- Email: [email protected]
Multidisciplinary Team Meetings in Cancer Care: An Idea Whose Time has Gone?
Clinical Oncology 27 (2015) 728e731 Contents lists available at ScienceDirect
Clinical Oncology journal homepage: www.clinicaloncologyonline.net
Editorial
Multidisciplinary Team Meetings in Cancer Care: An Idea Whose Time has Gone? A.J. Munro Tayside Cancer Centre, Ninewells Hospital & Medical School, Dundee, UK Received 15 July 2015; accepted 19 August 2015
Multidisciplinary team (MDT) meetings are believed to play an indispensable role in the care of patients with cancer. After nearly 20 years of development and implementation [1,2] it is worth questioning this belief: are MDT meetings still essential, or have they outlived their usefulness [3]? Cancer services in the UK in the early 1990s were far from satisfactory. There were gross variations in clinical practice and the quality of reporting on pathological specimens and radiological investigations was often dismal. In order to improve matters, the Government commissioned the CalmaneHine report [4]. Its intention was to provide ‘a strategic framework to help commissioners and providers of cancer services to make well informed and wise decisions’. One of the means chosen to instantiate this, articulated in the Cancer Plan of 2000 [5], was the MDT meeting. The role of the MDT meeting was, from its outset, primarily educational. It was a mechanism for promoting and diffusing best practice rather than designed to dictate the micromanagement of individual patients. The most robust data on the epidemiology of MDT meetings comes from the National Health Service (NHS) in England. The total number of cancer MDTs in England is 1241 [6]. There are, each year, over 55 000 meetings and the total time consultants spend in relation to these meetings is nearly 1.2 million hours, equivalent to around 550 full-time consultants. Using the data from NHS reference costs [7], and assuming an average of 5 min discussion time per patient, there are a total of 106 630 h of MDT meetings in England per year. The average number of patients discussed at each MDT meeting is typically between 15 and 30. Many of these discussions are repeat business. Over 10% of new patients
Author for correspondence: A.J. Munro, Tayside Cancer Centre, Ninewells Hospital & Medical School, Dundee DD1 9SY, UK. Tel: þ44-1382-496491. E-mail address: [email protected]
need more than one discussion simply because the necessary information or specialist advice is unavailable at the initial meeting; some patients with clinical presentations that are less than straightforward are victims of the ‘Flying Dutchman’ phenomenon, blown from one site-specific MDT to another until finally reaching safe haven; patients often require repeat discussions during the course of their management; patients on regular follow-up are often brought back for discussion after abnormal test results. Using data from the peer-review reports [6], the total hours per annum spent by consultants on MDT working can be calculated and allocated according to specialty. Nonsurgical specialties bear a disproportionately large share of the burden associated with MDT meetings. At any one time during the working week, between 10 and 15% of clinical oncologists are incarcerated in MDT meetings. MDT duties consume 7e8% of the workforce in clinical radiology. MDT meetings in the UK are now operating on an industrial scale, the cost is considerable. On the basis of NHS reference costs, the total MDT costs per annum to NHS England are £129.6 million per year which, pro rata, would make the total UK cost £154.3 million per year. The overall average number of discussions per patient is 4.0; the base cost per patient is £428 and is £485 if a modest allowance is made for opportunity cost. Are these costs justified by results? Do MDT meetings add value? If MDT meetings were drugs, would the National Institute for Health and Care Excellence (NICE) approve them for clinical use? Unfortunately, despite over 300 publications on the subject, there is little evidence upon which to base any estimate of the value of MDT meetings. There is abundant analysis of process, but no demonstrable impact of MDT meetings alone upon the outcome that matters most to patients e the probability of achieving cure of their disease at a price, in terms of adverse effects, that is acceptable. The reorganisation of cancer services has had some role in improving survival rates for patients with cancer. This does not imply that the improvements are the direct result
http://dx.doi.org/10.1016/j.clon.2015.08.008 0936-6555/Ó 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
A.J. Munro / Clinical Oncology 27 (2015) 728e731
of MDT meetings. It is asking too much of the MDT process to expect it to eliminate all disparities in outcomes for patients with cancer. There are simply too many other influential factors: socioeconomic deprivation; burden of illness (multimorbidity); age structure of the population; geographical influences on access to care. However, it is reasonable to expect that MDT discussions should iron out differences in the treatments that are used within specific groups of patients. The evidence suggests that this has not happened. There are wide variations in the use of radiotherapy across England [8], differences that seem to reflect geography and the nature of the centre (small/large; teaching/non-teaching), rather than demand or capacity. The national bowel cancer audit [9] shows that there are big differences, at both trust and network level, in rates of utilisation of radiotherapy and in proportions of patients treated primarily with abdominoperineal excision of the rectum. The Malthus project [10] and work from Australia [11] have established