Tumor Board Essay

Tumor Boards and Multidisciplinary Physicians: An Ethnographic Inquiry of the Influence of Social Hierarchy on Cancer Treatment Decision-Making

Abstract

The purpose of hospital tumor boards is for multiple specialists together to find the best treatment program for patients, but decision outcomes do not always represent the multispecialty perspectives within the board. Scholars have found that multidisciplinary tumor board groups are not always effective in delivering their expected output and suggest many practical barriers exist to effectiveness. Recent research has investigated aspects of interdependencies among healthcare workers, but we still know little about the culture and structure of individual tumor boards and the subsequent effect

on treatment decision making. Through inductive exploration of tumor board social environment, this study reveals a distinct stratification exists in tumor boards and finds that social hierarchies found in most tumor boards influence the decision-making process for cancer treatment prescription. It is the first in-depth multihospital ethnographic critical case study of multiple tumor boards examined in both the United States and United Kingdom examining the social phenomena of hierarchy and under the theoretical framework of social hierarchy theories.
Future research should focus on better understanding how decision-making is affected in collaborative structures.

Key words: Tumor board, social hierarchy, decision-making, cancer management, tumor board effectiveness

Interdisciplinary teams are an indispensable characteristic of modern organizational work, particularly in healthcare settings, as the complexity and demands of the healthcare environment require the knowledge and expertise of specialists working together to solve multifaceted, complex patient-care problems (Heinemann and Zeiss 2002). Extant studies in healthcare have found that when individuals contribute their expertise to the group, patients achieve optimized care (Alpert et al. 1992; Evans 1994; Henry et al. 1992; Pike et al. 1993; Stichler 1995). Indeed, throughout the literature, it is suggested that effective interdisciplinary interaction leads to improved patient outcomes, including shorter hospital stays, lower hospital costs, increased patient and family satisfaction, and symptom control, as well as improvements in the diagnostic and prognostic capacities of healthcare professionals (Hearn and Higginson, 1998).
One interdisciplinary team commonly found in the healthcare setting is the multidisciplinary tumor board (MDT) also known as tumor boards (TBs). The National Cancer Institute defines a tumor board (TB) as “a treatment planning approach in which a number of doctors who are experts in different specialties (disciplines) review and discuss the medical condition and treatment options of a patient” (National Cancer Institute, 2017). In multidisciplinary tumor boards, members collaborate with others who have specialized knowledge of oncology and physiology (Fleissig et al. 2006) with the collective aim of coordinating multidisciplinary perspectives and care to help the oncology team devise the best treatment program for the patient through high-quality diagnosis, evidence-based treatment planning, and delivery of care (Fleissig et al. 2006). Thus, effectiveness, quality, and efficiency of TBs is related to TB’s ability to coordinate multidisciplinary input to reach a consensus on the best clinically-supported treatment for the patient (Lamb et al. 2013). According to Fleissig (2006),
“The multiprofessional composition of teams should increase the likelihood that individual patients are offered the most appropriate treatment for their condition, because management plans would be based on a broad range of expert knowledge from the start, and all aspects that influence treatment options would be considered” (p. 936).
While the purpose of hospital tumor boards is for multiple specialists to arrive at a treatment decision based on clinical evidence and multidisciplinary perspectives, studies have found that these multidisciplinary groups are not always effective in delivering their expected output (El Saghir et al. 2014; Fleissig et al. 2006; Keating et al. 2012; Lamb et al. 2013; Reeves et al. 2015; Tang et al. 2013; Taylor et al. 2012). This problem has prompted scholars to challenge the idea of tumor boards (Blayney 2012; El Saghir et al. 2014; Keating et al. 2012; Portor 2010), suggesting that they might not always function well (El Saghir et al. 2014; Gatcliffe and Coleman 2008; Keating et al. 2012; Lamb et al. 2013; Landrum et al. 2012; Reeves et al. 2015; Tang et al. 2013; Taylor et al. 2012). Therefore, researchers question tumor board effectiveness in relation to the resources required to conduct them (Blayney 2012; El Saghir et al. 2014; Keating et al. 2012; Portor 2010; Taylor et al. 2012).
The extant literature suggests that many practical barriers to successful implementation and effectiveness might exist in tumor boards (Fleissig et al., 2006) and there have been some attempts and speculation as to the causes. Some studies have suggested that physician decision-making differs by the organizational structure of which the physician is a part (Keating et al., 2012; El Saghir et al., 2014), logistical difficulties, and resistance from professionals and the institution (Fleissig et al., 2006). Other studies have suggested that the lack of a feedback loop in the process has obstructed decision-making in tumor boards (El Saghir et al., 2014; Keating et al., 2012; Lamb et al., 2011, 2012, 2013. Other studies have considered economics and self-interest as contributing factors of ineffectiveness (Francis, Polissar, & Lorenze, 1984; Hemenway et al, 1990; Henson et al., 1990; Mariotto et al, 2011; Mitchell, 2008, 2013; Porter, 2010). In many of these studies, the authors take a prescriptive position in identifying a number of key organizational requirements for tumor boards to better achieve their goals and function effectively. They propose that factors such as positive leadership and team dynamics, adequate administrative support and time, complete and good-quality information, and sufficient funding all might contribute to team effectiveness in delivering expected output (El Saghir et al., 2014; Fleissig et al., 2006; Lamb et al., 2011, 2012, 2013; Reeves et al., 2015; Tang et al., 2013; Taylor et al., 2012). Although researchers have identified these shortcomings with tumor boards and have made some attempts to address these deficiencies, to date, they have neither confidently established a mechanism to better understand the factors that contribute to functionality and effectiveness nor explained the phenomenon with sociological theory. As Taplin et al. (2015, p. 245) stated,
