A newly appointed general surgery program director is sitting alone in her office on a Sunday evening, three weeks into the job, going through a filing cabinet her predecessor left behind.
Inside are seven years of morbidity and mortality conference slide decks. Case after case: an anastomotic leak, a retained instrument near-miss, a delayed diagnosis on a Friday-night admission. Each slide deck ends the same way, with a discussion slide and sometimes a bullet point or two under "action items." What she cannot find anywhere is whether any of those action items were ever actually implemented, whether the scheduling change that came up twice in one year ever happened, or whether the near-miss in 2023 was the second time that exact failure mode had occurred, because nobody wrote down that there was a first time.
Her predecessor, a well-regarded surgeon who ran the program for five years before moving to another institution, is reachable by phone but is three states away and has already mentally moved on. The two of them have spoken twice since the handoff, both times about administrative logistics rather than the accumulated clinical wisdom sitting in this cabinet.
She knows, because she trained here as a resident a decade ago, that this program has had at least one other retained-instrument near-miss before the one in the 2023 folder. She remembers being told about it informally as a PGY-2. It is not in any of these slide decks, because it happened under a different program director, in a different room, and whatever lesson came out of it left with that person years ago.
Every genuine systems lesson this program's M&M conference has ever surfaced exists only in the memory of whoever happened to be sitting in that room when it was discussed, and that memory walks out the door on an average five-year cycle.
Program directors are leaving faster than the knowledge can be handed off
The scale of the turnover behind this scene is not subtle.
General surgery program director tenure fell from 13.6 years in the 1990s to 6.4 years in the 2000s to 5.0 years in the 2010s, a 63 percent decline, according to Schimmel, Lund, Fox and colleagues writing in the Journal of Surgical Education in 2026. Forty percent of surgery program directors serve fewer than six years, despite ACGME's own tenure expectations, per an earlier Journal of Surgical Education study by Payne and colleagues in 2019.
This is not confined to surgery. Twenty-nine percent of internal medicine program directors left within three years of taking the role, according to a 2001 Academic Medicine study by Beasley, Kern and Kolodner, a figure that has held up as a persistent pattern rather than a one-time anomaly. More recently, cross-specialty program director tenure fell from 7.0 to 6.6 years in just the nine years from 2012 to 2021, according to Turlington and colleagues writing in the Journal of Graduate Medical Education in 2025, even as weekly PD workload dropped over the same period, meaning the departures are not simply a function of an ever-heavier job.
The consequence is measurable, not theoretical. Payne and colleagues found high-turnover surgery programs post an American Board of Surgery exam pass rate of 76 percent, against 83 percent at stable programs. That seven-point gap is the difference between a program whose institutional memory survives its own leadership changes and one that does not.
What M&M actually produces, and how little of it survives
Morbidity and mortality conference is medicine's oldest standing mechanism for turning error into learning. It is also, measured directly, remarkably bad at making that learning outlive the room.
A national survey of M&M conferences found that 14 percent of departments produced zero written guidelines or protocols from two full years of M&M discussion, and 45 percent produced only one or two, according to Ryan, McKee and colleagues writing in the Neurohospitalist in 2022. Read that together: nearly six in ten departments surveyed generated, at most, a couple of durable, written outputs from twenty-four months of accumulated case discussion.
That is not because the discussions lack substance. It is because the mechanism was never designed to persist anything. A separate study, examining M&M practice before the addition of dedicated quality-improvement tooling, found that failure modes were "never captured, action items rarely assigned, and follow-up rarely completed," according to Cromeens, Brilli, Kurtovic and colleagues writing in the Journal of Pediatric Surgery in 2016.
Put plainly: the room generates real, hard-won clinical knowledge every week, and the default outcome for nearly all of it is that it evaporates the moment the meeting ends, discussed once, remembered by whoever was present, and never again referenced unless the same problem happens a second time to someone who happens to recall the first.
The annual reset makes the compounding problem worse
M&M's persistence failure would be serious enough on its own. It compounds with a second reset that happens every single year: the complete turnover of the housestaff itself.
The "July effect" literature, a systematic review of 39 studies by Young and colleagues in the Annals of Internal Medicine in 2011, found that higher-quality, larger studies more often showed increased mortality or decreased efficiency at the academic year-end changeover. That is consistent with a training system that resets a meaningful share of its working clinical knowledge annually, layered on top of a program-director cycle that resets its institutional and curricular knowledge roughly every five years.
Two resets, operating on different clocks, both driven by the same underlying failure: a system that is extraordinarily good at generating knowledge through the daily and weekly grind of clinical training, and has built essentially nothing to keep that knowledge past the tenure of the people who happened to be present when it was generated.
Why this is different from the problems this series has already covered
It is worth being precise about what makes this specific gap distinct, because two adjacent problems have already been documented elsewhere in this series and are easy to conflate with it.
