group decisions in oncology: doctors’ perceptions of the legal responsibilities arising from...

Group decisions in oncology: Doctors’ perceptionsof the legal responsibilities arising frommultidisciplinary meetingsMA Sidhom1 and MG Poulsen2

1Liverpool Hospital Cancer Therapy Centre, Sydney, New South Wales and 2Southern Zone Radiation Oncology, Mater Centre,

Brisbane, Queensland, Australia

SUMMARY

There is growing consensus that multidisciplinary meetings (MDMs) are the optimal means of arriving at a compre-

hensive treatment plan for cancer patients. However, if a patient was grieved by a decision made by an MDM and

wished to recover damages, the courts would find all involved consultants responsible for decisions related to their

area of expertise. The aim of this study was to assess (i) whether doctors participating in oncology MDMs are aware

that they are individually accountable for the MDM decisions and (ii) whether MDMs are conducted in a way that

reflects this individual responsibility. A 35-question survey was developed and peer reviewed. Doctors attending

MDMs in four Australian tertiary-care hospitals were invited to respond. One hundred and thirty-six responses

(91% response rate) were received from 18 MDMs across 4 hospitals. Only 48% of doctors believe they are individ-

ually liable for decisions made by the MDM. This awareness was greater for an MDM where the patient attends,

than in those that were ‘discussion only’ (58 vs 37%; P = 0.036). Seventy-three per cent stated they would like fur-

ther education about their legal responsibilities in MDMs. Thirty-three per cent of doctors feel that the MDM dis-

cussion environment is suboptimal and radiation oncologists are significantly more likely to hold this view. Even

though 85% of doctors have disagreed with the final MDM decision in an important way at some time, 71% did

not formally dissent on those occasions. Doctors should be made aware of the legal implications of their participa-

tion in MDMs. A greater awareness of these responsibilities and improved team dynamics should optimize patient

outcomes while limiting exposure of participants to legal liability.

Key words: group decisions; medicolegal liability; multidisciplinary meeting.

INTRODUCTION

Managing patients through multidisciplinary meetings (MDMs)

has become the standard of care in many areas of oncology

owing to the complex, highly specialized and multimodal nature

of modern cancer care. These team meetings bring together

surgical, radiation and medical oncologists, pathologists, radi-

ologists, physicians and allied health practitioners to ensure the

most effective and efficient provision of health care.

However, these group decision-making forums pose

a unique medicolegal question. In medical law, responsibility

is held to be an individual matter, and responsibility in the pro-

vision of health care is generally traced back and attributed to

individuals. To many clinicians, it may not immediately be

apparent who is responsible in the context of group decisions

made by MDMs. However, in law, all doctors present at an

MDM would be deemed to owe a duty of care to the patients

discussed.1 This duty of care arises as the MDM is a formal

referral process from a treating physician to the MDM doctors.

When a patient is formally referred to a doctor, the latter

assumes a duty of care for that patient. Therefore, the doctors

MA Sidhom B.Ec.LL.B, MB BS; MG Poulsen FRANZCR.

Correspondence: Dr Mark A. Sidhom, Liverpool Hospital Cancer Therapy Centre, Campbell Street, Liverpool, NSW 2170, Australia.

Email: [email protected]

Conflict of interest: None.

Submitted 7 July 2007; accepted 19 July 2007.

doi: 10.1111/j.1440-1673.2007.01916.x

Radiation OncologyOriginal Article Journal of Medical Imaging and Radiation Oncology (2008) 52, 287–292

ª 2008 The AuthorsJournal compilation ª 2008 The Royal Australian and New Zealand College of Radiologists

participating in an MDM owe a duty of care to all of the patients

that are discussed, even if they do not ultimately become

involved in their medical care. In this way, all doctors in an

MDM are individually responsible and potentially liable for all

decisions of the MDM within their area of expertise. A breach of

this duty would render all participating doctors potentially

exposed to direct litigation by a patient. This principle of duty

of care arising from multidisciplinary team meetings has

recently been affirmed by the New SouthWales Court of Appeal

in the case of South Eastern Sydney Area Health Service &

Anor. v. King.2

RESEARCH QUESTIONS

This study was designed to address two main questions in the

context of multidisciplinary oncology clinics:

1 Are the doctors who participate in oncology MDMs aware

that their participation attracts personal responsibility and

potential liability for the decisions made by the entire group?

