Holistic Approaches to Problem-solving and Decision-making in Patient Care – Inter- and Trans-disciplinary

Holistic Approaches to Problem-solving and Decision-making in Patient Care – Inter-  and Trans-disciplinary

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

January 20, 2012

The desire to provide a more holistic problem-solving and decision-making in patient care has led many to have a closer look at disciplinary, multidisciplinary, interdisciplinary and transdisciplinary approaches.

Currently, most people would still use multi-, inter- and trans-disciplinary approaches interchangeably with no or little distinction to mean the use of different disciplines or specialties to provide holistic problem-solving and decision-making in patient care.  However, there are now more and more people putting significant distinctions among the three terms.

The differences between and among disciplinary, multidisciplinary, interdisciplinary, and transdisciplinary approaches are illustrated in the diagram below.

Source: http://www.hent.org/transdisciplinary.htm

As can be derived from the diagram, because of the presence of combination and simultaneous use of several disciplines or specialties, the inter- and trans-disciplinary approaches are considered holistic at best.   In interdisciplinary approach, there is some amount of integration of various disciplines or specialties used in the problem-solving and decision-making in patient care.  In the transdisciplinary approach, there is a greater amount of integration and extensive use of the various disciplines or specialties within and beyond their boundaries in the problem-solving and decision-making.

A simple way to remember the distinction among the different terms, particularly, inter-and trans-disciplinary is to look for presence of integration among various disciplines and specialties and its extent – no integration in disciplinary and multidisciplinary; integration is most extensive in trans-disciplinary.

NOTE: The current trend is towards a transdisciplinary approach.

Here is an exerpt from http://smallbusiness.chron.com/difference-between-transdisciplinary-team-multidisciplinary-team-18762.html to better understand a transdisciplinary approach.

“A transdisciplinary team allows members to contribute their own knowledge and expertise, but efforts are collective in determining best ideas or approaches. When transdisciplinary teams are used in health care, providers from multiple disciplines collaborate and share ideas from the beginning to create a total health care plan that covers all necessary diagnoses and treatment for a patient. For instance, someone recovering from serious physical trauma may require close collaboration between medical doctors, therapists and mental health care providers in the recovery.”

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2 Responses to Holistic Approaches to Problem-solving and Decision-making in Patient Care – Inter- and Trans-disciplinary

  1. rojoson says:

    Feedback by Dr. Ramy Roxas – Jan23, 2012 – Hi sir, I agree with you that most would use the term multidisciplinary interchangeably with inter- or transdisciplinary. In cancer care, the current norm is the “multidisciplinary team approach” (MDT), and most scientific studies do show better outcomes when cancer treatment planning is done under such an approach, so much so that “MDT” is now a law for all cancer patients in England.

    The required and mandated process for an MDT would be that all specialists involved in the care of a cancer patient (surgeons, med onco, rad onco, radiologists, pathologists, palliative care, pain specialists, nurses, rehab etc…) regularly meet together face to face (certainly not over the phone or via notes in the charts) – from the very beginning, through, up to the very end of the cancer journey – and come up with a treatment/management consensus every step of the way, with the patient always ultimately involved in the decision process.

    How would a Transdisciplinary or interdisciplinary approach be different – and even better? Or is this already transcisciplinary simply mislabelled as multidisciplinary?

    Certainly, this is still a far cry from what is currently happening to cancer care in our country, where specialists make treatment decisions on their own, within the paradigms of their own expertise, before passing the patients to the next expert for succeeding treatment. For instance, in rectal cancer, we continue to see many patients who get surgery first, then get passed on to medical oncology, then radiation oncology, only for someone to make a comment that perhaps preoperative chemoradiotherapy should have been done followed by surgery, then chemotherapy. What should have been done in the first place is for everyone to meet first, discuss with the patient all options, and come up with a treatment plan utilizing best current evidence and standards. But that is easy to say when all doctors work and get salaried within a cancer hospital where such a process is mandated. Is the MDT, Intedisciplinary or transdisciplinary process possible at all in our Philippine setting where individual private practice reigns, and the attending physician is supreme?

