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Table 1 Barriers to Optimal MCC Decision Making

From: Use of the theoretical domains framework and behaviour change wheel to develop a novel intervention to improve the quality of multidisciplinary cancer conference decision-making

TDF DOMAINTHEMESQUOTES
KnowledgeLack of awareness of CCO (governing body) guidelines regarding which cases should be discussed at MCC“I didn’t even know CCO guidelines existed” – P16
 The quality of the discussion and decision making process is contingent on the amount of knowledge the MCC participants hold“I’ve spend forty-five minutes at looking at the patient’s imaging having partial information … [this discussion is] kind of poor quality or sub-par, it has no place there. The level should be higher than that. – P3
Memory, Attention, Decision ProcessesMCC chairs do not always control the flow of MCC discussion“It gets frustrating because the discussion goes on way past the decision making point and we going to get into “at nauseum” discussions where there cannot be a black and white answer ... the discussion is out of line” – P8
 Presenting physicians (MRP) are not prepared for MCC discussion“I mean, we’re all players in there, they [surgeons] ask us [diagnostic imaging] to prepare for those rounds. I think it’s unacceptable that they’re not prepared for the rounds, you see what I mean? If they have two patients that they, at least for their patient, they have to know everything, and they should review [the reports]” – P3
 There is no standard format for presentation of cases or processes of discussion/decision making“What had been happening is we would print out the case list, me or, generally the nurse, would scribble the decision, and it would get put in a binder, and once again they get thrown out. So there was no way to even go back and document “Oh, this person’s been discussed on three different occasions,” or to pull up the last discussion” –P3
 The right specialists are not in the room at time of MCC discussion (linked to time demands)
- Practice site (community, academic) influences attendance and subsequently, decision making
“We’re limited in doing the multidisciplinary rounds by, usually by surgeons’ availability, because their time is [limited], we can’t really meet at lunch because they’re in the O.R. and, so, you know, we’re limited by that” –P4
“I’m in a difficult spot because I’m the sole oncologist [at a community site], so I have to attend so many MCC, but most people at academic centres, you’re one of 15 oncologists, so if you don’t show up, one of your colleagues will” – P1
 Decisions vary by the individuals present
- Hierarchy (age, seniority) influences decision making
“[There is] definite variability based on who is in the room. So the most is in surgery ‘cause you know, one surgeon operates, and the other feels like they can’t operate, so there’s a lot of surgical variation” –P7
“or even though we try to do evidence-based, sometimes the trial that we base our evidence on is not, not the best, right, and some people will say ‘Well, I’ll still use that data’, and some people will say ‘Oh, I’ll throw it away’” – P1
“There’s standard of care, then there’s a bit of art to oncology, and there’s different ways that people do things” –P1
EnvironmentGroup mandates to mitigate time demands (e.g., max number of cases, deadline to submit cases) are not always effective“Part of the frustration with MCC is the turnaround time...So for example … you have to have your case emailed in by Wednesday, or whatever it is to get on for the next week...well I see my new patients on Wednesdays, right, and so I will often... say “Please, please [discuss my case]” – P2
 Inadequate administrative supports (community and academic sites)“It’s a lot of legwork, that maybe academic [sites that have coordinators] don’t really appreciate, you know, but certainly I’m [med onc] the one who has to get that [imaging] disc, get it to the right person, make sure it’s uploaded, and sometimes I’ll go [to MCC] and my disc is not uploaded, so I can’t present [my case]” –P1
“I have no secretary, essentially. We have one on paper, and I ask her [to do] something and she [cannot] … seriously, no, no, I’m not joking, so we have no clerical help” –P3
 Inadequate physical resources (space, technology, access to imaging)“The teleconferencing itself, it’s a complex process, sometimes it’s time consuming, we don’t always hear each other that well” –P6
“We have barriers here with our technologies so it takes forever to load up images...and the computers we use are too slow I think, they always seize up”-P9
“So you have a problem, you’re in the room, and then you have somebody knocking at the door and saying ‘We have the room at five o’clock, so please finish your rounds” –P3
Social InfluencesLack of soft skills (e.g., effective communication, collaboration) among group“Groups, really, where people are not really collaborating...I mean, some people have pretty, can have pretty bad attitudes, and that’s known, right, and we have some rounds that work not as well as others for that reason” –P3
“We’re [a] pretty collegial group, so in our own environment there’s not much of a conflict, we can call each other idiots or swear but it’s very benign” –P12
“I was sitting around the table and [was able to] stop the side discussions and all the joking and all the irrelevant stuff but it’s much more difficult when you’re sitting here and you see them on TV [satellite site] making jokes and stuff” –P6
 Negative group dynamics/ Bullying“I can certainly see in certain centres there may be bullying from one group to the other or from one physician to the other. It’s just like high school” –P12
 Lack of psychological safety (ie: ability to ask questions/ make mistakes)“But the folks [at certain MCC] will be a major pain … they make you feel stupid … and I can name names of oncologists … who won’t go back to those rounds because they’re made to feel stupid at the rounds” –P2
