Journal of Clinical Neuroscience 17 (2010) 1130–1135

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Journal of Clinical Neuroscience

journal homepage: www.elsevier .com/ locate/ jocn

Clinical Study

Communication in and clinician satisfaction with multidisciplinary teammeetings in neuro-oncology

K.M. Field a,b,*, M.A. Rosenthal a,d, J. Dimou c, M. Fleet a,c,d, P. Gibbs a,b,d, K. Drummond c,e

a Department of Medical Oncology, Royal Melbourne Hospital, Parkville, Victoria, Australiab BioGrid Australia, 6 North, Royal Melbourne Hospital, Grattan Street, Parkville, Victoria 3050, Australiac Department of Neurosurgery, Royal Melbourne Hospital, Parkville, Victoria, Australiad Department of Medicine, University of Melbourne, Parkville, Victoria, Australiae Department of Surgery, University of Melbourne, Grattan Street, Parkville, Victoria, Australia

a r t i c l e i n f o

Article history:Received 3 December 2009Accepted 7 March 2010

Keywords:CommunicationDocumentationInstitutionalInterdisciplinary health teamManagement teamsMultidisciplinary communication

0967-5868/$ - see front matter � 2010 Elsevier Ltd. Adoi:10.1016/j.jocn.2010.03.001

* Corresponding author. Tel.: +61 3 9342 4642; faxE-mail address: Kathryn.field@mh.org.au (K.M. Fie

a b s t r a c t

Multidisciplinary Team (MDT) meetings are critical in the management of complex cancer cases. Thereare limited data regarding the effectiveness of neuro-oncology MDT meetings and the impact of docu-menting and disseminating the recommended patient management. We established a weekly neuro-oncology MDT meeting and developed a standard electronic communication process. A survey was issuedto participating clinicians to assess their level of satisfaction. The survey revealed that 100% felt the meet-ing and its documentation was very or extremely important, and 94% (n = 15) felt the meeting was effec-tive in documentation and communication of plans. There was a mixed response regarding whichpatients should be discussed: 44% (n = 7) thought all patients should be discussed and 56% (n = 9) thoughtonly those patients with complex management issues should be discussed. We have developed an effi-cient method of documenting and disseminating patient information arising from our neuro-oncologyMDT meeting. Clinician satisfaction was high.

� 2010 Elsevier Ltd. All rights reserved.

1. Introduction

Co-ordinated multidisciplinary care is a key component of opti-mal management of oncology patients.1 Emerging evidence indi-cates that a regular Multidisciplinary Team (MDT) meeting is akey enabler of high quality, consistent and co-ordinated cancercare.2–4 Indeed, governments are now recognising the importanceof multidisciplinary meetings and advocating for their broad adop-tion as a standard of care.2,3,5 MDT meetings are felt to improveefficiency of patient diagnosis and management; increase thedelivery of evidence-based treatment; improve clinical trialrecruitment and also help to address supportive care needs of a pa-tient.2–4,6

There is little systematic information regarding the effective-ness of neuro-oncology MDT meetings despite recommendationsthat they are necessary and that all patients be discussed in anMDT meeting.2,7 Specifically, there is no information regardingmethods of communication and acceptance of the MDT processby participating clinicians. As the management of neuro-oncologypatients is truly multidisciplinary, careful co-ordination of care viaan MDT meeting and appropriate documentation and dissemina-

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: +61 3 9342 8548.ld).

tion of discussion arising from MDT meetings would seem a com-ponent of optimal patient management.

The documentation and dissemination of an MDT meetingdiscussion and outcome is an important aspect of the meeting.It provides certainty for clinicians treating the patient at a subse-quent time as to the consensus plan for patient managementarising from the meeting discussion. From a medico-legal perspec-tive, MDT meeting documentation is also important in that partic-ipating clinicians are responsible for the ultimate managementdecision that is decided upon;6,8 and thus accurate representationof the management plan is essential.

This study evaluated participating clinicians’ perception of arecently implemented neuro-oncology MDT meeting; our methodof documenting and disseminating information; and comparedclinicians’ perceptions about an MDT meeting and its goals andobjectives with the regional Integrated Cancer Services (ICS)requirements for effective multidisciplinary team meetings.

