Mixed-methods Assessment of Incivility during Surgical Mortality and Morbidity Conference

Objective: This study assessed incivility during mortality and morbidity (M&M) conference. Background: A psychologically safe environment at M&M conference enables generative discussions to improve care. Incivility and exclusion demonstrated by "shame and blame" undermine generative discussion. Methods: We used a convergent mixed-methods design to collect qualitative data through nonparticipant observations of M&M conference and quantitative data through standardized survey instruments of M&M participants. The M&M conference was attended by attending surgeons (all academic ranks), fellows, residents, medical students on surgery rotation, advanced practice providers, and administrators from the department of surgery. A standardized observation guide was developed, piloted and adapted based on expert nonparticipant feedback. The Positive and Negative Affect Schedule Short-Form (PANAS) and the Uncivil Behavior in Clinical Nursing Education (UBCNE) survey instruments were distributed to the Department of Surgery clinical faculty and categorical general surgery residents in an academic medical center. Results: We observed 11 M&M discussions of 30 cases, over 6 months with 4 different moderators. Case presentations (virtual format) included clinical scenario, decision-making, operative management, complications, and management of the complications. Discussion was free form, without a standard structure. The central theme was that limited discussion participation from attending surgeon of record, as well as absence of a systems-approach led to blame and then blame then set the stage for incivility. Among 147 eligible to participate in the survey, 54 (36.7%) responded. Assistant professors had a 2.60 higher Negative Affect score (P=0.02), a 4.13 higher Exclusion Behavior score (P=0.03), and a 7.6 higher UBCNE score (P=0.04) compared with associate and full professors. Females had a 2.7 higher Negative Affect Score compared with males (P=0.04). Conclusion: Free-form M&M discussions led to incivility. Structuring discussion to focus upon improving care may create inclusion and more generative discussions to improve care.