MDT to HIM
Zhiping Yang, PhD,1,2 Daiming Fan,
PhD2,3
1 Shanghai Mingpin Institute of Holistic Integrative
Medicine, Shanghai, China
2 China Institute for Development Strategy of Holistic
Integrative Medicine, Xi’an, China
3 State Key Laboratory of Cancer Biology & National
Clinical Research Center for Digestive Diseases, Xijing Hospital of
Digestive Diseases, Fourth Military Medical University, Xi’an, China
Correspondence to: Professor Daiming Fan, 127# West Changle Road, Xi’an
710032, China; Tel, 86 29 84771501; Fax, 86 29 84771466; E-mail,
fandaim@fmmu.edu.cn
Conflict of Interest: None.
Multidisciplinary teams (MDT)s were introduced in 1995 following
evidence of variation in cancer care delivery in the UK documented in
the Calman-Hine report.1 Due to the well-recognized
benefits, such as standardization and continuity of care, effective use
of resources, improved patient outcomes and safeguarding of patients
from maverick doctors, the MDT has become a widely accepted approach for
the diagnosis, treatment and management of cancer
patients.1,2 It has since been extended to many other
medical fields involving complex diseases and conditions.
However, the decisions emerging from MDTs have not always been the best
options. Dr. Teo et al. described the outcomes of 47 patients who
underwent surgical resection despite a previous recommendation by a MDT
against surgery.3 From their experience, it was clear
that the decisions made by the local MDTs were inappropriate and
reversing the multidisciplinary decision changed the prognosis for the
patients in 32 out of 47 cases.
Why? The development of modern medicine is currently facing big
challenges because of the over-specialization and over-division of
medical disciplines and the fragmentation of medical
knowledge.4 Even now the senior professional in the
team is only an expert in a very limited field or specialty. Teamwork
has increasingly been used to solve this dilemma. As a knowledge team in
health care, a MDT is constituted by a group of diverse health
professionals, each contributing to the common goal of providing health
care in accordance with his/her competence.5 All
professionals are doing their best within the limitations imposed by
current scientific approaches and their own knowledge, but concerted
efforts do not necessarily result in positive or optimal healthcare
delivery for patients because the expanded procedures do not have any
impact on survival. Sometimes, it may even lead to harmful outcomes.
That is why iatrogenic factors have become the third leading cause for
overall mortality in the USA.6
More worryingly, MDTs may encourage overtreatment. Collective decision
making is known to reduce the sense of individual responsibility and to
encourage riskier decisions. Under these circumstances, decisions made
collectively in MDTs may be biased towards recommending aggressive
treatments that have little positive effect but cause patients much
misery.7 Who makes the final decision at the MDT
meeting? It appears that every clinician in a MDT now fears making
clinical decisions.2 They consider the MDT to be a
defensive tool for escaping personal and legal responsibility in
achieving a therapy plan.
In order to improve the working of MDTs, we need two things: a holistic
view and integrative thinking. The human body is an organic whole with
dynamic changes, and powerful self-regulatory and compensation
mechanisms. It has been demonstrated that factors such as failure to
consider holistic information or patient’s views and lack of personal
knowledge of the patient being discussed all had an adverse impact on
effective clinical decision making in MDTs.8 However
holistic thinking looks at the human being as a whole and places
patients in a larger context, involving natural, social, psychological,
and other factors. The All of Us Research Program (formerly named
Precision Medicine Initiative) in fact aims to determine whole health
related factors, including lifestyle, socioeconomic factors,
environment, and biologic characteristics to advance precision
diagnosis, prevention, and treatment by enrolling a large diverse cohort
of at least 1 million persons in the USA.9
What is integrative thinking? Roger Martin, a famous Canadian management
scientist, once elaborated on the concept of integrative thinking: that
is, holding two contradictory views in the mind at the same time, and
from here he came up with a solution combining the advantages of both
perspectives. It aims to deal with opposing views in a constructive way,
not at the expense of choosing one over the other, but in an innovative
way to eliminate the confrontation between the two views. The new views
contain some elements of the opposing points and are superior to both of
the original opposing points.10 In order to use
integrative thinking it is necessary to grasp several principles: first,
expand the scope of the key factors in decision-making; Second, consider
multi-faceted and indirect causality; Third, in the decision-making
process, the problem is not divided between several independent
individuals to solve one by one, but to deal with each part while
maintaining the integrity of the problem. The fourth is to struggle to
find innovative solutions, each idea and process is more efficient and
accurate than the previous one. For instance, when an advanced cancer
patient is faced with options such as surgery, chemotherapy,
radiotherapy, and biological therapy; the order and degree of the
treatments, and whether they are to be used in combination or
sequentially; this requires integrative thinking to make the final
decision in the MDT. This is the Holistic Integrative Medicine (HIM)
that we have proposed and advocated.4,11
To construct a new medical system more suitable for human health and
disease management, HIM regards the human body as a holistic unit;
organically integrates the most advanced knowledge and theories in each
medical field and the most effective practices from various clinical
specialties; and then develops corresponding revisions and adjustments
according to social, environmental, and psychological
conditions.4 From MDT to HIM, we should establish a
multidisciplinary working model to formulate an individualized
integrated healthcare plan to achieve an optimal effect using the
perspective of HIM.