The introduction of the multi-disciplinary team (MDT) into the regular practice of cancer and other specialties within medicine must surely be one of the leading advancements in delivery of healthcare in the last decades. By setting clear guidelines and targets for management of cancer, for example, NCAT has overseen a widespread improvement in consistency of decision making and the timely application of appropriate treatment modalities. Coincident with new treatments, screening programmes, and increasing patient awareness of the importance of early diagnosis and lifestyle choices, the UK is beginning to see improving cancer outcomes.
However, in embracing the concept of multi-expert analysis of clinical problems, we should not be unaware of some of the dangers of such collective decision making, often in the absence of the patient who is the subject of the discussion.
CE Montague’s assertion that “War hath no fury like a non-combatant” suggested that it is tempting to advocate brave and dramatic acts of warfare if one is not directly involved in their delivery. There is a risk that an MDT may as a group act in a similar manner. Though this may sometimes be a strength, there is the possibility that a team may reach a decision which the clinician who will actually be delivering the treatment is not entirely comfortable with. Guidelines for management of a condition can perversely actually compound the difficulties, as the MDT will always tend to follow perceived wisdom and care pathways, sometimes in the absence of detailed knowledge of the patient’s other medical history and desires. Many of the team will never have seen the results of interventions advocated, nor indeed the consequences of associated complications. The true measure of a good doctor however must surely be the ability to make judgements taking in to account all factors involved. It is not necessarily appropriate, for example, to undertake radical, non-curative surgery for cancer which itself carries a significant morbidity and mortality. Sometimes these decisions are better discussed with a patient and family than with a team of professionals, most of whom will never meet the patient. An individual member of the MDT who is presented with their consensus view however, will find it difficult to then advocate a different course of action in discussions with the patient, whether this be of a more or less conservative nature.
The security an individual may feel as part of a collective decision making team can certainly be influential upon the opinions expressed, and we should be cautious of the peer pressure on those who will finally treat the patient that an MDT can exert. We should also take care that such decisions do not in any way dilute clinicians’ individual sense of responsibility to the patients they treat. Although we can genuinely celebrate the advent of the MDT, let us use our collective knowledge wisely.
Mark Watts is a consultant oculoplastic surgeon, Arrowe Park Hospital, Wirral, and has been a member of the cutaneous oncology MDT there since its inception approximately 15 years ago.
He has just completed a four year term of office as vice president and chair of education at the Royal College of Ophthalmologists, London.
Competing interests: None declared.