 Certain individuals dominate the conversation“Well everything is always driven by a few people but there is always an opportunity – no body is shut down. If they don’t speak, its because they choose not to” –P12
“[at some rounds] we have forceful individual who want to take over, want to shine” – P3
Social/Professional Role and IdentityThe desire to discuss cases collaboratively at MCC is not tied to professional role/identity (i.e.: some physicians don’t feel that they must attend MCC in order to effectively fulfill their professional role)“The impact of that [MCC] would be extremely minimal. If you’ve got a well-trained clinician, they can decide which [cases] need to be discussed” –P9
 Preference of ‘solo practice’ versus ‘collaborative style’ defines willingness to regularly attend MCC“The other barrier to that is that surgeons are very proud and autonomous in the way that they want to perform in operation and they don’t want to take criticism very easily and so volunteering to subject yourself to scrutiny and criticism may not be very acceptable to a lot of surgeons” –P7
“I mean, the problem that I have with [not attending] is that I find it hard to believe that anyone in a large-volume centre that treats very complicated cases doesn’t have any cases where they need peoples’ help ... how could you be treating two-hundred people a year and not have questions on, like, 10% of them, I mean, it just doesn’t make any sense” – P14
 Professional identity (linked to specialty/ hospital site) and beliefs dictate treatment recommendations and preferences“When [academic physicians] go out [to a community site], they [community physicians] get their backs up and they resent the fact that you’re the “professor” coming … and it’s like ‘Huff, you think you know more than me!’ – P14
EmotionEmotions during MCC discussions can run high and lead to conflict“There is definitely conflict” – P1
“Every once in a while, some good-old fights break out” – P2
 Feeling underappreciated; undervalued in the MCC decision making process“Nobody, honestly, has the appreciation of the amount of time … we [radiologists] put in those rounds and the time it takes … no clue or no appreciation, or no idea, actually, how detailed and how, the amount of time we have to spend at looking, at looking at [the images] –P3
“The fact that they [radiologists] do as many MCC as they do with no direct compensation whereas everybody else in that room is [compensated] in some form. It’s not fair” – P8
 Emotion and recent experiences affect decision making“The one thing that’s hard to capture is the mood that the physicians are in – there can be fluctuations in the mood where you can present the same case weekly three times, and get a different opinion depending on the mood of the specialists that may be involved in the decision making”–P12
Beliefs about capabilitiesCapacity to make a decision is limited when there are conflicting decision recommendations“You’ll see them arguing over, you know, long-course radiation chemo-radiation versus short-course, and sometimes whether you need any radiation pre-op if you do a good TME (total mesorectal excision). So as a non-surgeon, non-rad onc, it’s quite confusing when I make the referral and then we have two completely different opinions, and I think a lot of medical oncologists feel that same way, that on that particular issue, that we’re a bit lost” –P1
 Individuals use MCC to empower their own decisions“In as much as that if something goes wrong, at least I can say ‘Well, it wasn’t just my decision, it was everyone’s’” –P16
“You know, if somebody attends tumor boards regularly and you like the way they think and their opinion then you’re more likely to want to work with them … And by virtue or referring to that person, you refer less to the persons that you don’t like” –P7
Beliefs About ConsequencesThere are little to no perceived negative consequences to individuals not participating in MCC discussion (as long as the hospital site meets the minimum provincial requirements)“There’s unfortunately no consequence to not attending tumor board” –P12
 Perceived consequences around the impact of MCCs on patient care is positive“I think there are advantages personally and I think there are advantages for the patient” –P4
Behavioural RegulationRegulation takes place at a hospital level, and not individual level (theme correlates with beliefs about consequences)“The surgeon wanted to do a radical prostatectomy, everyone, even all of the surgeons were like ‘No!’ like, “This is wrong’, and he did it anyways” –P14
ReinforcementsCarrots vs. Sticks: Beliefs that lack of ‘sticks’ is a barrier to efficient MCC discussion and decision making“If people can’t comply [with MCC goals] you either say ok we’ll let inefficiency reign … and offenders will stay offenders … or you’re gonna say no were serious about this, therefore the rules are absolute” – P8
“I don’t believe that carrots help. Going to MCC and learning, it should be a carrot enough. So, I think, I think there’d have to be a stick. It would have to be, if you don’t show up, then you lose... ‘you lose money, you lose ability to see patients’, or whatever it is. You theoretically could give people a financial bonus to go but I have a philosophical problem with paying people for things they should be doing already” –P14
“It’s hard to police that though unless you have, you really would need a physician champion, who’s senior enough and has the authority to say “Well, that’s your question [which wasn't submitted according to protocol], we’re not reviewing that this week.” –P17
OptimismEvidence of disfavor for CCO guidelines regarding which cases to discuss at rounds/ how MCC are evaluated“Well their [CCO’s] intent is to try and encourage MCC to happen, I think they’re a little bit too prescriptive and they’re not practical for some disease sites and some institutions. Same thing with the sub-specialties that are required to be there, it is not always logical to have all the sub-specialties there. For instance, from the perspective of hepatobiliary rounds, radiation oncology is not usually all that common” –P9