optimal rates for utilisation of radiotherapy. A surprising number of centres and networks have rates that are outwith these bounds. Effective MDT processes would have been expected to ensure rates that approach the norm, and to prevent the wide and persisting variations in practice. The MDT process has not put an end to the problem of geographically based disparities in cancer care. Where you live still makes a difference: an 8-fold difference in the use of erlotinib or gefitinib [12]; a 2-fold difference in the use of radiotherapy in general [8]; a 1.5-fold difference in the chance of being left with a stoma after treatment for bowel cancer [13]; a 12-fold difference in your likelihood of being treated with preoperative radiotherapy for rectal cancer; an 8-fold difference in your chance of having abdominoperineal excision of the rectum for rectal cancer [9]. As an effector mechanism for implementing the principles underlying the CalmaneHine report the MDT process does not, by any objective criteria, seem to have been particularly successful. Any claims for the effectiveness of MDT meetings that rely upon the observation that patients who are not discussed at MDT meetings have lower survival rates are largely based on a fallacy, that of the self-fulfilling prophecy. People who die at and around the time of diagnosis are rarely discussed at an MDT meeting. Fit, young patients with early disease are far more likely to be discussed than frail elderly patients with advanced disease. The very fact that a patient is discussed at an MDT meeting therefore indicates, a priori, that such a patient is likely to do well. In the absence of any randomised trials, it is impossible, given this degree of selection bias, to make any useful comment on whether or not MDT discussion, per se, contributes to improved chances of survival. There is a highly questionable belief, among enthusiasts for the MDT process, that MDT meetings should make highly specific recommendations about how individual patients should be treated. In this view, it is insufficient for a team to suggest that a patient be given an appointment with a clinician to discuss options. The team must produce a
729
detailed and definitive plan. It would be highly unusual for an individual clinician to make such a recommendation concerning a patient whom they had never met, but somehow, magically, a team is considered competent to do so. It is not. It is clear that MDT meetings are consuming a disproportionate amount of the resources available for the care of patients with cancer. Nevertheless, there is no need to jettison MDTs completely. The solution is to hold meetings less frequently but with a more focused approach: dealing specifically with patients who have particularly complex problems and ensuring that there is no discussion without adequate information. A recent survey of team members highlighted some of the problems associated with MDT meetings [14]. Table 1 summarises some of these difficulties and offers some proposals as to how they might be mitigated. We should think more creatively about how we use IT systems and web-based technologies [15]. We could, by adopting modern technologies, have the best of both worlds. We could maintain the sense of a team working together, sharing information and experience, educating and supporting each other, while improving the quality, timeliness and sensitivity of the decision-making process. The everyday business of the team can be conducted electronically. E-mail alone is too cumbersome, and clogged with spam, but there are other solutions. An MDT meeting is not unlike a blog with comments and existing software, used for social media, can easily be adapted to provide a platform to support online MDT discussions. The concept of the virtual MDT [16] can be realised using simple, open source, software. To adopt novel approaches will require an act of political will at a high level within the NHS. Otherwise local enthusiasm for restrictive governance of information and inertia within IT departments will stultify any attempt at change. We seem to have painted ourselves into a corner. We adopted the MDT process for reasons that were predominantly political and, therefore, there was no perceived obligation to provide any supporting evidence. We are now expending considerable amounts of human and financial resources on an enterprise for which there is little objective evidence of benefit, which carries considerable opportunity costs and which neatly exemplifies Buxton’s Law: ‘it is always too early (for rigorous evaluation) until, unfortunately, it’s suddenly too late’. To suggest that we need to rethink and redesign the concept of the MDT process in cancer care is heresy. After all, quality performance indicators in Scotland and the cancer peer review system in England are both heavily based on assessments of the process and performance of MDT meetings. It is going to be very difficult to change the groupthink but, given the resources we currently seem to be wasting, this is something that, for the sake of the health service, we absolutely have to do. At a time, in the late 1990s, when clinicians needed to cooperate more, MDT meetings brought people together. We all learned a great deal about each other’s specialties, we gained an appreciation of the subtext that lay beneath a
730
A.J. Munro / Clinical Oncology 27 (2015) 728e731
Table 1 MDT meetings: problems and possible solutions Problem
Proposal
Intended effect
Costs are considerable
Restrict face-to-face MDT discussions to complex or unusual problems
Limited evidence for effectiveness
