day 7 the multi-disciplinary part of "multi-disciplinary research-driven care"

MD Anderson doctors practice multi-disciplinary research-driven patient care, and have done since our founding back in the early 1940s. There is a great history of MD Anderson that is well worth reading, written by Dr. James Olson, a historian and patient, and in it you can learn that research and collaborative care were part of us from the very beginning. I am now one of the many beneficiaries of this approach – let me tell you how it feels to be at the focus of a multidisciplinary team today, and I’ll talk about patient-focused research next time.

The roots of multi-disciplinary care come from the fact that modern medicine, and cancer care is an excellent example, is complex and rapidly evolving. That means that doctors specialize, and often spend many years in residency and fellowships becoming experts in a specific area, naturally at the expense of knowledge in other areas. Then they have to work hard to keep up with developments in their area, and can’t pay similar levels of attention to the other specialties. In the world of cancer there are typically three main groups of treating physicians, supported by a large group of other specialists. 

The treating physicians use the three main modes of cancer care: medicine, surgery and radiation. Usually the quarterback for the team is the medical oncologist, who is in charge of the medical treatment, traditionally chemotherapy and increasingly the modern targeted and biological therapies that are being developed. They are also likely to be with the patient throughout the arc of treatment and the years of follow up and so develop the most comprehensive picture of you. I met my oncologist this week, and we had a thorough discussion of what we know from the tests that are in, what we are waiting on, and what the options and best plans going forward are. Depending on your disease a surgeon is often also involved, and they will be an active part of the team when surgery is called for, and also participate in follow up as required, but in a less active role. Similarly the radiation oncologist will take over during radiation, and participate in follow up to ensure all went well and any emerging issues were managed, but then step back. 

Supporting this trio are many other doctors, who make essential contributions at key moments. For example, the radiologists read all the imaging and, as I have already experienced twice, take biopsies for diagnosis and of course follow up. With the exception of the interventional radiologists who do the biopsying (and often surgeons do these too) you rarely meet the radiologists, but you will see their names on the reports in your medical records. They spend many hours in carefully lit environments looking at images and make critical calls on whether a tumor has grown, or shrunk or changed. Similarly you rarely meet the pathologists who look at biopsy and surgical specimens, stain and prepare them and then render a central piece of the diagnosis – the path report. The team often looks to them to make the key call as to what kind of cancer you have. Pathology is undergoing a rapid revolution as molecular tests are supplementing traditional histology and microscopy. And then there are of course the teams that provide other services, such as the many laboratory tests for blood work, anesthesia and pain management, internal medicine if you have complications or other issues that need to be managed as you undergo cancer care. 

The core of the multi-disciplinary approach for us is that all these specialists talk to each other, all the time. They often convene formally at tumor-boards which are typically weekly conferences where cases are presented. Often a training doctor will present the patient’s overall status, and then the specialists will take it in turn to provide their data. For example, the pathologist may show a section on the screen and describe what they saw and their diagnosis. A radiologist may show an MRI and give their opinion. Then the team will discuss treatment options and decide on a path forward. Naturally, more unusual or challenging cases are typically presented at such meetings, and routine situations are unlikely to be, as well established paths exist. But outside of the tumor board, informal discussions are going on all the time too. In my case, for example, my oncologist was concerned about some subtle changes in some lymph nodes that the radiologist had noticed. She is consulting with the radiologist to find out more. And with the radiation oncologist as his treatment approach might need additional information, and that would have to be gathered before we begin treatment. So although the doctors take turns treating you, they are already aware of your case and are a team around you from the beginning. That is, to me, very reassuring. 

There is of course another key member of the team: you. More on that some other time.