Pandemic Morbidity and Mortality Conference

Let’s start with a simple chart, comparing our expectations to our results, with two choices, good or bad.

I came across this table dealing with surgical complications and fatalities during my training, but it is still a valuable way to analyze any retrospective consideration of our expected versus actual results. Expectations are the outcome the surgeon hopes for, and while we always hope for the best, sometimes we know that’s not in the cards – the patient will come out badly no matter what we do. The results are the result of our care. A good result is a satisfied and restored patient; a poor result can be one of several complications, including death.

  • Good expectations – good results: We do our job and do it well. We expected a good result and we got it. These were not patient cases presented at a Morbidity and Mortality (M&M) conference.
  • Bad expectations – bad results: Here we explain why we initially took on the case. Often we can blame the family or the patient for wanting “to get it all done”. It’s always an outside pressure that forces our hands.
  • Bad expectations – good results: These cases are an opportunity for a victory lap. But there is often an element of luck in these cases, so inappropriate M&M pride would only attract attention; nobody’s work is not perfect. Thus, victory laps are disguised as “interesting cases”.
  • Good expectations – bad results: These are the crates that give water to the M&M mill. Depending on who you’re talking to, you can present the facts and “beg” for mercy – something that’s usually rare. Or you might describe a series of “unfortunate moments,” mixed with overly optimistic judgment that led to your patient and now your downfall. The oral history of M&M conferences, as told by residents in the spotlight, was often stories of the wars of blame and shame that took place. “Dr. Dinerstein, why are you playing with that man’s leg?”

I mention this because much of the early and thoughtless retrospective analysis of our societal response, both individual and institutional, to COVID-19 follows a similar pattern. Let me share a few examples.

Governor Cuomo’s decision to return hospitalized nursing home patients to their respective nursing homes as quickly as possible. The prediction that these patients would overwhelm available hospital beds was a bad expectation. The too early return of patients who could still transmit the virus and become more reinfected in nursing homes was certainly a bad result. Here are the thoughts of Dr. Zucker, then New York’s health commissioner and deputy governor, as reported by CNBC.

“Zucker said Friday that at the time, New York’s coronavirus hospitalization rate was increasing “at a staggering rate” and the state’s intensive care unit capacity was running out. By allowing residents to return to nursing homes, it helped protect the health care system from collapse, he said.External pressure from rapidly shrinking hospital capacity “prompted them to do so”.

Consider President Trump’s decision to authorize Operation Warp Speed ​​(OWS) and develop and deploy a vaccine within months despite a long history of this requiring years. That such a feat could be accomplished in such a short time was a bad expectation. Here is a title from Stat:

“Operation Warp Speed ​​promised to do the impossible.”

OWS was announced in mid-May 2020 and 17,000,000 doses were distributed in early January 2021 – 8 months. President Trump took the victory lap,

“Operation Warp Speed ​​is second to none and unmatched anywhere in the world, and leaders of other countries have called me to congratulate us on what we have been able to do….”

And as you might expect, especially in politics, this has led to heightened scrutiny of, for example, the Business Insider headline:

“At least 75 lawmakers have bought and sold shares in companies that make COVID-19 vaccines, treatments and tests.”

This includes both sides of the aisle and those for and against vaccines. Don’t worry, all members have reported that others, including their spouses, were in charge of their investments; no pillow talk here.

As I said earlier, good expectations coupled with good results are rarely discussed. This was the case here too. These articles are alive and well in the medical literature but rarely reach the mainstream media. Here is a graph from Vox.

There is little doubt in the scientific community that vaccines prevent serious diseases, but that was the expectation.

Finally, there is the category of shame and blame – good expectations and bad results. We could consider many of Dr. Fauci’s statements and subsequent edits as the novel COVID-19 went against expectations.

“Dr. Anthony Fauci said the country could reach a level of population immunity where the virus no longer “dominates” people’s lives. “It’s entirely conceivable, and likely, in fact,” President Biden’s chief medical adviser said Tuesday.CBS Matinees.”

As I wrote, as the data changed, so did Dr. Fauci’s opinion — your political leaning determines whether this is a volte-face or just a reconsideration. Also, the concept of herd immunity was based on measles, which promotes a longer-lasting immunological defense and shows few mutations, two properties that we know now COVID-19 does not share.

There are so many other examples; consider the Great Barrington statement. They too based their recommendation on the concept of herd immunity,

“They argued that this policy would more easily lead to ‘herd immunity’ which would ultimately protect the elderly and infirm.”

But they wanted to apply it in a more strategic and targeted way to hopefully reduce the economic costs of the pandemic. Dr. Jay Bhattacharya, one of the authors of the statement, readily talks about his war wounds,

I had to review and rethink every aspect of my life, and there were some very difficult times,” he said. “It’s our crucible.”

Play the doctor card

It turns out that my surgical training prepared me for aspects of life that I hadn’t anticipated. Having had my share of “podium moments” and endured “the slingshots and arrows of outrageous fortune”, I am no longer as quick to judge as I once was. I’ve learned that the best of plans can quickly go south and there’s not much you can do to stop the slide. It’s easy to comment with hindsight, even more so when you’ve never really experienced one of your decisions leading to the death of a patient in your care.

Very few of the commentators who talk about what we should and shouldn’t have actually made life or death decisions for someone right in front of them physically and temporally. They should be more humble. As we continue to try to understand our response to the pandemic, we must remember the work of René Leriche, a French vascular surgeon.

“Every surgeon carries within him a little cemetery, where he goes to pray from time to time – a place of bitterness and regret, where he must seek an explanation for his failures.”

We must show compassion to ourselves and to our adversaries. In most cases, we did what we thought was best.