“We need more research on how cancer care teams function and affect long-term outcomes, and we need a better understanding of how lessons about teams in other settings applies to teams in cancer care. . . . Understanding and testing how various inputs, processes, and contextual factors influence MDT outcomes is critical for understanding how to best structure and invest in creating effective team-based approaches to care”
At present, there is an incomplete understanding of the intricacies of interdependent professional relationships and cultures in TBs (Taplin et al 2015) and in healthcare in general (Drinka & Clark, 2000; Schofield & Amodeo, 1999; Zwarenstein, Reeves, & Perrier, 2004). What is more, despite an increase in the prevalence of TBs, there remains little research on TB effectiveness for delivering their expected output in patient care (Fleissig et al., 2006). The question still exists as to how and why teamwork, inputs, structures, and processes influence cancer team effectiveness (Taplin et al. 2015). To the best of the researcher’s knowledge, the review of existing literature lacks empirical support of the effects of social hierarchy or interdisciplinary collaboration on cancer treatment decision-making. This current ethnographic study was guided by one research question: What social factors exist in multidisciplinary tumor boards and how might they affect tumor board effectiveness and the decision-making process? Through inductive observation, this study aimed to understand the social forces in tumor boards and address the research gap in the literature for understanding the intricacies of team collaboration with a specific focus on tumor boards interactions and influences on effectiveness.
The research question poses for a general exploration of tumor board environments but through this inductive exploration, many themes emerged uncovering social hierarchical structures in most tumor board environments influencing interactions during tumor board decision-making meetings. This manuscript focuses on the presence of social hierarchy which emerged in the study in hospital tumor boards and its effect on treatment decision-making. It is one of many themes uncovered in this study, so while this manuscript primarily focuses on the effects of hierarchy on decision-making, interactions were more complex and divulged several social experiences which will be reported in future papers.
Through inductive observation, this study addresses the research question by uncovering why tumor boards might fail to live up to their potential. The research draws on insights from organizational theories that have historical prominence in group decision-making, social hierarchy, and interdisciplinary collaboration. Two theoretical contexts which framed the ethnographic analysis of this study include: (a) Berger and Conner’s (1974) expectation states theory (EST), and (b) Berger, Cohen, and Zelditch’s (1972) status characteristics theory (SCT). The study uses an ethnographic research methodology to ground these theories with the emerging findings of the research to best illustrate and explain the phenomenon under investigation and inductively observed. Using qualitative ethnographic research of multihospital tumor board observations and interviews provides first-hand field insight into the hierarchical structure of hospital tumor boards and how this effects decision-making processes.
While the objective of hospital tumor boards is to incorporate multidisciplinary perspectives into treatment decision-making for cancer patients, socio/hierarchical forces found during this study to exist in most tumor boards might undermine this aim, thereby biasing decision-making outcomes and treatment recommendations for cancer patients. The study inductively found that a hierarchical structure exists in some tumor boards through the observance of status characteristics that stratify members in a distinct social order. As a result of this stratified social order, the social forces of hierarchy in tumor boards effect group interactions during decision-making processes, compromising the decision-making outcome of tumor boards. In this foundational study, two theme findings were identified: 1) Dominance by stratification of occupational specialization; and, 2) Dominance by expertise. Adaptive responses of social hierarchy, namely the: effects of social dominance and subordination are also revealed. This manuscript reviews these emergent findings and explains how hierarchy operates to undermine group decision-making processes and how this ultimately affects treatment ultimately prescribed to the cancer patient.
The study contributes to the current knowledge of cancer treatment by expanding upon prior findings through multihospital and multi-tumor board field research conducted for the first time in both the United Kingdom and United States. Additionally, its analysis incorporates social theories to support the social phenomenon inductively observed in hospital tumor boards. This is a first study of hierarchical structures on TB decision-making and effectiveness, answering a call in the extant literature for understanding the effect of TB structure and team dynamics on cancer management. It focuses on the exploration and theoretical explanation of organizational structures and member behavior in multidisciplinary tumor boards, and their effect on cancer treatment decision-making within the groups. The theme findings have theoretical implications to sociological and organizational theory providing contribution into where and how collaborative decision-making processes can go awry within a specific clinical setting.

