Evidence
Alert

To improve team decision-making in cancer care: streamline workload, shorten meetings, address logistics and keep a gender balance on the team

For the past 20 years, the cornerstone of cancer care has been Multidisciplinary Teams (MDTs) who meet regularly to discuss the treatment and progress of people with cancer and plan the next steps. MDTs bring together a wide range of healthcare professionals, including surgeons, radiologists, oncologists, cancer nurse specialists and histopathologists (who examine samples of patients’ cells and tissues in the laboratory).

MDT meetings are valued but their decision-making process, in particular the communication, has not been widely studied. New research explored the process of decision-making and communication in three cancer MDTs.

It found that barriers to effective team decision-making included gender imbalance, negative interactions between team members, logistical issues (such as with administration and equipment), time-workload pressures, and longer meetings in which large numbers of cases were discussed. Team decision-making was better when the team was larger with a gender balance and when the cases discussed at the meeting were complex, as well as when team members were asking and answering questions.

The report made a number of recommendations such as that workload should be streamlined, and meetings chaired by someone not required to contribute to the decision-making. Adequate preparation time ahead of the meeting, a limit on the maximum number of cases to be discussed and mandatory short breaks, could all make a difference.

What’s the issue?

MDTs are regarded as the gold standard of care for people with cancer. They include a range of specialists who meet weekly or fortnightly to review patients’ test results, their progress, needs and onward treatment.

In recent years, the rise in cancer incidence, severe staff shortages and financial pressures have increased the workload for these teams. MDT meetings have become longer with some lasting up to five hours and discussing the care of up to 70 patients.

Despite the central role of MDT meetings in cancer care, there has been little research into the communication process underpinning MDT decision-making. The researchers believe this is the first large-scale study to explore the influence that factors such as communication style, gender balance, workload, time pressure, logistical issues, case complexity and team size have on the quality of decision-making within MDT meetings.

What’s new?

This study included three MDTs at university hospitals in Greater London and Derbyshire. The MDTs each had 14-15 members and specialised in breast, colorectal and gynaecological cancers. Between 2015-16, the researchers videoed 30 meetings in which 822 patients were discussed. Some patients had complex cancer; others had suspected cancer or benign disease.

The researchers used a number of validated tools to assess the MDTs’ decision-making, interaction and communication. The first tool to capture the complexity of cancer cases (Measure of case-Discussion Complexity or MeDiC) was also used in the study. It combines the perspectives of team members on factors such as a patient's mental health, or other medical conditions, to give an overall score on the complexity of discussion on each patient.

The study found that:

  • decision-making was better in larger teams, in those which had a balance of genders, and when more complex cases were being discussed (since these discussions involved more team members). Question-and-answer style communication was helpful
  • barriers to decision-making during the meetings included antagonism, tension, and lack of acknowledgement of other members’ contributions; gender imbalance; and logistical issues with administration, equipment and meeting attendance
  • time and workload pressures hindered decision-making. The longer the meeting, and the more cases discussed, the worse the quality of decision-making and communication. The optimal number of patients discussed was 20. Beyond that, the quality of decision-making went down with every treatment recommendation made and negative reactions increased.
  • first versus second half of the meeting had different challenges. Patients discussed in the first half of the meeting had more complex needs. In the second half, cases were more straightforward, but less time was spent discussing them as team members became tired. They also started to leave so the remaining group had less broad expertise.

Following the research, the team recommend:

  • Streamlining MDT workload to help reduce the time all MDT members spend in the meetings. Only patients with complex needs requiring input from various specialists should be discussed. The MeDiC tool may help to select patients.
  • A maximum limit on the number of cases discussed at a single meeting.
  • A mandatory short break during the meeting.
  • Better preparation to smooth out logistical issues ahead of meetings, for example, using a checklist to ensure all information is readily available.
  • An MDT meeting chair who does not contribute to the clinical discussion could steer the team through the workload by reducing tensions, promoting positive interaction and communication, and ensuring a more uniform decision-making process.
  • Staff selection for MDTs should factor in gender.

Why is this important?

Prior to January 2020, cancer MDTs were obliged to discuss all patients. Recent NHS England and NHS Improvement guidelines state that only people with complex cancer need to be discussed - not those whose treatment is following a standard pathway.