  2. rojoson says:

    Thanks, Ramy, for the feedback and inputs.

    No.1. I fully agree with what you said.

    No. 2. “How would a Transdisciplinary or interdisciplinary approach be different – and even better? Or is this already transcisciplinary simply mislabelled as multidisciplinary?”

    YES, what you described as multidisciplinary is already a transdisciplinary or at least an interdisciplinary.

    No. 3. Last week, I did a write-up on this issue in my Online Collaborative Interactive Learning on Breast Wellness Center. See below. I like to share this with you. It was in the process of answering the questions that I realized the distinctions among the four words that contain “disciplinary.” In that write-up, I started with multidisciplinary. Then, I included the concept of interdisciplinary. I did not include yet the concept of transdisciplinary. Now, that I am exposed to transdisciplinary, I will use transdisciplinary as the fourth concept.

    Dr Rey

    Brainstorming and Discussion on

    QI.29 Implementation of Strategic / Operational Plan for a Breast Wellness Center / Clinic – Multidisciplinary and InterdisciplinaryTeam

    Instruction:

    Formulate a concept paper that contains an action plan for setting up a multidisciplinary / interdisciplinary team in both a personal (individual) and corporate (hospital) breast center / clinic.

    ROJoson’s Inputs

    One of the biggest challenges in a corporate or hospital Breast Wellness Center / Clinic is the setting up of a multidisciplinary and interdisciplinary team.

    Why is the setting up of a multi- and interdisciplinary team being advised in the administration of a corporate (hospital) breast center / clinic?

    Corollary to this, why is the setting up of a multi- and interdisciplinary team being advised in the management of a breast cancer patient?

    The primary concern of a corporate (hospital) breast center / clinic is the management of patients with breast cancers which are very common and very challenging to manage. It is an axiom nowadays that breast cancer is a disease requiring multi- and interdisciplinary management. Why? Paraclinical diagnostic procedures are often needed after a clinical evaluation and these entail the assistance of imaging, microscopic and other paraclinical specialists in providing the technological procedures and the interpretation of results. Treatment is often multimodal and surgical oncologists, medical oncologists and radiation oncologists are often needed for collaborative and coordinated assessment and treatment, . Psychological and rehabilitation management during and after treatment is frequently needed and these entail the assistance of reconstructive specialists, physiatrists, psychologists, psychiatrists, and support groups.

    In other words, the givens or assumptions in advocating a multi- and interdisciplinary management, particularly in breast cancer patients, are that no single specialist knows everything and that no single specialist can do everything for a breast cancer patient who usually needs multiple modalities of diagnostic and treatment management.

    For the non-cancer breast disorders, though not as frequently needed, there is also a need for a multi- and interdisciplinary team of specialists for evaluation and management.

    What exactly is the difference between multidisciplinarity and interdisciplinary?

    Multidisciplinarity is a non-integrative mixture of disciplines in that each discipline retains its methodologies and assumptions without change or development from other disciplines within the multidisciplinary relationship.

    An interdisciplinary field is a field of study that crosses traditional boundaries between academic disciplines or schools of thought, as new needs and professions have emerged.

    http://wiki.answers.com/Q/What_is_the_difference_between_multidisciplinary_and_interdisciplinary

    The general objective of involving various specialists (multidisciplinarity) is the promotion of an effective, accurate, comprehensive and unified (interdisciplinary) evaluation and management of patients with breast disorders.

    Multi- and interdisciplinary management comes in two forms, sequential and simultaneous.

    “Sequential” means the patient is first seen by a breast specialist clinician and then referred to other specialists in the multi- and interdisciplinary team. “Simultaneous” means the patient is seen by a team of breast specialist clinicians at the first instance the patient goes inside the corporate (hospital) breast center / clinic. Currently, the sequential set-up is more frequently seen than the simultaneous set-up as the practice is usually a patient consulting a certain single physician and not several physicians at the same time. Also, it is difficult to have all the different specialists present at the same time at all times ready to serve a patient coming in for consultation.

