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I'm a radiologist and writing helps me make sense of the world.

"My method is to take the utmost trouble to find the right thing to say, and then to say it with the utmost levity" -George Bernard Shaw

Friday 1 April 2011

MDTs and the Bourgeois

Site-specific cancer multidisciplinary team meetings (MDTs) are a prominent feature of the working lives of all Fellows of the RCR, radiologists and oncologists alike. We attend them dutifully yet we rarely question anything about them. OK, we moan like hell when they don’t run smoothly but that is about it. I contend there are aspects of MDTs that are strikingly unusual.

First is the love: hate feelings that MDTs engender. On one hand, few relish them. They are tolerated at best, made passable by decent colleagues. Part of this is their reputation as a time-occupying lesion; the preparation and attendance takes most of a session. A degree of scepticism is warranted: the cost of running a single MDT is approximately £1000 per hour in wages alone.

On the other hand, by improving communication they undoubtedly improve patient care. If a loved one were to sprout a nasty, we would want them discussed at a well-run MDT complete with a full array of experienced specialists.

Second, MDT is a misnomer. A victim of political correctness, you might argue. Rightly or wrongly, doctors of various specialities dominate the discussion. Others occasionally chip in but rarely do so despite more than a passing nod to egalitarianism. A Clinical, Radiological And Pathology meeting would be more accurate but the acronym is rather unfortunate.

Third, relative contribution is changing. In meetings of yesteryear, the radiologist hinted at a vague mass on blurry images from a relative barbaric contrast study. The physicians stroked their chins, postulating a hepatorhubarboma. The surgeons hacked it out via a 2-foot incision. The stage was then set for the pathologist to step up and administer the coup de grace. Case discussion was not over ‘until the pathologist sings’.

This is becoming less true. The radiologist often makes the diagnosis without physically laying hands on the patient - they now sing the harmony, the surgeon joins in on the chorus and the pathologist merely hums along. Then the physicians applaud effusively at the end. Although we all smile and nod at the pathologist, it isn’t clear what tune they are humming. Or if it is even a tune at all.

Last, I’ve observed several stereotypical but undesirable behaviours in the MDT room. Perhaps some sound familiar:-

- The Dylan Thomas. This person is an undoubted talent but also a loose cannon. As Clive James writes, “ ... there will always be a Dylan Thomas, and he will often do great things, even while borrowing more money that he earns, breaking his bargains, drinking the pub dry, pissing in your fireplace and wrecking every life with which he comes into close contact.”

- The Blatherer. Every time this person opens their mouth, everyone’s hearts sink. Often perfectly competent, their lack of succinctness and frequency of contribution diminishes everyone’s opinions of them.

- The (Ex-)Surgeon. This person has bimodal dress; either a suit / tie or scrubs. They prepare briefly yet meticulously. Unlike the Blatherer, they like it sharp and snappy: their differential diagnosis rarely reaches 2 conditions. Their sense of humour is so bone dry that most people think they don’t have one.

- The Hedger. In contrast to the (Ex-)Surgeon, this person sits so firmly on the fence that their backside is peppered with splinters. Their fear of being wrong robs them of the joy of being right. Their typical response to a question is to ask several questions in return. Whilst caring people, their lack of confidence and worrying about missing anything is ultimately their downfall.

- The Joker. Whilst usually a quite able individual, they love deviating from the matter in hand with humorous intent. There is a balance here; clinical abilities can be overshadowed by incessant buffoonery. They also run the risk of overstepping the line, causing offence and making a fool of themselves. Hence the Joker can become a paradoxical joke figure.

- The Git. This superficially charming but fundamentally oleaginous individual is bright and knows it. To them, modesty is just a seven-letter word beginning with ‘m’. They see MDTs as a sport where points are awarded for exposing the intellectual deficiencies of others whilst concealing their own shortcomings. Double points are gained for humiliating those more junior to them. These individuals tend to have several CEA points.

Several of these character traits are superficially enticing. Doesn’t everyone dream of breaking our behavioural shackles, perhaps becoming the latest Dylan Thomas of the MDT world? However, if we all did this, UK oncological practice would implode in a cataclysm of antisocial behaviour. Realism should prevail. I’m with Gustav Flaubert who famously wrote that, “One should live like a bourgeois, think like a demi-god”.