Indexing Title:

RJOSON’s Medical Anecdotal Report [05-8]

MAR Title: Difficulty with Multispecialist, Multidisciplinary Approach in Patient Care  

Date of Medical Observation: September, 2005

Narration:

A 50-year-old female with recurrent breast cancer was admitted to a private hospital for pain and weakness on the right lower extremity secondary to bone metastasis.  The patient has been under my medical supervision for the past seven years since she first consulted me for a breast concern.  I had operated on her twice and had treated her with chemotherapy and hormonal therapy.  I had referred her for radiotherapy of her left hip metastasis.  She was able to walk again after the radiotherapy.  Despite the progression of her breast cancer, she continued to trust me as a physician and would follow my advice.  At one point, she went for faith healing in Novaliches.  After one year, she came back to me and told me to take care of her until she dies.  She had accepted her diagnosis of cancer, present state of illness and the prognosis. She has resigned and consented to a palliative goal of treatment.  For this present confinement, she has agreed to a radiotherapy of her right hip metastasis.  She has refused more chemotherapy. 

While confined in the hospital, being a Health Maintenance Organization (HMO) patient, she was also referred by the HMO coordinator to a medical oncologist.  I, as the first attending oncologist, was not informed of the entry of the medical oncologist, until I heard it from the patient.  I did not make a fuss about the referral being done without my knowledge.

 Instead of getting the advantages of a collaborative multispecialist, multidisciplinary approach, the patient got more confused.  When the medical oncologist got into the picture, she right there and then started convincing the patient of getting into a chemotherapy regimen with an assurance that she would be able to walk in a month’s time in the mall.  She said chemotherapy is the logical choice and not radiotherapy.  Without getting the informed consent of the patient, she ordered in the chart to start the chemotherapy the next day she saw the patient. 

Confused, the patient asked me what she should do.  I told her to weigh all the options given to her by the medical oncologists and by me as objectively as she could and make the necessary decision.  I told her I will support whatever be her decision. 

Insights (Discovery, Stimulus, REINFORCEMENT) / (Physical, PSYCHOSOCIAL, ETHICAL):

Multispecialist, multidisciplinary approach to patient care, particularly to cancer patients, has been and is being advocated.  It is supposed to give better care than a unispecialist, unidisciplinary approach because of the latter’s limitations and on the premise that two heads are better than one.  Personally, I would agree to those advocating multispecialist, multidisciplinary approach as long as there would meeting of the minds and philosophies of the various disciplines, mutual respect, no ulterior motive in protecting their specialty and self-interest, and collaboration.  The ideal situation is hardly seen in the community and its prerequisites difficult to achieve.  With a collaborative multispecialist, multidisciplinary approach hard to come by, the least that the various specialists have to do is to be professional and ethical to their patients and to each other.  In a confined patient where two different specialists are called in to give their advice, the second specialist should discuss with the first specialist who saw the patient first, especially if there is a difference in opinion.  A consensus should be arrived at between these specialists before recommendation is given to the patient so as to avoid confusion.