Eur Radiol DOI 10.1007/s00330-015-3760-x
ONCOLOGY
The proliferation of multidisciplinary team meetings (MDTMs): how can radiology departments continue to support them all? Ravivarma Balasubramaniam 1 & Manil Subesinghe 1 & Jonathan T. Smith 1
Received: 10 July 2014 / Revised: 26 March 2015 / Accepted: 1 April 2015 # European Society of Radiology 2015
Abstract Objectives To quantify the changes in multidisciplinary team meeting (MDTM) workload for consultant radiologists working in a single UK tertiary referral cancer institution, assess its impact and suggest solutions to these challenges. Methods The annual number of MDTM cases was collated over a 5-year period (2009−2013). Qualitative information was obtained through questionnaire-based interviews of 47 consultant radiologists. Data analysed included number of MDTMs involved with, type of MDTM (oncological or non-oncological), time allocation for preparation and perceived deficiencies in the current MDTM. Results Thirteen thousand and forty-nine cases were discussed in MDTMs in 2009 with a continued yearly increase over the 5-year period. Fifty-five percent of MDTM attendances were at oncological MDTMs. Consultant radiologists attended a median of two MDTMs per week, each requiring 4 hours time commitment; 60 % used out-of-hours time for MDTM preparation. The most frequently cited MDTM deficiency was lack of sufficient clinical input. Conclusions The MDTM is a challenging but worthwhile demand on the modern radiologist’s time. Solutions to the increasing MDTM workload include demonstration of the benefits of MDTMs to hospital administrators to justify additional resources required, improving MDTM efficiency and ensuring this increased workload is accurately represented and remunerated in individual job plans.
* Jonathan T. Smith [email protected] 1
Department of Clinical Radiology, St. James’ University Hospital, Leeds Teaching Hospitals NHS Trust, Level 0 Bexley Wing, Beckett Street, Leeds LS9 7TF, UK
Key Points • MDTMs improve cancer outcomes and are being recommended for non-oncological conditions. • MDTM cases have more than doubled over 5 years at our institution. • Incorporating MDTM workload into current consultant radiologist job plans is difficult. • Solutions include demonstrating MDTM related benefits, improved efficiency, and accurate job planning. Keywords Tertiary care centres . Radiology . Neoplasms . Patient care team . Workload
Introduction Multidisciplinary team meetings (MDTMs), referred to as 'tumor boards' in the USA, are integral to the delivery of optimal cancer care in many Western countries. Prior to the introduction of MDTMs, cancer treatment was poorly standardised with management decisions often influenced by individual attitudes and beliefs without adequate formalised communication between surgeons, pathologists, radiologists and oncologists. Poor cancer survival rates in the UK when compared with other European countries were at least partly attributable to the wide variation in care received across the UK [1, 2]. In 1995, the Calman-Hine report [3] set out principles for the restructuring of cancer care and the framework for the delivery of uniformly high standard cancer care across the UK. Over the ensuing years, the concept of MDTMs and cancer networks were gradually introduced and established. At present, the MDTM is the forum in which all cancer patients are discussed and subsequent treatment decisions made and reviewed [4]. Studies have shown improved survival
Eur Radiol
outcomes associated with cancer care delivered through a MDTM [5–15]. The radiologist plays a crucial role in the MDTM, reviewing current and previous multi-modality imaging, including imaging from referring hospitals, and providing an overall impression of the patient’s current disease status. A gradual expansion in the numbers of cases discussed in the MDTM has been accompanied by an increase in the radiologist's workload and time commitment. In light of the paucity of literature quantifying the radiologist’s workload in MDTMs, we provide a retrospective analysis of MDTM workload and changes occurring over time in a single UK tertiary referral cancer institution radiology department. Questionnaire-based interviews of consultant radiologists at our institution provide an insight into the impact of MDTM workload on each individual and an opportunity to gauge opinion on the current challenges associated with MDTMs. We identify potential solutions to these challenges that should help sustain high quality radiological support to MDTMs.
Methods We performed a retrospective review of the overall MDTM workload in our tertiary referral cancer institution over a 5year period from 2009−2013. Information regarding the number of cases reviewed in MDTMs was acquired from the radiology information system (CRISTM; Healthcare Software Systems, Banbury, UK). This was consolidated with information from individual consultant radiologists using a qualitative structured interview-based questionnaire focusing on the amount and type of MDTM work performed. Interviews were carried out in 2013. Information on the number of MDTMs, type of MDTM (oncological or non-oncological), time allocation for preparation, perceived changes in the number of MDTMs and deficiencies in the current MDTM were obtained (Fig. 1). All questionnaire-based interviews were carried out by a senior radiology registrar. Only consultant radiologists who had worked for the trust for 5 years or more were interviewed to corroborate the data acquired from the radiology information system. Every eligible consultant radiologist was interviewed to ensure a complete consensus of opinion and participation from all sub-specialities. Each interview lasted approximately 15−20 minutes and all consultants were given the opportunity to document further opinions outside of the structured interview format. A coding framework of common themes that emerged from the interview data was constructed to allow both independent and collective analysis of the opinions as per standard qualitative research practice. Work undertaken in MDTMs at our institution is on a public hospital basis; consultant radiologists are remunerated by
the National Health Service. Their workload and remuneration is determined by a job plan which divides their workload into weekly programmed activities (PAs) or 4-hour sessions which involves DCC (Direct Clinical Care; including reporting sessions, intervention, MDTMs, on call, administration, etc.) and SPAs (Supporting Professional Activities; including research, audit, personal professional development, mandatory training, etc.). Hospital administrators review job plans annually to assess what aspects of the job plan should continue to be recognised and remunerated and how many PAs each activity should attract.