Any changes should be introduced in such a way that evaluation is possible. Randomised controlled trials using a step wedge design, would be an ethical and practical way to assess any new developments. An added advantage of this approach would be that the costs of existing arrangements would be adequately captured Use an electronically mediated system to capture information concerning an individual patient’s eligibility for clinical trials and promptly notify the relevant clinicians. Present recommendations from guidelines automatically to clinicians Discourage, using suitable gating mechanisms for referral, the abuse of the MDT process by lazy clinicians who would prefer not to make their own decisions
Decrease the direct and indirect costs by reducing frequency of synchronous meetings Demonstrate relative and absolute effectiveness of different models of MDT working
Recruitment to clinical trials and adherence to guidelines could be improved
Clinicians no longer feel confident in making individual decisions about how to manage patients but, instead, have become increasingly reliant upon the corporate shelter provided by the MDT Limited educational value, dominated by professional hierarchies
Ambiguities in the medico legal aspects of MDT working
Act as committees for impersonalised medicine: the most important member of the team, the patient, is excluded from the discussions. It is a form of trial in absentia, and violates the ancient legal principle of habeas corpus. Often there is no-one present at the meeting who has ever met the patient The process delays patient’s progress and increases anxiety while they await the team’s deliberations. The decisions that are reached could, on most occasions, have been taken far sooner by an individual clinician. There is often an illusory resolution of problems leading to a flurry of e-mails following each MDT
Use web systems to capture clinical data, details of discussions, and patient’s subsequent progress. Provide an easily interrogated audit trail.
Clarify the medico-legal position by insisting that the MDT process results in a recommendation, not a decision. The recommendation is then discussed by the patient and a relevant clinician. Any final decision rests with the patient, adequately and appropriately informed by a responsible clinician Use a web-based system to facilitate contributions from clinicians who have first-hand knowledge of the patients and who are able to represent an individual patient’s hopes, fears, and expectations.
Use an asynchronous approach so that electronically based discussions could take place at any time e no need to wait until the next scheduled MDT meeting. Patients with straightforward problems could be discussed online and recommendations made with 24e48 h Ensure that e-mails (or other electronic communications) are part of the MDT process
Improvements in recruitment to clinical trials and adherence to guidelines
Ensure that the MDT process does not become a convenient refuge for clinicians who are trying to shirk their traditional responsibilities
This will generate an electronic archive of knowledge and experience: an educational resource that can be used to guide future decisions. It is in the nature of web-based systems to be more democratic, less hierarchical, and this would encourage all team members to participate. Ensure that MDTs operate within an appropriate legal framework
To improve the relevance of discussions, allow for incorporation of patients’ preferences, and include information on multi morbidity
The interval between diagnosis and starting definitive treatment will be reduced
There is flexibility built in to the system so that recommendations, in changing circumstances, can be appropriately updated without undue delay
A.J. Munro / Clinical Oncology 27 (2015) 728e731
731
Table 1 (continued ) Problem
Proposal
Intended effect
The process has a tendency to descend into ritual, merely paying lip-service to the idea of a robust, wellinformed, discussion Clinicians in primary care are usually excluded from the team’s deliberations
Provide an audit trail of individuals’ contributions allowing easy identification of any inappropriate behaviour. Adopt a pluralist approach to contributions
Discussions become more open and varied e with evidence that the real issues have been appropriately discussed There would be greater involvement of primary care clinicians in the decision- making process
Use flexible web-based systems allowing general practitioners instant access to, and (potentially) participation in, discussion
MDT, multidisciplinary team.
written report, we learned about surgical procedures and how a patient’s general fitness might affect surgical decision making. The primary educational role of the MDT meeting has been fulfilled: knowledge and mutual understanding have improved. The analogy here is with training wheels on a bicycle. Previously, our ability to work in teams was wobbly, our understanding was uncertain, our progress was hesitant. MDT meetings provided us with training wheels and we gained stability and confidence. But we no longer need those wheels e they are redundant and simply act as an energy-consuming hindrance. The trouble is that the wheels now seem to have become more important than either the bicycle or the rider. Sir Bradley Wiggins would have been hard put to win the Tour de France with training wheels attached to his bicycle. It would certainly have been most illogical for his support team, ignoring rider and bicycle, to put all their effort into making sure that his training wheels were in perfect working order. Somehow we seem, with MDT meetings for cancer, to have reached this strange and anomalous position. It is time to throw away the training wheels: time to embrace electronic communication; time to concentrate on what really matters e providing prompt and appropriate care for individual patients with cancer.
