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The Organization of Multidisciplinary Care Teams: Modeling
Internal and External Influences on Cancer Care Quality
Mary L Fennell, Irene Prabhu Das, Steven Clauser, Nicholas Petrelli, Andrew Salner
Correspondence to: Mary L. Fennell, PhD, Department of Sociology, Brown University, Box 1916, Providence, RI 02912 (e-mail: [email protected]).
Quality cancer treatment depends upon careful coordination between multiple treatments and treatment providers, the exchange
of technical information, and regular communication between all providers and physician disciplines involved in treatment. This
article will examine a particular type of organizational structure purported to regularize and streamline the communication
between multiple specialists and support services involved in cancer treatment: the multidisciplinary treatment care (MDC) team.
We present a targeted review of what is known about various types of MDC team structures and their impact on the quality of
treatment care, and we outline a conceptual model of the connections between team context, structure, process, and performance and their subsequent effects on cancer treatment care processes and patient outcomes. Finally, we will discuss future
research directions to understand how MDC teams improve patient outcomes and how characteristics of team structure, culture,
leadership, and context (organizational setting and local environment) contribute to optimal multidisciplinary cancer care.
J Natl Cancer Inst Monogr 2010;40:72–80
Quality cancer care is complex and depends upon careful coordination between multiple treatments and providers and upon technical information exchange and regular communication flow
between all those involved in treatment (including patients, specialist physicians, other specialty disciplines, primary care physicians [PCPs], and support services) (1). Earlier in this supplement,
Taplin and others have pointed out the challenges of transferring
information and responsibility among providers and institutions;
a problem at the interfaces of care. Advances in surgical procedures, chemotherapy, computer technology, and targeted molecular and radiation therapies have all led to an increase in
multimodality therapy, which increases the number of interfaces
among cancer specialists and other clinicians in the treatment of
any single patient. Contemporary cancer care thus presents a
paradox: The potential for unparalleled quality and sophisticated
treatment is high, yet the number of potential “failure” events in
the continuum of cancer treatment (2) has multiplied significantly. Each failure in communication between various physicians
and care providers and every transition and interface miscue can
result in delayed treatment planning and implementation, unnecessary duplication of tests, incomplete follow-up, increased
patient anxiety, decreased patient satisfaction, and declines in
quality of life.
This article will examine a particular type of organizational
structure focused on the interfaces between multiple specialists
involved in cancer treatment: the multidisciplinary treatment care
(MDC) team. This structure has been identified as one method of
ensuring the exchange of patient-related and technical information
between all physicians and support services involved in a patient’s
care. The setting and format of the MDC encourage active
involvement of all actors (including the patient and his/her family)
in the development of a care plan. Once formed, MDC team meetings can be convened at multiple times throughout the process of
72 cancer care (Figure 1 in Taplin) (3) and can thus serve as an ongoing communication structure aimed at smoothing the transitions
between multiple stages of care.
MDC teams are the successors to the tumor conference, and
they have been an arrangement for coordinating cancer care for at
least 30 years (4,5). The health-care management literature advocates for more frequent use of MDC teams (6,7), and the National
Cancer Institute has historically supported their development and
diffusion, dating back to the cancer network demonstrations of the
late 1970s and early 1980s (5,8), and through the National Cancer
Institute Community Cancer Center Programs of recent times
(9). However, little, if any empirical evidence exists on the prevalence, efficacy, and diffusion of MDC teams in cancer treatment
or on their effectiveness in smoothing transitions across stages of
cancer care.
This article presents a targeted review of the literature (primarily since 2000) on what is known about various types of MDC team
structures and their impact on the quality of cancer care; the use of
multidisciplinary teams for health-care delivery in other diseases;
external environmental factors; and the influence that structural
characteristics at the level of the practice or hospital setting have
on the ability of MDC teams to improve care quality. A conceptual
model, informed by the literature, outlines the connections among
team structure, process, and performance, and their subsequent
effects on cancer treatment care processes and patient outcomes.
We include studies of management team structure and performance from the organizational behavior and management literature where appropriate. Finally, we discuss future research
directions for improving our understanding of how MDC teams
improve patient outcomes, and how characteristics of team structure, culture, leadership, and the characteristics of the organizations and environment within which they operate contribute to
optimal multidisciplinary cancer care.
