Complex pathologies associated with chronic health conditions must be dealt in a coordinated way and the ‘multidisciplinary team’ approach (MDTA) represents the most efficacious way of managing these patients. Over the last 25 years, the initial limited field for joint interventions by several specialists has been progressively expanded and this article reviews some of the conditions in which the MDTA has found useful application.
This has been the case in fields as diverse as primary healthcare, oncology, diabetes, cardiovascular, chronic kidney diseases and high-risk pregnancy. In the latter situation, an MDTA can offer clear advantages for pregnancies in solid organ recipient women. In these patients, a close collaboration is mandatory between a series of dedicated physicians (including, but not limited to, infertility and maternal–foetal medicine specialists, obstetricians, paediatricians, transplant physicians, geneticists and psychologists). Such a team should be active before, during and after pregnancy and should cope with all their reproductive health needs.
Introduction
During the second half of the twentieth century, advances in biomedical research and its applications in clinical management made it inevitable that medical and surgical disciplines once lumped together under the common name of ‘internal medicine’ and ‘general surgery’ be subdivided into dozens of specialties. Even disciplines once considered ‘a specialty’ were subdivided into sub-specialties.
Subdividing fields of research and clinical practice into a myriad of diverse compartments presented clear advantages and contributed in a major way to the incredible accumulation of knowledge that took place around the turn of the millennium. In spite of this, it was soon realised that even the ‘world of specialties’ had its drawbacks, as complex pathologies associated with chronic health conditions had to be dealt in a coordinated way. This reality convinced many that in specific cases the health-care system had to redesign the way to deliver the best care to critically ill patients. The diverse needs of certain types of patients forced specialists to come together to meet the high demands of these cases and to best utilise available resources. Indeed, from a public health perspective, at a time when every health system around the world is under pressure to optimise spending, the rational use of resources has become mandatory.
Over the last 25 years, the initial limited field for joint interventions by several specialists has been progressively expanded, as – if properly implemented – a cooperative approach to all the needs of an individual complex patient provides positive results that can be objectively measured.
This article looks into the diverse realities of what has come to be known as the ‘multidisciplinary team approach’ (MDTA) and, after providing representative examples of its many applications, focuses on how multidisciplinary teams (MDTs) can be usefully employed in improving pregnancy outcomes in women with a solid organ transplant and serve their reproductive health needs.
The multidisciplinary team approach
A few years ago, Baldwin reconstructed the path that led to the creation and development of the interdisciplinary health-care approach in the USA; he believes that the idea came from the success during World War II of multidisciplinary medical and surgical teams. In terms of public health, the applications of the concept were a consequence of President Johnson’s vision of ‘The Great Society’ where the poor and underserved had a right to access appropriate health care which could be best achieved through the creation of multidisciplinary community health centres providing comprehensive and continuous care to all citizens.
In other parts of the world, as spelt out by Hall and Weaver , conceiving a ‘team approach’ was the result of two main factors: the ageing population, particularly evident in Western countries, with a consequential rise in the incidence and prevalence of chronic diseases, and the increasing burden of caring for cancer patients in palliative care. In these situations, the focus of medicine had to be shifted from the concept of ‘curing’ to that of maximising the quality of life and adjusting patients to life with long-term illnesses. Two conflicting requirements had to be coped with: on the one hand, an increasing complexity of skills necessary in providing adequate care to these patients, and on the other the fact that no single, specialised health professional could deliver such care. Often, specialists prefer to stay within their specific discipline where everyone utilises the same specialised vocabulary and shares the same theoretical basis in addressing and interpreting problems encountered during their work.
The educational and conceptual approach followed by individual specialists has been defined as the ‘cognitive map’ of a discipline and may lead to an unwanted consequence: members of two separate specialties may well look at the same issue and simply ‘not see the same thing’ . This may lead to challenging communication problems and even open conflict within a team; the ways to confront and resolve such conflicts have been presented by Drinka and Clark who called for ‘creative approaches to intra-team conflicts’ . The same group has now developed a conceptual framework to analyse the different types of ethical issues involved in inter-professional teamwork, which hopefully will help in confronting and resolving any possible conflicts. To break down barriers, Lary et al. have advocated the creation of ‘multidisciplinary education models’ for students, concluding that utilising concepts of problem-based learning may offer a solution.