2 Are MDMs conducted in a way that reflects this individual

responsibility?

METHODS

Questionnaire items

To address these questions, a 35-item survey was developed.

The questionnaire was peer reviewed by surgical and oncology

colleagues. The first part of the survey questionnaire addressed

the characteristics of the respondents and the characteristics of

the MDM they attended. The second section was a series of

questions addressing the decision-making process of the MDM.

The third section addressed the doctors’ perceptions about the

extent of their individual responsibility in that group setting.

Sample and settings

The survey questionnaire was distributed to doctors attending

oncology MDMs at four Australian metropolitan hospitals. The

hospitals were large, publicly funded, tertiary-care teaching

hospitals. Eligible MDMs were (i) regular scheduled clinics

and (ii) attended by at least three medical subspecialties and

those that (iii) involved a formal discussion about the patients

during the scheduled time. Only doctors were requested to

complete the survey questionnaire as it was not within the

scope of this study to investigate the legal responsibility of allied

health practitioners within the medical team.

Procedure

From May to July 2005, the survey questionnaire was distribu-

ted to all eligible MDMs at the four hospitals. An overview of the

survey was given at the beginning of the MDM before distribu-

tion of the survey questionnaire, and this was confirmed by an

attached cover letter. The majority of doctors filled in the survey

questionnaire by the end of the MDM and returned it. Self-

addressed envelopes were left with those who were unable to

complete it on the day of distribution. Three follow-up calls were

made to this latter group to have the survey questionnaires

completed and returned. The questionnaires were designed

so that the respondents remained anonymous. The attitudes

of the three principal professional groups in the oncology

MDM (surgeons, radiation oncologists and medical oncologists)

were compared by chi-squared analyses. Significance levels

were set at 0.05.

RESULTS

Respondents

Eighteen oncology MDMs across the four hospitals were eligi-

ble. Of the 149 survey questionnaires that were distributed in

these clinics, 136 were completed and returned. This repre-

sented a 91% response rate. The respondent characteristics

are shown in Table 1 and the characteristics of the MDM in

Table 2. The majority of the respondents came from breast,

head and neck and lung cancer clinics. Surgeons and radiation

and medical oncologists were the main subspecialties. Over

two-thirds of respondents were staff specialists or visiting med-

ical officers and the other one-third comprised registrars and

residents.

Perceptions about the legal ramifications of

group decision-making in multidisciplinary

clinics

Perceptions regarding individual liability

The core question of the survey asked doctors who they

believed would be responsible and potentially liable if a decision

made by the MDM was subsequently determined to be negli-

gent. Less than half (48%) of the respondents correctly believed

that all specialists are accountable for the decisions of the MDM

they attend, irrespective of their participation in the discussion

or their involvement in the management of the patient. How-

ever, the remaining 52% of respondents incorrectly believed

Table 1. Respondent characteristics

Respondents (n = 136), n (%)

Qualifications

Consultant 94 (69)

Registrar 39 (29)

Resident 3 (2)

Subspecialty

Surgeon 37 (27)

Medical oncology 25 (18)

Radiation oncology 42 (32)

Radiologist 3 (2)

Pathologist 6 (3)

Haematologist 15 (11)

Physician 8 (7)

Sex

Male 85 (63)

Female 51 (37)

288 MA SIDHOM AND MG POULSEN


that a doctor would only be responsible if they became involved

in the management of the patient or at least actively discussed

the patient during the MDM.

Perceptions by specialty

There was no significant difference in awareness of individual

responsibility between the three main specialty groups, with

approximately the same proportions of the surgeons (54%),

radiation oncologists (51%) and medical oncologists (44%)

being unaware of their potential liability. These differences were

not statistically different.