Results MDTM workload Over 13,000 cases were discussed at MDTMs in 2009 with a continued yearly increase over the 5-year period. The most dramatic change in workload occurred between 2009 and 2010 with a near doubling of cases discussed (13,049 cases vs. 25,349 cases, respectively). More recently, the number of cases discussed in an MDTM has plateaued with only a small incremental annual increase observed after 2011 (Table 1). Forty-seven consultant radiologists were interviewed in 2013 with subspecialty interests including gastrointestinal= 7, musculoskeletal=5, thoracic=4, genitourinary=4, oncology=2, nuclear medicine=3, neuroradiology=5, breast=8, vascular=5 and paediatrics=4. The consultant radiologist cohort accounted for 122 MDTM attendances per week; 55 % (67/122) of MDTM attendances were at oncological MDTMs; 66 % (31/47) of consultant radiologists were involved in at least one oncological MDTM. The median duration of an MDTM was 2 hours with each consultant radiologist attending a median of two MDTMs per week, each requiring a median preparation time of 2 hours (Table 2). Sixty percent (28/47) of consultant radiologists admitted to regularly using ‘out of hours’ time to prepare for the MDTM and 45 % (21/47) perceived an increase in MDTM workload over the 5-year period.
MDTM benefits All consultant radiologists believed that involvement in the MDTM was beneficial to them; 66 % (31/47) found surgical and histological feedback of greatest value; 34 % (16/47) believed the MDTM improved their knowledge of novel surgical techniques and eligibility criteria for clinical trials; 13 % (6/47) highlighted that the MDTM provided a valuable forum for discussing rare and interesting cases.
Eur Radiol
Fig. 1 Multidisciplinary team meeting (MDTM) workload questionnaire
MDTM deficiencies The most frequently stated deficiency in MDTMs was a lack of sufficient clinical input. Forty percent (19/47) of consultant radiologists highlighted concerns regarding the absence of the referring clinician at the MDTM causing inadequate clinical
information being relayed and a lack of clarity with regard to the clinical question. Thirty-two percent (15/47) cited a lack of clerical support in providing assistance for documentation of MDTM decisions and recording of attendance at MDTMs, 26 % (12/47) felt the purpose of non-oncological MDTMs were not always clearly defined and 15 % (7/47) felt that the venue and/or the IT resources were insufficient to conduct an
Table 1 Annual number of cases discussed in a multidisciplinary team meeting (MDTM) between 2009 and 2013 (47 radiologists) Year
No. of cases discussed in an MDTM
Change from previous year (%)
2009 2010 2011 2012 2013
13049 25349 28602 29016 29171
+94.26 +12.83 +1.45 +0.53
Table 2 Individual consultant contribution to multidisciplinary team meetings (MDTMs) during 2013 No. of MDTM MDTM preparation Duration of attendances per week time (hours) MDTM (hours) Mean Median Range
2.6 2 1-5
1.7 2 0-4
2.3 2 1-4
Eur Radiol
MDTM and adequately demonstrate the salient imaging findings.
Discussion An MDT represents “a group of people of different health care disciplines, which meet together at a given time (whether physically in one place, or by video or tele-conferencing) to discuss a given patient and who are each able to contribute independently to the diagnostic and treatment decisions about the patient” [16]. The concept of the MDTM was aimed at improving decision-making between health-care team members using a structured format and evidence-based medicine to produce higher quality and more consistent cancer outcomes across the UK. Since its inception, studies have explored the impact of MDTMs on cancer outcomes. Kesson et al. [5] in a unique study conducted in the West of Scotland region found that the introduction of multidisciplinary care in breast cancer patients resulted in an 18 % lower breast cancer mortality at 5 years and 11 % lower all-cause mortality at 5 years in comparison with the control group. Smaller studies have shown similar trends towards increased survival through MDT support of more radical and optimised treatment options in breast [6, 7], urological [8], gynaecological [9, 10], lung [11, 12] and rectal malignancies [13–15]. The improvement in survival attributable to multidisciplinary care, although difficult to directly quantify, is partly related to the specialist review of diagnostic imaging and resultant alterations in management plans. This highlights the importance of radiologists in the decision-making process [7, 8]. Multidisciplinary care is thought to be contributory to the recently announced improved overall cancer survival rates observed in the UK with at least 50 % of patients now predicted to survive 10 years or more [17]. Over the past two decades, MDTMs have evolved alongside the increasing complexity of cancer care as a consequence of more detailed diagnostic imaging strategies coupled with a greater number of therapeutic options. The MDTM provides an invaluable opportunity to engage in continuous professional development [18], a statement supported by the views obtained in our study. Close liaison with clinical colleagues allows assimilation of up-to-date knowledge of currently available and more novel therapeutic options. The provision of histopathological correlation of radiological findings provides a method to audit reporting accuracy and improve individual practice through a process of learning and reflective practice. Importantly, in addition to personal benefits, members of the MDT firmly believe that patients benefit from an improved quality of care through MDTM discussion [19]. For all the benefits gained, there are significant problems that remain unresolved and further issues that threaten the
continued provision of high quality radiology support to MDTMs. Our study demonstrates a continual increase in cases discussed in MDTMs with a near doubling of cases discussed between 2009 and 2010. The increase in MDTM workload at our institution is multi-factorial. The expanding role and integration of the MDTMs into clinical care over a short time period is a major causal factor which has been exacerbated by the centralisation of cancer care to tertiary referral cancer institutions. This mirrors the general trend in England with less than 20 % of patients managed by an MDT in 1995 in comparison with 80 % in 2004 [4]. Potential solutions to deal with the increase in MDTM workload include: 1. Demonstration of the benefits of MDTMs to hospital administrators to help justify additional resources. Improved patient outcomes, compliance with national and international guidelines and avoidance of displacement of other necessary work, e.g. teaching, audit and research, should help justify additional PAs to attend and prepare for MDTMs and/or expansion of the consultant radiologist workforce. 2. Improvement in MDTM efficiency. a. Administrative support. This is best achieved through an MDTM coordinator. Their responsibilities would include: vetting and organising of appropriate referrals to avoid premature discussion or unnecessary rediscussion of cases; circulation of MDTM lists and MDTM decision outcomes to core members of the MDT; ensuring that all clinical information, local and imported referral letters, pathology and radiology reports are available; and that records of attendance are kept. Further areas for improvements include provision of adequate IT facilities for viewing of radiological, pathological and endoscopic images, videoconferencing links to enable multi-site working and access to cancer databases/electronic patient records. b. Improved clinical input. The lack of sufficient clinical input and absence of the referring clinician was the most frequently cited MDTM deficiency in our study. Comprehensive clinical information and consistent attendance by the key members of the MDTM is paramount to making safe and clinically effective treatment decisions. Jalil et al. [20] reported that inadequate clinical history, lack of knowledge of patient’s co-morbidities and investigation results were key causes of impaired MDTM decision outcomes. Clear MDTM policies may improve this, e.g. cases are only discussed if a member of the clinical team in possession of all the relevant clinical background is present at the MDTM. MDTM attendance can be