An important variable in the functioning of a medical team is the interaction with the patient’s family, especially when, as it should happen, care moves out of medical institutions and the patient attempts to regain normality in her/his life.
In order to offer appropriate solutions to this multitude of issues, going beyond the ‘classic’ patient–physician relationship became necessary and the MDTA was born.
As the name implies, these teams are composed of specialists from different disciplines coming together to achieve a common goal. They can be of invaluable help in a variety of settings: health care (including mental health) is certainly a field where they can play a critical role; however, MDTs have been employed also in education and criminal justice, addressing a specific problem from all angles, providing comprehensive solutions capable of offering the best chance of accomplishing the set goal.
There are many perceived benefits to this approach : first, it gives a patient access to the right team of health-care professionals, who work together to plan the most suitable care option; second, it allows a full review of all the factors that may affect the treatment and help prevent unexpected problems; third, it may reduce delays in treatment and referral to services and less duplication of medical tests; and fourth, it facilitates transfer of appropriate and consistent information to the patient, as a holistic view of the situation can be provided.
In recent years, interest in the MDTA has increased exponentially and, since 2008, a specific forum exists for interdisciplinary studies: The Journal of Multidisciplinary Healthcare (JMDH) which aims to represent and publish research in health-care areas jointly delivered by practitioners of different disciplines.
The multidisciplinary team approach
A few years ago, Baldwin reconstructed the path that led to the creation and development of the interdisciplinary health-care approach in the USA; he believes that the idea came from the success during World War II of multidisciplinary medical and surgical teams. In terms of public health, the applications of the concept were a consequence of President Johnson’s vision of ‘The Great Society’ where the poor and underserved had a right to access appropriate health care which could be best achieved through the creation of multidisciplinary community health centres providing comprehensive and continuous care to all citizens.
In other parts of the world, as spelt out by Hall and Weaver , conceiving a ‘team approach’ was the result of two main factors: the ageing population, particularly evident in Western countries, with a consequential rise in the incidence and prevalence of chronic diseases, and the increasing burden of caring for cancer patients in palliative care. In these situations, the focus of medicine had to be shifted from the concept of ‘curing’ to that of maximising the quality of life and adjusting patients to life with long-term illnesses. Two conflicting requirements had to be coped with: on the one hand, an increasing complexity of skills necessary in providing adequate care to these patients, and on the other the fact that no single, specialised health professional could deliver such care. Often, specialists prefer to stay within their specific discipline where everyone utilises the same specialised vocabulary and shares the same theoretical basis in addressing and interpreting problems encountered during their work.
The educational and conceptual approach followed by individual specialists has been defined as the ‘cognitive map’ of a discipline and may lead to an unwanted consequence: members of two separate specialties may well look at the same issue and simply ‘not see the same thing’ . This may lead to challenging communication problems and even open conflict within a team; the ways to confront and resolve such conflicts have been presented by Drinka and Clark who called for ‘creative approaches to intra-team conflicts’ . The same group has now developed a conceptual framework to analyse the different types of ethical issues involved in inter-professional teamwork, which hopefully will help in confronting and resolving any possible conflicts. To break down barriers, Lary et al. have advocated the creation of ‘multidisciplinary education models’ for students, concluding that utilising concepts of problem-based learning may offer a solution.
An important variable in the functioning of a medical team is the interaction with the patient’s family, especially when, as it should happen, care moves out of medical institutions and the patient attempts to regain normality in her/his life.
In order to offer appropriate solutions to this multitude of issues, going beyond the ‘classic’ patient–physician relationship became necessary and the MDTA was born.
As the name implies, these teams are composed of specialists from different disciplines coming together to achieve a common goal. They can be of invaluable help in a variety of settings: health care (including mental health) is certainly a field where they can play a critical role; however, MDTs have been employed also in education and criminal justice, addressing a specific problem from all angles, providing comprehensive solutions capable of offering the best chance of accomplishing the set goal.
There are many perceived benefits to this approach : first, it gives a patient access to the right team of health-care professionals, who work together to plan the most suitable care option; second, it allows a full review of all the factors that may affect the treatment and help prevent unexpected problems; third, it may reduce delays in treatment and referral to services and less duplication of medical tests; and fourth, it facilitates transfer of appropriate and consistent information to the patient, as a holistic view of the situation can be provided.
