Neurosurgery’s Morbidity Meetings May Be Harming the Surgeons They Aim to Teach

Every surgical department has a room where the hardest cases come back to life on a screen. The morbidity and mortality conference, or M&M, is one of the oldest rituals in medicine: surgeons gather, complications are listed, deaths are reviewed, and the profession formally asks what went wrong. In neurosurgery, where operations unfold inside the brain and spinal cord and where a single misstep can leave a patient permanently disabled, these meetings carry an especially heavy weight. A new systematic review published in Global Surgical Education, the journal of the Association for Surgical Education, suggests that the way neurosurgeons run these conferences may be quietly working against both of the goals they are meant to serve: better patient care and healthier surgeons.

The review, led by Omar Alomari and Beyzanur Güney of Hamidiye International School of Medicine at the University of Health Sciences in Istanbul, together with colleagues from Bahçeşehir University and Istiniye University, set out to answer two questions at once. First, how are M&M conferences actually structured and used in neurosurgery? Second, drawing on evidence from across medicine, do the designs of these meetings account for the psychological toll that adverse events take on the clinicians involved? The authors describe the gap between those two concerns as a structural-emotional mismatch: quality improvement systems built around auditing and accountability, with almost no architecture for the human beings who caused or witnessed the harm.

Methodologically, the study followed the PRISMA 2020 reporting guidelines, the international standard for systematic reviews. The team searched four databases, Web of Science, Medline via PubMed, Scopus, and Embase, from their inception to December 15, 2025. They included neurosurgical studies that analyzed the structure and effectiveness of M&M conferences, alongside a broader cross-specialty literature examining the psychological impact of adverse events and what researchers call blame culture. Study quality was appraised with the MINORS index, a validated methodological instrument for non-randomized research, and the qualitative synthesis drew on reflexive thematic analysis, the approach developed by Virginia Braun and Victoria Clarke for identifying patterns across heterogeneous qualitative data.

What emerged from the search is telling in itself. Only ten neurosurgical studies met the inclusion criteria, and their dominant preoccupations were error taxonomy and surveillance: how to classify complications, how to count them, and how to track them over time. Several of the included studies, such as work developing standardized titles for adverse events across more than 7,000 cranial and spinal procedures, or new neurosurgical complication classifications derived from monthly M&M conferences, represent genuine advances in measurement. Others demonstrated real educational and safety value; one Japanese study found that an M&M conference could reduce avoidable morbidity in neurosurgery while improving resident education, and a French pilot showed that surveillance of unplanned returns to the operating theatre could be meaningfully combined with mortality and morbidity review.

But when the authors layered the cross-specialty evidence over this neurosurgical foundation, four recurring structural deficits came into focus, each with a name that captures a specific failure mode. The first is the Silence Gap: the exclusion of high-trauma events from discussion. The cases most likely to devastate a surgeon emotionally, catastrophic intraoperative hemorrhages, unexpected deaths in young patients, devastating spinal cord injuries, are precisely the ones most often left out of formal review, either because they feel too raw, too legally exposed, or too difficult to present. The conference, in other words, tends to skip the very cases that generate the deepest wounds.

The second deficit is the Taxonomy Trap. Because neurosurgical M&M literature is dominated by classification schemes, meetings frequently prioritize naming an error over processing it. A complication gets slotted into a category, graded for severity, and logged, and the conversation moves on. Classification is indispensable for surveillance and research, but it is not the same as understanding, and it offers the surgeon who lived through the event nothing in the way of meaning-making or recovery. The review’s authors argue that this emphasis on categorization crowds out the reflective, systems-oriented discussion that modern patient safety science, from James Reason’s human error work to Safety-II thinking, has long recommended.

Third comes the Culpability Focus. Traditional M&M formats ask whether a complication was avoidable and, implicitly or explicitly, who was responsible. The review found that this framing reinforces blame rather than systems analysis. The concept of the second victim, coined by Albert Wu in a 2000 BMJ paper, describes the clinician who is traumatized by an adverse patient event: the healthcare provider who feels personally responsible, experiences shame, guilt, and isolation, and may lose confidence, withdraw from colleagues, or leave the profession. Susan Scott and colleagues mapped the natural history of this recovery, showing that second victims move through recognizable stages of distress, and that organizations can dramatically shorten that journey with structured support. Cross-specialty studies in anesthesiology, general surgery, and emergency medicine have repeatedly found that perioperative catastrophes leave lasting emotional scars, and that many physicians never discuss their errors with anyone.

The fourth deficit, Ritual Fatigue, addresses the conferences themselves. When participants do not perceive that M&M meetings lead to real change, when the same complications recur, when discussion produces no actionable interventions, attendance becomes a hollow exercise. The review links this perceived inefficacy to disengagement and to the broader burnout crisis in the specialty. Surveys of US neurosurgery residents have documented high rates of burnout, and studies across surgical specialties have associated perceived medical errors with resident distress and eroded empathy. A conference that consumes hours each month without visibly improving care becomes one more administrative burden layered onto an already exhausted workforce.

The synthesis is careful to preserve what M&M conferences do well. The tradition, famously chronicled by sociologist Charles Bosk in Forgive and Remember, has always been a mechanism for managing medical failure, and the review’s included studies show measurable benefits: reduced avoidable morbidity, better complication documentation, alignment work with hospital quality metrics, and educational value for trainees learning to anticipate and recognize complications. The problem is not the existence of the conference but its emotional architecture. Current neurosurgical models, the authors conclude, emphasize accountability at the expense of psychological safety, and cross-specialty evidence confirms that traditional formats often exacerbate shame and isolation rather than providing rituals for grief processing.

The prescription the review offers is a redesign grounded in restorative justice and emotional support. Concretely, that means building meetings that include the high-trauma cases rather than avoiding them, pairing accountability questions with systems analysis, creating explicit space for the clinician involved to be supported rather than scrutinized, and connecting M&M programs to institutional second victim resources such as rapid response teams of the kind pioneered in Missouri. Models like the Ottawa M&M model and revised formats that emphasize patient safety over blame have already shown in other specialties that a structured, systems-focused conference can improve both educational quality and safety culture. For neurosurgery, a field defined by high stakes and high expectations, the message of this review is that sustainable practice requires conferences designed for the whole human system in the room: the patient who was harmed, the team that must learn, and the surgeon who must recover enough to operate again tomorrow.

Subject of Research: Structure and psychological impact of morbidity and mortality conferences in neurosurgery

Article Title: Morbidity and mortality conferences in neurosurgery: a systematic review of current practice and narrative synthesis of the second victim phenomenon

Article References: Alomari, O., Güney, B., Kiliç, D., Ertem, O., Korkmak, M., Akakin, A., Ekşi, M. Ş., & Kiliç, T. (2026). Morbidity and mortality conferences in neurosurgery: a systematic review of current practice and narrative synthesis of the second victim phenomenon. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 146. https://doi.org/10.1007/s44186-026-00553-z

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00553-z

Keywords: neurosurgery, morbidity and mortality conference, second victim phenomenon, burnout, medical errors, patient safety, quality improvement, blame culture, surgeon well-being, systematic review, restorative justice, surgical education