One is program-director turnover and institutional memory in graduate medical education broadly, the churn in leadership, the loss of curricular rationale, the compressed handoff windows. That is a real and separate failure, concerning how a program is run.
The other is complication-matched peer consultation, the tactical, real-time need a surgeon has in the six hours after an intraoperative complication, when she needs someone who has personally managed that exact clinical scenario.
This article is about neither of those directly. It is about the M&M conference specifically as a knowledge artifact, and the fact that it is, by legal design and cultural habit, confined to a single department's four walls. A retained-instrument near-miss discussed in one hospital's M&M this month is, in principle, exactly the kind of systems-level lesson another hospital's surgery department three states away would benefit from knowing about in de-identified, aggregate form. Nothing carries that lesson across the institutional boundary, and the reason is not merely inattention. It is structural, and partly legal.
The structural failure: legal protection and institutional design both cut against sharing
M&M is designed as a live, oral, single-institution ritual, with no standard mechanism to persist findings across years, let alone across institutions. That design was never accidental. Peer-review-privilege statutes, which vary by state, protect M&M discussion from discovery in malpractice litigation specifically to encourage the candor that makes the conference valuable in the first place. A surgeon will admit, in that room, exactly what went wrong and why, in a way she would never put in writing anywhere a plaintiff's attorney could later obtain it.
That legal protection is precisely why the knowledge cannot easily travel. Any cross-institution sharing mechanism has to be built to preserve peer-review privilege by sharing only de-identified, systems-level lessons, never case-level detail, and building that distinction correctly, reliably, and defensibly is a real design constraint, not a minor technicality.
ACGME accredits programs and sets requirements but does not maintain a cross-program registry of M&M lessons or program-director decision rationale. Its mandate is standard-setting and compliance auditing, not knowledge curation.
Specialty societies publish curricula and milestones, not institution-specific implementation history. APDS for surgery and APDIM for internal medicine own the content of what should be taught. Neither owns the record of what a specific program actually tried, what worked, and what a specific M&M discussion actually surfaced.
Departing program directors have no venue, and often no expectation, that their M&M lesson history or curriculum reasoning should be handed to a successor beyond an informal conversation, if that. The handoff described in the cold open, a filing cabinet and two phone calls about logistics, is not an unusually poor transition. It is close to the norm the research describes.
The result is a knowledge-management failure hiding inside what looks, on the surface, like a routine teaching ritual and a routine HR event. Graduate medical education treats M&M as pedagogy and program-director turnover as a staffing matter. They are, structurally, the same failure: a system generating enormous amounts of hard-won, safety-relevant institutional knowledge every year, with no mechanism built to keep any of it past the people currently in the room.
What would actually work
Persist de-identified, systems-level lessons separately from case-level M&M discussion, never merging the two. The mechanism has to be built from the ground up around the peer-review-privilege boundary, not retrofitted to respect it later, because the legal protection is the reason candor exists in the room at all.
Track resolution status, not just discussion. A lesson that was identified but never fixed is different information from a lesson that was identified and resolved, and the current default, discussion with no follow-up tracking, cannot distinguish between them.
Attach curriculum-decision rationale to a persistent, successor-accessible record. Why a rotation was restructured, why a supervision policy changed, matters as much to a new program director as the clinical M&M lessons do, and it evaporates on the same handoff cycle.
Route a new program director's specific question to whoever has already solved it, at this program or a peer program. A program-memory ledger that only stores documents does half the job; the other half is connecting "has anyone solved this exact rotation-scheduling problem" to the actual person who has, whether they are still at this institution or moved on years ago.
Exclude case-level and peer-review-protected content categorically, not by discretion. Because state peer-review-privilege statutes vary, the guardrail cannot rely on individual judgment call by call; it needs to be a structural feature of what can and cannot enter the shared record.
Make handoff a structured instrument, not an informal conversation. A departing program director completing a defined handover document, covering curriculum rationale and de-identified systems lessons, converts what is currently an accident of goodwill and time pressure into something a successor can actually rely on.
Frame it explicitly as a complement to ACGME accreditation, never a substitute. Any credible version of this has to be clear that it does not replace self-study, site visits, or program-letter-of-accreditation processes; it fills the gap those processes were never designed to fill.
What you can do now
If you are a program director, incoming or outgoing
Write your own M&M pattern list before you leave, whether or not anyone asks for it. The recurring systems issues you have watched come up more than once, in your own words, are the single most valuable document you will produce and almost certainly the one nobody will ask you for.
Ask your predecessor, directly and specifically, what M&M lesson from years ago you have not seen repeated in writing. A filing cabinet of slide decks answers what happened. It rarely answers what was learned, and that question has to be asked out loud.
Build a resolution column into your M&M tracking now. Case, discussion, action item, status, next review date. It is a small addition to an existing process and it is the difference between the Ryan et al. finding of near-zero durable output and a program that actually closes its own loops.