2. Materials and methods

In January 2008, a weekly neuro-oncology MDT meeting wascommenced at Royal Melbourne Hospital (RMH) in Victoria, Aus-tralia. This hospital is the largest provider of care for patients withcentral nervous system (CNS) tumours in Victoria, with an annual

Table 1Clinician survey responses

Discipline n (%)Neurosurgeon 5 (31%)Radiologist 4 (25%)Medical Oncologist 2 (12.5%)Care Co-ordinator 2 (12.5%)Pathologist 1 (6%)Radiation Oncologist 1 (6%)Psychiatrist 1 (6%)

Importance of neuro-oncology MDT meeting?Not important 0Somewhat important 0Very important 4 (25%)Extremely important 12 (75)

Importance of documentation at an MDT meeting?Not important 0Somewhat important 0Very important 10 (62.5%)Extremely important 6 (37.5%)

Which patients should be discussed?Complex management only 9 (56%)All patients 7 (44%)Unsure 0

Should a patient have to consent for MDT discussion?No 15 (94%)Yes 1 (6%)Unsure 0

Should the GP receive a copy of the MDT documentation?No 0Yes 16 (100%)

K.M. Field et al. / Journal of Clinical Neuroscience 17 (2010) 1130–1135 1131

caseload of about 200 patients. The MDT meeting occurs on a Mon-day morning for 30 minutes prior to the multidisciplinary neuro-oncology clinic. On average 15–20 clinicians and allied health pro-fessionals attend the meeting, including neurosurgeons, medicaland radiation oncologists, radiologists, pathologists, care co-ordi-nators and a neuro-psychiatrist. Five patients are discussed eachweek, selected by the neurosurgical team or requested by anotherclinician if issues have arisen. This represents approximately 50%of new patients under the service.

2.1. Development of MDT documentation

An effective and inexpensive method of documenting discus-sion and management plan arising from the MDT meeting wasdeveloped by clinicians from BioGrid Australia, a data linkage facil-ity that co-ordinates the hospital’s neuro-oncology database, theAustralian Comprehensive Cancer Outcomes Research Database(ACCORD).

The aim of this documentation was to record clinician atten-dance; the histopathological type of tumour; discussion of man-agement issues; further management plan (surgery, radiotherapy,chemotherapy, palliative care) and the aim of the treatment (cura-tive, long term [>12 months] control; short term [<12 months]control; and palliative only). In addition the form was developedto identify any referrals needed to other clinicians or allied healthservices. An electronic version was developed with the aim of rapiddissemination by email; electronic recording for clinician accessvia the hospital database; and ability to fax to the general practi-tioner (GP) and insert into the patient file within 24 hours.

2.2. Clinician surveys

In July 2009 after 18 months of weekly MDT meetings, a surveywas emailed to all attendees of the MDT meeting. Non-responderswere then invited to participate during the subsequent MDT meet-ing. This survey asked participants to rate the level of importanceof the MDT and documentation of MDT proceedings; to selectthe three main reasons why (in their opinion) an MDT meetingshould occur; to indicate whether they felt that the RMH MDTmeeting was effective in documentation and communication; toindicate which patients should be discussed (all versus complexmanagement only); whether a patient should give consent to bediscussed; and whether GPs should receive a copy of thedocumentation.

2.3. Audit and support from regional Integrated Cancer Services (ICS)

The Western and Central Melbourne Integrated Cancer Services(WCMICS) are funded by the Victorian Department of Human Ser-vices to implement the Victorian Government’s Cancer ServicesFramework.9 The aim of this service is to improve care of cancerpatients and a significant component of this is strengthening mul-tidisciplinary care. A particular goal is that all cancer services willhold regular high-quality multidisciplinary meetings providing theopportunity to plan treatment and care for all cancer patients.7

The CNS tumour group component of ICS began a project in2007 to enhance co-ordination of patient care, in which neuro-oncology MDT meetings were a key focus. Aims included improv-ing documentation of meeting outcomes and communication ofoutcomes to the patient’s GP. An audit of the neuro-oncologyMDT meeting was undertaken including: facilities; frequency ofmeetings and number of patients discussed; attendees; whetherpatients provide consent; whether supportive care issues are con-sidered; documentation; and communication to the GP and the pa-tient themselves. The ICS provided a computer for weekly useduring the MDT meeting to facilitate documentation.

3. Results

3.1. MDT documentation

A one page MDT meeting documentation form (Fig. 1) wasdeveloped and is completed during the meeting by the MedicalOncology Fellow. At the conclusion of the meeting the form isemailed to all participants of the MDT meeting as well as any rel-evant other clinicians. The neuro-oncology care co-ordinator isresponsible for faxing this form to the patient’s GP and printing acopy to insert in the patient file. As of July 2009, the hospital com-puter system allows a password protected view of the MDT meet-ing form on the hospital intranet for all clinicians involved in thecare of that patient.