Eur Radiol
improved if they are recognised as protected sessions in all medical specialities, as supported by The Royal College of Radiologists [18]. c. Strong leadership. A strong MDTM chairperson can facilitate constructive discussions, clarify decisions for recording and ensure the overall smooth running of the MDTM. In addition, they can lobby on behalf of the MDTM for access to additional resources required for improvements. 3. Accurate job planning. This is an invaluable tool for radiologists to help record MDTM workload related to preparation for and attendance at these meetings. Evidence from our study and elsewhere in the literature, is suggestive that the significant expansion in MDTM workload for radiologists has not been proportionally supported with resources or remuneration within existing job plans. MDTM-related work, termed 'non-countable' activity, is more difficult to quantify in comparison with modality based activities as part of job planning [21]. Moreover, there are medico-legal implications of recording MDTM outcomes, where responsibility lies with the individual rather than a group. These guidelines [22] dictate that individuals are required to document decisions on behalf of their sub-specialty interest. Time available during or after the meeting for this purpose is limited as is funded clerical support for reasons detailed earlier. Barriers to appropriate financial remuneration include defining and recognising specialist team members' individual contributions to MDTMs and derived quality metrics obtained from robust patient data to determine the subsequent impact on outcomes. In our study 60 % of consultants regularly use unfunded 'out of hours' working to prepare for the MDTM. Our radiology department invests on average 210 hours per week on preparation alone and a further 280 hours in attendance at MDT meetings. This approximates to five consultant radiologists on a full-time work commitment of ten programmed activities (PAs) solely to accommodate the requirements of MDTMs without contributing to other facets of clinical radiology or supporting professional activity. However, in the tough financial climate that the NHS currently faces, where a greater than expected number of financially autonomous NHS foundation trusts are in financial deficit, the creation of new jobs is fraught with difficulty [23]. We recommend that: a. Radiologists should be alert to the correct number of PAs of DCC that should be allocated to MDTMs in their job planning process. A daily work diary as recommended by the British Medical Association is a helpful tool for this. b. Hospital managers should be aware that allocating radiologists to MDTMs may displace other work in
their job plan and may have a detrimental impact on delivery of other services. c. The introduction of MDTMs into new/existing specialities as part of a business case should always take into account the impact on service delivery specialities such as pathology and radiology. The expansion of non-oncological MDTMs accounting for 45 % of MDTMs at our institution is also important to recognise. It is common for national and international guidelines to advise discussion of benign disease processes in MDTMs. More work is required to study the impact of the MDTMs on quality of provision of care and whether this is cost effective. The future of MDTMs remains in the balance. We face an increasingly ageing population with an estimated 45 % increase in the number of cancers by 2030 [24]. Demand upon radiology services continues to increase with a 39 % rise in the total number of imaging investigations performed over the last 10 years in the UK [25]. These will undoubtedly place significant pressure on the burgeoning workload of MDTMs. The proposal for extended working hours and 24-hour service provision [26] will significantly limit the time available for radiologists to contribute to MDTMs. There are limitations to our study. Our aim was to measure the increase in MDTM workload and assess its impact on radiologists. We achieved this through a retrospective study design and questionnaire-based interviews. The interviews were not anonymous and the working relationship between the consultant radiologist and interviewer (senior radiology registrar) may have potentially impacted upon responses given. Although most relevant to radiology departments in large UK cancer institutions, we believe that insights gained and solutions proposed are applicable to smaller departments, which may have a greater limitation on resources, and also non-UK institutions where MDTM workload may be similarly increasing. Our study is most relevant to radiologists who participate in MDTMs but also to individuals involved in departmental management, hospital administration and resource allocation.
Conclusion The introduction of the MDTM has undoubtedly had significant benefits on the standardisation of cancer care across the UK resulting in sustained improvements in cancer survival outcomes. However, at our institution, there has been a significant increase in MDTM workload over the last 5 years with a commonly held perception that there are insufficient resources within current job plans to continue to provide high quality radiological support for MDTMs. We have identified potential solutions to this problem including: demonstration of the
Eur Radiol
benefits of MDTMs to hospital administrators to justify additional resources; improving the efficiency of the MDTMs; and ensuring that increased MDTM workload is accurately represented and remunerated in consultant radiologist job plans. Acknowledgments We would like to thank Mrs Catherine Parchment Smith for help with editing this manuscript. The scientific guarantor of this publication is Dr Jonathan Smith. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. No complex statistical methods were necessary for this paper. Institutional Review Board approval was not required because no identifiable patient data was analysed. Written informed consent was not required for this study because no human subjects were used. Written informed consent was waived by the Institutional Review Board. Methodology: retrospective, observational, performed at one institution.
