Clinical decision-making in a multidisciplinary gynaecological cancer team: a qualitative study

Authors


Dr J Kidger, Department of Social Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK. Email judi.kidger@bris.ac.uk

Abstract

Objective  To explore the factors that influence treatment decision-making in a gynaecological cancer team (MDT).

Design  Qualitative study using interviews and observations.

Setting  Gynaecological cancer MDT meetings and participants’ offices.

Sample  A gynaecological cancer MDT and members of that team.

Methods  Observations of ten MDT meetings and semistructured interviews with 16 team members. Data analysis using the constant comparison technique of grounded theory and ethnography.

Main outcome measures  Factors affecting treatment decisions in the MDT meetings.

Results  Disease-centred information was central to decision-making, whereas patient-centred factors such as patient choice and co-morbidity were more peripheral. This was partly due to variation in team members’ type and level of participation: senior clinicians occupied the most dominant roles in discussions and decision-making, whereas nurses contributed less but were more likely to focus on patient-related factors. Three main decision-making pathways emerged: a short discussion followed by a clear decision, a prolonged discussion ending in a definite treatment plan, and a lengthy discussion with no clearly stated decision at the end. The type of pathway followed depended on a case’s complexity and the extent of agreement among team members.

Conclusions  The process of treatment decision-making was not consistent for all women but was affected by factors such as the complexity of the case, which team members participated, and the extent of team members’ agreement. Improvements are needed to ensure patient-centred information is included for all women and that clear decisions are reached and recorded in all cases.

Introduction

The delivery and organisation of cancer services in the UK has undergone rapid and considerable change over the past decade. One of the key changes is the introduction of multidisciplinary teams (MDTs) that contribute to, and participate in, decisions about the clinical management of women.1 For gynaecological cancers, working in multiprofessional teams is one of the key recommendations of the Improving Outcomes Guidance, which provides detailed information about the membership, structure, and organisation of gynaecological cancer MDTs (www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publications Policy AndGuidance/DH_4005385).

Working effectively in multiprofessional teams has several theoretical benefits: it may be safer because a team creates additional defences against error by monitoring and double-checking decisions, it may reduce patient anxiety because the patient has the knowledge that their treatment is based upon the opinion of several experts, it provides continuity of care and may enhance the implementation of protocols, and weekly meetings may also improve team communication because of greater opportunities to talk. Despite these many potential advantages, and the intuitive appeal of team working, a recent review of multidisciplinary cancer teams concluded that research showing the effectiveness of MDT working is scarce.2

To develop methods for cancer teams to work effectively, it is first necessary to understand how MDTs work together and how treatment decisions are made and implemented.3 The research literature on team behaviour has found that effective working is influenced by a number of factors including the amount of cohesion or conflict that exists, the style of leadership, and the level and type of member participation in the group decision-making process.4 Factors that have been found to influence the decision-making process of MDTs in particular are effective team working skills, the dominance of team members with medical knowledge, the importance of compliance with policy initiatives, and whether a patient is known to the team.5,6 In gastrointestinal cancer teams, studies have shown that if data about patient choice and general health status are omitted at the time of the MDT meeting then MDT treatment recommendations are unlikely to be implemented.3,7 The aim of this study was to develop this knowledge base by exploring the factors that influence clinical decisions in a gynaecological MDT.

Methods

Qualitative methods were used as they are ideally suited to understanding and exploring complex social processes in context.8 The study setting was a gynaecological cancer MDT that meets weekly and makes approximately 300 treatment decisions each year.

Nonparticipant observations of weekly team meetings and semistructured interviews with 16 team members, were conducted over a 10-week period. Using these two data collection methods enabled triangulation of the findings, and ensured a richer, more detailed understanding of the decision-making process. Before the study started, J.K. and J.M.B. visited the MDT twice to inform them of the project and gain written informed consent from all members. Further written information regarding the interviews was provided and informed consent gained from each interviewee.