3.2. Clinician surveys

Sixteen meeting participants were surveyed with a 100% re-sponse rate (Table 1). The clinicians consisted of: neurosurgeons(n = 5), radiologists (n = 4), medical oncologists (n = 2), care co-ordinators (n = 2), a pathologist, a radiation oncologist and a psy-chiatrist. All respondents felt that having an MDT meeting was ex-tremely (75%, n = 12) or very (25%, n = 4) important; while thedocumentation of the MDT meeting was felt to be extremelyimportant (37%, n = 6), or very important (63%, n = 10). The major-ity, 94% (n = 15) thought that the MDT meeting was effective indocumentation and communication. The remaining clinician re-mained unsure.

Of the three options selected by each clinician the three mostfrequent choices for the main reasons that MDT meetings shouldoccur were: communication between team members (100%),establishing appropriate patient referrals (69%), and accuratelyrecording the management plan (63%). Other reasons included:identifying potential patients for clinical trials (31%), communicat-ing with the patient’s GP (19%), addressing the patient’s psychoso-cial needs (13%) and for medico-legal reasons (6%) (Fig. 2).

Fig. 1. Neuro-oncology Multidisciplinary Team (MDT) documentation form. It is filled in electronically by the Medical Oncology Fellow at the time of the neuro-oncologyMDT meeting.

1132 K.M. Field et al. / Journal of Clinical Neuroscience 17 (2010) 1130–1135

There was a mixed response regarding which patients should bediscussed: 44% (n = 7) thought all patients should be discussed and

56% (n = 9) thought only those patients with complex managementissues should be discussed. The majority of respondents, 94%

0 2 4 6 8 10 12 14 16Number of responses

Medico-legal reasons

Address psychosocial needs

Communication with GP

Identify pts for clinical trials

Accurately record management plan

Facilitate referrals

Communication between specialists

Fig. 2. Clinician perception of main reasons for a Multidisciplinary Team (MDT) meeting.

K.M. Field et al. / Journal of Clinical Neuroscience 17 (2010) 1130–1135 1133

(n = 15) felt that patient consent was NOT required prior to discus-sion at a MDT meeting. All respondents thought that the GP shouldreceive a copy of the documentation.

3.3. ICS audit

An audit was undertaken that assessed the neuro-oncologyMDT meeting. This audit compared results with a previous auditof the neuro-oncology MDT meeting as well as comparing it withall other tumour stream MDT meetings held within the WCMICShospitals. Overall the review was positive. In particular, improve-ments were seen in the development of a written team protocol;documentation of the treatment plan and communication withthe GP; and improvement in the content and style ofdocumentation.

When compared with other, non-CNS MDT meetings in the re-gion, the neuro-oncology MDT meeting discusses a similar propor-tion of new patients (approximately 50%); has a more experiencedclinical fellow rather than junior medical staff recording the MDTmeeting discussion; and always records the outcome electronicallycompared with 25% of other MDT meetings doing the same. A

Table 2Audit of the neuro-oncology MDT meeting to Integrated Cancer Services objectives

Objective Ne

A regular multidisciplinary meeting is held to discuss treatment planning Ye

All core disciplines regularly attend multidisciplinary meetings and provideinput to the treatment plan where relevant

Ye

Meeting protocols are developed outlining responsibilities of teammembers, meeting terms of reference, communication processes, andcriteria for patient referral to the meeting

Ye

All relevant patient medical information is available at themultidisciplinary meeting

Ye

Supportive care issues are considered for all patients when developing thetreatment plan

Ye

The treatment plan is documented and placed in the medical record so thatit accessible to all team members

Ye(El

Outcomes of the multidisciplinary meeting are communicated to thepatient’s GP in a timely manner

YeFa

Patients are informed of the proposed treatment plan and given theopportunity to provide input.

Ye(ve

All new patients are discussed 50Patients should give their consent to be discussed 20

faxed copy of the MDT meeting discussion, sent to the GP for all pa-tients in our MDT meeting, is only sent in 5% of other MDT meet-ings; the majority of communication to the GP from other MDTmeetings is in the form of subsequent clinic letters. Patient consentis not formally sought for the neuro-oncology MDT meetingwhereas for other MDT meetings verbal consent is obtained in25% of cases and written consent in 20% of cases. At the time ofthe second audit, the neuro-oncology MDT meeting was shownto meet the majority of the WCMICS objectives (Table 2).