If you chair a department or lead a GME office
Require a structured handover document as a condition of a program-director transition, not an optional courtesy. Given that 40 percent of surgery program directors serve fewer than six years, this transition will happen, likely more than once, during any given accreditation cycle, and treating it as routine rather than exceptional is the realistic planning assumption.
Ask your compliance office to clarify, in writing, what can and cannot be shared outside your institution under your state's peer-review-privilege statute. That answer should exist before anyone tries to build a cross-institution sharing practice, not be discovered after the fact.
If you are a resident or fellow
Ask your program directly whether M&M action items from prior years were ever implemented. It is a fair question, and the Cromeens et al. finding that follow-up is "rarely completed" absent dedicated tooling suggests many programs will not have a ready answer, which is itself useful information about the program you are training in.
Frequently asked questions
How long do residency program directors typically stay in the role? General surgery program director tenure fell from 13.6 years in the 1990s to 5.0 years in the 2010s, a 63 percent decline, according to a 2026 Journal of Surgical Education study, and 40 percent of surgery program directors serve fewer than six years. Cross-specialty tenure fell from 7.0 to 6.6 years between 2012 and 2021 alone.
Does program director turnover affect board exam pass rates? Yes, in general surgery specifically. A 2019 Journal of Surgical Education study found high-turnover programs posted a 76 percent American Board of Surgery exam pass rate, compared with 83 percent at stable programs, a measured, not merely theoretical, consequence of turnover.
What happens to lessons learned in M&M conferences? Most do not survive as durable, written outputs. A national survey published in the Neurohospitalist in 2022 found 14 percent of departments produced zero written guidelines or protocols from two full years of M&M discussion, and 45 percent produced only one or two.
Why doesn't M&M conference share lessons across hospitals? Because it is designed as a single-institution, live, oral ritual protected by state peer-review-privilege statutes, which shield discussion from discovery in litigation specifically to preserve candor. Any cross-institution sharing mechanism has to share only de-identified, systems-level lessons, never case-level detail, to avoid undermining that legal protection.
What is the July effect in teaching hospitals? It refers to documented changes, generally toward worse outcomes or lower efficiency, at the annual academic-year turnover when new trainees and often new supervisory staff begin. A 2011 systematic review of 39 studies in the Annals of Internal Medicine found the higher-quality, larger studies more often showed increased mortality or decreased efficiency during this changeover.
How do new residency program directors learn a program's institutional history? Almost entirely informally: a stack of prior meeting materials, an informal conversation with a predecessor if one happens, and personal memory if the incoming director trained at the same program. No standard, structured handover instrument or cross-program lesson registry currently exists to make this systematic.
The bottom line
A program that trains dozens of residents a year, running M&M conference weekly for a decade, generates a genuine, hard-won body of safety-relevant knowledge. Measured directly, fewer than half of the departments in one national survey produced even one or two durable, written lessons from two full years of that work.
Layer on top of that a program-director cycle that has compressed by 63 percent since the 1990s, and an annual housestaff turnover that resets working clinical knowledge every July, and the picture is of a system extraordinarily good at generating hard-won lessons and almost entirely unequipped to keep any of them past the people who happened to be in the room.
Nobody owns fixing this, and the reasons are structural rather than a failure of anyone's diligence. ACGME sets standards, not knowledge registries. Specialty societies own curricula, not local implementation memory. Peer-review-privilege statutes protect the candor that makes M&M valuable, and that same protection is exactly why the lessons cannot easily be shared outward, without deliberate design built around the boundary from the start.
The new program director in her office on a Sunday evening is not failing at her job. She is doing precisely what the system asks of her: starting from a filing cabinet, because that is what the system has ever provided.
Every genuine systems lesson this program's M&M conference has ever surfaced exists only in the memory of whoever happened to be sitting in that room when it was discussed, and that memory walks out the door on an average five-year cycle.
Part of a series on the missing professional infrastructure of healthcare. Previously: The Preceptor Cliff
Evidence note: sources include Schimmel, Lund, Fox et al., "Who's Left to Lead? General Surgery Program Director Attrition Over Time," Journal of Surgical Education, 2026; Payne, Dent, Al Fayyadh et al., Journal of Surgical Education, 2019; Beasley, Kern and Kolodner, Academic Medicine, 2001; Turlington, Newland, Cahn, Campbell and Kavic, Journal of Graduate Medical Education, 2025; Ryan, McKee et al., Neurohospitalist, 2022; Cromeens, Brilli, Kurtovic et al., Journal of Pediatric Surgery, 2016; and Young et al., Annals of Internal Medicine, 2011, on the July effect. This article is distinct from this series' earlier coverage of general program-director turnover and institutional memory, and from its coverage of real-time complication-matched peer consultation; it addresses specifically the M&M conference as a knowledge artifact and the legal and cultural reasons its lessons stay confined to one department. Peer-review-privilege protections vary by state and this article does not constitute legal guidance on what any specific institution may share.