Observations

Nonparticipant observation of meetings was performed by J.K. This ‘naturalistic’ method of data collection was chosen as it is well established that self-reports about behaviour are biased for a number of reasons.9 The aim of the observations was to record the decision-making process that took place within the team, noting particularly who took part in discussions, what information was included, and how decisions were reached. Observations were recorded by hand during the meeting using an observation schedule to ensure a systematic approach (Box 1) and were typed up immediately after each meeting.

Table Box 1. .  Topic guide for observation of MDT meetings
Observation schedule
General issues
 Who attends, seating arrangements, who chairs and how, equipment use, time keeping
Issues considered for each patient
 Who presents the case and what information is provided?
 Who contributes to the ensuing discussion?
 What information is considered – e.g. pathology, radiology, co-morbidity, patient wishes/views?
 How is the final decision reached and recorded?
 Are there any disagreements, and how are these resolved?
 What further steps are agreed upon, and whom do these involve?

Interviews

Team members were recruited for interview by opportunistic invitation before or after MDT meetings. To ensure the full range of disciplines were represented, some interviewees were subsequently specifically targeted through e-mail. Everybody that was approached agreed to be interviewed. The final number represented approximately 65% of attendees and covered the full range of professions involved in the meetings (Box 2). The purpose of the interviews was to explore members’ private accounts of the team meetings, in particular their perceptions and views of the decision-making process and their role in this, why decisions occurred as they did, and thoughts on how meetings could be improved. The interviews were semistructured: in each case, a checklist of topics was followed (Box 3) to ensure the same key issues were covered but with sufficient flexibility to allow each interviewee to raise issues that were important to him or her. The checklist was piloted with two interviewees to ensure questions and follow-up probes were comprehended. The interviews took place in offices in the hospital and were conducted by J.K. All the interviews were tape-recorded and transcribed.

Table Box 2. .  Summary of interviewees
Role in the teamNo. of participants
Surgical oncologists3
Medical oncologists3
Pathologists2
Radiologists3
Nurses4
Team co-ordinator1
Table Box 3. .  Interview topic guide
Interview topic guide
How do you feel the last meeting you attended went? What worked well? What could have been done differently/better?
What do you see as the purpose of your MDT meetings? Is this generally achieved? Why/why not?
How are decisions made in your team? What types of information are used? Prompts: pathology, radiology, patient choice, co-morbidity, other patient factors What role do you play?
What do you think about the decision-making process in general? What works well? What doesn’t? What could be done differently/better?

Analysis

A qualitative analysis was undertaken in accordance with constant comparison techniques derived from grounded theory and ethnography.10 Typed observation recordings and interview transcripts were scrutinised to identify common themes that were organised into a coding frame. As the analysis proceeded and new themes or variants on themes emerged, the coding frame was refined in a continuous iterative process.11 To ensure validity, all cases were accounted for, with apparent outliers being used to further develop and clarify the coding frame.11 Selected sections of interview transcripts and observation notes were analysed by a second member of the research team (J.B.) and the similarity of the themes that emerged from the two independent analyses checked to improve reliability.12 Observation data and interview data were initially coded separately, resulting in two separate coding frames. Themes that were relevant to both were then considered together, with the interview data being used to confirm, challenge, or clarify the observation findings.

Results

An overall description of the meetings is first presented, and key aspects of this process are then considered in more detail, accompanied by illustrative case examples and quotations.

Overall description of the MDT meetings

Meetings lasted up to 90 minutes and took place in a dedicated meeting room with members seated around a conference table. The team included approximately 25 regular members, with several visiting observers present. The room was equipped with facilities to project radiological and pathological information. Meetings were organised by an MDT co-ordinator and chaired by a consultant gynaecological oncologist (J.M.). The co-ordinator circulated the list of women to be discussed before the meeting to all members.