4. Discussion

To our knowledge this is the first time that participating clini-cian perspectives with respect to a neuro-oncology MDT meetinghave been examined and reported. We have also outlined howwe developed and implemented our MDT meeting, which mayprove useful for other sites where this is under consideration.The demonstration here that an MDT meeting in neuro-oncologyis widely supported by participants provides further impetus tothe growing consensus that MDT meetings should be considereda standard of care.1–3,5,7

uro-oncology MDT meeting Other tumour stream MDT meeting

s (weekly) Yes(65% weekly)(20% fortnightly)(15% monthly)

s (80%) Yes (80%)

s (100%) Yes (55%)

s (100%) Yes (80%)

s (80%) Yes 70%

s (100%) Yes (95%)ectronically 100%) Electronically 25%s (100%) Sometimes 45%xed within 24 hours Usually 45%

Always 10% (85% via subsequent clinic letter)s (100%) Yes (50%)rbally only) (verbally only)

% 55%% (verbal) 45%

25% (verbal)20% (written)

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Neuro-oncology is undeniably a multidisciplinary tumourstream, and globally there exist recommendations for neuro-oncol-ogy MDT meetings. Formal Canadian recommendations for thetreatment of glioblastoma multiforme state that all new patientsshould be presented and discussed at an MDT.10 In 2006 in the Uni-ted Kingdom (UK), the National Institute for Health and ClinicalExcellence (NICE) guideline manual for improving outcomes forpatients with CNS tumours declared neuro-oncology MDT meet-ings to be ‘pivotal’ in the management of patients with CNS tu-mours, that attendance should be essential, and that all patientsshould be reviewed in an MDT meeting.5

It is striking, therefore, that so little exists in the published lit-erature outside general policy recommendations regarding theimportance of neuro-oncology MDT meetings. The UK NICE in2006 acknowledged that there was limited evidence other than ex-pert opinion and consensus-based guidelines for the optimal con-figuration of neuro-oncology MDT meetings.5 The AustralianGovernment’s Cancer Australia website, in light of the increasedrecognition of the importance and significance of MDT meetings,includes a ‘resource and reference list’ for multidisciplinary teams,care co-ordination and managed clinical networks.11 Only one12 isrelated to neuro-oncology. While there is some evidence that pae-diatric patients with CNS tumours are discussed effectively in MDTmeetings13 the same is difficult to find for adult neuro-oncologypatients. One study compared adult patients with high-grade gli-oma from two hospitals (one which held an MDT meeting andone which did not) and found improvements in the MDT meetinggroup in clinical quality outcomes including post-resection imag-ing; adjuvant chemotherapy (GBM); and earlier radiotherapy startdate (GBM). There was a non-significant trend to improved mediansurvival.12 Improvements in staging accuracy and survival associ-ated with MDT meetings from other tumour streams have beenobservered.14,15

Attending clinicians felt that the neuro-oncology MDT meetingand its documentation were extremely or very important, and 94%thought that the MDT meeting was effective in communication anddocumentation of plans. This represents clear clinician support forthe neuro-oncology MDT meeting. This support mirrors at leastone study of a colorectal cancer MDT meeting where 97% ofrespondents considered that the MDT meeting improved the over-all quality of patient care and also improved staff training and mor-ale.16 However, despite general support in available literature forthe role of MDT meetings in co-ordinated oncology care, thereare critics of the movement towards this being a necessary qualitystandard. While MDT meetings are purported to be beneficial interms of improving treatment decisions, co-ordinating cancer careand improving team morale, objective evidence of these goalsbeing reached is sparse, which has resulted in caution from someexperts in suggesting that MDT meetings are universally effec-tive.17 A UK review concluded that despite widespread introduc-tion of MDT meetings, that there was little evidence for anydirect effect on the quality of patient care.17,18 A systemic reviewof MDT meetings in the management of lung cancer pooled 16studies and found minimal association between MDT meetingsand improved lung cancer survival, although the authors con-cluded that it was difficult to actually demonstrate this outcome.19

This contrasts with other reports, including an analysis of the effectof a breast cancer MDT meeting in the United States which foundthat for the 75 patients reviewed, treatment recommendationswere changed in 43%.20

Capturing the discussion and management plan is important forfuture hospital clinicians who may not attend the meeting but bedirectly involved in the patient’s management; and also for the pa-tient’s GP. However, there is minimal published research availableregarding effective methods of documenting and disseminating pa-tient information arising from MDT meetings. The method of doc-

umentation developed for this project meets the requirements ofcapturing clinician attendance; documenting the complexities ofthe individual case, the formal management plan and highlightingreferrals needed; and is easily able to be emailed or faxed to thetreating clinicians, meeting participants and the GP as well asbeing filed in the history. We were not able to find other publishedliterature describing alternative methods of documenting MDTmeeting discussion.

