Multidisciplinary team meetings

It’s 8 15 am on Monday morning. You’re sitting at the back of a darkened room, a plastic cup of lukewarm hospital coffee in your hands. A group of consultants crowd around a set of x ray films on the light box. The multidisciplinary team (MDT) meeting may not be the highlight of your week, but it plays an important part in the treatment of patients.

During your time as a medical student, particularly in the later clinical years, you will likely be invited to these meetings. Teamwork has become a buzzword in many areas of clinical medicine. MDT meetings bring together experts in different specialties to discuss the management of patients with a given condition or disease. The outcome of this discussion is usually a consensus that carries with it the combined experience of all individuals present.^w1

In the United Kingdom the 1995 Calman-Hine report recommended the establishment of MDTs, and they are now widely used in all parts of the National Health Service, especially in cancer services.^w2 In fact the NHS cancer plan requires that all patients receive clinical management that has been considered by an MDT.^w3 MDT working is also widely accepted in other countries, including the United States,^w4 Australia,^w5 and Scandinavia.^w6

Why hold MDT meetings?

Throughout their treatment, a patient with cancer will encounter many health professionals. A patient may be seen first by their general practitioner and then be referred to a specialist cancer surgeon or physician. The patient will usually have to pay a visit to a radiologist for imaging and staging. Depending on treatment modality, the patient may also be seen by an oncologist, a specialist nurse, and a dietician, and the palliative care team may be involved.

The idea behind MDT meetings is to streamline this fragmented journey, to improve coherence and continuity of care. Modern cancer care has become too complex to be organised by a single doctor. Instead of each healthcare professional being isolated, they are encouraged to see themselves as part of a team, with everyone informed of the overall picture and included in decision making about treatment for individual patients.

Also, because of the use of treatment protocols and constant monitoring patients can expect prompt and more standardised treatment. And thanks to regional cancer networks the best standard of care can be achieved even in small peripheral hospitals, where not all specialties might be available.^w7

MDT meetings are not limited to dealing with patients with cancer. MDT meetings to assess discharge are used when a patient is medically fit for discharge but perhaps not emotionally or socially ready to go home. MDT meetings are also used to manage the rehabilitation of patients with stroke, in psychiatry and mental health and in the care of elderly patients, for example. Although there are slight differences between hospitals and specialties, the meetings share a common goal—to bring together the team of health and social care professionals who are all looking after different aspects of an individual patient’s care and welfare.

Who attends the meetings?

MDT meetings are commonly held weekly or sometimes every two weeks or monthly. Their composition differs depending on the aim and specialty concerned. There are core team members, without whom the meeting does not usually proceed. For example, an MDT meeting for stroke rehabilitation may be led by a care of the elderly physician, and is attended by nurses, occupational therapists, physiotherapists, and social workers. In cancer the meetings are routinely attended by a surgeon and an oncologist as well as a radiologist, a pathologist, and a clinical nurse specialist. Everyone, depending upon their speciality, has a different perspective and role at the meeting (box).

What happens at the meeting?

The type of patients who are discussed at meetings varies and depends on the number of patients involved and the complexity of the cases. For example, in a stroke rehabilitation unit, all patients are discussed to ensure support is in place for each patient to be discharged safely. In a breast cancer MDT, most cases are routinely discussed after diagnosis because the initial surgery is often followed by radiotherapy or chemotherapy or both. On the other hand, only complex or unusual cases may be selected for a dermatology MDT meeting because in most cases simple surgical excision is the only available treatment.

Relevant patient information, such as notes, x rays, and histology slides, are brought to the meeting. Increasingly, use is made of direct access to the hospital intranet and patient administration system so that results and scans can be looked up and appointments booked straight away. Videoconferencing between different hospital sites is also used. Arranging this is usually the task of the MDT coordinator, who also records and follows up the outcomes of the meetings. The cooperation of medical secretaries is also essential.