The chair opened the meeting briefly and moved quickly to the first patient on the list. Each patient was presented, usually by the senior clinical fellow, who drew on the patient’s notes to provide a summary of clinical presentation, current treatment plan, history of disease and outcomes, diagnosis already reached, and where appropriate, the particular reason for the patient’s inclusion at the meeting. Less commonly, the chair or another consultant presented the patient, and in one or two cases, a nurse initiated the presentation, before passing it to the relevant consultant. A pathologist then presented slides for that particular patient, pointing out relevant details, noting their interpretation, and highlighting anything that remained unclear to them. Sometimes this was followed by a radiologist presenting relevant information in a similar way. The consultant oncologists often asked questions or made comments during such presentations. A discussion regarding the next step for the patient then ensued, which generally involved the relevant pathologist and/or radiologist, the surgical consultants, the senior clinical fellow, and the medical oncologists. The nurses sometimes contributed information at this point, most commonly if they were asked a question. It was very rare for a registrar to participate in the discussions. Once all discussion had ended, the chair swiftly moved the meeting on to the next patient. The meeting concluded with a ‘round the table’ process in which each team member was asked for any other business. The nurses in particular used this time to ask about patients not on the list or to report back on patients who had received treatment. The chair and co-ordinator also used this time to discuss administrative issues. The chair then closed the meeting, usually after checking nobody had anything else to say, but sometimes because time had run out.

Three main themes emerged that were key to understanding the decision-making process that took place: (i) the unsystematic consideration of patient-related factors such as co-morbidity, psychosocial situation, and wishes compared with the privileged role of information relating to disease pathology in decision-making; (ii) the variation in team members’ role and level of participation in discussions, depending on their profession; and (iii) the differing pathways and outcomes of the discussions that occurred.

Patient-centred versus disease-centred information

Disease-based information about each patient was fundamental to the team’s discussion and decision-making. Each treatment discussion was constructed around either a pathology or a radiology presentation and report, indeed several cases were observed where the radiological information was not available, and the discussion and decision for that particular patient were therefore postponed. All interviewees confirmed this essential status of disease-based information:

If the pathology is not there, then you can’t make a decision (consultant oncologist).

By contrast, other types of information about each patient were included much less frequently in discussions. Co-morbid health status sometimes played a role in treatment decisions but was not routinely discussed. It was most likely to be included where the patient was in particularly poor health or had an unusual condition (Box 4). In other words, a patient was assumed to be well unless information was provided otherwise. Mental health was considered as frequently as physical health, in relation to how much treatment a patient was likely to be able to withstand psychologically. Relatedly, a patient’s circumstances and support needs were considered infrequently, and only where they were perceived to have an impact on the most appropriate decision or on the course of action most acceptable to the patient.

Table Box 4. .  Co-morbid health status impacting on team decision-making
Consultant radiologist gives summary of radiology findings
Surgeon: that’s not the answer I wanted
Nurse: I know she’ll want surgery
Surgeon: the thing is she’s not fit, she has an extremely high sodium level, she’s also not with it
Nurse: I spoke to her last week and she was fine
Medical oncologist starts going through possible reasons for the sodium level
Senior clinical fellow: we’ve gone through all those things
Surgeon: my feeling is I’d kill her with surgery
Senior clinical fellow: well she‘d be suitable for radiotherapy
Medical oncologist asks radiologist if he has the imaging with him. They continue to discuss, conclude that a CT chest scan is needed
Chair: so, are we going to book at CT scan today?
Medical oncologist: yes
Chair: good, a plan

When physical or mental health was referred to, this tended to be with the use of nonmedical, subjective words and phrases such as ‘frail’, ‘not that bad’, or ‘psychologically wrecked’. Team members did not always agree with each other’s descriptions, as seen in Box 4 where the nurse disagreed with the surgical oncologist’s description of the patient as ‘not with it’.

Most interviewees appeared satisfied that co-morbidity was included as needed in team decisions; however, three commented that it should be discussed more frequently and in a more accurate manner:

It probably needs more attention than it’s being given at the moment. It’s alluded to but there isn’t any formal discussion, you know people say oh they seem quite fit or whatever. It could be a lot clearer (consultant oncologist).

Part of the reason that such information may not be included more systematically was suggested by one surgical consultant:

Although you can quantify co-morbidity fairly objectively, there’s nothing quite like seeing them for yourself.

This was supported by a number of cases that were observed, where team members were uncertain about the appropriateness of a particular treatment for a patient, and the decision was postponed until the relevant physician had seen her.

