lung cancer multidisciplinary team meetings: a survey of participants at a national conference

ORIGINAL ARTICLE ara_2154 146..151

Lung cancer multidisciplinary team meetings: A survey ofparticipants at a national conferenceS Bydder,1,2 A Hasani,3 C Broderick4 and J Semmens5

Departments of 1Radiation Oncology, 3Medical Oncology, Sir Charles Gairdner Hospital, 2School of Population Health, University of Western Australia,4WA Cancer and Palliative Care Network, 5Centre for Population Health Research, Curtin Health Innovation Research Institute, Curtin University of

Technology, Perth, Australia

S Bydder FRANZCR, MBA; A Hasani FRACP;

C Broderick RN; J Semmens PhD

CorrespondenceProf Sean Bydder, Department of Radiation

Oncology, Sir Charles Gairdner Hospital, Perth,

Australia.

Email: [email protected]

Conflict of interest: None.

Submitted 20 July 2009; accepted 3 November

2009.

doi:10.1111/j.1754-9485.2010.02154.x

Summary

Multidisciplinary meetings (MDMs) are a useful aid for the development ofcomprehensive treatment plans for cancer patients. However, little is knownabout the requirements for effective MDM function. Attendees at a nationallung cancer conference who participated at least weekly in lung cancer MDMswere surveyed. The survey addressed the attendees’ perceptions regardingthe aims of MDMs, and for their own institutional MDMs, the importance andneed for improvement for each of: (i) the attendance of nine disciplinegroups; and (ii) 15 aspects related to MDM function derived from the lite-rature. The survey also asked participants if MDMs met their needs. Therewas a general agreement on the aims of the meetings. There was also anagreement on the importance of various groups’ attendance and each ofthe examined aspects of MDMs. However, many respondents reported theirmeetings required moderate or substantial improvements in one or moreareas. More than 20% of the respondents indicated improvement wasrequired for the attendance of three discipline groups (palliative care physi-cians, pathologists and cardiothoracic surgeons) and 10 of the 15 examinedaspects (more than half in the case of computerised databases). Only 9% ofthe respondents reported that none of the features surveyed needed eithermoderate or substantial improvement. MDMs met the needs of 79% of therespondents. We found general agreement on the aims of the meetings, theimportance of various groups’ attendance at MDMs and each of the examinedaspects of MDMs. However, moderate or substantial improvements werethought to be required by many respondents. The performance of individualinstitutions’ MDMs and the resources they have available to achieve their aimsshould be assessed and periodically reviewed. The survey applied here mayprovide a framework for MDM members to do this.

Key words: medical education; multidisciplinary care; quality assurance.

Introduction

There is a growing consensus that multidisciplinarymeetings (MDMs) are a useful aid to the development ofcomprehensive treatment plans for cancer patients.1,2

A number of guidelines and resources are now avail-able (e.g. through the Cancer Learning Website www.cancerlearning.gov.au). Despite such guidelines,4–7 thereis no consensus on issues such as the resources

required, who should attend, how decisions should bemade and recorded and what model of meeting is best.Furthermore, it is not clear what factors are critical toensure that MDMs work well. This is an important issue– a recent survey found one-third of MDM participantsfelt the discussion environment was suboptimal.8

The use of MDMs may be particularly important forpatients with thoracic malignancies.9,10 There is circum-stantial evidence for better survival in some groups of

Journal of Medical Imaging and Radiation Oncology 54 (2010) 146–151

© 2010 The AuthorsJournal compilation © 2010 The Royal Australian and New Zealand College of Radiologists146

lung cancer patients if their case is discussed in anMDM.11,12 The aim of the present study was to examinethe operation of lung cancer MDMs across Australia. Weundertook a survey of participants attending a nationallung cancer meeting to assess the factors affecting MDMfunction in detail.

Methods

A survey was designed to identify potentially importantdeterminants of lung cancer MDM function based onpublished checklists and the results of literature reviews.A number of checklists have been developed, based onnational forums, cancer services standards and expertopinion, suggesting requirements for MDMs.3–7 Commonthemes include leadership, structure, time, venue, envi-ronment, operational policies, team function, recordingtreatment planning decisions and data collection. Iden-tified barriers and challenges to MDMs have also beendocumented and belong to two broad categories –system barriers (such as inadequate resources) andbehavioural and environmental barriers (such as resis-tance and poor communication).5 The survey questionswere developed to addressed a combination of theseissues.

The questions, with response options in bold, are sum-marised below. The format of the Web-based question-naire presented the questions in a more user-friendlyformat.