    The corporate (hospital) breast center / clinic can be constructed in two ways. One is a single unified structural unit that houses all the specialists in the team and the diagnostic and treatment facility. This facilitates simultaneous multi- and interdisciplinary management of the patient at the quickest time possible.

    The other set-up is that there are several structural units within reasonable proximity to each other that house all the specialists in the team and diagnostic and treatment facility. This can also allow multi- and interdisciplinary management of patient to take place at the shortest time possible. In this latter set-up, sequential management is usually the case but simultaneous management is also possible depending on the nature of the established policies and procedures.

    In both set-ups, whether one single unified structural unit or several separated structural units in proximity, it is relatively easy nowadays to recruit different specialists to constitute the multidisciplinary team and house them in the said units. It is also relatively easy to get the different specialists to come together for a conference to either discuss practice guidelines and administrative concerns or deciding on actual management of a particular patient. The more challenging, however, is how to make the different specialists in the multidisciplinary team work in a interdisciplinary manner or transforming the mulitdisciplinary team into an interdisciplinary team, that is, how to make them work harmoniously together and integrating their specialties into one unified way of managing patients as well as contributing to the sustainability of the center / clinic.

    The crux of the challenge is really how to manage the mindsets of the different medical specialists to come out with a consensus and standardization on the management of patients with breast disorders. Of course, there are other specific challenges like personality and work ethics that may hinder an effective teamwork which have to be managed by the administration of the corporate (hospital) breast center / clinic.

    For a successful transformation of a multidisciplinary team to an interdisciplinary team, there must be open-mindedness, effective communication, collaboration, coordination, and consensus among all the members of the team. These elements should lead to an agreement on a common and unified philosophy and mindset in the management of all patients coming into the corporate (hospital) breast center / clinic. In other words, the team should be able to collaborate in the formulation and implementation of a unified clinical practice guidelines in the management of all patients of the breast center / clinic. Thus, it is essential that the administrator of the corporate (hospital) breast center / clinic consider, not only the technical qualifications but also the behavioral and personality qualifications of the specialists who will make-up the multi-and interdisciplinary team.

    In the case of a personal (individual) breast clinic, such as one that is run by a breast surgical or medical or radiation oncologist, a multi- and interdisciplinary management is also encouraged and advised. The set-up will naturally and initially be one of “sequential,” meaning the patient is first seen by a breast specialist clinician and then referred to other specialists as needed. A simultaneous set-up in the form of multi- and interdisciplinary referral and discussion can be initiated by an individual breast specialist when needed.

    In the absence of a formally established corporate (hospital) multi- and interdisciplinary team in which an individual breast specialist clinician can be a member of, what should the latter do?

    He should identify in his hospital or community specialists other himself who are usually needed in the comprehensive management of patients with breast concerns, particularly, cancer. He should establish good and mutually-beneficial relationship with them in terms of promoting a future multi- and interdisciplinary teamwork, with the end in mind of establishing a multi- and interdisciplinary team, even on an informal basis. He should always have in mind that oftentimes patients with a breast concern need a multi- and interdisciplinary evaluation and management and that he should not deprive them of this opportunity when indicated. Lastly, he should always have in mind that the general objective of involving various specialists (multidisciplinarity) is the promotion of an effective, accurate and comprehensive evaluation and management of all his patients with breast disorders.

    My action plan to promote a multi- and interdisciplinary teamwork in the management of my breast patients:

    1. Identify plastic surgeons, medical specialists, radiation oncologists, radiologists, pathologists and support groups whom I can establish mutually-benefical relationship in the management of my breast patients, especially, those with breast cancers.
    2. Establish a collaborative effort with the other specialists in continual education in specific and comprehensive management of patients with breast disorders and try to come out with a unified philosophy and integrated approach.
    3. Establish a mutually-beneficial relationship with the other specialists in the management of patient with breast disorders, particularly, in terms of referral benefits.

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