References [1] Fleissig A, Jenkins V, Catt S, Fallowfield L. Multidisciplinary teams in cancer care: are they effective in the UK? Lancet Oncol 2006;7(11):935e943. [2] Taylor C, Munro AJ, Glynne-Jones R, et al. Multidisciplinary team working in cancer: what is the evidence? BMJ 2010;340:c951. [3] Chinai N, Bintcliffe F, Armstrong EM, Teape J, Jones BM, Hosie KB. Does every patient need to be discussed at a multidisciplinary team meeting? Clin Radiol 2013;68(8):780e784.
[4] Calman K, Hine D. A policy framework for commissioning cancer services: a report by the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales 1995. [5] Department of Health. The NHS Cancer Plan. A plan for investment A plan for reform. London 2000. [6] Department of Health England. National Peer Review Report Cancer Services 2012/2013. An overview of the findings from the 2012/2013 National Peer Review of Cancer Services in England. London 2014. [7] Department of Health England. Reference costs 2013e2014. London 2014. [8] Hoskin PJ, Forbes H, Ball C, et al. Variations in radiotherapy delivery in England e evidence from the National Radiotherapy Dataset. Clin Oncol 2013;25(9):531e537. [9] Health and Social Care Information Centre. National Bowel Cancer Audit. Available at: http://www.hscic.gov.uk/bowel; 2015. [10] Jena R, Mee T, Kirkby NF, Williams MV. Quantifying uncertainty in radiotherapy demand at the local and national level using the Malthus model. Clin Oncol 2015;27(2):92e98. [11] Delaney GP, Barton MB. Evidence-based estimates of the demand for radiotherapy. Clin Oncol 2015;27(2):70e76. [12] Prescribing and Primary Care Team Health and Social Care Information Centre. Use of NICE appraised medicines in the NHS in England e 2012, experimental statistics. London: HSIC; 2014. [13] Public Health England Knowledge and Information Team (Northern & Yorkshire), University of Leeds, University of Southampton. Quality of life of colorectal cancer survivors in England. Report on a national survey of colorectal cancer survivors using patient reported outcome measures (PROMs) 2015. [14] Jalil R, Ahmed M, Green JSA, Sevdalis N. Factors that can make an impact on decision-making and decision implementation in cancer multidisciplinary teams: an interview study of the provider perspective. Int J Surg 2013;11(5):389e394. [15] Patkar V, Acosta D, Davidson T, Jones A, Fox J, Keshtgar M. Using computerised decision support to improve compliance of cancer multidisciplinary meetings with evidence-based guidance. BMJ Open 2012;2(3). Epub 2012/06/27. [16] Munro AJ, Swartzman S. What is a virtual multidisciplinary team (vMDT)? Br J Cancer 2013;108(12):2433e2441.
