- Department of Neurosurgery, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 6236, Los Angeles, CA, 90095-7436, USA
- Department of Otolaryngology, Wexner Medical Center at the Ohio State University, Columbus, OH, 43210, USA
- Brain Tumor Center, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, CA, 90404, USA
- Department of Neurological Surgery, Wexner Medical Center at the Ohio State University, Columbus, OH, 43210, USA
- Department of Surgery, Division of Neurosurgery, University of Ottawa, Ottawa, Ontario, K1Y 4E9, Canada
Correspondence Address:
Nancy McLaughlin
Department of Surgery, Division of Neurosurgery, University of Ottawa, Ottawa, Ontario, K1Y 4E9, Canada
DOI:10.4103/2152-7806.109527
Copyright: © 2013 McLaughlin N This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: McLaughlin N, Carrau RL, Kelly DF, Prevedello DM, Kassam AB. Teamwork in skull base surgery: An avenue for improvement in patient care. Surg Neurol Int 25-Mar-2013;4:36
How to cite this URL: McLaughlin N, Carrau RL, Kelly DF, Prevedello DM, Kassam AB. Teamwork in skull base surgery: An avenue for improvement in patient care. Surg Neurol Int 25-Mar-2013;4:36. Available from: http://sni.wpengine.com/surgicalint_articles/teamwork-in-skull-base-surgery-an-avenue-for-improvement-in-patient-care/
Abstract
Background:During the past several decades, numerous centers have acquired significant expertise in the treatment of skull base pathologies. Favorable outcomes are not only due to meticulous surgical planning and execution, but they are also related to the collaborative efforts of multiple disciplines. We review the impact of teamwork on patient care, elaborate on the key processes for successful teamwork, and discuss its challenges.
Methods:Pubmed and Medline databases were searched for publications from 1970 to 2012 using the following keywords: “teamwork”, “multidisciplinary”, “interdisciplinary”, “surgery”, “skull base”, “neurosurgery”, “tumor”, and “outcome”.
Results:Current literature testifies to the complexity of establishing and maintaining teamwork. To date, few reports on the impact of teamwork in the management of skull base pathologies have been published. This lack of literature is somewhat surprising given that most patients with skull base pathology receive care from multiple specialists. Common factors for success include a cohesive and well-integrated team structure with well-defined procedural organization. Although a multidisciplinary work force has clear advantages for improving today's quality of care and propelling research efforts for tomorrow's cure, teamwork is not intuitive and requires training, guidance, and executive support.
Conclusions:Teamwork is recommended to improve quality over the full cycle of care and consequently patient outcomes. Increased recognition of the value of an integrated team approach for skull base pathologies will hopefully encourage centers, physicians, allied health caregivers, and scientists devoted to treating these patients and advancing the field of knowledge to invest the time, effort, and resources to optimize and organize their collective expertise.
Keywords: Multidisciplinary, neurosurgery, outcome, skull base, teamwork
INTRODUCTION
Skull base surgery, as a subspecialty including open and endoscopic approaches, continues to evolve, favoring minimal access approaches in order to reduce surgical morbidity and mortality, preserve neurological function, as well as cosmesis.[
To date, various groups have published their team approach or clinical experience regarding the treatment of specific skull base entities.[
Through concrete examples of multidisciplinary work, this manuscript reviews the impact of teamwork on care for patients afflicted with skull base pathologies, highlights the critical concepts of teamwork, and discusses its challenges and future avenues. Organizing healthcare over the full cycle of care of a particular condition (e.g., cancer) has been found advantageous on multiple levels; thus, this review will emphasize its importance.[
TEAMWORK: A NECESSITY
Physicians have traditionally been viewed as providers of medical services, either during an acute illness or regularly in the context of chronic conditions. However, their role is expected to go beyond the delivery of medical services in their area of specialty. Patients rely on their physicians to oversee the quality of services delivered at all levels of the pyramid of care, for acute and chronic conditions. Patients’ outcomes, defined as survival and degree of recovery based on quality of life indicators, progress of recovery, and sustainability, also relies to various extents on their care team.[
CONTEMPORARY EXAMPLES OF TEAMWORK
Different professions and specialties work together at multiple stages of a patient's care plan: Case review sessions such as tumor boards, multidisciplinary clinics, multidisciplinary surgeries, care coordination meetings, etc.[
Multidisciplinary case reviews or tumor boards
Lutterbach, et al. published the only study to date assessing the efficacy of a newly founded brain tumor board at their institution.[
Wheless, et al. prospectively investigated the impact of the multidisciplinary tumor board in diagnosis, staging, and treatment plan for patients with head and neck tumors.[
Overall, multidisciplinary case reviews and tumor boards are being recognized by many health care systems as central to improve patient safety, patient care and outcomes.[
Multidisciplinary clinic