Journal of the National Cancer Institute Monographs, No. 40, 2010
Figure 1. Multidisciplinary treatment care (MDC) intervention across transitions in cancer care.
Rationale and Definitions
Tumor Boards
Traditional cancer treatment strategies began with individual consultations initiated by the internist or family practitioner with the
relevant cancer specialist and subsequent patient referral to other
specialists for specific cancer care treatments. The tumor board
(also called a cancer conference) evolved as a formal attempt to
engage multiple specialties, such as radiology, surgery, pathology,
radiation oncology, and medical oncology, in cancer care to collectively review complex cases or newly diagnosed patients (10).
These discussions are typically held on a monthly basis, following diagnosis and primary treatment and without the patient or
family present. They are essentially consultative, with the collective knowledge of the tumor board enabling the physician in
charge to evaluate the effectiveness of treatment recommendations. The tumor board usually considers the patient’s situation at
one point in time only, not along the treatment pathway. Given
their collective “conference” structure with all major specialties in
attendance, tumor boards can facilitate multidisciplinary treatment
planning (11,12).
Journal of the National Cancer Institute Monographs, No. 40, 2010 Over time, tumor boards have shifted focus somewhat toward
prospective treatment planning as a way of building consensus
about diagnostic and management decisions. In fact, the
Commission on Cancer now requires that at least 75% of the cases
presented to tumor boards be prospective (13). Patients also may
be presented several times (in absentia) to the tumor board for
further treatment decisions or as a follow-up to “close a loop” from
a previous meeting.
Multidisciplinary Care Teams
With growing emphasis on multimodal therapy, the coordination
of cancer care continues to evolve from the tumor board to a more
proactive, interactive structure involving a broad range of specialists (14). Although the tumor board engages multiple medical disciplines to inform the patient treatment plan, the physician
presenting the case ultimately weighs the recommendations and
determines the course of treatment. MDC teams, however, allow
for collaborative consultation continuously along the treatment
pathway. This approach permits the consideration of the cancer
patient’s psychosocial needs in the development of care pathways
73
and protocols, referral networks, and research trial eligibility. Two
key elements distinguish MDC teams from tumor boards: “the use
of a team structure” and “involvement of the patient” (7). The team
concept is integral to the effective functioning of multidisciplinary
care, given the need to communicate and collaborate among the
clinical and other affiliated disciplines. Patient involvement with the
MDC team is essential to ensure patient-centered care as well as
patient and family understanding of diagnosis and treatment options.
Treatment Processes and Team Composition. Typically,
MDC teams within oncology are disease focused—for example,
head and neck, breast, thoracic, or genitourinary (5,7,11,15). The
core disciplines integral to the multidisciplinary approach to cancer
care are medical oncology, radiation oncology, surgical oncology,
cancer site specialist (breast and thoracic), primary care, and nursing
(4,10,15). Although the PCP is sometimes listed as an essential
member of the MDC team (10), there are no empirical studies available that establish how frequently this actually occurs or under what
conditions PCP membership on the MDC is most likely to occur.
Nor is it clear from the anecdotal studies of MDC teams whether
and how often the PCP works actively with the MDC team.
However, philosophically and practically, primary care seems essential to facilitate the continuity of medical management of a suspicious
malignancy and to coordinate all of the care the patient receives over
time. Consequently, in oncology care, primary care plays an important role in postacute and posttreatment care as well as in consultation regarding other chronic illnesses that the patient experiences.
Additional medical disciplines represented on the MDC team
may include pathology, pulmonology, diagnostic radiology, interventional radiology, and gastroenterology. Furthermore, to integrate quality-of-life considerations and support services during
and subsequent to treatment, psychologists, social workers, nurses,
nutritionists, and clergy or spiritual advisors also may be necessary.
These additional team members may be physically present at the
MDC meeting or available for consult. This ensures that the
patient is informed and guided during and after treatment, from
inpatient status to outpatient status, moving patient care prospectively (12,16). Table 1 summarizes the ways in which the MDC
team has differed historically from tumor boards, although in practice these distinctions can sometimes be blurred and models can
blend various dimensions (17).