11.
12.
13.
14.
15.
16.
References 17. 1.
Sainsbury R, Haward B, Rider L et al (1995) Influence of clinician workload and patterns of treatment on survival from breast cancer. Lancet 345:1265–1270 2. Birkmeyer NJO, Goodney PP, Stukel TA et al (2005) Do cancer centers designated by the National Cancer Institute have better surgical outcomes? Cancer 103:435–441 3. Calman K, Hine D (1995) A policy framework for commissioning cancer services: a report by the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales. Available via: http://webarchive.nationalarchives.gov.uk/20130107105354/http:// www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ en/documents/digitalasset/dh_4014366.pdf. Accessed 26 Mar 2015 4. Griffith C, Turner J (2004) United Kingdom National Health Service, Cancer Services Collaborative "Improvement Partnership”, Redesign of Cancer Services. A National Approach. Eur J Surg Oncol 30(Suppl 1):1–86 5. Kesson EM, Allardice GM, George DW et al (2012) Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13722 women. BMJ 344, e2718 6. Gabel M, Hilton NE, Nathanson SD (1997) Multidisciplinary breast cancer clinics. Do they work? Cancer 79:2380–2384 7. Chang JH, Vines E, Bertsch H et al (2001) The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience. Cancer 91:1231–1237 8. Kurpad R, Kim W, Rathmell WK et al (2011) A multidisciplinary approach to the management of urologic malignancies: does it influence diagnostic and treatment decisions? Urol Oncol 29:378– 382 9. Junor EJ, Hole DJ, Gillis CR (1994) Management of ovarian cancer: referral to a multidisciplinary team matters. Br J Cancer 70: 363–370 10. Crawford R, Greenberg D (2012) Improvements in survival of gynaecological cancer in the Anglia region of England: are these an effect of centralisation of care and use of multidisciplinary management? BJOG 119:160–165
18.
19. 20.
21.
22.
23.
24.
25.
26.
Forrest LM, McMillan DC, McArdle CS et al (2005) An evaluation of the impact of a multidisciplinary team, in a single centre, on treatment and survival in patients with inoperable non-small-cell lung cancer. Br J Cancer 93:977–978 Bydder S, Nowak A, Marion K et al (2009) The impact of case discussion at a multidisciplinary team meeting on the treatment and survival of patients with inoperable non-small cell lung cancer. Intern Med J 39:838–841 Burton S, Brown G, Daniels IR et al (2006) MRI directed multidisciplinary team pre-operative treatment strategy: the way to eliminate positive circumferential margins? Br J Cancer 94:351–357 Morris E, Haward RA, Gilthorpe MS et al (2006) The impact of the Calman-Hine report on the processes and outcomes of care for Yorkshire's colorectal cancer patients. Br J Cancer 95:979–985 MacDermid E, Hooton G, MacDonald M et al (2009) Improving patient survival with the colorectal cancer multi-disciplinary team. Color Dis 11:291–295 The Department of Health (2004) Manual for cancer services. The Department of Health, London, Available via: http://webarchive. nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/ prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/ digitalasset/dh_4135597.pdf. Accessed 26 Mar 2015 Cancer Research UK (2014) Cancer survival statistics. Available via: http://www.cancerresearchuk.org/cancer-info/cancerstats/ survival. Accessed 26 Mar 2015 The Royal College of Radiologists (2005) Cancer Multidisciplinary Team Meetings - Standards for Clinical Radiologists, 2nd edn. The Royal College of Radiologists, London, Available via: https://www. rcr.ac.uk/publication/cancer-multidisciplinary-team-meetings-% E2%80%93-standards-clinical-radiologists. Accessed 26 Mar 2015 Sharma A, Sharp DM, Walker LG et al (2008) Colorectal MDTs: the team's perspective. Color Dis 10:63–68 Jalil R, Ahmed M, Green JSA et al (2013) Factors that can make an impact on decision-making and decision implementation in cancer multidisciplinary teams: an interview study of the provider perspective. Int J Surg 11:389–394 The Royal College of Radiologists (2012) Clinical radiology workload: guidance on radiologist's reporting figures. The Royal College of Radiologists, London, Available via: https://www.rcr.ac.uk/sites/ default/files/publication/BFCR%2812%2912_workload_0.pdf. Accessed 26 Mar 2015 Sidham MA, Poulsen MG (2006) Multidisciplinary care in oncology; medicolegal implications of group decisions. Lancet Oncol 7: 951–954 Monitor (2014) NHS foundation trusts holding up under pressure. Monitor, London, Available via: https://www.gov.uk/government/ news/nhs-foundation-trusts-holding-up-under-pressure. Accessed 26 March 2015 Mistry M, Parkin DM, Ahmad AS et al (2011) Cancer incidence in the United Kingdom: projections to the year 2030. Br J Cancer 105: 1795–1803 NHS England (2014) NHS imaging and Radiodiagnostic activity in England 2012/2013 Release. NHS England, Leeds, Available via: http://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/ 2013/04/KH12-release-2012-13.pdf. Accessed 26 Mar 2015 The Department of Health (2012) Implementing 7 day working in imaging departments: good practice guidance. The Department of Health, London, Available via: https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/213707/dh_132083. pdf. Accessed 26 Mar 2015
ONCOLOGY
The proliferation of multidisciplinary team meetings (MDTMs): how can radiology departments continue to support them all? Ravivarma Balasubramaniam 1 & Manil Subesinghe 1 & Jonathan T. Smith 1
Received: 10 July 2014 / Revised: 26 March 2015 / Accepted: 1 April 2015 # European Society of Radiology 2015
Abstract Objectives To quantify the changes in multidisciplinary team meeting (MDTM) workload for consultant radiologists working in a single UK tertiary referral cancer institution, assess its impact and suggest solutions to these challenges. Methods The annual number of MDTM cases was collated over a 5-year period (2009−2013). Qualitative information was obtained through questionnaire-based interviews of 47 consultant radiologists. Data analysed included number of MDTMs involved with, type of MDTM (oncological or non-oncological), time allocation for preparation and perceived deficiencies in the current MDTM. Results Thirteen thousand and forty-nine cases were discussed in MDTMs in 2009 with a continued yearly increase over the 5-year period. Fifty-five percent of MDTM attendances were at oncological MDTMs. Consultant radiologists attended a median of two MDTMs per week, each requiring 4 hours time commitment; 60 % used out-of-hours time for MDTM preparation. The most frequently cited MDTM deficiency was lack of sufficient clinical input. Conclusions The MDTM is a challenging but worthwhile demand on the modern radiologist’s time. Solutions to the increasing MDTM workload include demonstration of the benefits of MDTMs to hospital administrators to justify additional resources required, improving MDTM efficiency and ensuring this increased workload is accurately represented and remunerated in individual job plans.