For example, in a cancer MDT meeting, the patient’s history is briefly presented by the surgeon. The result of a biopsy is then explained by the pathologist who reviews the histology, meaning he or she can answer questions directly. The radiologist is able to review scans with the surgical and oncology team. If a patient needs further surgery it can be decided on the spot who has space on their operating list. The cumulative experience of those present is especially valuable in more unusual or demanding cases, and heated debates are not unknown. Ideally, the outcome should be a consensus recommendation that draws on the input of everyone involved.

After the meeting, an action plan is documented. The following may happen:

• Treatment plans are formulated
• Dates for investigations are chased, and urgent cases brought forward
• Clinic appointments are made, and dates for surgery arranged
• Referral letters are written
• Agencies outside the hospital, such as social workers, are contacted
• Patients may be discussed at a future multidisciplinary team meeting to review their progress
• A letter outlining the main points of discussion and proposed treatment plan for each patient may be sent to the patient’s family doctor
• All outcomes are recorded on a database and reviewed regularly by the MDT coordinator

The data is also used to monitor waiting times and to identify bottlenecks and avoidable delays. In the UK this is particularly relevant because the government has stipulated that all patients with suspected cancer who are referred by means of a rapid or fast track appointment must be seen within two weeks and receive their first definitive treatment within two months from referral or one month from diagnosis.

The patient’s best interests?

The concept of MDT meetings has been criticised for prescribing what is thought to be the most appropriate course of treatment without anyone ever meeting the patient concerned. Usually, though, several people at the meeting will have met the patient, whose own wishes are central to the discussion. Recent experience from care of patients with cancer of the head or neck has shown the benefits of MDT working in terms of treatment outcome and cost effectiveness.^w8

Because the patient is discussed in their absence, prior knowledge of his or her medical, social, and psychological problems is vital. It is important to emphasise that the MDT meetings only make recommendations for treatment. The final decision naturally rests with patients and is reached in consultation with their doctor in clinic or at the bedside.

Relevance to students

As a medical student attached to a hospital firm you will hopefully be encouraged to attend the specialty’s MDT meeting. This can seem daunting as the questions raised at the meeting are sometimes quite complex. There are often many relatively senior people there whom you have never met before. This can be off putting, but it is worth persevering. You may feel unimportant at the moment, but as a doctor you will be expected to contribute or to lead the meeting.

Especially in the final year of your studies, it is worth making an effort to attend these meetings. You may find that one of the patients you previously saw in the clinic or on the wards is being discussed. Having a radiologist or pathologist explain their radiographs, scans, or slides may help you understand their condition. At the same time, the meetings are a good opportunity to experience team work in clinical medicine. Ethical dilemmas and psychosocial drawbacks of various treatments for a patient may be discussed, which are not usually mentioned in textbooks. And if you know the patient, your input as a medical student will certainly be welcomed.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

References w1-w8 are on student.bmj.com.

See Education http://student.bmj.com/issues/08/07/education/280.php.

1. Manual for Cancer Services. London, Department of Health, 2004.
2. Expert Advisory Group on Cancer. A policy framework for commissioning cancer services: a report to the chief medical officers of England and Wales. The Calman-Hine Report. London, Department of Health, 1995.
3. NHS Cancer Plan. September 2000.
4. Tripathy D. Multidisciplinary care for breast cancer: barriers and solutions. Breast J. 2003; 9: 60-63.
5. Zorbas H, Barraclough B, Rainbird K, Luxford K, Redman S. Multidisciplinary care for women with early breast cancer in the Australian context: what does it mean? Med J Aust. 2003; 179: 528-531.
6. Stalfors J, Lundberg C, Westin T. Quality assessment of a multidisciplinary tumour meeting for patients with head and neck cancer. Acta Otolaryngol. 2007; 127: 82-87.
7. Ruhstaller T, Roe H, Thurlimann B, Nicoll JJ. The multidisciplinary meeting: An indispensable aid to communication between different specialities. Eur J Cancer. 2006; 42: 2459-2462.
8. Westin T, Stalfors J. Tumour boards/multidisciplinary head and neck cancer meetings: are they of value to patients, treating staff or a political additional drain on healthcare resources? Curr Opin Otolaryngol Head Neck Surg. 2008; 16: 103-107.

   

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