Holistically focused case presentations

On a small number of occasions in all four teams a case was presented to the MDT meeting holistically, providing an overview of both the patient and their disease to frame any subsequent discussion:

Consultant Gynaecologist: she [is] rather a challenge to manage because she is very scared of hospitals and has gone away before finishing her test but she’s had a long history of just feeling vaguely unwell and then presented with shortness of breath…when I saw her in clinic last week she was very symptomatic and just

uncomfortable in her abdomen it felt like she had large volume ascites [accumulation of fluid in the abdomen] so we admitted her for symptom control but actually the scans showed that she didn’t have a lot of ascites it was mainly omental cake [where the

membrane lining the abdomen is abnormally thick] and we’ve done

194 the scans and I think we’ve done an omental biopsy as well so if we

could look at her scans first.

(Gynaecology, observation transcript)

In this example, the consultant gynaecologist presented information about the patient’s psychosocial wellbeing, describing her fear of hospitals before going on to outline her current symptoms. It is worth noting that this was still a relatively brief presentation, lasting for just under a minute.

Most holistic presentations led to multidisciplinary discussions: in this example, both the CNS and the psychologist were actively involved in the subsequent discussion. Contributions in these cases tended to be psychosocial in nature, for example relating to a patient’s state of mind, their preferences for treatment, or possible sources of support for those struggling.

The smaller number of holistic case presentations is in line with the findings from the previous chapter, which suggested that full multidisciplinary discussion was not necessarily desirable, or feasible, for every patient on the MDT patient list. Instead, holistic discussion, which incorporated patient centred information, tended to be particularly important where patients had limited treatment options, or in cases where there were concerns about a patient’s ability to cope with treatment. The smaller number of holistic case presentations could therefore be seen to reflect attempts to prioritise certain cases for full multidisciplinary discussion.

In these cases, a holistically focussed case presentation could frame the issue in a way that encouraged participation from lower status members of the team. In particular, a signal from a higher status member was one way of providing an opening for these contributions. This was evidenced when higher status members explicitly sought advice from others in the team: “now this is an interesting case I’d value your views” (Consultant Clinical Oncologist, Gynaecology, observation

195 transcript). This approach provided openings for lower status members to

contribute:

CNS: she just finds it extremely difficult I think she thinks by having treatment she’s doing something for herself

(Gynaecology, observation transcript)

There were some exceptions to this however. In two haematology cases (one from each team) information about the patient as a person was shared during the case presentation in order to emphasise the lack of other symptoms or problems:

“previously very fit and well, active, went to the gym three times [a week]” (StR, Haematology 2, observation transcript), or “there was nothing in the history…he’s a mountain biker, does spinning classes” (Consultant Haematologist, Haematology 1, observation transcript). In these cases, the aim of sharing information about the patient appeared to be to emphasise their strengths in relation to treatment. It was therefore perhaps unsurprising that in these cases the initial case presentation did not lead to wider multidisciplinary discussion.

The other exception where a holistic case presentation did not lead to input from lower status members of the team – even when there was an explicit prompt from a higher status member of the team – was when a lower status member of the team had not met the patient in question:

Consultant Gynaecologist 1: it [a mass identified on the scan] needs out

Clinical Oncologist: it’s very suspicious

Consultant Gynaecologist 2: I’ve seen her again today but she’s really reluctant to have surgery

Consultant Gynaecologist 3: is she? [sounds surprised]

Consultant Gynaecologist 1: …is she symptomatic?

196 Consultant Gynaecologist 2: she is symptomatic she’s had long

standing left sided pain and it was just getting worse

Consultant Gynaecologist 1: …which, who’s she under which one of you has seen her [to the CNSs]?

CNS: I’m not sure I haven’t seen her

Consultant Gynaecologist 1: …does she need to see one of our psychology colleagues to help her with her decision making?

Consultant Gynaecologist 2: no she’s signed a consent form today I had a chat with her

(Gynaecology, observation transcript)

In some cases therefore, a consultant was the only member of the team who had met the patient. In these cases, they provided the patient centred information both during the initial case presentation and then subsequently throughout the

discussion. Overall however, it was more common for lower status members of the team to provide this kind of information in response to a holistic case presentation.