* Jonathan T. Smith [email protected] 1
Department of Clinical Radiology, St. James’ University Hospital, Leeds Teaching Hospitals NHS Trust, Level 0 Bexley Wing, Beckett Street, Leeds LS9 7TF, UK
Key Points • MDTMs improve cancer outcomes and are being recommended for non-oncological conditions. • MDTM cases have more than doubled over 5 years at our institution. • Incorporating MDTM workload into current consultant radiologist job plans is difficult. • Solutions include demonstrating MDTM related benefits, improved efficiency, and accurate job planning. Keywords Tertiary care centres . Radiology . Neoplasms . Patient care team . Workload
Introduction Multidisciplinary team meetings (MDTMs), referred to as 'tumor boards' in the USA, are integral to the delivery of optimal cancer care in many Western countries. Prior to the introduction of MDTMs, cancer treatment was poorly standardised with management decisions often influenced by individual attitudes and beliefs without adequate formalised communication between surgeons, pathologists, radiologists and oncologists. Poor cancer survival rates in the UK when compared with other European countries were at least partly attributable to the wide variation in care received across the UK [1, 2]. In 1995, the Calman-Hine report [3] set out principles for the restructuring of cancer care and the framework for the delivery of uniformly high standard cancer care across the UK. Over the ensuing years, the concept of MDTMs and cancer networks were gradually introduced and established. At present, the MDTM is the forum in which all cancer patients are discussed and subsequent treatment decisions made and reviewed [4]. Studies have shown improved survival
Eur Radiol
outcomes associated with cancer care delivered through a MDTM [5–15]. The radiologist plays a crucial role in the MDTM, reviewing current and previous multi-modality imaging, including imaging from referring hospitals, and providing an overall impression of the patient’s current disease status. A gradual expansion in the numbers of cases discussed in the MDTM has been accompanied by an increase in the radiologist's workload and time commitment. In light of the paucity of literature quantifying the radiologist’s workload in MDTMs, we provide a retrospective analysis of MDTM workload and changes occurring over time in a single UK tertiary referral cancer institution radiology department. Questionnaire-based interviews of consultant radiologists at our institution provide an insight into the impact of MDTM workload on each individual and an opportunity to gauge opinion on the current challenges associated with MDTMs. We identify potential solutions to these challenges that should help sustain high quality radiological support to MDTMs.
Methods We performed a retrospective review of the overall MDTM workload in our tertiary referral cancer institution over a 5year period from 2009−2013. Information regarding the number of cases reviewed in MDTMs was acquired from the radiology information system (CRISTM; Healthcare Software Systems, Banbury, UK). This was consolidated with information from individual consultant radiologists using a qualitative structured interview-based questionnaire focusing on the amount and type of MDTM work performed. Interviews were carried out in 2013. Information on the number of MDTMs, type of MDTM (oncological or non-oncological), time allocation for preparation, perceived changes in the number of MDTMs and deficiencies in the current MDTM were obtained (Fig. 1). All questionnaire-based interviews were carried out by a senior radiology registrar. Only consultant radiologists who had worked for the trust for 5 years or more were interviewed to corroborate the data acquired from the radiology information system. Every eligible consultant radiologist was interviewed to ensure a complete consensus of opinion and participation from all sub-specialities. Each interview lasted approximately 15−20 minutes and all consultants were given the opportunity to document further opinions outside of the structured interview format. A coding framework of common themes that emerged from the interview data was constructed to allow both independent and collective analysis of the opinions as per standard qualitative research practice. Work undertaken in MDTMs at our institution is on a public hospital basis; consultant radiologists are remunerated by
the National Health Service. Their workload and remuneration is determined by a job plan which divides their workload into weekly programmed activities (PAs) or 4-hour sessions which involves DCC (Direct Clinical Care; including reporting sessions, intervention, MDTMs, on call, administration, etc.) and SPAs (Supporting Professional Activities; including research, audit, personal professional development, mandatory training, etc.). Hospital administrators review job plans annually to assess what aspects of the job plan should continue to be recognised and remunerated and how many PAs each activity should attract.