MDC Team Intervention. The Zapka et al. (2) model of the cancer
care continuum assumes that each patient transitions through different types of care after diagnosis. Through these transitions, the
MDC team can play an important role by facilitating communication and prospectively addressing the psychological and physical
effects of therapy and/or cancer on a patient’s quality of life. We
have elaborated on Zapka’s model to indicate where the MDC team
can intervene to improve the delivery of care. Figure 1 displays
transitions in care beginning with diagnosis (which is often initiated
by a primary care encounter that occurs outside of the hospital or
cancer center) through end of life, recurrence or remission. Those
intervention points include the following: 1) changes in major
treatment modality through the cancer experience (eg, surgery,
radiation, chemotherapy); 2) posttreatment survivorship care and/
or surveillance, which occurs following treatment; and 3) decisions
to engage end-of-life or palliative care, which require a modified
treatment plan (3). An important feature of the MDC team
approach is that a patient can experience MDC team intervention
at different points in the illness experience. For example, survivorship care plans developed by the oncologist in coordination with an
MDC team either during or following the initial MDC meeting are
intended to outline routine follow-up at the completion of the
treatment regimen. The plan, transferred from the oncologist on an
MDC team, includes monitoring for new or recurrent tumors and
ongoing health promotion, all of which is presumably coordinated
by the PCP. If a tumor recurs or a new tumor is found, then intervention of the MDC team would be necessary again. Thus, the
interfaces between specialists and PCPs in follow-up care are critical, but the specific pathways and methods for handling those
interfaces are not well understood (18–20). Further, Haward et al.
(21) have described the difficulties in defining the actual MDC
team for breast cancer, given team members will sometimes exist or
join midstream over the entire process of treatment.
The Structure and Operation of
Multidisciplinary Teams
The “multidisciplinary care” label is used quite widely in contemporary cancer practice to describe diverse care structures, some of
which look more like tumor boards than MDCs. So far, we have
identified two important dimensions of team focus that can be used
Table 1. Comparing tumor boards and multidisciplinary care teams
Dimension
Tumor boards
Multidisciplinary treatment care teams
Stage of cases
Newly diagnosed; complex cases
Approach
Focus
Consultative; advice provided to lead MD
Treatment only
Primary purpose
Participants
Education and training
Open to any practitioner
Timing
Case review
At one point in time
Retrospective; prospective planning potential
more recently
Face-to-face only
Physician in charge
Absent
Functioning
Treatment decision process
Patient
74 Newly diagnosed, complex cases, plus “repeat” cases at
later stages
Collaborative, consultation between all members of team
Treatment and patient’s quality of life (rehabilitation;
psychosocial needs; long-term care)
Planning treatment and care management
Focused on care team responsible for managing patient
care for specific disease site
Multiple points along treatment pathway
Prospective
In-person or virtual
Consensus
Encouraged to be present
Journal of the National Cancer Institute Monographs, No. 40, 2010
to differentiate MDC teams: a focus on specific disease or tumor
sites and a focus on the care continuum, from active treatment
through end of life. A third dimension deserves discussion: the
distinction between “actual” vs “virtual” teams. Actual teams perform their work (consultation, care planning, changes in care plans)
with all teams members present at the same time and place. This is
similar to Thompson’s (22) notion of a “mediating” coordination
structure as the best strategy to use when faced with complicated
“reciprocal” technologies (tasks that require feedback and communication between all performers). Virtual teams are those in which
team members do not meet face-to-face, or do so only infrequently.
Using a virtual team strategy, the MDC would operate similarly to
either a tumor conference (meeting only once) or the traditional
pattern in which patients are seen in a sequence of separate appointments with multiple physicians over a short period of time. Virtual
teams are similar to the concept of “teams without colocation”
described by Hinds and Bailey (23).
The locus of coordination differs between actual and virtual
teams. For actual teams, care coordination occurs within team
meetings and care options are discussed “live,” as would follow-up
coordination. Careful records of care plan decisions made during
MDC team meetings (eg, use of a treatment summary document
as recommended by the Commission on Cancer), and their communication to all team members, is essential. Virtual teams rely
upon coordination through a staff or clinic coordinator and require
formally structured communication.
In the rest of this section, we review what is known about
important characteristics of team structure (the formal design, rules,
arrangements, and divisions within teams) and team processes (the
ways in which teamwork is performed, the activities involved in teamwork, and the interactions that take place between team members).
