate a small amount of literature. Now, I'm not talking about a full on journal club. Just one or two key data points from high level data and high level studies that may inform best practices or show where practice variation is to be expected. Yeah. You'll see too if people have made their own personal journal club on the slides that you never get to it, right? The if in that, especially if you have a strong moderator. 'cause a strong moderator invites and encourages discussion, a robust discussion, engage the audience, et cetera. And. You may be able to make reference to those, uh, and should make reference to the data the literature itself. But again, this is not a journal club discussion. Yeah. You know, the, the really the role of that moderator is, if it hasn't come up already, is to ask that mature question. What would you have done differently? You know, sometimes that answer is nothing and that's fine. You know, m and m is, it is not guaranteed that every case is gonna yield a different decision, but it, it's a guarantee that [00:31:00] we examine that decision carefully. So that's how we almost end every m and m, you know, the resident will present the case and. It's a very simple question. All right, well what would you have done differently? Uh, I remember doing a case as a trainee and getting into the senior years at some point. And I couldn't think of anything to do differently. Like I had nothing. And that was the first time. Usually you can think of something. Okay. Right. You wanna be very careful saying There's nothing I can do differently. 'cause there's almost always something now you don't want to. Wander off into the ridiculous part of it. But I remember asking, just like we talked about, you know, I asked all these different people just gonna say, Hey, I don't have anything. I don't have anything. I'd say differently. Is it okay? You know, I was reassured. Yes. And I, and I stood up there, gave the presentation, went well, and then it was at the end, you know, what would you differently? I said, you know, in this case, nothing. And no one said anything. I was like, whew. Ran back to my seat. Fair enough. And, and so that brings us to our final topic though, which is how attendings can best support trainees and set the tone and set a great example for [00:32:00] a strong, thoughtful, and informative and educational Eminem. Yeah. Attendings set the tone right. Uh, expectations should be clear. We talked about the word humility before. That should be modeled. I've seen staff, and I really appreciate this and I've done this a time or two too, and I think it totally lowers the temperature of the room. It's if you've had a similar complication before, you can say so. And that single statement can turn that Eminem discussion from something like a public judgment into something more benign. It's a, it's a, something like a shared experience, right? A shared professional learning experience, uh, because of that single statement. Yeah. I've also seen, and I've attendings, you know, the residents really up there kind of just taking it. And it's nice when the attending steps up and says this, you know what, I did this, this is my decision. You know, that, uh, I think is, uh, I, I really respect that when that happens. And, you know, that comes down to transparency. You know, transparency [00:33:00] matters. You know, you don't wanna be the attending who's known for trying to hide your complications. You're, you're, you know, we all, we've all known those people. And, uh, it's, it's not an admirable quality. So you don't wanna be the person that tries to distance yourselves like we talked about, you know, run towards your complications, all that does. When, when you behave that way, is there roads, trust? And it creates a culture where, you know, residents feel like they have to protect people instead of telling the truth and learning. Yeah. Totally. And now attendings can listen up to this part. 'cause these, these are some tangible pearls from current trainees of things that faculty can do that make Eminem more. Kind of easily presentable for their, their trainees, both from a practical standpoint and setting the tone and culture like we've already been talking about. And that's the IT residents benefit when cases are identified early. So they have plenty, plenty of time to, to prepare their presentation when expectations [00:34:00] for the case are clear. When the attending of record is physically present for the discussion, your presence matters. Even if you don't say much, being there signals that the resident is not alone and presenting the case and sharing the complication and that this is a shared responsibility. Iman, do you have any other thoughts as the other trainee on the call here? Yeah, I mean, I think that as a trainee, the first question you get asked by the attending in the room really sets the tone for the rest of the discussion. And so, uh, that first question, if it's if it's really an accusatory type or a sarcastic comment towards you, it's hard as a trainee to know how to respond. The room tightens up and I think it makes the productive conversation less likely to happen. But if that first question is a nice leading question for the resident, that really helps everyone kind of understand. The situation, what's going on, and it opens the door to a whole new discussion. So I, I really think that that first, uh, attending that comment on that case has a really important job for the resident. Yeah. Yeah, healthy culture's important [00:35:00] and health an the unhealthy one gets quiet. Well, I guess it could be either really probably too end of the spectrum, really loud, or people harassing each other and yelling and, you know, or really quiet and, and you don't want that either. You want a good discussion. And you had mentioned it, Cody, you gotta show up. You gotta be there in person. And staff need to be there in person to discuss their complications. Sometimes there's good reasons and we understand that. Um, oftentimes I think it's really nice to share that reason. If God forbid, you know, you can't be there to share why. So that I've gone as far as, hey, literally outta the country or whatever, and, and, and they wanted to present that case at a certain time and tell the matter, please tell everyone why I'm not there, because I would like to be there to discuss, you know, to discuss these, these patients. Super important. Yeah. I think one important kind of closing, you know, closing point is that, you know, Eminem is one of the best opportunities to learn and teach how experts think. Like I said, it's, it's become my favorite conference and probably conference. I, I learned the, the most, you know, not just what the [00:36:00] experts would do in that situation, but why? I find a lot of these like key decision points that are discussed in m and m are when you're reading in the textbook. It's when it says to consider doing something. You know, if you're in the situation, consider leaving a drain or considering a loop, ostomy or cons. Consider a temporary abdominal closure. What the hell does that mean? Yeah. So this is that time where we're like, okay, what does that mean? You know, when what, like going back to what we were talking about before, what is your threshold for doing that? And, and learning from the people who have decades of experience on when they consider to do those things and when, not only when they consider to do it, but when they decide to do it. So, uh, for me it's, again, it's not just the correct answer, but it's the reasoning that got you to that answer. And this is the time to learn that. All right guys. I think this has been great. Um, but we've been talking for long enough for three or four m and m cases to have been presented. So let's finish up today by providing the listeners with just a few kind of quick rapid fire pearls that they can carry into their [00:37:00] next m and m presentation. So I'll throw one out there to first to start, which is clarity over density. If the audience can't follow the story, they cannot learn from it. Yep. A neutral tone invites better discussion. Chronology drives comprehension, so build the timeline and the decision points will reveal themselves. That being said, highlight your decision points and explain why you chose an option over another end with concrete improvement ideas. Re remember that m and m is sacred, so treat as such. It's a defining feature of surgical professionalism, and it's one of the places where we show what we stand for as a field. At its best, it reminds us of why surgery holds itself as a higher standard. Not because we're perfect, but because we're committed to getting better together. Yes, sir. All right, everyone. Thanks for listening to Behind The Knife. If you found this helpful, share it with a co-resident who's about to present an m and m and send us your own best m and m [00:38:00] presentation, pearls and it is always remember to dominate the day.