Results MDTM workload Over 13,000 cases were discussed at MDTMs in 2009 with a continued yearly increase over the 5-year period. The most dramatic change in workload occurred between 2009 and 2010 with a near doubling of cases discussed (13,049 cases vs. 25,349 cases, respectively). More recently, the number of cases discussed in an MDTM has plateaued with only a small incremental annual increase observed after 2011 (Table 1). Forty-seven consultant radiologists were interviewed in 2013 with subspecialty interests including gastrointestinal= 7, musculoskeletal=5, thoracic=4, genitourinary=4, oncology=2, nuclear medicine=3, neuroradiology=5, breast=8, vascular=5 and paediatrics=4. The consultant radiologist cohort accounted for 122 MDTM attendances per week; 55 % (67/122) of MDTM attendances were at oncological MDTMs; 66 % (31/47) of consultant radiologists were involved in at least one oncological MDTM. The median duration of an MDTM was 2 hours with each consultant radiologist attending a median of two MDTMs per week, each requiring a median preparation time of 2 hours (Table 2). Sixty percent (28/47) of consultant radiologists admitted to regularly using ‘out of hours’ time to prepare for the MDTM and 45 % (21/47) perceived an increase in MDTM workload over the 5-year period.
MDTM benefits All consultant radiologists believed that involvement in the MDTM was beneficial to them; 66 % (31/47) found surgical and histological feedback of greatest value; 34 % (16/47) believed the MDTM improved their knowledge of novel surgical techniques and eligibility criteria for clinical trials; 13 % (6/47) highlighted that the MDTM provided a valuable forum for discussing rare and interesting cases.
Eur Radiol
Fig. 1 Multidisciplinary team meeting (MDTM) workload questionnaire
MDTM deficiencies The most frequently stated deficiency in MDTMs was a lack of sufficient clinical input. Forty percent (19/47) of consultant radiologists highlighted concerns regarding the absence of the referring clinician at the MDTM causing inadequate clinical
information being relayed and a lack of clarity with regard to the clinical question. Thirty-two percent (15/47) cited a lack of clerical support in providing assistance for documentation of MDTM decisions and recording of attendance at MDTMs, 26 % (12/47) felt the purpose of non-oncological MDTMs were not always clearly defined and 15 % (7/47) felt that the venue and/or the IT resources were insufficient to conduct an
Table 1 Annual number of cases discussed in a multidisciplinary team meeting (MDTM) between 2009 and 2013 (47 radiologists) Year
No. of cases discussed in an MDTM
Change from previous year (%)
2009 2010 2011 2012 2013
13049 25349 28602 29016 29171
+94.26 +12.83 +1.45 +0.53
Table 2 Individual consultant contribution to multidisciplinary team meetings (MDTMs) during 2013 No. of MDTM MDTM preparation Duration of attendances per week time (hours) MDTM (hours) Mean Median Range
2.6 2 1-5
1.7 2 0-4
2.3 2 1-4
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MDTM and adequately demonstrate the salient imaging findings.
Discussion An MDT represents “a group of people of different health care disciplines, which meet together at a given time (whether physically in one place, or by video or tele-conferencing) to discuss a given patient and who are each able to contribute independently to the diagnostic and treatment decisions about the patient” [16]. The concept of the MDTM was aimed at improving decision-making between health-care team members using a structured format and evidence-based medicine to produce higher quality and more consistent cancer outcomes across the UK. Since its inception, studies have explored the impact of MDTMs on cancer outcomes. Kesson et al. [5] in a unique study conducted in the West of Scotland region found that the introduction of multidisciplinary care in breast cancer patients resulted in an 18 % lower breast cancer mortality at 5 years and 11 % lower all-cause mortality at 5 years in comparison with the control group. Smaller studies have shown similar trends towards increased survival through MDT support of more radical and optimised treatment options in breast [6, 7], urological [8], gynaecological [9, 10], lung [11, 12] and rectal malignancies [13–15]. The improvement in survival attributable to multidisciplinary care, although difficult to directly quantify, is partly related to the specialist review of diagnostic imaging and resultant alterations in management plans. This highlights the importance of radiologists in the decision-making process [7, 8]. Multidisciplinary care is thought to be contributory to the recently announced improved overall cancer survival rates observed in the UK with at least 50 % of patients now predicted to survive 10 years or more [17]. Over the past two decades, MDTMs have evolved alongside the increasing complexity of cancer care as a consequence of more detailed diagnostic imaging strategies coupled with a greater number of therapeutic options. The MDTM provides an invaluable opportunity to engage in continuous professional development [18], a statement supported by the views obtained in our study. Close liaison with clinical colleagues allows assimilation of up-to-date knowledge of currently available and more novel therapeutic options. The provision of histopathological correlation of radiological findings provides a method to audit reporting accuracy and improve individual practice through a process of learning and reflective practice. Importantly, in addition to personal benefits, members of the MDT firmly believe that patients benefit from an improved quality of care through MDTM discussion [19]. For all the benefits gained, there are significant problems that remain unresolved and further issues that threaten the
continued provision of high quality radiology support to MDTMs. Our study demonstrates a continual increase in cases discussed in MDTMs with a near doubling of cases discussed between 2009 and 2010. The increase in MDTM workload at our institution is multi-factorial. The expanding role and integration of the MDTMs into clinical care over a short time period is a major causal factor which has been exacerbated by the centralisation of cancer care to tertiary referral cancer institutions. This mirrors the general trend in England with less than 20 % of patients managed by an MDT in 1995 in comparison with 80 % in 2004 [4]. Potential solutions to deal with the increase in MDTM workload include: 1. Demonstration of the benefits of MDTMs to hospital administrators to help justify additional resources. Improved patient outcomes, compliance with national and international guidelines and avoidance of displacement of other necessary work, e.g. teaching, audit and research, should help justify additional PAs to attend and prepare for MDTMs and/or expansion of the consultant radiologist workforce. 2. Improvement in MDTM efficiency. a. Administrative support. This is best achieved through an MDTM coordinator. Their responsibilities would include: vetting and organising of appropriate referrals to avoid premature discussion or unnecessary rediscussion of cases; circulation of MDTM lists and MDTM decision outcomes to core members of the MDT; ensuring that all clinical information, local and imported referral letters, pathology and radiology reports are available; and that records of attendance are kept. Further areas for improvements include provision of adequate IT facilities for viewing of radiological, pathological and endoscopic images, videoconferencing links to enable multi-site working and access to cancer databases/electronic patient records. b. Improved clinical input. The lack of sufficient clinical input and absence of the referring clinician was the most frequently cited MDTM deficiency in our study. Comprehensive clinical information and consistent attendance by the key members of the MDTM is paramount to making safe and clinically effective treatment decisions. Jalil et al. [20] reported that inadequate clinical history, lack of knowledge of patient’s co-morbidities and investigation results were key causes of impaired MDTM decision outcomes. Clear MDTM policies may improve this, e.g. cases are only discussed if a member of the clinical team in possession of all the relevant clinical background is present at the MDTM. MDTM attendance can be