7.3.4 Summary

To summarise, there were different approaches to the initial case presentation and this appeared to have an impact on the extent to which lower status members of the team contributed to the subsequent discussion. In general, the lack of a clear case presentation made it more difficult for anyone in the meeting who had not met the patient to contribute constructively to the decision making process. This was not always necessarily problematic, for example, in cases that could be managed according to evidence-based protocols. However, in the Gynaecology team the failure to present a case properly was attributed with impairing multidisciplinary discussion, and making it more difficult for CNSs and StRs to contribute.

197 A clear clinical or holistic initial case presentation could ensure that everyone in the meeting was aware of key issues relating to the decision that needed to be made. It also seemed to enable teams to prioritise the contributions of particular groups by signalling the nature of the issue to be considered. In the examples observed, it was more likely that a holistic case presentation would draw in contributions from CNSs or StRs than a clinically focused presentation would. Nonetheless, a clinically focused presentation did not necessarily exclude contributions from lower status members of the team. Similarly, a holistic presentation did not guarantee their input. Specific behaviours from higher status members of the team, including the use of signalling during a presentation, and direct questioning, also made

contributions from these groups more likely.

7.4 Chapter Summary

While the literature on cancer MDTs has highlighted the existence of inequalities in participation during MDT meetings (Lanceley et al., 2008, Kidger et al., 2009, Lamb et al., 2011b, Raine et al., 2014a), much less consideration has been given to the specific factors that inhibit or facilitate contributions from lower status groups. By exploring the decision making process in these four MDTs, this chapter has

increased our understanding of the way that the physical layout of the meeting, the leadership style of the MDT Lead, and the initial case presentation can impact on multidisciplinary discussion. Table 16 (p. 199) summarises the factors that inhibited multidisciplinary discussion, and the contribution of lower status groups. Those that encouraged multidisciplinary discussion are summarised in Table 17 (p. 200).

Of course, a key point already made is that for some discussions, input from lower status groups may not have made a difference to the outcome or final decision anyway. The factors described above that limited contributions from lower status groups are therefore not necessarily in and of themselves problematic.

198 Nonetheless, it is important to identify these factors because the literature suggests that behaviours that accentuate the effects of the status hierarchy are often

unintentional. As a result, even leaders who want to encourage other team members to contribute may not behave in ways that demonstrate this (Morrison, 2011). If MDTs are to incorporate the views of lower status groups when they are important therefore, they must be cognisant of the range of factors that can potentially inhibit them.

Before concluding this chapter, it is also important to recognise that although status hierarchies clearly played an important role in the decision making process in these four cancer MDT meetings, regardless of the team environment or context, some individuals are more likely to speak up than others. This suggests that as well as status, factors such as gender, personality or disposition may also play a role in levels of participation in MDT meetings. For example, individuals who display high levels of extraversion have been shown to be more likely to speak up (Morrison, 2011, Bienefeld and Grote, 2013). In addition, some of the differences described between the four MDTs may in part reflect differences in specialty and case load, although the fact that there were such marked differences between the two haematology teams suggests that this point should not be over-emphasised.

Nonetheless, in the Skin team for example it was possible to clearly distinguish between different approaches based on disease type in a way that may not necessarily be possible in other specialities.

199 Table 16: Summary of factors that inhibited multidisciplinary discussion

Factor Reason for impact Influenced by Team

1. Hierarchical seating arrangements

Competition for space can exclude lower status groups sitting at the back of the room

Verbal cues suggesting a lack of

willingness to listen can create a sense of futility about value of contributing

Accentuated by a lack of structure during discussion

Accentuated by focus on efficiency during discussion

The need to ensure accuracy of information recorded

Difficult to contribute for those who have not met the patient being discussed

Reason for discussion

Which professionals have met the patient being discussed

Framing issue as medical, surgical or diagnostic can exclude patient centred information

Reason for discussion

Signalling or questioning by higher status individual

All

200 Table 17: Summary of factors that facilitated multidisciplinary discussion

Factor Reason for impact Influenced by Team

1. Non-hierarchical seating 2. Support for lower status

groups from a third party

Can encourage lower status to work together to contribute

Role of third party (in this case Psychologist)

Can indicate that contributions are welcomed and valued

Needs to be directed specifically at lower status groups

Framing issue in order to encourage sharing of patient centred information

Which professionals have met the patient being discussed

All