Clinical Oncology journal homepage: www.clinicaloncologyonline.net
Editorial
Multidisciplinary Team Meetings in Cancer Care: An Idea Whose Time has Gone? A.J. Munro Tayside Cancer Centre, Ninewells Hospital & Medical School, Dundee, UK Received 15 July 2015; accepted 19 August 2015
Multidisciplinary team (MDT) meetings are believed to play an indispensable role in the care of patients with cancer. After nearly 20 years of development and implementation [1,2] it is worth questioning this belief: are MDT meetings still essential, or have they outlived their usefulness [3]? Cancer services in the UK in the early 1990s were far from satisfactory. There were gross variations in clinical practice and the quality of reporting on pathological specimens and radiological investigations was often dismal. In order to improve matters, the Government commissioned the CalmaneHine report [4]. Its intention was to provide ‘a strategic framework to help commissioners and providers of cancer services to make well informed and wise decisions’. One of the means chosen to instantiate this, articulated in the Cancer Plan of 2000 [5], was the MDT meeting. The role of the MDT meeting was, from its outset, primarily educational. It was a mechanism for promoting and diffusing best practice rather than designed to dictate the micromanagement of individual patients. The most robust data on the epidemiology of MDT meetings comes from the National Health Service (NHS) in England. The total number of cancer MDTs in England is 1241 [6]. There are, each year, over 55 000 meetings and the total time consultants spend in relation to these meetings is nearly 1.2 million hours, equivalent to around 550 full-time consultants. Using the data from NHS reference costs [7], and assuming an average of 5 min discussion time per patient, there are a total of 106 630 h of MDT meetings in England per year. The average number of patients discussed at each MDT meeting is typically between 15 and 30. Many of these discussions are repeat business. Over 10% of new patients
Author for correspondence: A.J. Munro, Tayside Cancer Centre, Ninewells Hospital & Medical School, Dundee DD1 9SY, UK. Tel: þ44-1382-496491. E-mail address: [email protected]
need more than one discussion simply because the necessary information or specialist advice is unavailable at the initial meeting; some patients with clinical presentations that are less than straightforward are victims of the ‘Flying Dutchman’ phenomenon, blown from one site-specific MDT to another until finally reaching safe haven; patients often require repeat discussions during the course of their management; patients on regular follow-up are often brought back for discussion after abnormal test results. Using data from the peer-review reports [6], the total hours per annum spent by consultants on MDT working can be calculated and allocated according to specialty. Nonsurgical specialties bear a disproportionately large share of the burden associated with MDT meetings. At any one time during the working week, between 10 and 15% of clinical oncologists are incarcerated in MDT meetings. MDT duties consume 7e8% of the workforce in clinical radiology. MDT meetings in the UK are now operating on an industrial scale, the cost is considerable. On the basis of NHS reference costs, the total MDT costs per annum to NHS England are £129.6 million per year which, pro rata, would make the total UK cost £154.3 million per year. The overall average number of discussions per patient is 4.0; the base cost per patient is £428 and is £485 if a modest allowance is made for opportunity cost. Are these costs justified by results? Do MDT meetings add value? If MDT meetings were drugs, would the National Institute for Health and Care Excellence (NICE) approve them for clinical use? Unfortunately, despite over 300 publications on the subject, there is little evidence upon which to base any estimate of the value of MDT meetings. There is abundant analysis of process, but no demonstrable impact of MDT meetings alone upon the outcome that matters most to patients e the probability of achieving cure of their disease at a price, in terms of adverse effects, that is acceptable. The reorganisation of cancer services has had some role in improving survival rates for patients with cancer. This does not imply that the improvements are the direct result
http://dx.doi.org/10.1016/j.clon.2015.08.008 0936-6555/Ó 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
A.J. Munro / Clinical Oncology 27 (2015) 728e731
of MDT meetings. It is asking too much of the MDT process to expect it to eliminate all disparities in outcomes for patients with cancer. There are simply too many other influential factors: socioeconomic deprivation; burden of illness (multimorbidity); age structure of the population; geographical influences on access to care. However, it is reasonable to expect that MDT discussions should iron out differences in the treatments that are used within specific groups of patients. The evidence suggests that this has not happened. There are wide variations in the use of radiotherapy across England [8], differences that seem to reflect geography and the nature of the centre (small/large; teaching/non-teaching), rather than demand or capacity. The national bowel cancer audit [9] shows that there are big differences, at both trust and network level, in rates of utilisation of radiotherapy and in proportions of patients treated primarily with abdominoperineal excision of the rectum. The Malthus project [10] and work from Australia [11] have established optimal rates for utilisation of radiotherapy. A surprising number of centres and networks have rates that are outwith these bounds. Effective MDT processes would have been expected to ensure rates that approach the norm, and to prevent the wide and persisting variations in practice. The MDT process has not put an end to the problem of geographically based disparities in cancer care. Where you live still makes a difference: an 8-fold difference in the use of erlotinib or gefitinib [12]; a 2-fold difference in the use of radiotherapy in general [8]; a 1.5-fold difference in the chance of being left with a stoma after treatment for bowel cancer [13]; a 12-fold difference in your likelihood of being treated with preoperative radiotherapy for rectal cancer; an 8-fold difference in your chance of having abdominoperineal excision of the rectum for rectal cancer [9]. As an effector mechanism for implementing the principles underlying the CalmaneHine report the MDT process does not, by any objective criteria, seem