We are particularly interested in examining how team structure and
process can affect team performance, and the relationship between
team performance and patient care processes and outcomes.
Team Structure
Most studies of team structure within both the cancer-related and
general health-care delivery literatures tend to conceptualize team
structure as either team composition (24,25) or team size (26).
Generally, the influence of both variables on team performance or
patient outcomes is mixed. The composition of the team is contingent upon type of disease and whether the team pursues a limited
focus or one that encompasses the entire care continuum. The
influence of team size is nonlinear: Effective teams require a minimal size to cover needed disciplines; size increases as the complexity
of the tumor treatment increases and management focus broadens.
However, larger teams are generally more difficult to coordinate,
and thus, larger size tends to correlate with poorer team performance and patient outcomes (27). It is also worth considering how
the presence of nonspecialty care MDs might create more challenges than added value to the MDC team process, particularly
when team size approaches 10 or more members, when not all
members are relevant to a given discussion, and when team membership may not be constant across the treatment process.
Several articles have provided descriptive information on the
process of organizing MDC teams, sometimes including team
structural issues. Boon et al. (6) emphasize the level of structural
Journal of the National Cancer Institute Monographs, No. 40, 2010 complexity in describing team-oriented practice types and how
hierarchy formally defines roles within the team. Wright et al. (10)
describe province-wide (Canadian) standards for MDC models,
which mention a number of team structure issues, such as whether
statements of team mission, goals, and objectives exist; whether
team protocols for meeting schedules, agenda, and minutes have
been developed; whether the team has access to technical support
for information technology, data needs, and coordinating staff; and
whether the team has adopted statements of standards and/or
medical guidelines. These descriptive pieces are helpful, but
empirical data on team structure are lacking. Moreover, little work
has been done on leadership structure within teams, including
leadership rotation, selection protocols, or length of term.
Team Process
A much larger literature exists on multidisciplinary team processes.
Team processes have been defined through a wide variety of variables, from the standard emphases on team coordination and communication factors, through team climate, culture, and identity issues.
A number of these studies are summarized by Lemieux-Charles and
McGuire (25) in their excellent review of health-care team effectiveness. Among the key findings are that 1) full participation of all
team members is considered necessary for MDC teams to function
effectively, although status differences among team members may
depress team functioning (26,28); 2) teams with shared egalitarian
values tend to work together effectively, leading to improved team
performance, although value structures and the degree of meritocracy at team formation influence performance (18); and 3) team
coordination improves team performance, but this effect can be
diluted or mitigated by the emergence of conflict (29).
The Impact of Team Process on Team Performance and on
Quality of Care in Cancer Treatment. The literature also
describes how team processes may affect team performance or the
process of patient care. Following the model of the cancer care continuum by Zapka et al. (2), if the interfaces between treatment stages
are improved, then ultimately both patient care quality and patient
care outcomes will improve. The literature on health-care teams
has defined MDC teams as a crucial mechanism for improving
“integrative health care” (6) and “collaborative health care” (30).
However, the literature has scant quantitative evidence on the relationship between team performance and clinical effectiveness.
Lemieux-Charles and McGuire (25) summarize the literature on
health-care team performance as lacking specificity in conceptualization of team performance and having inconsistent empirical
results. Our limited review found at least four different conceptual
and measurement approaches used to assess team performance:
•team “functioning” (26), which can be thought of as team
process variables, such as coordination mechanisms and
conflict (31);
•clinical- or patient-reported outcomes, such as improved health
(6,31), patient functional status (26), or other measures of
patient, family, staff satisfaction (32);
•the “quality of the team’s work,” which uses indicators such as
timeliness, productivity, accuracy (21), and goal achievement,
which encompasses meeting standards, compliance with clinical
75
practice guidelines (33), and innovation in treatment (25); and
•indicators of organization-level efficiency, such as care cost and
cost-effectiveness (6).
Of these measures, the third set—in particular, indicators of
team performance and innovation—appear most promising for
defining and measuring team performance in terms of qualities
that describe how people work together as members of an MDC
team and the effectiveness of their work together.