In recent years, interest in the MDTA has increased exponentially and, since 2008, a specific forum exists for interdisciplinary studies: The Journal of Multidisciplinary Healthcare (JMDH) which aims to represent and publish research in health-care areas jointly delivered by practitioners of different disciplines.
Examples of MDTAs
Over the years, the MDTA has been applied to a number of areas in medical care. The following are examples of useful applications of the concept.
Primary health care
By the end of the last century, ample research in primary health-care settings had singled out a number of benefits when professionals are working as part of a supportive, well-functioning team , including better mental health and increased team effectiveness.
Some 20 years ago, Poulton and West began to investigate barriers to effective teamwork, outlined theories leading to team effectiveness and explored ways of applying these theories to primary health care. Their aim was the development of a model of effectiveness for primary health-care teams (PHCTs), which can be used to guide teams in their work. They compiled effectiveness criteria in four major areas: consumer outcomes, quality of care, team viability and organisational issues. Subsequently, they described four models to achieve team effectiveness: the goal model, the internal process model, the systems resource model and the constituency approach. The last seems to be the most appropriate for the working of PHCTs . They described applications of the constituency approach in developing measures of PHTCs’ effectiveness and outlined the disadvantages of the model exploring the next steps in research towards developing an improved model of primary health team effectiveness. Finally, they addressed the question of what predicts the effectiveness of PHCTs and found that clarity of and commitment to team objectives was the key factor in forecasting the overall effectiveness of the PHTC.
Oncology
An area where the need for MDT work is widely accepted is oncology and a country that pioneered this approach is the UK. Following the publication in 1995 of the Calman-Hine report dealing with the reorganisation of cancer services in that country, the new approach has been adopted in many centres in the hope of providing patients with the best care. Guidelines were issued specifically stressing the need for good communication between health-care professional members of an MDT, and between the MDT and patients to improve efficiency, bolster morale and provide better work satisfaction.
In 2001, Jenkins et al. published the results of a survey of the expectation of the role of members of an MDT working on breast cancer in providing information to female patients. They found that in most cases health professionals in a team were able to fulfil their roles and identified two or three individuals as the main providers of information for each topic, although the breast nurse invariably played a major ‘unseen’ role. The study concluded that in order for patients to receive comprehensive and consistent information, MDTs will require extra training, especially in communication skills and in how to effectively work together.
The same group subsequently analysed the different roles in conveying information to patients played by members of multidisciplinary cancer teams . The results show that, whereas the role of the surgeon, oncologist, radiologist and clinical nurse specialist was well recognised, the role of the other team members was less well understood. A point worth mentioning is the high level of emotional exhaustion in team leaders and nurses and the feeling of low-level personal accomplishment experienced by histopathologists and radiologists.
Today, in the UK, standard practise requires that treatment for cancer patients be planned at an MDT meeting, and it is now mandatory to treat cancer patients through MDTs. This approach is perceived as being capable of improving communication, coordination and decision making between health-care professionals and patients, especially at the time treatment options are evaluated . In addition, the MDT approach ensures better adherence to evidence-based guidelines, better decision concerning treatment and – more importantly – an association with better clinical outcomes including survival.
In spite of progress in this field, a study conducted a few years ago indicated that many practical barriers to the successful implementation of the MDTA still exist and that despite the increased delivery of cancer services by this method, research showing the effectiveness of MDT working is scarce.
Studies have also addressed the issue of assessing MDT working effectiveness and an observational tool has been developed that may contribute to the evaluation of their performance . Finally, relatively recently, the new and evolving role of MDT coordinators has been established. The duties of coordinators involve selecting topics and guiding discussions at MDT meetings, facilitating and coordinating logistics for such meetings and playing a crucial role in bridging the communication gaps. Their functioning has been investigated with the aim to assess their needs; the study identified unmet areas and training requirements, such as oncology, anatomy and physiology; audit and research; peer review; and leadership skills .
An interesting trial was conducted in the UK using telemedicine to carry out multidisciplinary meetings of an MDT managing breast cancer patients. Results were comparable to those obtained by on-site meetings and, if passing the threshold of 40 meetings per year, this approach became cheaper .