to have been particularly successful. Any claims for the effectiveness of MDT meetings that rely upon the observation that patients who are not discussed at MDT meetings have lower survival rates are largely based on a fallacy, that of the self-fulfilling prophecy. People who die at and around the time of diagnosis are rarely discussed at an MDT meeting. Fit, young patients with early disease are far more likely to be discussed than frail elderly patients with advanced disease. The very fact that a patient is discussed at an MDT meeting therefore indicates, a priori, that such a patient is likely to do well. In the absence of any randomised trials, it is impossible, given this degree of selection bias, to make any useful comment on whether or not MDT discussion, per se, contributes to improved chances of survival. There is a highly questionable belief, among enthusiasts for the MDT process, that MDT meetings should make highly specific recommendations about how individual patients should be treated. In this view, it is insufficient for a team to suggest that a patient be given an appointment with a clinician to discuss options. The team must produce a
729
detailed and definitive plan. It would be highly unusual for an individual clinician to make such a recommendation concerning a patient whom they had never met, but somehow, magically, a team is considered competent to do so. It is not. It is clear that MDT meetings are consuming a disproportionate amount of the resources available for the care of patients with cancer. Nevertheless, there is no need to jettison MDTs completely. The solution is to hold meetings less frequently but with a more focused approach: dealing specifically with patients who have particularly complex problems and ensuring that there is no discussion without adequate information. A recent survey of team members highlighted some of the problems associated with MDT meetings [14]. Table 1 summarises some of these difficulties and offers some proposals as to how they might be mitigated. We should think more creatively about how we use IT systems and web-based technologies [15]. We could, by adopting modern technologies, have the best of both worlds. We could maintain the sense of a team working together, sharing information and experience, educating and supporting each other, while improving the quality, timeliness and sensitivity of the decision-making process. The everyday business of the team can be conducted electronically. E-mail alone is too cumbersome, and clogged with spam, but there are other solutions. An MDT meeting is not unlike a blog with comments and existing software, used for social media, can easily be adapted to provide a platform to support online MDT discussions. The concept of the virtual MDT [16] can be realised using simple, open source, software. To adopt novel approaches will require an act of political will at a high level within the NHS. Otherwise local enthusiasm for restrictive governance of information and inertia within IT departments will stultify any attempt at change. We seem to have painted ourselves into a corner. We adopted the MDT process for reasons that were predominantly political and, therefore, there was no perceived obligation to provide any supporting evidence. We are now expending considerable amounts of human and financial resources on an enterprise for which there is little objective evidence of benefit, which carries considerable opportunity costs and which neatly exemplifies Buxton’s Law: ‘it is always too early (for rigorous evaluation) until, unfortunately, it’s suddenly too late’. To suggest that we need to rethink and redesign the concept of the MDT process in cancer care is heresy. After all, quality performance indicators in Scotland and the cancer peer review system in England are both heavily based on assessments of the process and performance of MDT meetings. It is going to be very difficult to change the groupthink but, given the resources we currently seem to be wasting, this is something that, for the sake of the health service, we absolutely have to do. At a time, in the late 1990s, when clinicians needed to cooperate more, MDT meetings brought people together. We all learned a great deal about each other’s specialties, we gained an appreciation of the subtext that lay beneath a
730
A.J. Munro / Clinical Oncology 27 (2015) 728e731
Table 1 MDT meetings: problems and possible solutions Problem
Proposal
Intended effect
Costs are considerable
Restrict face-to-face MDT discussions to complex or unusual problems
Limited evidence for effectiveness
Any changes should be introduced in such a way that evaluation is possible. Randomised controlled trials using a step wedge design, would be an ethical and practical way to assess any new developments. An added advantage of this approach would be that the costs of existing arrangements would be adequately captured Use an electronically mediated system to capture information concerning an individual patient’s eligibility for clinical trials and promptly notify the relevant clinicians. Present recommendations from guidelines automatically to clinicians Discourage, using suitable gating mechanisms for referral, the abuse of the MDT process by lazy clinicians who would prefer not to make their own decisions
Decrease the direct and indirect costs by reducing frequency of synchronous meetings Demonstrate relative and absolute effectiveness of different models of MDT working
Recruitment to clinical trials and adherence to guidelines could be improved
Clinicians no longer feel confident in making individual decisions about how to manage patients but, instead, have become increasingly reliant upon the corporate shelter provided by the MDT Limited educational value, dominated by professional hierarchies
Ambiguities in the medico legal aspects of MDT working
Act as committees for impersonalised medicine: the most important member of the team, the patient, is excluded from the discussions. It is a form of trial in absentia, and violates the ancient legal principle of habeas corpus. Often there is no-one present at the meeting who has ever met the patient The process delays patient’s progress and increases anxiety while they await the team’s deliberations. The decisions that are reached could, on most occasions, have been taken far sooner by an individual clinician. There is often an illusory resolution of problems leading to a flurry of e-mails following each MDT
Use web systems to capture clinical data, details of discussions, and patient’s subsequent progress. Provide an easily interrogated audit trail.