There were some limitations to this study. We have not exam-ined the effect of MDT meeting discussion on patient outcomes,nor have we examined the frequency at which the MDT meetingrecommended plan is actually followed for patients. This is impor-tant; a large study regarding the implementation of decisionsmade by a MDT meeting found that 15% of decisions made at theMDT meeting were not implemented, mainly for reasons of co-morbidity or patient choice.21 To date we have not been formallyrecording whether patient management actually changed as a re-sult of the meeting, as this is one aim of MDT meetings, we nowplan to add this question to the MDT forms for each patient. Theissue of medico-legal responsibility has also not been explored inour clinician survey, although it is noted that only one clinicianlisted this as a reason why MDT meetings should occur. Literatureindicates that doctors may not be fully aware of the legal implica-tions of their participation in MDT meetings.6,8,22 Additional limi-tations to the meeting format itself include the short half hourtime slot allocated to the meeting; issues when a key member ofthe MDT is absent (for example a pathologist or a radiation oncol-ogist); and potential gaps in delivery of the MDT documentation toall relevant clinicians – although this has been addressed by havinga care co-ordinator to fax the form to relevant health professionalsas well as being electronically recorded and thus available on thehospital database.

A further limitation of our study and the meeting format is thelack of input to the survey by other allied health staff such as socialworkers and palliative care staff, who are clearly important withrespect to the global and holistic management of neuro-oncologypatients. Having a neuro-psychiatrist attend the meetings, andincluding discussion of referrals to palliative care, psychiatry or so-cial work, is one way to partly address this gap. Ideally the MDTwould include a neurologist with specific interest in neuro-oncol-ogy or epilepsy, and a palliative care physician. This would serveto enrich the quality of patient care, including management of sei-zures and other neurological sequelae of disease, as well as optimalsymptom control. We would recommend that, where possible,these members of the medical and allied health community are in-cluded in neuro-oncology MDT meetings and recognise this as ashortcoming of our own. Referrals are identified and made whereappropriate to these relevant teams.

There remain areas for improvement and areas where discrep-ancies exist between clinician perceptions and governmentobjectives. Due to time constraints, those with complex multidisci-plinary management issues are prioritized for the meeting. Themajority of respondents considered that only patients with com-plex management issues should be discussed. This is consistentwith other MDT meetings in the regional ICS area but contrastswith the objective of government policy recommending that everynew cancer patient is discussed in a multidisciplinary setting.1,5

Notably, a study of a urological cancer MDT meeting concludedthat routine discussion of all cancer cases at MDT meetings madeno difference to the clinical management in the majority (98%) ofcases, and where management changes did occur, they were inpre-identified complex cases which had been flagged by theclinicians.23 The authors suggested that a selective rather than a‘blanket’ approach to who is discussed at an MDT meeting is appro-priate. Anecdotally members of the MDT acknowledge that in idealcircumstances all patients presenting with malignant glioma

K.M. Field et al. / Journal of Clinical Neuroscience 17 (2010) 1130–1135 1135

should be discussed; however as the hospital is a tertiary referralcentre this remains impractical. The possibility of a ‘brief discus-sion’ format where approval of management and referral forstraightforward cases has been suggested and could be developedin the near future.

Overall, our report highlights the benefits and improvementsover time of an Australian neuro-oncology MDT meeting, as wellas the implementation of an effective method of documentation.This adds to limited medical literature supporting neuro-oncologyMDT meetings and adds to a growing body of evidence that MDTmeetings are beneficial for both clinicians and patients alike. Ongo-ing collaboration between neuro-oncology centres both withinAustralia and worldwide and prospective evaluation of the effectof MDT meetings on clinical endpoints such as recruitment to clin-ical trials; chemotherapy administration rates and survival out-comes, will be beneficial in further understanding the role of theMDT meeting in neuro-oncology.

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