Diabetes
Uncontrolled diabetes represents a leading health risk for morbidity, disability and premature mortality, between 18% and 31% of patients also having undiagnosed or undertreated depression . For this reason, for years, a multi-disciplinary approach has been advocated for the long-term management of these subjects.
Back in 1995, a Scandinavian group published the results of a retrospective study aimed at evaluating the effect of a multidisciplinary programme for the prevention and treatment of diabetic foot ulcers in southern Sweden on diabetes-related lower extremity amputations over a 12-year period. They found that the annual number of amputations at all levels decreased from 38 to 21, with a decrease in incidence from 19.1 to 9.4/100,000 inhabitants ( p = 0.001). In addition, re-amputation rates decreased from 36% to 22% ( p < 0.05) between the first and last 3-year period. They concluded that the introduction of an MDTA produced a sustained long-term decrease in the incidence of major amputations, as well as a decrease in the total incidence of amputations in diabetic patients.
The MDTA to the long-term management of diabetic patients is now widely applied, and recently an American group reported on an effective team approach to the complex ambulatory care of these patients, with special emphasis on the coexistence of psychosocial and physical disorders. The management team, which included resident and faculty physicians, a pharmacist, a social worker, nurses, behavioural medicine interns, office scheduler and an information technologist, developed a package for the integrative care of diabetic patients during routine office visits.
An interesting variant of the MDTA is one provided through a mobile clinic in Israel for patients with poorly controlled type 2 diabetes. In these subjects, Maislos and Weisman conducted a randomised, controlled intervention comparing an interdisciplinary and a traditional treatment. At the 6-month follow-up, they observed significant improvements in plasma glucose (−1.5 mmol/l; p = 0.003) and HbA(1C) (−1.8%; p = 0.00001) in the intervention group, but not in the control group. The compliance and response rates were 85% and 71% for the intervention group and 32% and 35% for the control group, respectively.
Cardiovascular diseases
In 1996, Hill and Houston-Miller noted that the dramatic reduction in cardiovascular morbidity and mortality obtained through changes in lifestyle and modification of other risk factors in controlled trials could not be achieved in clinical practice. They concluded that one major reason was that the MDTA used in clinical trials was insufficiently incorporated into standard clinical practice, and they cited the 1995 American Heart Association consensus statement ‘Preventing Heart Attack and Death in Patients with Coronary Disease’ stressing that the proportion of patients continuing proper interventions over the long term “can be significantly increased by a team approach in which healthcare professionals − including physicians, nurses, and dieticians − manage risk reduction therapy by using follow-up techniques that include office or clinic visits and telephone contact. In many healthcare settings, the team approach will be the preferred technique for optimising risk reduction.”
The same year, almost as an answer to the call by Hill and Houston-Miller, the Kaiser Permanente integrated managed care consortium Colorado Branch, created the Collaborative Cardiac Care Service (CCCS) made up of a nursing and a pharmacy team in which patient care activities complemented each other. The CCCS MDT brings together primary care physicians, cardiologists and other health-care professionals and focuses on activities that have been shown to improve patient outcomes. They recognise that managing cardiovascular risk factors is a complex, multifactorial process, requiring sustained interventions over many decades of single or multiple risk factors within the context of coexisting biological, psychological and social factors. They also acknowledge that patients’ active collaboration is required not only to adopt but also to sustain health-promoting behaviours indefinitely, adhering to both medication regimens and lifestyle modifications. An essential component of the programme is the training of health professionals in behavioural sciences and in making multiple contacts with their patients.
Another example of MDT intervention in the field of cardiovascular diseases is that created at the Albany Medical College in the USA . Their approach is based on the idea that patients could improve the benefits to be obtained by the multiple specialists commonly involved with patients with systemic cardiovascular disease if their interventions are properly coordinated. This insures that atherosclerosis prevention through risk factor modification, as well as diagnosis and therapy for the presenting problems, can be simultaneously managed.
A novel approach to cardiovascular disease prevention through an MDT approach has been in place at the Albert Einstein-Montefiore Hospital in New York . They have taken on the challenge presented by various inherited cardiovascular conditions and created an interdisciplinary model of care addressing the complex genetic, psychological, ethical and medical issues involved in treatment. As the genetic basis of many complex conditions is discovered, the advantages of an interdisciplinary approach for delivering personalised medicine seem to become more evident.