Clarify the medico-legal position by insisting that the MDT process results in a recommendation, not a decision. The recommendation is then discussed by the patient and a relevant clinician. Any final decision rests with the patient, adequately and appropriately informed by a responsible clinician Use a web-based system to facilitate contributions from clinicians who have first-hand knowledge of the patients and who are able to represent an individual patient’s hopes, fears, and expectations.
Use an asynchronous approach so that electronically based discussions could take place at any time e no need to wait until the next scheduled MDT meeting. Patients with straightforward problems could be discussed online and recommendations made with 24e48 h Ensure that e-mails (or other electronic communications) are part of the MDT process
Improvements in recruitment to clinical trials and adherence to guidelines
Ensure that the MDT process does not become a convenient refuge for clinicians who are trying to shirk their traditional responsibilities
This will generate an electronic archive of knowledge and experience: an educational resource that can be used to guide future decisions. It is in the nature of web-based systems to be more democratic, less hierarchical, and this would encourage all team members to participate. Ensure that MDTs operate within an appropriate legal framework
To improve the relevance of discussions, allow for incorporation of patients’ preferences, and include information on multi morbidity
The interval between diagnosis and starting definitive treatment will be reduced
There is flexibility built in to the system so that recommendations, in changing circumstances, can be appropriately updated without undue delay
A.J. Munro / Clinical Oncology 27 (2015) 728e731
731
Table 1 (continued ) Problem
Proposal
Intended effect
The process has a tendency to descend into ritual, merely paying lip-service to the idea of a robust, wellinformed, discussion Clinicians in primary care are usually excluded from the team’s deliberations
Provide an audit trail of individuals’ contributions allowing easy identification of any inappropriate behaviour. Adopt a pluralist approach to contributions
Discussions become more open and varied e with evidence that the real issues have been appropriately discussed There would be greater involvement of primary care clinicians in the decision- making process
Use flexible web-based systems allowing general practitioners instant access to, and (potentially) participation in, discussion
MDT, multidisciplinary team.
written report, we learned about surgical procedures and how a patient’s general fitness might affect surgical decision making. The primary educational role of the MDT meeting has been fulfilled: knowledge and mutual understanding have improved. The analogy here is with training wheels on a bicycle. Previously, our ability to work in teams was wobbly, our understanding was uncertain, our progress was hesitant. MDT meetings provided us with training wheels and we gained stability and confidence. But we no longer need those wheels e they are redundant and simply act as an energy-consuming hindrance. The trouble is that the wheels now seem to have become more important than either the bicycle or the rider. Sir Bradley Wiggins would have been hard put to win the Tour de France with training wheels attached to his bicycle. It would certainly have been most illogical for his support team, ignoring rider and bicycle, to put all their effort into making sure that his training wheels were in perfect working order. Somehow we seem, with MDT meetings for cancer, to have reached this strange and anomalous position. It is time to throw away the training wheels: time to embrace electronic communication; time to concentrate on what really matters e providing prompt and appropriate care for individual patients with cancer.
References [1] Fleissig A, Jenkins V, Catt S, Fallowfield L. Multidisciplinary teams in cancer care: are they effective in the UK? Lancet Oncol 2006;7(11):935e943. [2] Taylor C, Munro AJ, Glynne-Jones R, et al. Multidisciplinary team working in cancer: what is the evidence? BMJ 2010;340:c951. [3] Chinai N, Bintcliffe F, Armstrong EM, Teape J, Jones BM, Hosie KB. Does every patient need to be discussed at a multidisciplinary team meeting? Clin Radiol 2013;68(8):780e784.
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