No formal case presentation

During the observation period, in a small proportion of cases in each team, patients were raised for discussion in the meeting without any sort of formal case

presentation. This was more likely to happen in the Skin and Gynaecology teams than in either of the Haematology teams. Where there was no formal case

presentation, this was often because a patient had previously been discussed by the team, or because no active treatment was required (or treatment had already been initiated). In the Skin cancer team for example, basal cell carcinoma cases were not always preceded by a formal case presentation, particularly when this involved the routine reporting of a complete excision (the removal of skin tissue with a margin that is clear of disease):

Consultant Dermatopathologist: This was a curette defined excision she also had a fibro-epithelial polyp shaved off

Consultant Dermatologist: this is the right nasal labial fold Consultant Dermatopathologist: …it says here right cheek Consultant Dermatologist: ok…any tumour in it?

Consultant Dermatopathologist: no

Consultant Dermatologist: ok so likely complete…there was no tumour in that

Consultant Dermatopathologist: correct [the team move on to the next patient]

(Skin, observation transcript)

188 As illustrated in this example, the patient’s name was not verbalised, although the dermatologist described the procedure undertaken. Following this it was

established very quickly that there was no tumour in the specimen and the team immediately moved on to the next patient.

In cases such as these the treatment protocol was for patients to be routinely followed up as a matter of course: they did not need further surgical treatment if the lesion had been successfully removed. In addition, as noted above, basal cell carcinoma cases were usually less serious than melanoma cancers, and were therefore dealt with much more quickly during the MDT meeting.

In both Haematology teams the two full observation transcripts and field notes from all meetings indicated that the absence of a formal case presentation was the exception rather than the norm. For example in one case in Haematology 1, there was no initial presentation given as the team realised immediately that the scan due to be reviewed was not ready. Although a brief discussion subsequently took place about whether or not the patient in question should proceed with her scheduled chemotherapy, the formal presentation of the case and review of the scan was deferred until the following week.

There were some exceptions to this in the Gynaecology team however. In this team the lack of a proper case presentation was specifically cited as a barrier to

participation during the interviews, particularly in cases where other members of the team did not know the patient being discussed. In these cases, the lack of a presentation was seen to be problematic because it was then very difficult for other members of the team to contribute to the decision making process in a meaningful way:

189 The biggest problem from my point of view is that I often don’t know all

of the patients…[and] unless you know the background to the case well it’s very difficult to disagree. (Oncology StR, Gynaecology, interview)

This impacted on multidisciplinary discussion more generally, and was not limited solely to lower status professionals. However, as one consultant gynaecologist noted, if the team genuinely wanted to gather opinions from the full range of professionals in the team, it was essential to make an effort to include everyone, starting with a clear presentation of each case:

They’re [consultant gynaecologists] not mindful of the fact that many people don’t know the patient at all, that if you want people to be involved you have to make an effort to involve them. (Consultant Gynaecologist, Gynaecology, interview)

At times, this reflected the practical realities of a specialist MDT receiving referrals from other MDTs in the surrounding area. This was because in some cases no one in the team had met the patient when they were being discussed:

Consultant Gynaecologist 1: oh this is this lady who oh god she’s got something to do with [a doctor at another Trust]…he’s been texting me asking me what’s happening I said I’m sure she’s got a plan so she’s having her surgery tomorrow so…I don’t know why they were all getting anxious about it

Consultant Gynaecologist 2: a VIP or?

Consultant Gynaecologist 1: I don’t know I didn’t meet her in clinic…I think we should we should meet these new patients, I feel.

Just so we know what is going on

Consultant Gynaecologist 2: yeh, absolutely (Gynaecology, observation transcript)

190 However, it is worth noting that in the other teams – including the other specialist MDTs in Skin and Haematology 2, which received external referrals from

surrounding MDTs - if a patient was not known to anyone present, discussion was usually either deferred, or reference made to the patient’s clinical notes to provide some sort of context for a discussion.

In the main then, lack of a case presentation could be seen as an attempt to minimise the time spent in the MDT on cases where there was little need for extended discussion, for example the routine reporting of pathology results or where there was no active treatment required. In the Gynaecology team however, there were also occasions where lack of a case presentation was seen as a barrier to multidisciplinary discussion because it excluded those who did not know a patient from contributing.