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improved if they are recognised as protected sessions in all medical specialities, as supported by The Royal College of Radiologists [18]. c. Strong leadership. A strong MDTM chairperson can facilitate constructive discussions, clarify decisions for recording and ensure the overall smooth running of the MDTM. In addition, they can lobby on behalf of the MDTM for access to additional resources required for improvements. 3. Accurate job planning. This is an invaluable tool for radiologists to help record MDTM workload related to preparation for and attendance at these meetings. Evidence from our study and elsewhere in the literature, is suggestive that the significant expansion in MDTM workload for radiologists has not been proportionally supported with resources or remuneration within existing job plans. MDTM-related work, termed 'non-countable' activity, is more difficult to quantify in comparison with modality based activities as part of job planning [21]. Moreover, there are medico-legal implications of recording MDTM outcomes, where responsibility lies with the individual rather than a group. These guidelines [22] dictate that individuals are required to document decisions on behalf of their sub-specialty interest. Time available during or after the meeting for this purpose is limited as is funded clerical support for reasons detailed earlier. Barriers to appropriate financial remuneration include defining and recognising specialist team members' individual contributions to MDTMs and derived quality metrics obtained from robust patient data to determine the subsequent impact on outcomes. In our study 60 % of consultants regularly use unfunded 'out of hours' working to prepare for the MDTM. Our radiology department invests on average 210 hours per week on preparation alone and a further 280 hours in attendance at MDT meetings. This approximates to five consultant radiologists on a full-time work commitment of ten programmed activities (PAs) solely to accommodate the requirements of MDTMs without contributing to other facets of clinical radiology or supporting professional activity. However, in the tough financial climate that the NHS currently faces, where a greater than expected number of financially autonomous NHS foundation trusts are in financial deficit, the creation of new jobs is fraught with difficulty [23]. We recommend that: a. Radiologists should be alert to the correct number of PAs of DCC that should be allocated to MDTMs in their job planning process. A daily work diary as recommended by the British Medical Association is a helpful tool for this. b. Hospital managers should be aware that allocating radiologists to MDTMs may displace other work in
their job plan and may have a detrimental impact on delivery of other services. c. The introduction of MDTMs into new/existing specialities as part of a business case should always take into account the impact on service delivery specialities such as pathology and radiology. The expansion of non-oncological MDTMs accounting for 45 % of MDTMs at our institution is also important to recognise. It is common for national and international guidelines to advise discussion of benign disease processes in MDTMs. More work is required to study the impact of the MDTMs on quality of provision of care and whether this is cost effective. The future of MDTMs remains in the balance. We face an increasingly ageing population with an estimated 45 % increase in the number of cancers by 2030 [24]. Demand upon radiology services continues to increase with a 39 % rise in the total number of imaging investigations performed over the last 10 years in the UK [25]. These will undoubtedly place significant pressure on the burgeoning workload of MDTMs. The proposal for extended working hours and 24-hour service provision [26] will significantly limit the time available for radiologists to contribute to MDTMs. There are limitations to our study. Our aim was to measure the increase in MDTM workload and assess its impact on radiologists. We achieved this through a retrospective study design and questionnaire-based interviews. The interviews were not anonymous and the working relationship between the consultant radiologist and interviewer (senior radiology registrar) may have potentially impacted upon responses given. Although most relevant to radiology departments in large UK cancer institutions, we believe that insights gained and solutions proposed are applicable to smaller departments, which may have a greater limitation on resources, and also non-UK institutions where MDTM workload may be similarly increasing. Our study is most relevant to radiologists who participate in MDTMs but also to individuals involved in departmental management, hospital administration and resource allocation.
Conclusion The introduction of the MDTM has undoubtedly had significant benefits on the standardisation of cancer care across the UK resulting in sustained improvements in cancer survival outcomes. However, at our institution, there has been a significant increase in MDTM workload over the last 5 years with a commonly held perception that there are insufficient resources within current job plans to continue to provide high quality radiological support for MDTMs. We have identified potential solutions to this problem including: demonstration of the
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benefits of MDTMs to hospital administrators to justify additional resources; improving the efficiency of the MDTMs; and ensuring that increased MDTM workload is accurately represented and remunerated in consultant radiologist job plans. Acknowledgments We would like to thank Mrs Catherine Parchment Smith for help with editing this manuscript. The scientific guarantor of this publication is Dr Jonathan Smith. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. No complex statistical methods were necessary for this paper. Institutional Review Board approval was not required because no identifiable patient data was analysed. Written informed consent was not required for this study because no human subjects were used. Written informed consent was waived by the Institutional Review Board. Methodology: retrospective, observational, performed at one institution.
