There are limited data on how morbidity and mortality (M+M) conferences impact physician behaviors. These conferences are present at all major teaching hospitals, however, it is unclear what impact they have on physician behavior. At a tertiary care center, a patient underwent 2 esophagogastroduodenoscopies (EGDs) and high-resolution manometry for dysphagia and voice hoarseness. A third EGD revealed a mass in the hypopharynx that had been missed on the previous 2 EGDs. The mass was resected and found to be a poorly differentiated squamous cell carcinoma.