Organizational Layers Surrounding
Multidisciplinary Teams
Setting
MDC teams function within varied organizational cultures that can
facilitate or impede the quality of care provided to patients. Both
organizational culture and management support are contextual elements that operate in private practice as well as hospital settings.
Organizational culture (as distinct from the team’s culture) as well
as teamwork have been associated with variation in quality of care
in quality improvement research (34,35). For example, MDC teams
located within hospitals that value cross-disciplinary consultation
are more likely to flourish compared with MDC teams embedded
within hospitals where medical specialties are firmly placed in
“silos.”
Recognizing that a variety of culture types exists within organizations, Bosch et al. (35) measured organizational culture as four
distinct types: “group,” “developmental,” “rational,” “and hierarchical”. Three of these culture types are relevant to discerning the
impact of organizational context on team performance: 1) the
“group culture,” which highlights participation, teamwork, and
cohesiveness; 2) the “hierarchical culture,” which highlights coordination, stability, rules, and regulations; and 3) the “developmental culture,” which highlights innovation, change, and flexibility.
Management support to implement MDC teams within the
practice or hospital setting is another aspect of context that affects
team performance. In a study within clinics of the Department of
Veterans Affairs, Lukas et al. (34) identified the personal support
of organizational leaders and their willingness to reward care
delivery teams as strongly associated with greater implementation
of a clinical innovation and team effectiveness. Of course, practical management support of team activities through the provision
of necessary resources also has a positive effect on team
performance.
Professional Factors
The organizations where multidisciplinary cancer professionals
normally work can influence clinician behavior within MDC teams,
particularly if team members are subject to different financial incentives, referral policies, or hospital and/or practice characteristics (location, composition, and management oversight) (36). Different
medical specialists and affiliated health professionals are all subject
to the specific norms and expectations of their own professional
groups, and these do not always align (37). For example, the professional values of social workers are considerably different from those
of clinical oncologists. Normative influences, such as expectations
concerning the nature of professional interactions, also may inform
styles and standards of practice (38). The practice policies of
76 “home” organizations may favor medical specialists and thus define
whether clinicians participate on MDC teams and the nature of
their participation. For example, if the specialist clinician works in
a setting where MDC team participation is highly encouraged and
colleagues are actively engaged in MDC teams, he/she would be
motivated to network with neighboring hospitals and cancer programs. In contrast, if one of the specialists on an MDC team practices at a competing hospital, the likelihood of collaboration for
patient-centered care would be low. Collaboration can also be
linked to reimbursement and financial incentives.
External Factors Influencing
Multidisciplinary Care Teams
Several important environmental factors (or external layers of context) also are likely to influence team functioning. This influence
can be examined using the conceptual framework provided by institutional theory as applied to health-care organizations (39,40),
which emphasizes two categories of environmental constraints:
technical and institutional. “Technical environments” not only
relate primarily to market structures, economic health of the environments, and production concerns but also include demographic
characteristics of local communities, geographic location (such as
urban vs rural communities), and technological concerns (such as
availability of state-of-the-art treatment facilities, health-care
personnel). These sorts of factors provide direct and measurable
feedback to the organization about how well it is performing.
“Institutional environments” involve the social and political structures to which organizations must conform, including public opinion, legal structures (41), professional expectations and ideologies,
and regulatory structures (42–45), which include state and federal
reimbursement mechanisms and rates, and the expectations and
reimbursement practices of major third-party payers within the
community. Feedback from these environments may be explicit
(such as receipt of accreditation) or normative (what the benchmark
hospitals have adopted), but they are at best indirectly related to
how well the organization is performing. Institutional theory also
includes an emphasis on structures of connections or linkage
between organizations as strategies to control access to resources,
confront institutional constraints, and reduce environmental uncertainty (46,47).
