CONCEPT
Morbidity and Mortality Conference
The weekly surgical ritual Gawande considered the most important institution in medicine — a structured, regularized, culturally embedded study of failure that converts individual complications into collective professional learning.
Every week in virtually every surgical department in the developed world, a group of surgeons gathers to review the cases that went wrong. A surgeon presents the history, the operative plan, what happened, and what failed. The department discusses causes, evaluates avoidability, and proposes changes in practice. The discussion is analytical, not punitive — the goal is not to assign blame but to extract maximum institutional learning from every adverse outcome. Gawande considered the M&M conference the defining institution that separated professions which improved over time from industries that stagnated. It is the structural mechanism through which individual episodic learning becomes cumulative professional knowledge.
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The conference's regularity is its essential feature. It is held weekly regardless of whether the preceding week produced complications. This regularity serves two purposes Gawande considered non-negotiable. First, it forces review of minor complications — far more common than major ones and often containing the most actionable learning — before they