Information about the patient’s views or choices regarding possible treatments was also not included in discussions as a matter of course. Such information was included when at least one of the following applied: the patient had expressed an unusually strong opinion – usually contrary to the team’s preferred treatment plan – the best treatment option was unclear or the case involved exceptional factors such as the patient being very young (two examples are presented in Box 5).

Table Box 5. .  Patient views impacting on treatment decisions
Patient A: patient has a very strong opinion
Chair: I don’t think I should do more surgery in this case, but the patient and her husband are very determined to continue treatment, so I backed off
Medical oncologist: chemo isn’t an option because of the bowel obstruction
Chair asks consultant radiologist to undertake further tests
Chair: So, taking the personalities of the patient and her husband into account we will pursue, but it is totally unrealistic
Patient B: best treatment unclear
Radiology presentation has revealed patient still has pelvic mass following chemotherapy
  Chair: OK, so we’ll give it a go. I’ll talk to her today about surgery
  Nurse: this patient is very frail, she’s very thin, doesn’t eat
  Chair: who’s overseeing her chemo?
  Medical oncologist: me
  Chair: do you have concerns about her frailty?
Medical oncologist hesitates. Chair reads through patient’s notes
 Nurse: her mobility is poor as well, she can‘t go up and down stairs
 Chair: So we are going to lose her anyway?
 Nurse: I’m not very optimistic about surgery personally
 Medical oncologist: I do have some concerns about her
 Chair to nurse: what’s her frame of mind? Is she a leave me alone I want to die kind of person?
 Nurse: she doesn’t say a lot
Decision is made for chair and medical oncologist to hold joint consultation with patient to discuss options

The observed lack of systematic discussion of patient’s views appeared at odds with a consensus among the interviewees that this is an extremely important factor in decision-making:

We don’t make decisions, ultimately it is down to the patient. What we give patients is advice, they are then free to take it or walk away (surgical oncologist).

However, this disparity is explained when the point at which the patient’s wishes should be taken into account is considered. Several of the interviewees felt that a patient’s views should not be sought until after the team had discussed possible options:

What patients need is clarity of options and a decision of progress, you’ve got to be able to rule out what’s not feasible or at least have good reasons, so a patient understands why it’s not being recommended, and that’s what the team does (surgical oncologist).

By contrast, other interviewees argued that a patient’s wishes should ideally be taken into account at the point of decision-making within the MDT. However, it was acknowledged that there were difficulties to achieving this:

Some patients I know in detail, and I can say this patient definitely does not want any more treatment. But sometimes patients are discussed and I haven’t had that conversation with them (nurse).

Some interviewees were aware that despite the ideal of always incorporating patient choice, the reality was that patient’s views were much more likely to be taken into account where decisions were less clear cut:

There are going to be team decisions made where this is our absolute recommendation and there’s no argument about it, but there are going to be some circumstances where you will talk to the patient and see what they think (medical oncologist).

Variation in participation by different professions

As noted in the description of a typical meeting above, team discussions and decisions were dominated by the consultant oncologists and fellow. The consultant pathologists and radiologists also played a central role, although this tended to be limited to information provision. The dominance of senior medical personnel explains the observation that disease-centred information was privileged in discussions, as the contributions that came from nursing staff were much more likely to concern patient-related factors such as patient’s views, co-morbidity, personal circumstances, and support needs. The nurses generally only participated when asked specific questions and also their contributions were sometimes given less weight, as illustrated in Box 4, where the nurse’s comment about the patient wanting surgery is not responded to.

However, there were examples of nurses taking a more central role, for example introducing a patient for discussion, successfully challenging what others have said, and contributing significantly to decisions. The discussion regarding patient B, in Box 5, illustrates this, as the nurse here successfully challenges a decision for more surgery in favour of further consultation. Such examples indicate that the nurses did feel able to make a contribution when they felt they should, an observation that was confirmed by the nurses who were interviewed:

I think everybody is very approachable. You’re not made to feel that you can’t speak and say what you want, which I think is important, because no matter how small, you know it can be something that’s really vital to that patient’s care (nurse).