Traditionally, when the opinion of multiple disciplines was needed to establish a plan, patients had to entertain serial individual consultations with each specialist, sometimes weeks or even months apart. Recently, some centers have innovated in coordinating a “one-stop” service, with all consultations occurring as part of a single appointment or multiple appointments on a single day.[
Multidisciplinary surgery
Skull base surgery, as a subspecialty, has evolved thanks to the close collaboration between surgical specialties, which inspired refinement of conventional approaches and conception of new procedures. Resection of vestibular schwannomas extending from the internal auditory canal to the cerebellopontine angle is a well-known example of interdisciplinary surgery (neurosurgery and otorhinolaryngology), where each specific pathoanatomical step is performed by the surgeon best acquainted with the regional particularities.[
CRITICAL CONCEPTS IN TEAMWORK: TEAM STRUCTURE AND PROCESSES
Multidisciplinary teams seek an efficient and productive way to achieve the goals set forth.[
Team structure
The first key concept is team structure: A good structural organization is essential to the success of a multidisciplinary team.[
Team processes
The second important concept is team processes. A well-established procedural organization is important for the effective functioning of the group.[
ADVANTAGES OF MULTIDISCIPLINARY TEAMS
The most important advantage of a multidisciplinary work force is the improvement of the overall value of care, defined as achievement of the best outcome as efficiently as possible for patients afflicted with complex pathologies.[
CHALLENGES FOR MULTIDISCIPLINARY TEAMS
Challenges of multidisciplinary teamwork
Although a multidisciplinary team approach seems intuitive to optimally manage patients with skull base pathologies, establishing this practice organization, maintaining it, and assuring its progress can be challenging. Physicians used to working with a “subspecialty silo mentality” may not have incentives to change their traditional work habits. Multidisciplinary teamwork calls for interaction between team members beyond simple referrals and reading consultation notes. Some physicians may find that reviewing cases during a weekly or monthly multidisciplinary meeting interferes with their clinic and surgery schedule workflow. They may also be reticent to discussing their patients in tumor boards or scheduling patients for multidisciplinary clinics if this implies sharing some of their clinical decision making with other team physicians. Payment differentials have potentially discouraged some physicians in engaging in team work. Various payment scenarios could potentially represent financial incentives for physicians to become involved.
Ideally, team members’ recommendations should be founded on evidence-based medicine and available practice guidelines. While most patients will not be controversial as to their optimal management, some cases can be treated by two or more surgical approaches and/or nonsurgical therapies. Differences in opinions among team members stimulate discussion and may shed light on alternative treatment avenues not considered by some team members. Patients should be informed of consensus decisions but also of divergent opinions if appropriate. Overall, the success of multidisciplinary team work depends not only on the individual physicians’ commitment but also the visionary support of the team leader and the institution's administration.
Learning to work as a team and integrate new members
Recent data has clearly shown that teamwork training processes improve system performances.[
The multidisciplinary team will be called upon to change and adapt as new members will need to be included as the field of skull base surgery progresses.[
Education and research
Multidisciplinary teams should act as educational resources, encouraging team members to contribute to continuous medical education in their respective disciplines. Team members must keep up to date in their own field and educate their respective professional communities on state-of-the-art practices. Although members currently possibly attend to their annual specialty meetings, a symposium on treatment of skull base pathologies is beneficial. This multidisciplinary meeting stimulates members to show their achievements and establish new collaborations. It is a forum where all disciplines are recognized as an active part of the patient's care over the full cycle of care. In the near future, international multidisciplinary meetings specific to a medical condition or subspecialty may become a key element to improving holistic care. These meetings should also implicate researchers working on clinical and/or basic science projects. Exchange of knowledge among specialists devoted to the care of specific pathologies fuels research ideas and opportunities.
In summary, a multidisciplinary team approach is essential to optimally manage patients with skull base pathologies and further improve outcomes. Such collaboration is essential to help fully integrate clinical care, basic and translational research and clinical trials. Increased recognition of the relevance of multidisciplinary teams for skull base pathologies will encourage centers devoted to treating these patients to invest time, efforts, and resources in optimizing their collaboration, as this may be also critical in expertise recognition, resource allocation, and value-based competition.