1 What is your position at the lung cancerMDMs? Respiratory physician, cardiotho-racic surgeon, medical oncologist, radia-tion oncologist, palliative care physician,nuclear physician, radiologist, nursecoordinator, other

2 For each of: review of diagnosis, staging,formulation of a treatment plan, follow-up ofpatient outcomes, an educational opportunity:Rate the following according to how stronglyyou agree they are the main aims of MDMs:strongly disagree, disagree, neitheragree nor disagree, agree, stronglyagree.

3a For each of: attendance of respiratory phy-sicians, attendance of surgeons, attendanceof radiation oncologists, attendance ofmedical oncologists, attendance of nuclearphysicians, attendance of radiologists,attendance of pathologists, attendance ofpalliative care physicians, attendance oflung cancer nurse coordinators. How impor-tant do you believe each of the following isto lung cancer MDMs in terms of producinggood outcomes from the meeting? Noimportance, little importance, moderateimportance, very important

3b For each of: having a computerised databaseof cases; having overhead projection ofcases; having a designated meeting coordi-nator (other than a nurse coordinator), venuesize and suitability; having enough time toadequately discuss patients; having a recordof attendees; having a patient list prior toeach meeting, documentation of discussionrecommendation, ensuring the discussionrecommendations are available for review byattendees after the meeting, documentationof alternative opinions (‘dissenting voices’);having a letter sent to the GP documentingthe meeting outcome; having a defined chair-person, the ability of the chairperson to drawdifferent disciplines into discussion, theability of a chair to arrive at decisions, abilityto access patient notes at the meeting. Howimportant do you believe each of the follow-ing is to lung cancer MDMs in terms of pro-ducing good outcomes from the meeting? Noimportance, little importance, moderateimportance, very important

4a and b For each of those features listed in 3a and 3b:For the lung cancer MDMs you attend, pleaserate how much you feel they need to beimproved in each of the following areas togive best possible patient outcomes? Noimprovement, a little improvement,moderate improvement, substantialimprovement

5 How strongly do you agree that the lungcancer MDM you currently attend meets youroverall needs? Strongly disagree, dis-agree, neither agree nor disagree, agree,strongly agree

An invitation to the survey was emailed in November2008 to Australian- and New Zealand-based attendees ofthe 2nd Australian Lung Cancer Conference (ALCC) heldin August 2008.13 The survey was done electronicallyusing a commercial service.14 Responses were included ifreceived from clinicians who currently attended a lungMDM.

For the purposes of analysis, ‘agreement’ and ‘strongagreement’ were grouped together. Eighty per cent ormore was termed strong consensus, with 50% or moretermed consensus. A substantial proportion was used todescribe proportions greater than 20%. Fisher’s exacttest was used to compare proportions for meetings thatmet needs against those that did not.

Results

Initially, 160 potentially eligible attendees with validemail addresses were recorded. Seventeen invitees indi-cated they were not eligible. There were 77 (54%) of 143

Multidisciplinary team meetings

© 2010 The AuthorsJournal compilation © 2010 The Royal Australian and New Zealand College of Radiologists 147

remaining potentially eligible responses. There were 23(30%) respondents from NSW, 19 from Qld (25%), 17(22%) from Vic, 7 (9%) from WA, 3 from SA (4%), 2from Tas (3%), 1 from ACT (1%) and 5 (7%) from NZ.

Table 1 shows respondents’ roles. There were rela-tively large numbers of respiratory physicians, medicaloncologists, radiation oncologists and nurse coordina-tors, with 14 or more in each of these groups.

Table 2 shows the levels of agreement with each of theaims of the MDMs. There was strong consensus for eachof these, except for follow-up of outcomes.

Table 3 shows both ratings of the importance andneed for improvement for the attendance of nine MDMdiscipline groups. These were rated moderate(ly) or veryimportant in 84–100% (i.e. a strong consensus for all).The need for moderate to substantial improvement inattendance ranged from 7 to 45%. It was over 20% forthree groups – palliative care, pathologists and cardio-thoracic surgeons.

Table 4 shows both rating of the importance and needfor improvement for 15 aspects of MDMs. These wererated moderate(ly) or very important in 73–100% (with astrong consensus for all but attendance record). The needfor moderate/substantial improvement ranged from 16 to55%. This was over 20% for 10 aspects (and over half ofresponses regarding a computerised database).

Overall, 70 (91%) of respondents reported the needfor moderate or substantial improvement for either: atleast one of attendance for the nine discipline groups orfor one of the 15 listed aspects of MDMs.