We can apply this framework to consider a number of the
major external factors facing multidisciplinary teams in cancer
care. The structure of both cancer services and hospital markets
are important aspects of the technical environment that can influence the scope of operation and success of MDC teams. This
would include levels of competition for cancer services in the local
market, market position of the focal cancer program and the host
hospital, managed care penetration, market concentration, and
presence of one or more academic medical centers. Location of the
MDC team and its host cancer program in either an urban or rural
community can significantly influence which type of team structure is even possible. Virtual teams, integrating telemedicine technologies, are more common within rural areas because cancer
specialists may be significant distances away from the physical
location of the cancer program. Using factors in the institutional
environment, MDC teams may be embedded within regions where
Journal of the National Cancer Institute Monographs, No. 40, 2010
major third-party payers do not provide an option for reimbursement of physician time devoted to MDC team conferences or to
hospitals where MDC teams are sponsored. The development of
collaborative linkages between hospitals and other health-care
providers to diffuse innovative treatments in cancer care has been
examined, and those linkages may enhance the survival and effectiveness of MDC teams (48,49).
Modeling Team Context, Structure, and
Process and Their Influence on Team
Performance and Patient Outcomes
Prior attempts to conceptually model the influence of MDC teams
on quality of care have suffered from an exclusive focus on the
effects of team process, or by defining team structure only as team
composition (24). Most models have not considered the impact of
context and environment on the development of team structures
and processes (50), and they have not considered the direct and
indirect effects of team structure and process on team performance
or on subsequent changes in care process or quality-of-care differences. Further, extant models have not conceptualized the MDC
team as a longitudinal structure, nor have they included change
over time in team composition or structure as either a correlate or
covariate of change in treatment stage or transitions across stages.
As summarized by Lemieux-Charles and McGuire (25), Wright
et al. (10), and Houssami and Sainsbury (50), the empirical results
of the extant literature are at best inconclusive and not consistently
embedded within a conceptual model.
We propose a conceptual model that builds upon two prior,
well-known theories: Donabedian’s framework for linking
structure–process–outcomes (51,52) and a contextualization of
Donabedian’s framework based on institutional theory, in which
MDC teams are embedded within hospitals or health-care organizations, and further embedded within technical and institutional
layers of the larger organizational environment (24,25,53). Our
model includes the contextual influences of hospital or health-care
organization characteristics and the additional external influences
of the technical and institutional environments of health-care
organizations as well as the causal relationships between MDC
team structure, team process, team performance, and both process
and outcome measures of patient-level quality of care. In brief,
both structure and process are primary determinants of health-care
organizational performance. The model assumes that if highquality structures and processes are put into place, good performances will result.
Figure 2 displays the core of our model for conceptualizing
MDC team influences on the quality of patient care: Donabedian’s
structure–process–performance trilogy, surrounded by multilevel
characteristics of the hospital or health-care organization in which the
team is located, and by characteristics of the larger environment
within which the hospital is embedded (market, population demographics, urban–rural location, and institutional pressures). The
focus on the Donabedian trilogy is extended to include the link
between team performance to changes in patient care processes
(such as efforts to improve the interfaces between stages of cancer
care and communication and coordination between multiple care
providers), to intermediate outcomes (such as increased accrual to
Journal of the National Cancer Institute Monographs, No. 40, 2010 clinical trials), and other care outcomes (such as survival rates,
patient satisfaction, and improved functioning). Figure 2 also summarizes visually where our knowledge base on MDC teams is
strongest (solid bold arrows) and where it is weak (dotted arrows).
The figure itself only provides the skeleton of a conceptual framework; the exact specification of relationships expected between
variables of context or environment and team structure, process,
and outcomes is beyond the scope of this article. However, we have
provided some preliminary indications of where relationships
are expected in our review of organizational, professional, and
environmental factors that might influence team functioning.
Taken by itself, Figure 2 also does not provide an explicit
framework for incorporating our concerns about change over time
in team composition and structure. However, considering Figures
1 and 2 together may provide a method for considering timing of
both MDC team interventions and stages of the MDC team “lifecycle” where team composition may change. Figure 1 identifies
three possible transition stages in the cancer care continuum where
MDC team intervention may be needed; those three transition
points are suggested as a minimum, as there may be additional
points to consider. Those transition points may also correspond to
stages where team composition may or could change, as different
care issues become more or less dominant. For example, the initial
MDC team meeting would require full attendance by all practitioners, both primary and specialty care, and including nonmedical
specialists related to survivorship issues for a particular patient.
