In the last fews weeks I have had the pleasure of participating in a few discussions and meeting a lot of different healthcare professionals and patients. A topic that has come been touched or mentioned a few time, is MDC, or multidisciplinary care.
From an oncology perspective, this has traditionally always referred to tumor boards, or tumor conferences. This has been a forum for various physicians to come together to discuss difficult or interesting cancer diagnosis, discuss treatment options, clinical guidelines or research, and to learn from one another. The traditional attendance according to the ACoS CoC (American College of Surgeons Commission on Cancer) standards has been that a quorum was defined as Radiologist, Pathologist, Medical Oncologist, Radiation Oncologist, and ideally a Surgeon. In some organizations an invitation was extended to primary physicians. Typically all of the physicians sat in the front and discussed the cases. Supportive staff was in the back.
Fast forward a few years and there has been a movement in the world to make this wonderful meeting more robust and begin to discuss difficult cases upfront, collaboratively, and begin to formulate the best treatment plan and options for newly diagnosed cancer patients. I would say over the course of the last 10 years, between the changes in accreditation, standards of care, clinical pathways, and awareness that this movement has grown and flourished.
I have had the privilege of going across the country and participating in several hundreds of these meetings. I still learn a lot each time I attend, and am surprised at all of the great work being done.
At the same time, I also see a lot of variation amongst programs. Some topic academic facilities are very robust. Some communities organizations have pooled resources and figure out the power in these meetings and have taken best practices and models from academics. Other organizations, both academic and community based, are operating in the more traditional models yet.
In the mid 2000’s there was a pilot project called the National Community Cancer Care Programs through the NCI, or better known as the NCCCP. I was fortunate enough to work at one of the original 16 pilot sites in Billings, MT at the Billings Clinic. Here I was fortunate enough to work with some pioneers in community oncology care from the Director of Oncology, Medical Director of the Program, Manager of Medical Oncology, and the other Oncology Department Chairs. This is where I got my first taste of the behind the scenes research, frameworks, and best practices that people through the US and at the NCI were partnering together on the behalf of raising the bar for cancer patients.
Especially since 80% of all oncology care is in community based programs, it was well needed.
One of the major tools in the toolbox is the MDC Assessment Tool. What this tool did was establish a framework by which all programs could use as a plan to assess where their current multidisciplinary conferences were based on the traditional framework of tumor boards/conferences. It also provides a roadmap for planning, budgeting, and improvements to help programs move into the best practices of what a true MDC Conference should all entail.
The tool is here:
MDC Assessment Tool Version 3.0 Final approved (click the link for tool)
As you can see, the Assessment Tool is broken into 9 major pillars.
1 Case Planning
2 Physician Engagement
3 TreatmentTeam Integration
4 Integration of Care Coordinators (not limited to only navigators, but broadens the team)
7 Clinical Trials
8 Quality Improvement
9 Medical Records
It administers definitions based on a 5 point system. Point 1 would baseline everyone on the traditional models of cancer or tumor boards/conferences. These conferences were retrospective in nature, offered educational opportunities for physicians to learn about difficult cases, but did not impact the quality or value of care that a patient received.
The further you move along the continuum towards 5, or the top of the rating scale, the more of a truly multidisciplinary approach you take to administering care to cancer patients. This will help to ensure that patients are being treated according to best practices, guidelines, current research, and that no patient is treated prior to a team of medical professionals having the ability to provide opinions and value to a patients care.
I believe one of the biggest changes I have seen in implementing this across the US in the last few years was changing who participates in the conversation. The days of physicians being at the head table, talking amongst themselves, and no one else really contributing are passing. The realization that non-pyhsicians can add value to patient care is becoming more widely acceptable.
One of the items I have stressed is that patients and families define “value” very differently than physicians or healthcare administrators. Patients define it in terms of time, ease and simplicity, coordination, communication, and understanding. The art is that a lot of the people in the back of the room already new this, and more importantly, they could translate the information and plans from the MDC Conferences into something that patients valued.
The 1 + 1 = 3.
A few other items to highlight based on best practices and things I have worked with organizations to implement.
Infrastructure: this can be done in a virtual capacity or in a dedicated facility. Virtual may allow more people to attend and be part of the dialogue. It gives greater access to patients in smaller communities to more specialized treatments and physician expertise, as well as supportive teams. Down side is that people can multitask and not be committed in the current conversation. Relationships can be difficult to form when it is virtual versus face to face. Trust is essential.
Physically dedicated spaces allow for more robust conversation. It can also lead to a better understanding of how people work, expectations, and then being able to get through a greater number of cases in shorter amounts of time. It also provides a platform to move from a conference to development of clinics. A clinic is a next level that brings the patients to the center of the dialogue, in one facility, on a single day, and they have a plan in hand prior to leaving for home.
Clinical Trials: A robust MDC will rely heavily on two groups, the pathologist and the clinical trial coordinators. As pathology comes back it can be expedited to the clinical trials program to pre-screen patients that are being recently or newly diagnosed with cancer with all of the available and open clinical trials within the facility. I have seen oncology service lines move from 2-3% enrollment to 15-18% enrollment when leveraging the team correctly and ensuring that information travels seamlessly both up and downstream to team members. I actually used this infrastructure to help a few organizations save their clinical trial membership, turn the programs around, an increase accrual rates.
Lastly is pathology. Traditionally pathologists have been the physicians known for being in the basement, looking into their microscopes, and everyone waiting on their reports to know if a patient has cancer or not. I remember in my own training asking a radiation oncologist what was I looking for on the pathologists slide, and him telling me not to worry and just hope he says it is cancer. Times have changed a lot, and I doubt most physicians would ever utter those words today. However, the art is bringing a pathologist to the front lines in discussions with patients, getting their message out to the team members sooner rather than later, and allowing the process to move as quickly as possible.
I developed an entire service line with the basis that time is of the essence for cancer patients, brought pathologists to the forefront, and accelerated the time from diagnosis to treatment plan in 3 days or less as a commitment to our cancer patients. I did not have the luxury of this tool when I went about creating that program. However in the past few years I have leveraged this tool to help oncology service lines and cancer programs accomplish this same feat, accelerating the turn around times for patients, and it all begins and ends with pathology.
I hope this tool and few insights will help you as you begin to plan, grow, and improve your current cancer program.
If you have any questions, suggestions, or want some help, please feel free to let me know. I am always more than willing to help improve programs and provide additional insight into cancer care globally.
As always, you can feel free to contact me at: CANCERGEEK@GMAIL.COM
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