Collective Wisdom and Multidisciplinary Tumor Boards

Abstract

While perusing the program for the 95th American Association of Oral and Maxillofacial Surgeons Annual Meeting, Scientific Sessions, and Exhibition in Orlando, Florida, on September 9 to 12, 2013, I noted several references to the team approach. These included an open forum on cleft and craniofacial care: “team approaches in the 21st century”; “the total team concept for effective scheduling”; and “training the oral and maxillofacial surgery anesthesia team—don't be caught unprepared.” Regardless of the specific discipline, the team approach exemplifies the philosophy of Aristotle that the whole (multidisciplinary involvement) is greater than the sum of its parts (individual decision making). In the case of healthcare, the outcomes are more likely to be favorable and successful when all members of the multidisciplinary healthcare team align with a common goal.Multidisciplinary care occurs in many formats in contemporary healthcare systems. Comprehensive input on patient treatment is able to be achieved through multidisciplinary clinics, development of medical center–wide multidisciplinary cancer programs, the creation of multidisciplinary diagnosis and treatment protocols, formation of a cancer service collaborative, or the use of multidisciplinary tumor conferences, colloquially referred to as tumor boards.1Hong N.J.L. Wright F.C. Gagliardi A.R. Paszat L.F. Examining the potential relationship between multidisciplinary cancer care and patient survival: An international literature review.J Surg Oncol. 2010; 102: 125Crossref PubMed Scopus (136) Google Scholar Owing to the diversity of formats, multidisciplinary cancer care has been variably defined but fundamentally encompasses collaborative patient care by a team of individuals, with all diagnostic and treatment options discussed and specifically tailored for each patient. Thus, patients with cancer benefit from what can be referred to as “collective wisdom.” Under such circumstances, the inherent collective wisdom associated with multidisciplinary decision making, specifically as a part of tumor board discussions, is likely to result in more favorable outcomes than independent clinician decision making. Although the team composition can vary by cancer site and institution, contributors typically include surgeons, medical oncologists, radiation oncologists, pathologists, radiologists, nuclear medicine physicians, palliative care providers, nurses, nutritionists, and social workers. Head and neck tumors boards uniquely benefit by the added presence and contributions of speech pathologists. The specific advantages of multidisciplinary tumor boards include the perceived satisfaction and psychological benefits for patients; comprehensive treatment decision-making by all involved specialists; improved clinical integration of care for medical centers and healthcare providers; ongoing education for practitioners, residents, and fellows; and increased patient access to clinical trials. In fact, tumor boards have been perceived to be so valuable that the American College of Surgeon's Commission on Cancer Program accreditation has required cancer programs to conduct multidisciplinary tumor boards that prospectively review cases and discuss management decisions.2American College of Surgeons/Commission on Cancer Cancer Program Standards 2012: Ensuring Patient-Centered Care V1.2. American College of Surgeons, Chicago, IL2011Google ScholarThe factors that enhance or impede effective decision-making at tumor board meetings have also been investigated. Lamb et al3Lamb B.W. Brown K.F. Nagpal K. et al.Quality of care management decisions by multidisciplinary cancer teams: A systematic review.Ann Surg Oncol. 2011; 18: 2116Crossref PubMed Scopus (267) Google Scholar reviewed 2,848 studies found using the search terms “decision-making,” “neoplasm,” “multidisciplinary,” and “team.” Of the 2,848 studies, 37 met their inclusion criteria. They were able to draw conclusions regarding the effect of the multidisciplinary team on care decisions; the efficacy of the multidisciplinary team's decision-making process; the process in which the multidisciplinary team arrived at care management decisions; and team culture and leadership in multidisciplinary teams. Regarding the effect of the multidisciplinary team on care decisions, 6 of the 37 studies identified that tumor board meetings resulted in a change in care management in 2% to 52% of patient cases. This was reflected by a change in the patient's pathologic diagnosis, staging, and use of chemotherapy. With regard to the efficacy of the multidisciplinary team's decision-making process, most studies concluded that a few treatment recommendations were not implemented, estimated to be 1% to 16%. The process by which care management decisions were typically driven is by physician members on the basis of biomedical information. The views of nurses were often ignored at tumor board meetings; however, larger and more diverse teams were associated with increased team effectiveness. Although nursing personnel were more likely to involve patients in the process, physicians were less likely