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References 17. 1.
Sainsbury R, Haward B, Rider L et al (1995) Influence of clinician workload and patterns of treatment on survival from breast cancer. Lancet 345:1265–1270 2. Birkmeyer NJO, Goodney PP, Stukel TA et al (2005) Do cancer centers designated by the National Cancer Institute have better surgical outcomes? Cancer 103:435–441 3. Calman K, Hine D (1995) A policy framework for commissioning cancer services: a report by the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales. Available via: http://webarchive.nationalarchives.gov.uk/20130107105354/http:// www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ en/documents/digitalasset/dh_4014366.pdf. Accessed 26 Mar 2015 4. Griffith C, Turner J (2004) United Kingdom National Health Service, Cancer Services Collaborative "Improvement Partnership”, Redesign of Cancer Services. A National Approach. Eur J Surg Oncol 30(Suppl 1):1–86 5. Kesson EM, Allardice GM, George DW et al (2012) Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13722 women. BMJ 344, e2718 6. Gabel M, Hilton NE, Nathanson SD (1997) Multidisciplinary breast cancer clinics. Do they work? Cancer 79:2380–2384 7. Chang JH, Vines E, Bertsch H et al (2001) The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience. Cancer 91:1231–1237 8. Kurpad R, Kim W, Rathmell WK et al (2011) A multidisciplinary approach to the management of urologic malignancies: does it influence diagnostic and treatment decisions? Urol Oncol 29:378– 382 9. Junor EJ, Hole DJ, Gillis CR (1994) Management of ovarian cancer: referral to a multidisciplinary team matters. Br J Cancer 70: 363–370 10. Crawford R, Greenberg D (2012) Improvements in survival of gynaecological cancer in the Anglia region of England: are these an effect of centralisation of care and use of multidisciplinary management? BJOG 119:160–165
18.
19. 20.
21.
22.
23.
24.
25.
26.
Forrest LM, McMillan DC, McArdle CS et al (2005) An evaluation of the impact of a multidisciplinary team, in a single centre, on treatment and survival in patients with inoperable non-small-cell lung cancer. Br J Cancer 93:977–978 Bydder S, Nowak A, Marion K et al (2009) The impact of case discussion at a multidisciplinary team meeting on the treatment and survival of patients with inoperable non-small cell lung cancer. Intern Med J 39:838–841 Burton S, Brown G, Daniels IR et al (2006) MRI directed multidisciplinary team pre-operative treatment strategy: the way to eliminate positive circumferential margins? Br J Cancer 94:351–357 Morris E, Haward RA, Gilthorpe MS et al (2006) The impact of the Calman-Hine report on the processes and outcomes of care for Yorkshire's colorectal cancer patients. Br J Cancer 95:979–985 MacDermid E, Hooton G, MacDonald M et al (2009) Improving patient survival with the colorectal cancer multi-disciplinary team. Color Dis 11:291–295 The Department of Health (2004) Manual for cancer services. The Department of Health, London, Available via: http://webarchive. nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/ prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/ digitalasset/dh_4135597.pdf. Accessed 26 Mar 2015 Cancer Research UK (2014) Cancer survival statistics. Available via: http://www.cancerresearchuk.org/cancer-info/cancerstats/ survival. Accessed 26 Mar 2015 The Royal College of Radiologists (2005) Cancer Multidisciplinary Team Meetings - Standards for Clinical Radiologists, 2nd edn. The Royal College of Radiologists, London, Available via: https://www. rcr.ac.uk/publication/cancer-multidisciplinary-team-meetings-% E2%80%93-standards-clinical-radiologists. Accessed 26 Mar 2015 Sharma A, Sharp DM, Walker LG et al (2008) Colorectal MDTs: the team's perspective. Color Dis 10:63–68 Jalil R, Ahmed M, Green JSA et al (2013) Factors that can make an impact on decision-making and decision implementation in cancer multidisciplinary teams: an interview study of the provider perspective. Int J Surg 11:389–394 The Royal College of Radiologists (2012) Clinical radiology workload: guidance on radiologist's reporting figures. The Royal College of Radiologists, London, Available via: https://www.rcr.ac.uk/sites/ default/files/publication/BFCR%2812%2912_workload_0.pdf. Accessed 26 Mar 2015 Sidham MA, Poulsen MG (2006) Multidisciplinary care in oncology; medicolegal implications of group decisions. Lancet Oncol 7: 951–954 Monitor (2014) NHS foundation trusts holding up under pressure. Monitor, London, Available via: https://www.gov.uk/government/ news/nhs-foundation-trusts-holding-up-under-pressure. Accessed 26 March 2015 Mistry M, Parkin DM, Ahmad AS et al (2011) Cancer incidence in the United Kingdom: projections to the year 2030. Br J Cancer 105: 1795–1803 NHS England (2014) NHS imaging and Radiodiagnostic activity in England 2012/2013 Release. NHS England, Leeds, Available via: http://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/ 2013/04/KH12-release-2012-13.pdf. Accessed 26 Mar 2015 The Department of Health (2012) Implementing 7 day working in imaging departments: good practice guidance. The Department of Health, London, Available via: https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/213707/dh_132083. pdf. Accessed 26 Mar 2015
