Multidisciplinary team meetings in Hematology: a national mixed-methods study

Multidisciplinary team meetings (MDTMs) are a current international practice to facilitate the care of cancer patients. They bring together health professionals from different disciplines whose skills are essential to establish the diagnosis and to make a decision offering patients the best management according to the state of the medical science. They promote the coordination of communication and treatment, thereby improving the decision-making process and the quality of care [1‐5].

In France, the first Cancer Plan (2003–2007) [6] defines MDTMs’ requirements (membership, standards, quorum, procedures and formal reporting criteria for records) and objectives: to standardize the management of cancer patients, analyze medical files and evaluate treatment risks and benefits with the aim of proposing an appropriate decision in accordance with evidence-based medicine (EBM).

According to professionals involved in cancer care in France, MDTMs can improve physicians’ adherence to reference guidelines, inclusions to clinical trials, elaboration of personalized plans of care and the transparency of therapeutic choices. In addition, these meetings play a pivotal role in medical training and the process of updating the relevant knowledge [7‐9].

MDTMs are particularly useful in complex cases (e.g., allogeneic hematopoietic cells transplantation – allo-HCT, transition from curative to palliative care decisions), the frequency of which has been estimated to range between 25 and 40% of examined cases [10, 11]. Nevertheless, the time allocated to the discussion of these complex situations during MDTMs may be insufficient due to the significant number of files that must be treated [12‐14]. Other impediments of MDTMS, such as poor attendance, insufficient data, lack of administrative support and inadequate leadership, can negatively impact decision-making and the potential effect of MDTMs on the organization of treatment [15].

Research has reported contradictory results concerning the impact of MDTMs on the quality of decision-making and patient outcomes [16‐19] and the reported data also show variability in terms of the implementation of the recommendations made during these meetings [3, 20]. Understanding the MDTM process in the context of different medical specialties may contribute to the task of identifying core factors related to effective MDTM work.

To date, little evidence has been collected concerning MDTMs in hematology field [21‐24]. In the most extensive data set, including all types of MDTMs, hematology was an outlier in relation to several statements regarding the process of clinical decision-making in MDTMs and its impact on the timeliness of care, as well as on patient choices, involvement, staging and survival rates [25].

Hematological malignancies account for approximately 10% of new cancer diagnoses in Western countries and are the sixth most prevalent form of cancer overall. Intensive and innovative treatments, often potentially lifesaving, are core practices in hematology; however, their toxicities often lead to potentially life-threatening or distressing side effects. Thus, the implementation of MDTMs in the context of hematology may require adjustments to ensure that the modalities of such meetings are able to produce benefits for patients and health care professionals.

Our nationwide, mixed-methods study explores the perceptions of participants in French hematology MDTMs concerning these meetings.

Our study is the first nationwide, mixed-methods study to explore the perceptions of participants in hematology MDTMs.

Some results seem to be specific to the decision-making process associated with hematology.

The frequent solicitation of external experts reflects the complexity of hematologic practice, given the existence of hundreds of different hematologic malignancies and the need for accurate and specific expertise to ensure the best possible therapeutic proposal.

In fact, our respondents seem to value the benefit of collegiality more in the contexts of complex cases and difficult situations, even with respect to the management of benign diseases or difficult diagnoses, than in the context of the systematic discussion of every new cancer case, which is actually the regulatory requirement in most countries [29].

With respect to other kinds of tumors, core participants in the MDTMs usually include medical oncologists, radiotherapists and surgeons. In hematology, the therapeutic aspect relies exclusively on clinical hematologists, and while others in attendance are considered to provide substantial help regarding accurate diagnosis and staging, they are frequently less involved in the choice of treatment itself. This situation leads to a particular definition of the MDTM composition required for hematology, which, moreover, can vary depending on the more specific type of disease (e.g., generalist, lymphoid, myeloid) or treatment (auto or allo-HCT, car-T-cells therapy).

Moreover, the frequent anticipation of treatment even prior to discussion at an MDTM in the context of rapidly progressive diseases (such as acute leukemia or aggressive lymphoma) seems to be a particular aspect of hematological practice.

Besides hematology specificities, our study highlights relevant points regarding MDTMs’ decisional process and ethical issues, which may also concern other medical specialties.

As noted in the literature, essentially in the contexts of boards pertaining to solid tumors, our results show that the decision-making process associated with MDTMs is affected by organizational and interpersonal factors [4, 11, 15, 19].