Perceptions by clinic subtype: patient attends versus

discussion only

The doctors’ perceptions of their individual responsibility were

also assessed based on the type of MDM they were involved in,

that is, whether it was a ‘discussion-only’ clinic versus one

where the patient attended. Most participating doctors in the

former subtype of MDM never meet the patient. It is important

to note that the courts would see no difference between these

two settings. Each forum would equally give rise to a duty of

care between the doctors in the MDM and the patient.

There was a statistically significant difference in perceptions

of liability between the two types of MDM. In those MDMs where

the patient attends, only 42% of doctors involved in that setting

were unaware of their potential liability. However, in discussion-

only MDMs, 63% of respondents believed that their participa-

tion in that MDM did not attract individual responsibility and

potential liability (P = 0.04, chi-squared analysis).

Protective environment

The majority of doctors (76%) perceived that the process of

assessing and managing patients through MDMs decreased

the chances of being sued successfully. No doctor felt that this

forum increased the chances of being sued successfully, and

24% believed it made no difference. When asked if managing

patients through an MDM had now become the standard of care

for patients with that cancer subtype, 77% stated that this was

the case, whereas another 12% believed it was only indicated in

complex cases. The remaining 11% believed that the MDMwas

an optional decision-making forum.

Benefits and limitations of MDMs

Doctors were asked to rank the benefits gained from multidis-

ciplinary discussions. Over half (61%) believed that the greatest

benefit is that the best possible management plan is generated.

The other main benefits were coordinated service delivery

(18%), minimization of error (11%) and the MDM providing

a good learning environment for the participants (10%). Doctors

perceived the two main limitations to the effectiveness of the

MDM being the failure to adequately work up patients before

their discussion (69%) and inadequate time and resources in

the MDM (45%).

Desire for education about legal responsibilities

The majority of doctors (73%) stated that they would like further

information and education about their legal responsibilities that

arise from their participation in MDMs. Of the 27% who stated

they did not want further information, approximately half incor-

rectly understood the legal ramifications of MDM decisions.

Extent to which administration of MDMs

reflects individual responsibility

The second main issue the survey aimed to address was

whether MDM are conducted in a way that reflects the fact that

each of the participating doctors are individually responsible

and potentially liable for the decisions made in the MDM.

Discussion environment

In the first place, if each participating doctor is personally

accountable for the decisions of the MDM, then it is to be

expected that the discussion environment during the meeting

would be open and allow for the expression of all opinions.

Every opinion should be heard and duly regarded. Similarly,

no individual or specialty should dominate the decision-

making at the expense of others if all doctors present will

ultimately be responsible for that decision.3 Sixty-seven per

cent of doctors surveyed did believe that the discussion envi-

ronment was open and free in that way. However, 33% of

doctors perceived that the discussion environment was sub-

optimal, with muted discussion, if the dominant opinion was

well known.

Twenty-two per cent of surgeons and 21% of medical oncol-

ogists felt the discussion environment was suboptimal. How-

ever, a significantly higher proportion of radiation oncologists

(49%) felt this was the case (P = 0.003).

Table 2. MDM characteristics

Respondents (n = 136), n (%)

MDM

Breast 31 (23)

Lung 30 (22)

Head and neck 32 (24)

Gynaecology 17 (12)

Lymphoma 18 (13)

Skin 4 (3)

Other 4 (3)

Frequency

Weekly 132 (97)

Monthly 4 (3)

Type

Patient attends 80 (59)

Discussion only 56 (41)

MDM, multidisciplinary meeting.

LEGAL DUTIES IN MULTIDISCIPLINARY CARE 289


Disagreement and dissent

Participants were asked how frequently they disagreed with the

final decision of the MDM in an important or fundamental way,

for example the decision about the primary treatment method.

Fifteen per cent of doctors stated that this never occurred, and

the other 85% stated that it occurred to some extent (58%

rarely, 25% occasionally and 2% often). However, of those

doctors who have disagreed in the past, only 29% said that in

those occasions did they formally dissent. The other 71% stated

that they have never formally dissented in an MDM, even when

they had an important or fundamental disagreement.