to do so. With regard to team culture and leadership, members of multidisciplinary tumor boards perceived the team as an environment in which optimal management plans can be formulated, treatment is coordinated, and the likelihood of error is reduced. A system of rotating leadership of the team has been shown to reduce interprofessional conflicts and to improve team working and team morale with the team. Such teams across several countries have been most commonly led by surgeons. Other factors ensuring effective decision-making at tumor board meetings have included the observation of protected time, not only during the meeting, but also before the meeting. Protected time for pathologists, radiologists, and others to properly prepare cases for presentation will increase the effectiveness of the tumor board meeting. In addition, the number of team members present, the timing of meetings, the number of cases, and whether the cases are discussed at the beginning or end of the meeting can also affect the quality of case discussion and decision-making at tumor board meetings.4Lamb B.W. Sevdalis N. Benn J. et al.Multidisciplinary cancer team meeting structure and treatment decisions: A prospective correlational study.Ann Surg Oncol. 2013; 20: 715Crossref PubMed Scopus (56) Google ScholarDespite international support for multidisciplinary cancer care and tumor boards, one of the most elusive and poorly understood associations is the effect of such involvement on patient survival. Although whether the care dictated by multidisciplinary tumor boards improves patient outcomes has been debated, recent evidence has emerged of improved patient survival owing to these discussions. This notwithstanding, for a complex care pathway that involves diagnosis, staging, case discussion, patient consultation, treatment, and follow-up, it might not be possible to attribute positive changes in survival to the tumor board discussion itself, particularly with the increased sophistication of the diagnosis and treatment of cancer.In the final analysis, multidisciplinary tumor board meetings represent an effective method of centralizing the initiation of patient care in an academically stimulating environment through collective wisdom. Such discussions give focus to patient care, stimulate intellectual thought, and personalize decision-making processes. In a world overwhelmed by electronic communication, it has been comforting for me to be able to talk to colleagues who congregate with me at a head and neck tumor board meeting at the same time and in the same place, all in the best interests of successful patient care. While perusing the program for the 95th American Association of Oral and Maxillofacial Surgeons Annual Meeting, Scientific Sessions, and Exhibition in Orlando, Florida, on September 9 to 12, 2013, I noted several references to the team approach. These included an open forum on cleft and craniofacial care: “team approaches in the 21st century”; “the total team concept for effective scheduling”; and “training the oral and maxillofacial surgery anesthesia team—don't be caught unprepared.” Regardless of the specific discipline, the team approach exemplifies the philosophy of Aristotle that the whole (multidisciplinary involvement) is greater than the sum of its parts (individual decision making). In the case of healthcare, the outcomes are more likely to be favorable and successful when all members of the multidisciplinary healthcare team align with a common goal. Multidisciplinary care occurs in many formats in contemporary healthcare systems. Comprehensive input on patient treatment is able to be achieved through multidisciplinary clinics, development of medical center–wide multidisciplinary cancer programs, the creation of multidisciplinary diagnosis and treatment protocols, formation of a cancer service collaborative, or the use of multidisciplinary tumor conferences, colloquially referred to as tumor boards.1Hong N.J.L. Wright F.C. Gagliardi A.R. Paszat L.F. Examining the potential relationship between multidisciplinary cancer care and patient survival: An international literature review.J Surg Oncol. 2010; 102: 125Crossref PubMed Scopus (136) Google Scholar Owing to the diversity of formats, multidisciplinary cancer care has been variably defined but fundamentally encompasses collaborative patient care by a team of individuals, with all diagnostic and treatment options discussed and specifically tailored for each patient. Thus, patients with cancer benefit from what can be referred to as “collective wisdom.” Under such circumstances, the inherent collective wisdom associated with multidisciplinary decision making, specifically as a part of tumor board discussions, is likely to result in more favorable outcomes than independent clinician decision making. Although the team composition can vary by cancer site and institution, contributors typically include surgeons, medical oncologists, radiation oncologists, pathologists, radiologists, nuclear medicine physicians, palliative care providers, nurses, nutritionists, and social workers. Head and neck tumors boards uniquely benefit by the added presence and contributions of speech