The second intervention point corresponds to the transition
between preoperative treatment (if needed) and primary treatment; at this stage, cancer specialists and the PCP would be most
needed. And finally, the third intervention point occurs between
the completion of primary and adjuvant treatment and the transition to survivorship, palliative treatment, or end-of-life care. At
this transition point, the team membership might emphasize
primary care and nonmedical specialists, with less input needed
from the cancer specialists. Thus, at each transition point, there
may be changes in active team composition, and in team processes,
to best align with contingencies faced at each stage.
Directions for Future Research
Despite the research advances on the organization, functioning,
and performance of health-care teams, our understanding of the
prevalence of various forms of MDC teams in cancer care and our
knowledge of what affects the performance of MDC teams still has
many gaps. Major unanswered questions include the following: In
what circumstances do which types and structural configurations of
MDC teams function best? What characteristics of physicians and
other clinical specialists lead to optimal team performance and for
which disease sites? What external regulatory influences (especially
reimbursement incentives) prohibit or enhance the sustainability of
MDC teams in private practice and community cancer centers?
Perhaps the most important question of all is: Which MDC team
models and configurations lead to optimal patient outcomes, in
terms of improved cancer and overall survival, patient experience,
and health-related quality of life?
These gaps in knowledge reflect in part a lack of attention to
research applications in cancer care delivery. Our review found
77
EXTERNAL FACTORS
HEALTHCARE ORGANIZATIONAL CONTEXT: SETTING & PROFESSIONAL
CHARACTERISTICS
Team Focus & Structure:
Team
Performance
Team
Process
Care
Processes
LINKAGE ENVIRONMENTS
TECHNICAL
Virtual vs. Actual
Acve Care vs. Connuum
Disease Type
Paent
Outcomes
INSTITUTIONAL
NOTE: The bold arrow linking team process to team performance represents the relave abundance of studies on this connecon,
whereas the doed arrow symbolizes the lack of research on the effects of team performance on cancer care processes, or of
external factors on team structure, process, or performance.
Figure 2. The organization of multilevel effects on multidisciplinary treatment care teams and their impact on cancer care processes and
outcomes.
scant research relating to how cancer specialists work together as
clinical teams in either virtual or actual MDC team settings. With
the exception of some research in breast cancer, very little attention
has been given to the patient experience in different multidisciplinary care models and how patient experience, care support, and
health-related quality of life is affected by “dose–response” or the
amount, duration, and scope of MDC team involvement. Almost
no research exists comparing the different models and how performance attributes (eg, team cohesion, coordination of care, adherence to guideline-based care, reduced costs, and improved
outcomes) vary by characteristics of the breadth of specialties and
subspecialties, the organizational setting (eg, academic based vs
community based), and the environmental context within which
these programs function. In particular, the relationship between
MDC team involvement and physician and patient engagement in
clinical research, including clinical trials, is a high-priority research
topic. Finally, we need to further develop our conceptual models of
MDC team settings or context and team structure and functioning to
actively consider change over time in team composition. MDC
teams are not single-dose interventions; they are longitudinal care
78 structures that require theoretical approaches that go beyond the
more typical cross-sectional snapshots of team structure, process,
and performance.
Even if more research applications in cancer specialty care were
pursued, a problem would still exist. Although much can be
learned from existing studies of team-based care in other diseases,
much of that literature is descriptive. Intervention studies are
needed to create the foundation of empirical evidence to understand how MDC team structure influences MDC team processes
and ultimately influences MDC team performance. In particular,
studies of how team composition, culture, organizational characteristics and environmental factors either directly affect MDC
team performance or serve as key mediators or moderators to its
success are needed. These studies are rarely done in any disease
context but are especially needed in cancer care if the organization
of cancer treatment services will keep pace with the future trajectory of personalized medicine.
Understanding these complex interrelationships is challenging
and we hope that the conceptual framework described in this
article will assist in thinking through these issues. In particular, we
Journal of the National Cancer Institute Monographs, No. 40, 2010
hope it will guide measurement work to better understand how
these different levels of influence—the microsystem of provider
and patient interfaces, the mesolevel of organizational structures
and team processes, and the macrolevel of the market and policy
environment—influence MDC performance, and in turn, patient
and family outcomes. Only then can we begin to understand the
potential for multidisciplinary care to become a foundation for
optimal cancer care delivery in the 21st century.
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Affiliations of authors: Department of Sociology, Brown University,
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Journal of the National Cancer Institute Monographs, No. 40, 2010