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Too Many Cooks Spoil the Broth?

Too many cooks, spoil the broth?

Working in healthcare is an interesting experience. If I had a dollar for every time I've heard the term "Multi-disciplinary Team" in a medical setting, I would be a millionaire by now. We've heard about how having a team of experts in various areas of patient care is great for the patient - and many would agree. But medical care is as advanced as it is complex. In this much celebrated approach of patient care, could there be occasions where we face a situation of "too many cooks spoiling the broth"? 

Having Multi-disciplinary teams (MDT) isn't a new concept. Many top medical centres have adopted this practice as part of their treatment decision making and care for their patients - NCCS included. As part of the ongoing desire to improve cancer care delivery to patients, doctors from NCCS propose new approaches for cancer centres worldwide to transform these challenges into improvements in cancer care and into research opportunities. Some of these are based on their own experience, while others are aspirational goals for the future. A commentary was submitted by Associate Professor Gopal Iyer, Senior Consultant Surgical Oncologist and Dr Melvin Chua, Senior Consultant Radiation Oncologist and was published in the journal, Nature Reviews Clinical Oncology in December 2018.


Senior Consultant Surginal Oncologist Associate Professor Gopal Iyer (left) and Senior Consultant Radiation Oncologist Dr Melvin Chua (right)

Many cooks, many flavours

For those unfamiliar, Multi-disciplinary Team (MDT) meetings involve a group of specialised healthcare professionals from various disciplines, who come together to review challenging cases and make decisions on treatment recommendations for individual patients. For example, cancer MDT meetings involve cancer treatment experts such as radiation oncologists, surgical oncologists, radiologists and pathologists. Not only that, but other medical or patient care experts may be present as well, such as medical social workers, geneticists, palliative care experts or psychologists.

So what then is the purpose of MDT meetings? The primary aim is to implement evidence-based practices into the management of patients. It also offers patients a 'one-stop shop' to obtain multiple expert opinions and audits on the process of making these decisions. In NCCS, this system has been in place for the past 20 years, since it opened its doors in 1999. For Assoc Prof Gopal and Dr Chua, there is a constant need to improve the systems and processes surrounding these meetings, given the ever-changing landscape of managing cancers. This allows better care and faster implementation of research findings and evidence-based practices into routine practice.

Why MDTs work is the fact that it provides a more well-rounded and holistic approach that is matched by the relevant medical expertise in securing better outcomes for patients, especially in patients with advanced-stage disease or complex cases. At these meetings is also a platform to facilitate outcome-centric research through the systematic collection of data from patients across different tumour types, such that over time, a very dense and accurate data repository will be developed to inform on management of future patients. 


Multi-disciplinary Team (MDT) meetings involve a group of specialised healthcare professionals from various disciplines coming together to review challenging cases and make decisions on treatment recommendations.

Many cooks, too many opinions?

Several observations and proposed improvements were raised by Assoc Prof Gopal and Dr Chua. Take one of the first steps for a MDT meeting - listing cases for discussion. Most cases that are brought up for discussion is at the discretion of MDT members. If so, what cases are then selected by the panel? These range from 'all cases', to 'advanced stage only', or 'teaching/complicated cases only'. This focus varies between centres and also even within the same centre, depending on various factors such as case volume, for example. Citing from the paper by Dr Gopal and Dr Chua: "When the focus is only on selected patients, the decision of which ones to list for discussion is often left to the 'dominant' MDT members.." [Gopalakrishna Iyer, Melvin Chua; Nature Reviews Clinical Oncology; 2018] This idea of 'dominant' MDT members is in context of hierarchy, where medical centres in Asian cultures may tend to exhibit a tendency to defer to those in senior positions.

By taking on this selective approach, MDT teams are susceptible to delivering sub-optimal quality of care - especially for centres that may have a cost to the patient for listing and discussing their cases for MDT. 


Dr Melvin and A/Prof Gopal discuss a particularly complex case

Don't reinvent the wheel, improve it!

One of the proposed improvements are the auditing of cases listed for discussion and the tracking of case listings from the point of consultation. By tracking post-meeting decisions, including compliance to eventual treatment, this leads to better data which can be used to assess the benefits of these approaches to MDT and whether compliance to MDTs recommendations leads to better patient outcomes. 

While MDTs are great, the implementation of MDT decision is variable and demonstrates variable practical challenges associated with the implementation science*. Standardising how MDTs are done is perhaps, difficult. But with constant and strict internal audits, there is the existing hope that this "good practice" moves more into the realm of stricter science. It's not so much how it's done, but the principles behind MDTs. MDTs can be a great tool to address the a patient's care from multiple angles and cover all bases. However, MDTs done without the proper ethos or core values may not serve the interests of the patient as much as it should. With these core principles audited, measured and intact, this certainly helps comprehensive cancer centres improve current treatment standards. But above and beyond that, this is especially crucial for those centres hoping to reorganise their services under MDT lines. 

On the topic of continuous improvement, where does NCCS stand with MDTs? Dr Gopal and Dr Chua are currently assessing and working out the processes on an institution-wide basis. Like with any process of improvement, before the first step is taken, an honest recognition of any deficiencies. The next step is to recognise and understand that change isn't always straightforward, especially in Asian contexts like in Singapore. There are always ways to engage, study and improve. Dr Gopal and Dr Chua plan to start first at a group/team level. 

*Definition of "Implementation Science" - the scientific study of methods to promote the uptake of research findings and other evidence based practices into routine practice, and hence to improve the quality and effectiveness of health services. (source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4573926/)

Final word

MDTs are a good thing - the practice offers different points of view, different areas of expertise, all coming together to find the best way forward for a patient's care and treatment. But these teams need to have the right ethos and right values enforced, audited and measured. Only then can this practice be better managed and continually improved to be as effective as it can be for a patient's benefit. The eventual aim of Dr Gopal and Dr Chua is simply, "better care". Better care for patients by improving the MDT effort, which has been in place in NCCS since the very beginning.