Chronic kidney diseases
In 2000, Levin stated that, when dealing with renal diseases, three concomitant strategies should be in place: (1) early identification of patients with chronic renal failure, (2) initiation of treatment at the earliest possible stage in order to delay progression of the condition and co-morbid diseases, and (3) proper determination of the optimal time required to prepare these patients for renal dialysis. He believed that to achieve these objectives the timeliness of referral to a multidisciplinary renal care team is of paramount importance, and he mentioned that, in Canada, diabetes and/or hypertension cause renal disease in up to 40% of patients requiring dialysis. Given that these patients were often monitored by internists, endocrinologists or cardiologists, a substantial proportion (20–50%) of them started dialysis without consultation with a nephrologist. This is unsatisfactory as guidelines for the initiation of renal replacement therapy change with time .
Levine’s recommendations have been recently substantiated by Bayliss et al. who implemented an MDTA to chronic kidney disease management to decrease the rate of decline of glomerular filtration rate (GFR). Using a 4-year historical cohort, they compared 1769 persons referred to an outside nephrologist to 233 referred to an MDT consisting of a nephrologist, a pharmacy specialist, a diabetes educator, a dietician, a social worker and a nephrology nurse. Both groups received the usual primary care. In multivariate repeated-measures analyses, MDT care was associated with a mean annual decline in GFR of 1.2 versus 2.5 ml/min per 1.73 m 2 for the usual care. They concluded that the MDT was responsible for the slower decline in GFR in patients subjected to this approach.
High-risk pregnancy
When pregnancy represents a risk condition, an MDTA may be beneficial and there are several examples of its advantages.
The team approach seems very useful for pregnant adolescents. Over 15 years ago in the USA, a comparative study analysed the outcome of pregnancy in adolescents and single young women who attended or did not attend a non-urban, antenatal multidisciplinary clinic providing education about pregnancy, childbirth, infant care, contraception and healthy lifestyles . Investigators observed that maternal weight gain and infant birth weight were significantly higher in the MDT group, while preterm labour, intrauterine growth retardation and anaemia were significantly higher in the non-clinic group. Among the latter adolescents, the likelihood of a caesarean section was almost three times higher and the need for neonatal intensive care unit transfer arose only in this group.
The team model is also important in the management of cardiovascular complications in pregnancy: In 1997, the National Institutes of Health of the USA convened a workshop to carry out a systematic review of information and develop recommendations for research and education of peripartum cardiomyopathy, a rare life-threatening cardiomyopathy occurring in previously healthy women, with diagnosis confined to a narrow period and requiring echocardiographic evidence of left ventricular systolic dysfunction. They concluded that symptomatic patients should receive standard therapy for heart failure, managed by an MDT . In 1999, an Israeli group used an MDT in counselling a pregnant patient with myotonic dystrophy, a rare autosomal, dominant, degenerative neuromuscular and neuroendocrine disease. As pregnancy can aggravate the maternal disease, pregnancy management becomes critical and the contribution of various specialists mandatory, because complications include stillbirth, premature labour, polyhydramnios, abnormal presentation, prolonged labour, increased operative delivery, postpartum haemorrhages and anaesthetic accidents . Finally, excellent results were obtained through an MDT in patients with spontaneous coronary dissection, a rare and potentially life-threatening condition usually occurring late in pregnancy .
Already 20 years ago, Perry advocated an MDTA to the management of pregnant patients with end-stage renal disease focussing on the obstetric nursing plan of care. This model seems to have been successful, with a recent review by Bili et al. showing that, in the majority of patients with mild renal function impairment and well-controlled blood pressure, pregnancy is usually successful and does not alter the natural course of the disease. A combined multidisciplinary effort led to advances in knowledge about the interaction of pregnancy and renal function resulting in the improvement of foetal outcome in patients with chronic renal failure and also in the management of pregnant women with end-stage renal disease maintained on dialysis.
One application of the MDT approach to pregnant women that needs to be mentioned is breast cancer diagnosed during gestation. A Spanish group recently assessed maternal and neonatal outcome in 25 of these women and concluded that they present a high incidence of complications unrelated to antineoplastic treatment, requiring an individualised MDT team approach to achieve satisfactory neonatal outcomes .

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