pathologists. The specific advantages of multidisciplinary tumor boards include the perceived satisfaction and psychological benefits for patients; comprehensive treatment decision-making by all involved specialists; improved clinical integration of care for medical centers and healthcare providers; ongoing education for practitioners, residents, and fellows; and increased patient access to clinical trials. In fact, tumor boards have been perceived to be so valuable that the American College of Surgeon's Commission on Cancer Program accreditation has required cancer programs to conduct multidisciplinary tumor boards that prospectively review cases and discuss management decisions.2American College of Surgeons/Commission on Cancer Cancer Program Standards 2012: Ensuring Patient-Centered Care V1.2. American College of Surgeons, Chicago, IL2011Google Scholar The factors that enhance or impede effective decision-making at tumor board meetings have also been investigated. Lamb et al3Lamb B.W. Brown K.F. Nagpal K. et al.Quality of care management decisions by multidisciplinary cancer teams: A systematic review.Ann Surg Oncol. 2011; 18: 2116Crossref PubMed Scopus (267) Google Scholar reviewed 2,848 studies found using the search terms “decision-making,” “neoplasm,” “multidisciplinary,” and “team.” Of the 2,848 studies, 37 met their inclusion criteria. They were able to draw conclusions regarding the effect of the multidisciplinary team on care decisions; the efficacy of the multidisciplinary team's decision-making process; the process in which the multidisciplinary team arrived at care management decisions; and team culture and leadership in multidisciplinary teams. Regarding the effect of the multidisciplinary team on care decisions, 6 of the 37 studies identified that tumor board meetings resulted in a change in care management in 2% to 52% of patient cases. This was reflected by a change in the patient's pathologic diagnosis, staging, and use of chemotherapy. With regard to the efficacy of the multidisciplinary team's decision-making process, most studies concluded that a few treatment recommendations were not implemented, estimated to be 1% to 16%. The process by which care management decisions were typically driven is by physician members on the basis of biomedical information. The views of nurses were often ignored at tumor board meetings; however, larger and more diverse teams were associated with increased team effectiveness. Although nursing personnel were more likely to involve patients in the process, physicians were less likely to do so. With regard to team culture and leadership, members of multidisciplinary tumor boards perceived the team as an environment in which optimal management plans can be formulated, treatment is coordinated, and the likelihood of error is reduced. A system of rotating leadership of the team has been shown to reduce interprofessional conflicts and to improve team working and team morale with the team. Such teams across several countries have been most commonly led by surgeons. Other factors ensuring effective decision-making at tumor board meetings have included the observation of protected time, not only during the meeting, but also before the meeting. Protected time for pathologists, radiologists, and others to properly prepare cases for presentation will increase the effectiveness of the tumor board meeting. In addition, the number of team members present, the timing of meetings, the number of cases, and whether the cases are discussed at the beginning or end of the meeting can also affect the quality of case discussion and decision-making at tumor board meetings.4Lamb B.W. Sevdalis N. Benn J. et al.Multidisciplinary cancer team meeting structure and treatment decisions: A prospective correlational study.Ann Surg Oncol. 2013; 20: 715Crossref PubMed Scopus (56) Google Scholar Despite international support for multidisciplinary cancer care and tumor boards, one of the most elusive and poorly understood associations is the effect of such involvement on patient survival. Although whether the care dictated by multidisciplinary tumor boards improves patient outcomes has been debated, recent evidence has emerged of improved patient survival owing to these discussions. This notwithstanding, for a complex care pathway that involves diagnosis, staging, case discussion, patient consultation, treatment, and follow-up, it might not be possible to attribute positive changes in survival to the tumor board discussion itself, particularly with the increased sophistication of the diagnosis and treatment of cancer. In the final analysis, multidisciplinary tumor board meetings represent an effective method of centralizing the initiation of patient care in an academically stimulating environment through collective wisdom. Such discussions give focus to patient care, stimulate intellectual thought, and personalize decision-making processes. In a world overwhelmed by electronic communication, it has been comforting for me to be able to talk to colleagues who congregate with me at a head and neck tumor board meeting at the same time and in the same place, all in the best interests of successful patient care.