Indeed many interviewees commented on the involvement of nurses being crucial to the team working well:

The specialist nurses are the people that know the patient best, so it is very important that they can say no, that’s not right (consultant oncologist).

Pathways to decision-making

It emerged from the observation data that discussion regarding each patient tended to take one of three paths, which are illustrated in Box 6. For many of the women, the next step was clear cut; discussion was brief and ended with a decision that was either explicitly stated or implied by a team member taking responsibility for what would happen next. Where it was not so clear what the best treatment option was for a patient, lengthier discussion ensued. In some cases, such discussion ended in agreement from all involved, and the chair or another consultant would conclude with a statement confirming what was to happen. However, where such discussions involved disagreement or questions that were difficult to answer, the meeting often moved on without a clear decision being stated and without the questions or differing view points being resolved. The observation that final decisions were not always clear and universally agreed was confirmed by three interviewees:

Table Box 6. .  Examples of differential pathways and outcomes of discussions
Discussion quick and decision clear
Patient introduced, pathologist reports on findings
 Surgeon: so we need to remove the rest of the diseased area
 Medical oncologist: yes
 Chair: super
 Surgeon: OK will do
Discussion long, ends with agreement and clear decision
Surgeon introduces an ‘enormous 76 year old lady’, gives history of disease and symptoms, followed by a pathologist presenting her report
 Surgeon: it looks like it’s endometrial, but we can’t be sure. My feeling is I can’t deal with it without removing her vagina, and that’s not an option
 Medical oncologist: she would require a really high toxicity of chemo if we went down that road
 Surgeon: what about radiotherapy?
 Medical oncologist: that would only be palliative. Maybe we should get in touch with the palliative team, and wait and see if the patient becomes well enough?
 Chair: surely chemo should be an option?
 Surgeon: I agree
 Chair: you’ve said she’s obese, how is she otherwise
 Surgeon: um, she has a dicky ticker
 Medical oncologist interrupting: OK let’s go for chemo. We can write to the patient to offer that
 Chair: OK, so that’s the plan passes details to nurse, you’re the glue
 Nurse: I’ll make sure she’s contacted
Discussion long, no clear decision and unresolved questions
Radiologist presents patient, concludes that lots of disease present
 Long discussion follows about problems of trying chemotherapy
  Chair: OK. Are there any other health factors that are relevant here?
  Medical oncologist 1: it’s important if we can give a clear plan saying this is palliative, ‘cause that will help her carer
  Surgeon: we still don’t have a diagnosis
  Chair: so what are we going to do? Pause would you do radiotherapy?
  Medical oncologist 2: with the disease she has you would be brave to do that as she is going to die soon
  Surgeon: it’s most likely to be a malignant endometrial carcinoma
  Chair: okey dokey, interesting case
Moves discussion on to next patient

I think we could be much more rigorous about making sure we’ve all agreed on a decision, because very often we’ve come to a decision and actually there’s four or five people talking around a room, and they may all have different takes on what we’ve decided on (consultant oncologist).

Despite the fact that the discussion moved on without an explicit decision being made a number of times in each team meeting, members were only observed to interrupt and clarify what had been decided on a few occasions. It is likely that time constraints at least partially explained why this did not happen more often, as the team typically discussed upwards of 20 women and meetings regularly seemed pushed to finish on time. The role of time in inhibiting discussion was confirmed by one interviewee:

There are some times when you feel hesitant to say, you know we’re running late, you feel there’s something important to say and you know others are pushing to move things forward therefore you hesitate to say something (consultant oncologist).

Discussion

Understanding how MDTs reach treatment decisions is critical to developing and implementing interventions to improve their function and ensure high-quality decisions are made. This study found three key features characterised the MDT’s discussions and decision-making – a differential emphasis on different types of information, with disease-centred information taking precedence over patient-centred factors, variation in the extent and type of participation by the different professionals involved, and discussions not always ending with a clear decision due to case complexity and/or disagreement among team members.