Consensus

The survey investigated to what extent there is a drive to come

to a consensus in the MDM group setting. Doctors were asked

whether they believe the group of doctors in the MDM should

come to a consensus on only one treatment option if a disease

could be reasonably treated by more than one method. Fifty-

one per cent of doctors stated that the MDM should strive to

reach a consensus unless the MDM is evenly divided on two

options and 9% stated that the MDM should always seek to find

a consensus position. The remaining 40% felt that if even one

doctor in the MDM differed in their opinion, then all options

should be put to the patient for them to decide between them.

Information about treatment options

Doctors were asked how often patients would be better

informed about their treatment options had they seen each

subspecialty individually rather than in the setting of the MDM.

Only 4% of doctors said that this never occurred, whereas the

remaining 96% of respondents stated that on some occasions,

patients were not as well informed about their treatment options

following the MDM process alone. Fifty-three per cent said that

the failure to inform patients occurred, but rarely, whereas 43%

believed it occurred in more than 10% of patients.

DISCUSSION

The Baume report on the provision of radiation oncology ser-

vices in Australia has acknowledged that MDM discussion and

management in many subtypes of cancer has become the stand-

ard of care.4 This movement towards multidisciplinary care is

similarly promoted in the UK5 and USA.6 There are results

showing that patients who are managed through such group

meetings have better survival outcomes,7 as well as shorter

waiting times,8 and more robust treatment-decision-making pro-

cesses9 than those managed without formal multidisciplinary

discussions. The opinions of the doctors surveyed in this study

reflects this movement towards group meetings in oncology,

with the vast majority stating that such management forums

were now the standard of care, especially in complex cases.

There is the perception that the MDM is not only beneficial for

patients, but also a medicolegally protective decision-making

environment for the doctors.10

However, this study shows that many doctors participating

in MDMs do so without fully appreciating the legal responsibility

and potential liability generated by their involvement. This

danger is greatest in discussion-only clinics, where a high pro-

portion of doctors are unaware of their legal responsibility,

presumably because of their more distant association with the

patients. It is this particular form of MDM that may surprise

doctors most should a patient wish to litigate against an alleged

negligent act or omission.

This study also shows that, to some extent, MDM do not

function in a way that reflects this individual liability. As dis-

cussed, a considerable proportion of respondents do not feel

that the discussion environment is optimal. If all doctors are

ultimately responsible for the final decision, then there should

be a free and open discussion environment where all opinions

are actively sought, regarded and respected,11 and this process

should lead to more accurate decisions.12 Another finding of the

survey is that there is reluctance to formally dissent, even when

there is a significant disagreement with the final MDM decision.

Perhaps there is a desire to be non-confrontational, and there is

the mistaken belief that those doctors in the MDM whose opin-

ions have prevailed will be the sole ones to be held accountable.

This is also partly borne out by the fact that many doctors feel

the need to obtain a consensus position. Perhaps if all doctors

realized that they were individually responsible, then there

would be less drive for consensus and more emphasis on pro-

viding patients with a number of options as determined reason-

able by the doctors. This would likely alleviate the perceived

failure to adequately inform some of the patients about their

treatment options. A refusal by the majority to put forth an indi-

vidual doctor’s opinion to the patient would prompt a dissenting

opinion by the latter, thereby freeing them from responsibility for

the decision. Of course, this would not be likely to happen and

the result would be that the patient would be given all options,

which is the ideal scenario.13 A single treatment option should

be offered to the patient only when there is a unanimous agree-

ment among the MDM specialists.