This work supports the change to guidelines. Its finding that the quality of decision-making and communication goes down with longer meetings and more cases underlines the need to reduce the workload at MDT meetings. Further, since the quality of decision-making was highest for the most complex cases, it implies that changes to the guidelines should not impact on patient care.

What’s next?

This study is part of larger research into the functioning of cancer MDTs, exploring factors such as individual behaviour and the working environment and how they affect decision-making and communication.

Further research should explore the impact of streamlining on the quality of decision-making and communication. It should also look at how factors explored in the current study (gender balance, team size, communication, time-workload pressure, logistical issues, case complexity, effective chairing), impact the quality of MDT decisions. This could be assessed against the clinical guidelines, post-meeting implementation of MDT decision, treatment compliance and patient satisfaction with MDT recommendation.

It will be important to find a reliable way of selecting the patients to be discussed at MDT meetings. In this study, the MeDiC tool identified patients with complex care needs among those being discussed. Development and testing of the tool is continuing, for example, its use ahead of MDT meetings to select those patients to be discussed.

You may be interested to read

The full paper: Soukup T, and others. A multicentre cross‐sectional observational study of cancer multidisciplinary teams: Analysis of team decision making. Cancer Medicine. 2020;9:7083–7099

Study further exploring the relationships between MDT communication, workload, case complexity and gender in MDT meetings: Soukup T, and others. Relationships Between Communication, Time Pressure, Workload, Task Complexity, Logistical Issues and Group Composition in Transdisciplinary Teams: A Prospective Observational Study Across 822 Cancer CasesFrontiers in Communication. 2020;5:583294

Study looking at challenges and solutions that may help MDTs operate more efficiently: Soukup T, and others. Streamlining cancer multidisciplinary team meetings: challenges and solutions. British Journal of Hospital Medicine. 2020;81:1-6

Study describing the development of the MeDiC tool for streamlining MDT workload: Soukup T, and others. A measure of case complexity for streamlining workflow in multidisciplinary tumor boards: Mixed methods development and early validation of the MeDiC tool. Cancer Medicine. 2020;9:5143-5154

Soukup T. Insider’s Guide to Developing a Psychometric Tool (MeDiC) for Cancer Multidisciplinary Teams Using a Multiphase Mixed-Methods Approach. SAGE Research Methods Cases: Medicine & Health. 2020. doi: 10.4135/9781529744064

Funding

This study was funded by the NIHR Applied Research Collaboration (ARC) South London and via the Imperial Patient Safety Translational Research Centre at Imperial College London, Department of Surgery and Cancer

Commentaries

Study author

MDT meetings involve a heavy workload for staff. They are expensive and exert financial pressure on healthcare resources. It is important that MDTs organise their meetings in a way that takes into consideration team size, gender balance, fatigue and short break, caseload and length of the meeting, quality of communication and chairing, as well as logistical issues and whether they could be addressed ahead of the meeting. What is more, the new guidelines should be reducing the workload at MDT meetings, but they also mean that the most complex cases, which will benefit more from the MDT discussion, need to be identified. Currently there is no reliable way to do so.

To the best of our knowledge, we have developed the first tool (MeDiC) to assess the complexity of cancer patients managed by an MDT. It should help streamline MDT meetings in an accurate, reliable and consistent manner. MeDiC combines the range of perspectives within a multidisciplinary team on what constitutes a complex case. The next step is evaluation of the tool in real clinical environments.

Tayana Soukup, Research Scientist, King’s College London

Workforce researcher

This paper could prompt cancer multidisciplinary teams to organise their meetings differently, in particular, paying attention to scheduling meetings to maximise attendance and allowing plenty of time for discussing all patients. I was surprised at how big an effect gender imbalance had on information sharing and the quality of decisions, compared to other influences.

Cancer multidisciplinary teams could benefit from discussing ways of improving their meetings. Online workshops could provide the setting for teams to learn strategies from each other.

Christina Saville, Research Fellow at the University of Southampton, with prior research experience in cancer services

Oncologist

The paper will reinforce known perception, but it is hard to change current practice due to time and workload pressures. There is also little room for change within small teams.

Recognition of the importance of the MDT lead may help: the necessary quality, training and time commitment and job planning, as would reducing unnecessary discussions, in line with standard management guidelines.

Ernie Marshall, Medical Oncologist, Clatterbridge Cancer Centre NHS Foundation Trust

Conflicts of Interest

Several authors have received fees or funding from Cancer Alliances, pharmaceutical, training and healthcare companies.