Although interviewees recognised how important patient-centred information is in decision-making, such information was not included routinely in the process. Part of the reason for this disparity appeared to be difficulties in deciding how and when to include it. The participation of nurses in the MDT provided one way in which patient-related factors could be incorporated into discussions, but for them to contribute this information more systematically, they would need opportunities to speak to each patient before the meeting. On the other hand, some participants felt that information regarding patients’ wishes and health status was best ascertained during consultation with a clinician following the team’s discussion. This would avoid exacerbating the problem of time constraints within the meetings and the difficulties of nurses gathering information on women added to the list last minute. However, it may lead to more decisions being reversed than they would be if patient-related factors were considered earlier on in the decision-making process.3 In fact, it is likely that patient-centred information is best considered at multiple points along the treatment journey, as specific issues may affect treatment decisions at different stages,13 and patients’ preferences and co-morbidity may well change over time.14,15 The key issue is to ensure it is taken into account for all women, not just those who are unusual in some way.

For patient-centred information to be considered more systematically, nurses would need to take a more central role in the discussion of every patient. The observed difference in participation between nurses and doctors and its possible detrimental impact on interdisciplinary team working has been reported previously and reflects the wider power differentials that operate.16 However, nurses are in a unique position to ascertain patient preferences – regarding treatment options but also regarding the extent to which they want to be involved in decision-making17– and to identify patients’ support needs in dealing with the physical and psychosocial aspects of their disease and its treatment in the context of their lives. Their ability to communicate such issues to the rest of the team,18 is a vital resource that needs to be fully integrated into the decision-making process, to ensure optimal decisions are made and that patients receive the continuing support that they need alongside their clinical treatment. Given the power imbalances that exist, one way to ensure nurses’ knowledge and views are always taken into account would be to follow a checklist for each patient that included the areas that nurses are more likely to contribute to, such as patient-centred factors.

A final way to improve the process of treatment decision-making would be to ensure a decision is definitely made for each patient and recorded during the meeting. For example each decision and the person to action it could be projected somewhere immediately visible to all team members such as a computer screen. In cases where further information is needed, or the patient needs to be consulted, this interim decision could still be recorded and updated as necessary later. This would avoid the current situation where particularly complex cases or disagreement among team members were sometimes left unresolved and would ensure all decisions were acknowledged by the whole team. Good team working skills, adequate infrastructure, clear policies regarding treatment of cancers and knowledge of the current evidence base would help ensure all discussions can be concluded in this way.

One potential weakness of this study is that only one MDT was observed, which may mean that the results are not applicable to other teams in other institutions. Further research is therefore needed to test the generalisability of these findings. A second potential weakness was the possibility that the presence of the observer affected the decision-making process. Given the team’s focus on getting the job done within the limited time available and the fact that it was quite usual for several observers to attend each meeting, it is likely that this effect was minimal. The study may have been improved by obtaining full videotape recordings of the meetings that could subsequently have been subject to dual analyses by a clinical and a qualitative researcher. However, such an approach can also seem intrusive to participants, thereby increasing the risk that being observed will affect behaviour.

Optimal methods for treatment decision-making in MDTs are currently not established. This study has found that teams need to ensure patient preferences and co-morbidity are consistently considered for all patients and that the decision-making process results in final outcomes that are clear and satisfactory to all members. Novel interventions in MDTs to explore issues such as maximising the role and contribution of all members, improving team working skills, establishing when and how to include patient preference and co-morbidity, and the best ways to record decisions could all help achieve these goals.

Disclosure of interest

None declared.

Contribution to authorship

J.K. conducted the data collection and analysis, contributed to the interpretation of the results, and wrote the paper. J.M. contributed to the study design and interpretation of the results and commented on the paper. J.D. contributed to the study’s conception and design and commented on the paper. J.B. conceived and designed the study and contributed to data collection, analysis, interpretation, and paper writing.

Details of ethics approval

The study was approved by the Local Research Ethics Committee (05/Q2006/39).

Funding

The study was funded as part of an MRC Clinician Scientist Award (J.M.B.).

Acknowledgements

We are grateful to the members of the MDT for allowing us to observe meetings and for taking part in interviews. This study was sponsored by the University of Bristol.

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