The responses regarding whether lung cancer MDMscurrently met overall needs were ‘strongly disagree’1 (1%), ‘disagree’ 9 (12%), ‘neither agree nor dis-agree’ 6 (8%), ‘agree’ 41 (53%) and ‘strongly agree’20 (26%). Tables 5 and 6 compare the need formoderate/substantial improvement for 61 (79%) ofthe respondents whose MDM met their needs, with 16(21%) whose MDM did not meet their needs. Meetingsthat did not meet needs were statistically more likelyto need moderate/substantial improvement in theattendance of three discipline groups (cardiothoracicsurgeons, palliative care, nursing coordinators) and12 of the aspects (but not time, venue, overheadprojection).

Discussion

We found a general agreement on the aims of meet-ings, the importance of various groups’ attendanceat MDMs and each of the examined aspects of MDMs.However, moderate or substantial improvements werethought to be required by many respondents. This wasgreater than 20% for the attendance of three disciplinegroups (palliative care physicians, pathologists and car-diothoracic surgeons), and 10 of the 15 examinedaspects (e.g. more than 50% in the case of computer-ised databases). Although 79% of the respondentsfelt their needs were met, only seven (9%) reported noaspect of their MDMs did not require moderate/substantial improvement. This suggests that someMDMs are not functioning satisfactorily, but also thateven those working adequately may be improved byattention to the features examined.

The responses to the survey questions are obviouslysubjective. Also, the participants may not be able toaccurately judge the importance of different factors onMDM performance. However, the MDM participants are inthe best position to judge their own requirements for asatisfactory MDM. In addition, all respondents wouldhave significant experience in multidisciplinary care. It isalso possible that participants may have been biased

Table 1. Survey respondents’ roles

Role Frequency (%)

Respiratory physician 20 (26%)

Cardiothoracic surgeon 6 (8%)

Radiation oncologist 14 (18%)

Medical oncologist 15 (20%)

Palliative care physicians 0 (0%)

Nuclear physician 1 (1%)

Radiologist 1 (1%)

Nurse coordinator 14 (18%)

Pathologist 2 (3%)

Other 4 (5%)

Total 77 (100%)

Table 2. Extent of respondents’ agreement with the perceived main aims of

multidisciplinary meetings

Main aim Agree/strongly agree

Review of diagnosis 66 (86%)

Staging 73 (95%)

Treatment plan formulation 76 (99%)

Follow-up of outcomes 57 (74%)

Educational opportunity 69 (90%)

Table 3. Respondents’ perceptions of their importance and need for

improvement in attendance of different disciplines

Moderate/very

important

Moderate/substantial

improvement required

Respiratory physician 77 (100%) 7 (9%)

Cardiothoracic surgeon 77 (100%) 21 (27%)

Radiation oncologist 77 (100%) 11 (14%)

Medical oncologist 77 (100%) 5 (7%)

Nuclear medicine physician 65 (84%) 15 (19%)

Radiologist 75 (97%) 9 (12%)

Pathologist 68 (88%) 23 (30%)

Palliative care 69 (90%) 35 (45%)

Nurse coordinator 75 (97%) 11 (14%)

S Bydder et al.


towards either under- or over-emphasising problems,but the range in proportions requiring moderate or sig-nificant improvement for different aspects arguesagainst this. The aim of the survey was in part to identifywhere there is a consensus of opinion and also to identify

areas of most concern, in particular to identify prioritiesfor further efforts at improvement or investigation.

The response rate was not as high as would have beenideal, but is typical of surveys. In fact, it may be betterthan the figures suggest as it not possible to identify how

Table 4. Respondents’ perceptions of their importance and need for improvement in examined aspects

of multidisciplinary meetings (MDMs)

Moderate/very important Moderate/substantial

improvement required

Computerised database 74 (96%) 42 (55%)

Overhead projection 62 (81%) 28 (36%)

Meeting coordinator 72 (94%) 27 (35%)

Venue 74 (96%) 14 (18%)

Time 77 (100%) 18 (23%)

Attendance record 56 (73%) 21 (27%)

Patient list prior 64 (83%) 14 (18%)

Plans documented 77 (100%) 30 (39%)

Availability of plans 75 (97%) 32 (42%)

Dissent documented 68 (88%) 37 (48%)

Letter to general practitioner 74 (96%) 35 (45%)

Defined chair 75 (97%) 12 (16%)

Chair ‘draws in’ disciplines 75 (97%) 15 (19%)

Decision by chair 73 (95%) 12 (16%)

Notes available at MDM 71 (92%) 21 (27%)