The discrepancy between doctors’ perceptions and actual

medicolegal responsibility has perhaps occurred because of the

way in which MDMs have developed over time. Initially, many of

the meetings might have been formed as a relatively informal

gathering of specialists to discuss complex cases and take

opinions from colleagues, in which there was no intention to

impart responsibility to others. Although this might be the basis

on which MDMs began, the necessarily formal way that MDM

are now conducted generates a duty of care between the doc-

tors present in the MDM and the patient. This is reflected in the

recent introduction of two newMedicare Benefit Schedule items

in Australia. Items 871 and 872 provide rebates to medical

practitioners who lead or participate in multidisciplinary treatment



planning meetings for cancer patients. The initiative confirms

both the importance of a multidisciplinary team approach to

assessing and managing cancer patients and the formal nature

of these deliberations, which warrants remuneration. It is im-

portant to note, however, that billing is not a prerequisite to

establishing a duty of care, and a practitioner who does not

bill for their involvement in a MDM may still be deemed to

owe a duty of care to the patients that are discussed if indicated

by the circumstances.

For those doctors who are deemed to be employees of the

hospital, the hospital as an employer would likely bear any

financial loss from a successful action.14 This indemnity will also

frequently extend to independent contractors working within the

hospital.15 However, even if a doctor does not ultimately have to

incur the expense of being found negligent, there is always an

option for the employer (the hospital) to take other remedial or

disciplinary action against the doctor for the negligent failure as

determined by the courts. Aside from any financial expense is

the personal, professional and psychological cost of being

involved in a court action and being found to have acted or

omitted deficiently in the care of a patient.

Recommendations

It would be a relatively simple task to correct the current defi-

ciencies in the decision-making process of MDMs, as detected

by this study.

Education

Educating doctors about their medicolegal responsibilities

would be the mainstay of any solution. If doctors realized that

all participants in the MDM were potentially liable, then this

should promote mutual respect and an open discussion envir-

onment, resulting in a reduced risk of error and an improved

decision-making process.16 Furthermore, if any doctor felt that

their opinion had not been appropriately considered, and if they

disagreed with the final decision, they would formally dissent

and have this recorded to remove responsibility for that deci-

sion. It is encouraging that the majority of doctors answering the

survey questionnaire stated that they would like further infor-

mation and education about the legal responsibilities arising in

the MDM. The professional medical colleges would be well

placed to disseminate information about the medicolegal

responsibilities arising from participation in MDMs.

Adequate resources and recording

Hospital administrators should ensure that MDMs are adequately

resourced in terms of personnel, meeting room, equipment and

limit on patient numbers. If doctors feel that the resources are

inadequate for the volume of patients being seen, then this

should prompt a review. In addition to this, there should be

detailed recording of the discussion, especially if any of the

doctors state their disagreement with the decision. Oncology

information computerized software would cope well with docu-

menting this type of information so that it could be collected in

an efficient manner and stored in the patient’s record.

More patient involvement in decision-making

Patients want to have more information about their treatment

options and the effect of their treatment.17 The flow of information

from the various subspecialties to the patient is often suboptimal

in the MDM setting, and it may become desirable for patients to

enter the meeting at the time of their case discussion. This would

have to be carefully balanced with the potential drawbacks of

having a patient present in the MDM, such as restricting the free

flow of information, limited understanding of medical terminology

and efficiency issues such as reduced throughput of patients.

Each relevant specialty should see the patient after the discus-

sion when there is more than one potential treatment option.

Individual recording of decision

To reflect individual responsibility, each doctor should docu-

ment their agreement, disagreement or abstention from each

decision made in the MDM. This process should be a constant

reminder that each doctor is individually responsible for the

combined team decision.

CONCLUSION

The discrepancy between doctors’ perceptions and their actual

responsibility in MDMs does not mean that there is an impend-

ing medicolegal crisis in multidisciplinary clinics. MDMs function

well and are providing a good service to patients. Doctors feel

that it is a protective medicolegal environment, and that is most

probably the case. However, MDMs are becoming increasingly

used, seeing higher volumes of patients each year. The devel-

oped society is also becoming increasingly litigious, as evi-

denced by soaring medicolegal claims over the last two

decades. Given these factors, it is inevitable that actions will

be brought in the future against decisions made in MDMs.

Improving the process as suggested above will protect doctors

from any such litigation, but ultimately should also provide a

better outcome for patients, making them more informed and

promoting the best possible decision.18

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