The most frequently quoted organizational factor is the insufficient time allocated to the tasks of preparing for the meeting and to examining all files accurately. Variations in terms of the quality of file discussion and insufficient time for in-depth discussion of complex files are relevant issues that have been described previously [3, 8, 13]. Regarding this issue, a French retrospective analysis of MDTM data highlighted the conflict between the need to respond to the completeness required by the Cancer Plan and the importance of prioritizing multidisciplinary [9]. As other studies have shown [2], the absence of institutional acknowledgment is also considered to be an obstacle to MDTM efficiency: organizational factors impact participants’ attendance negatively, which is a primary reason for the failure to implement MDTM decisions. Among the reasons for the failure to implement MDTM recommendations, our results indicate patient refusal, which may be attributed to poor consideration of patients’ choices and their psychological and social conditions throughout the decision-making process [13, 30‐34].

Our data highlight the relevant issue of the usefulness of psychosocial information.

Participants seem to be ambivalent regarding this subject: quantitative data show that a quarter of the respondents consider that patient preferences are insufficiently took into consideration, but less than 15% think that neither these preferences nor psychosocial data are essential to make therapeutic choices. Qualitative data contribute to understand this point: psychosocial data seem to be considered relevant in clinical situations that entail a significant risk of "unreasonable stubbornness" (e.g., allo-HCT indications) or in cases in which a PC decision could be discussed.

Due to the paucity of psychosocial data in medical files, the issue of the subjective perception of the patients' conditions and preferences by the referent hematologist has been raised. To address this issue, the participation of nurses and other health care professionals and PC teams in MDTMs is suggested [10], and such participation has already been implemented in some countries [19]. Nevertheless, some evidence shows that the inclusion of nursing personnel is viewed as less important [14, 35‐37]. Indeed, several authors have shown that the biomedical approach tends to take precedence over other points of view [15, 35, 38, 39].

The decision-making process is influenced by MDTM dynamics, which are themselves affected by the number of participants involved in the meetings, team relationships and the performance of the MDTM coordinator.

The group’s size is related to its diversity and range of abilities, but it may negatively affect the equality of participation and the effectiveness of the decision-making process [11]. Regarding the number of participants, our data highlight the issue of a possible discrepancy between two main tasks of an MDTM: the decision-making process and the goal of training and knowledge updating.

Team relationships and the coordinator role influence the involvement of the participants, the decisions made at the MDTM and, indirectly, the implementation of those decisions. Indeed, the internal elements of these groups (cultures, beliefs, attitudes, and the interactions among group members), interpersonal factors (lack of trust or respect between team members) and hierarchical stances can impede the decision-making process. It has been shown that team dynamics, ranging from interactive debates to exchanges dominated by single individuals, may impact interactivity and MDTM discussions [14, 37].

Our qualitative data highlight the participants’ concerns about the influence of subjective factors on clinical decisions. A recent French study, based on an ethnographic observation of MDTMs related to breast and ovarian cancer and referred to Longino’s theory of scientific deliberation [40] showed that MDTMs do not always respond to the conditions required to ensure objectivity and rationality. Nevertheless, the author noted that the lateral control among peers and the collective evaluation of the most recently available data contribute to limiting the influence of subjective preferences in the MDTM setting [41].

The meeting climate and quality of the decision-making process both impact the participants’ opinions regarding recommendations made at the MDTM. Some evidence shows that approximately one-third of MDTM participants disagree regarding the decisions ultimately made at such meetings [42]. This unexpressed dissent influences the participants’ feelings concerning the way in which the MDTM can interfere with doctor–patient interactions, although other research has shown that MDTMs do not affect this relationship [43].

These issues regarding MDTM dynamics and the pivotal role of the MDTM coordinator have been acknowledged [43‐47]. The role of personal qualities and nontechnical skills in managing MDTMs has been emphasized, and specific leadership training for MDTM chairs has been recommended [3, 48, 49].

In spite of organizational and interpersonal issues, hematologists – as professionals of other medical specialties, seem to highly appreciate MDTMs and largely recognize its value as part of the decision-making process.

Our study is the first nationwide, mixed-methods study to explore the perceptions of participants in hematology MDTMs. It highlights certain aspects of the decision-making process in this medical specialty, such as the frequent need for referral, the particular definition of the participants’ specialties and the recurrent clinical emergencies. But it also points out organizational and interpersonal issues, which may interfere with MDTMs’ performance.

Organizational obstacles are mainly related to a lack of institutional recognition of this medical activity (in terms of time pressure and workload) and to the compulsory registration of all files. Poor team ambience negatively influences MDTM discussions and the implementation of its recommendations. A main result of our qualitative study underscores the influence of subjective factors on clinical decisions, which are expected to adhere to scientific data and EBM. These findings raise important ethical issues, which should be explored by larger research – not only in the Hematology, but also in the context of other medical specialties.