Table 5. Attendance of different disciplines requiring moderate/substantial improvement by whether the

participants’ needs were met

Do not meet needs (n = 16) Meets needs (n = 61) P value

Respiratory physician 3 (19%) 4 (7%) 0.152

Cardiothoracic surgeon 11 (69%) 10 (16%) <0.001

Radiation oncologist 3 (19%) 8 (13%) 0.689

Medical oncologist 2 (13%) 3 (5%) 0.276

Nuclear medicine physician 3 (19%) 12 (20%) 1

Radiologist 4 (25%) 5 (8%) 0.083

Pathologist 8 (50%) 15 (25%) 0.067

Palliative care 13 (82%) 22 (36%) 0.02

Nurse coordinator 6 (38%) 5 (8%) 0.008

Table 6. Examined aspects of multidisciplinary meetings requiring moderate/substantial improvement by

whether participants’ needs were met

Do not meet needs (n = 16) Meets needs (n = 61) P value

Computerised database 13 (82%) 29 (48%) 0.023

Overhead projection 7 (44%) 20 (33%) 0.557

Meeting coordinator 10 (63%) 17 (28%) 0.017

Venue 3 (19%) 11 (18%) 1

Time 5 (32%) 13 (21%) 0.508

Attendance record 8 (50%) 13 (21%) 0.030

Patient list prior 8 (50%) 6 (10%) 0.001

Plans documented 10 (63%) 20 (33%) 0.044

Availability of plans 12 (75%) 20 (33%) 0.004

Dissent documented 14 (88%) 23 (38%) 0.001



many of non-responders were actually ineligible (e.g. byvirtue of not attending regular lung cancer MDMs). TheALCC was designed to be multidisciplinary, and in factregistrations were limited by occupational role to ensurediversity13 – the survey responses reflected this.However, although a broad cross-section, the respon-dents may not be representative of all those who attendlung cancer MDMs in Australia. In particular, as partici-pants were attendees at a lung cancer conference, theymight be more expected to have better functioningMDMs than might be typical. Furthermore, the study onlyincluded those who already attend MDMs. These factorsare likely to lead to underestimation of the problemsidentified.

At present, there are little published data on MDMfunction. Sidhom and Poulsen surveyed MDM partici-pants at four hospitals in Queensland, Australia; lungcancer MDM participants represented 22% of the respon-dents.8 The survey focused on medicolegal aspects ofMDMs, but also assessed perceptions of the discussionenvironment. Overall, 33% of doctors felt that the MDMdiscussion environment was suboptimal. Interestingly,radiation oncologists were significantly more likely tohold that view. In this paper, we asked different ques-tions but had a similar result in that 21% of the partici-pants felt their needs were not met. We also looked inmore detail at various features and what specificallymight affect the value of MDM discussions.

There is growing enthusiasm for lung cancer MDMs, inpart because of evidence suggesting survival advantagesfor subgroups of non-small-cell lung cancer.11,12 MDMsrequire significant greater and different effort, resourcesand skills than might have been traditionally applied. Forexample, although difficulties in carrying out MDMs havebeen identified, there has been little discussion of theunique skills required (e.g. drawing participants intodiscussion). This has been assessed here. We have iden-tified specific areas that need improvement. One of themost pressing includes the attendance of some groups.This may well reflect the workload of participants. Thereis some concern that medical administrators do not rec-ognise, and therefore do not adequately resource, thetime required for roles not involved in direct patientcontact – this would include time preparing for andparticipating at MDMs.15

Recently, in Australia, there has been greater atten-tion to the medicolegal issues related to MDMs.8,16,17 Anumber of the questions in this survey are relevant,including the documentation of dissenting opinions,attendance records and ensuring patients’ notes areavailable. In Sidhom and Poulsen’s survey, even though85% of doctors have disagreed with the final MDM deci-sion in an important way at some time, 71% did notformally dissent on those occasions.8 These issuesappear to be recognised by most respondents to thecurrent survey; for example, almost half of the respon-dents identified a need for moderate/substantial

improvement in the documentation of dissenting opin-ions. It is important that MDMs perform as well as theycan. Improved documentation and transparency inapproach should assist in limiting liability for individualhealth professionals and health services.16

Conclusion

We found that almost all MDM participants can identifyan area for significant improvement in their own meet-ings. Ongoing quality improvement may be particularlyhelpful in ensuring the effectiveness of MDMs. It may beuseful to formally assess perceived performance of indi-vidual institutions MDMs and the resources they have.This could then be periodically reviewed. The surveyused in this study may provide a framework for this.Furthermore, we hope the survey results will assist andstimulate MDM members to gain the resources they needto improve the performance of MDMs they attend.

Acknowledgement

We thank the survey respondents for their help in thisinvestigation.

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lung cancer multidisciplinary team meetings: a survey of participants at a national conference

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