References
1. Adams R, Morgan M, Mukherjee S, Brewster A, Maughan T, Morrey D. A prospective comparison of multidisciplinary treatment of oesophageal cancer with curative intent in a UK cancer network. Eur J Surg Oncol. 2007. 33: 307-13
2. Armour Forse R, Bramble JD, McQuillan R. Team training can improve operating room performance. Surgery. 2011. 150: 771-8
3. Ausman JI. A revolution in skull base surgery: The quality of life matters!. Surg Neurol. 2006. 65: 635-6
4. Ausman JI. Treat the patient not the disease. Surg Neurol. 2003. 59: 139-
5. Awad IA, Fayad P, Abdulrauf SI. Protocols and critical pathways for stroke care. Clin Neurosurg. 1999. 45: 86-100
6. Awad SS, Fagan SP, Bellows C, Albo D, Green-Rashad B, De la Garza M. Bridging the communication gap in the operating room with medical team training. Am J Surg. 2005. 190: 770-4
7. Bambakidis NC, Kakarla UK, Kim LJ, Nakaji P, Porter RW, Daspit CP. Evolution of surgical approaches in the treatment of petroclival meningiomas: A retrospective review. Neurosurgery. 2007. 61: 202-9
8. Beckett P, Woolhouse I, Stanley R, Peake MD. Exploring variations in lung cancer care across the UK: The ‘story so far’ for the National Lung Cancer Audit. Clin Med. 2012. 12: 14-8
9. Borrill C, West M, Shapiro D, Rees A. Team working and effectiveness in health care. Br J Health Care Manage. 2000. 6: 364-71
10. Cancer EAGo.editors. A policy framework for commissioning canceer services: A report to the chief medical officers of England and Wales. The Calman-hine Report. London: Department of Health; 1995. p.
11. Chen AY, Callender D, Mansyur C, Reyna KM, Limitone E, Goepfert H. The impact of clinical pathways on the practice of head and neck oncologic surgery: The University of Texas M. D. Anderson Cancer Center Experience. Arch Otolaryngol Head Neck Surg. 2000. 126: 322-6
12. Choi BC, Pak AW. Multidisciplinarity, interdisciplinarity and transdisciplinarity in health research, services, education and policy: 1. Definitions, objectives, and evidence of effectiveness. Clin Invest Med. 2006. 29: 351-64
13. Cook G, Gerrish K, Clarke C. Decision-making in teams: Issues arising from two UK evaluations. J Interprof Care. 2001. 15: 141-51
14. Crawford R, Greenberg D. 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. 2012. 119: 160-5
15. Feeley TW, Fly HS, Albright H, Walters R, Burke TW. A method for defining value in healthcare using cancer care as a model. J Healthc Manag. 2010. 55: 399-411
16. Fennell ML, Das IP, Clauser S, Petrelli N, Salner A. The organization of multidisciplinary care teams: Modeling internal and external influences on cancer care quality. J Natl Cancer Inst Monogr. 2010. 2010: 72-80
17. Field R, West M. Teamwork in primary health care: 2. Perspectives from practices. J Interprof Care. 1995. 9: 123-30
18. Figueiredo EG, Deshmukh V, Nakaji P, Deshmukh P, Crusius MU, Crawford N. An anatomical evaluation of the mini-supraorbital approach and comparison with standard craniotomies. Neurosurgery. 2006. 59: ONS212-20
19. Friedland PL, Bozic B, Dewar J, Kuan R, Meyer C, Phillips M. Impact of multidisciplinary team management in head and neck cancer patients. Br J Cancer. 2011. 104: 1246-8
20. Gruen RL, Pitt V, Green S, Parkhill A, Campbell D, Jolley D. The effect of provider case volume on cancer mortality: Systematic review and meta-analysis. CA Cancer J Clin. 2009. 59: 192-211
21. Imola MJ, Sciarretta V, Schramm VL. Skull base reconstruction. Curr Opin Otolaryngol Head Neck Surg. 2003. 11: 282-90
22. Jansen L. Collaborative and interdisciplinary health care teams: Ready or not?. J Prof Nurs. 2008. 24: 218-27
23. Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P. Endoscopic endonasal skull base surgery: Analysis of complications in the authors’ initial 800 patients. J Neurosurg. 2011. 114: 1544-68
24. Kesson EM, Allardice GM, George WD, Burns HJ, Morrison DS. Effects of multidisciplinary team working on breast cancer survival: Retrospective, comparative, interventional cohort study of 13 722 women. BMJ. 2012. 344: e2718-
25. Kestle JR, Riva-Cambrin J, Wellons JC, Kulkarni AV, Whitehead WE, Walker ML. A standardized protocol to reduce cerebrospinal fluid shunt infection: The Hydrocephalus Clinical Research Network Quality Improvement Initiative. J Neurosurg Pediatr. 2011. 8: 22-9
26. Lutterbach J, Pagenstecher A, Spreer J, Hetzel A, Velthoven V, Nikkhah G. The brain tumor board: Lessons to be learned from an interdisciplinary conference. Onkologie. 2005. 28: 22-26
27. Maugeri-Sacca M, De Maria R. Translating basic research in cancer patient care. Ann Ist Super Sanita. 2011. 47: 64-71
28. McCallin A. Interprofessional practice: Learning how to collaborate. Contemp Nurse. 2005. 20: 28-37
29. McLaughlin N, Laws ER, Oyesiku NM, Katznelson L, Kelly DF. Pituitary Centers of Excellence. Neurosurgery. 2012. 71: 916-26
30. McLaughlin N, Prevedello DM, Kelly DF, Carrau RL, Kassam AB. A multicorridor 360 degree strategy. Jpn J World Neurosurg. 2011. 20: 190-9
31. Micallef J, Gajadhar A, Wiley J, DeSouza LV, Michael Siu KW, Guha A. Proteomics: Present and future implications in neuro-oncology. Neurosurgery. 2008. 62: 539-55
32. Molyneux J. Interprofessional teamworking: What makes teams work well?. J Interprof Care. 2001. 15: 29-35
33. Morris E, Haward RA, Gilthorpe MS, Craigs C, Forman D. The impact of the Calman-Hine report on the processes and outcomes of care for Yorkshire's breast cancer patients. Ann Oncol. 2008. 19: 284-91
34. Olofsson J. Multidisciplinary team a prerequisite in endoscopic endonasal skull base surgery. Eur Arch Otorhinolaryngol. 2010. 267: 647-
35. Porter ME. What is value in health care?. N Engl J Med. 2010. 363: 2477-81
36. Porter ME, Teisberg EO. How physicians can change the future of health care. JAMA. 2007. 297: 1103-11
37. Rutherford J, McArthur M. A qualitative account of the factors affecting team-learning in primary care. Educ Prim Care. 2004. 15: 352-60
38. Sadiq SA, Usmani HA, Saeed SR. Effectiveness of a multidisciplinary facial function clinic. Eye (Lond). 2011. 25: 1360-4
39. Sargeant J, Loney E, Murphy G. Effective interprofessional teams: “Contact is not enough” to build a team. J Contin Educ Health Prof. 2008. 28: 228-34
40. Shahlaie K, McLaughlin N, Kassam AB, Kelly DF. The role of outcomes data for assessing the expertise of a pituitary surgeon. Curr Opin Endocrinol Diabetes Obes. 2010. 17: 369-76
41. Sharp MC, MacfArlane R, Hardy DG, Jones SE, Baguley DM, Moffat DA. Team working to improve outcome in vestibular schwannoma surgery. Br J Neurosurg. 2005. 19: 122-7
42. Siwanuwatn R, Deshmukh P, Figueiredo EG, Crawford NR, Spetzler RF, Preul MC. Quantitative analysis of the working area and angle of attack for the retrosigmoid, combined petrosal, and transcochlear approaches to the petroclival region. J Neurosurg. 2006. 104: 137-42
43. Snyderman C, Kassam A, Carrau R, Mintz A, Gardner P, Prevedello DM. Acquisition of surgical skills for endonasal skull base surgery: A training program. Laryngoscope. 2007. 117: 699-705
44. Starmer H, Sanguineti G, Marur S, Gourin CG. Multidisciplinary head and neck cancer clinic and adherence with speech pathology. Laryngoscope. 2011. 121: 2131-5
45. Stephens MR, Lewis WG, Brewster AE, Lord I, Blackshaw GR, Hodzovic I. Multidisciplinary team management is associated with improved outcomes after surgery for esophageal cancer. Dis Esophagus. 2006. 19: 164-71
46. Tonn JC, Schlake HP, Goldbrunner R, Milewski C, Helms J, Roosen K. Acoustic neuroma surgery as an interdisciplinary approach: A neurosurgical series of 508 patients. J Neurol Neurosurg Psychiatry. 2000. 69: 161-6
47. Westin T, Stalfors J. Tumour boards/multidisciplinary head and neck cancer meetings: Are they of value to patients, treating staff or a political additional drain on healthcare resources?. Curr Opin Otolaryngol Head Neck Surg. 2008. 16: 103-7
48. Wheelwright R, Birchall MA, Boaden R, Pearce G, Lennon A. Critical path analysis in head and neck cancer: A management technique for surgical oncology. Eur J Oncol Nurs. 2002. 6: 148-54
49. Wheless SA, McKinney KA, Zanation AM. A prospective study of the clinical impact of a multidisciplinary head and neck tumor board. Otolaryngol Head Neck Surg. 2010. 143: 650-4
50. Xyrichis A, Lowton K. What fosters or prevents interprofessional teamworking in primary and community care? A literature review. Int J Nurs Stud. 2008. 45: 140-53
51. Zanation AM, Carrau RL, Snyderman CH, Germanwala AV, Gardner PA, Prevedello DM. Nasoseptal flap reconstruction of high flow intraoperative cerebral spinal fluid leaks during endoscopic skull base surgery. Am J Rhinol Allergy. 2009. 23: 518-21