Background
Multidisciplinary Hospital Tumor Boards as a Collaborative Decision-Making Endeavor
In both the United States and the United Kingdom, cancer is one of the leading causes of death. For every 100,000 people, it is estimated that there are 185 deaths attributed to cancer in the United States and 168.6 cancer deaths in the United Kingdom (American Cancer Society, 2017; Department of Health and Social Care, 2004). Today, the likelihood of developing cancer in one’s lifetime is 1 in 2 for men and 1 in 3 for women (Saporito, 2013, p. 36). As defined by the National Cancer Institute, “Cancer is a term for diseases in which abnormal cells divide without control and can invade nearby tissues” (“Cancer,” n.d., para. 1). It refers to a variety of different diseases taking many different forms and ranging widely in activity level. The disease has been linked to genetic, behavior, and environmental factors. Cancer makes hundreds of healthy cells mutate and grow uncontrollably; thus, it has been described as “a thief and biological con artist, breaking into and taking control of the mechanisms of a cell and coaxing it to grow and divide in dangerous ways” (Saporito, 2013, p. 35). Cancer is therefore not one disease; it is hundreds, and thousands (Saporito, 2013). It is a deadly combination of several cells and genes uncontrollably growing at the absence of growth inhibitors (Saporito, 2013). Complicating matters more, its cause is not limited to one agent or virus that can be tackled with a single treatment, vaccine or other therapeutic measure. Metastatic cells are difficult to spot, as there are over 1 billion blood cells to account for every metastatic cell, so treating such a disease requires more than one individual, approach, or discipline (Saporito, 2013).
The attributes of cancer—its effect on each individual, with a different genome, lifestyle, health, and habits—make it very difficult to manage. “The disease is much more complex than we have been treating it,” says MIT’s Phillip Sharp—a Nobel Prize winning molecular biologist who studies the genetic causes of cancer, ‘and the complexity is stunning’” (Saporito, 2013, p. p.32). There are a multitude of oncological treatment outcomes available, which makes a patient’s treatment prescription complex. In fact, drug companies have been trying for years to target mutations. But while there are hundreds of drugs that promise to combat a few of the mutations, that is not enough, given the complexity of the disease. This explains the 95% failure rate of new pharmaceutical products in oncology and the 50% failure rate of Stage III clinical trials (Saporito, 2013). Because no two patients are alike, outcomes will vary between one patient and another, so each requires a customized approach specific to his or her needs. “So, it will take not one hero [or treatment] but many” (Saporito, 2013, p. 32).
It takes a village (or multidisciplinary experts) to come together and make sense of, then prescribe the management of this biological condition. As minimally invasive technology in oncology has evolved and greater clinical outcomes have been achieved and demonstrated, today there are more multispecialty treatment options available for patients with cancer (Hong, Wright, Gagliardi, & Paszat, 2010; Taylor et al., 2010). With an increase in multimodal treatment options, there has been an increased emphasis on obtaining recommendations from multidisciplinary oncology teams. Thus, in this new age in healthcare, multidisciplinary oncology teams are now the mandatory rather than recommended advisory agents to these decisions in most countries (Taylor, Shewbridge, Harris, & Green, 2013),
Multidisciplinary physicians on a hospital oncology team have the varied clinical knowledge, experience, and technical expertise to treat cancer through various approaches (Schofield & Amodeo, 1999).

For this reason, decisions about the best treatment options for cancer patients are often made by these multidisciplinary teams, also known as physician-run hospital tumor boards. Tumor boards are formal meetings where relevant, key specialists with different backgrounds, norms, beliefs, values, learned operating models and practices meet to discuss the diagnosis and management of patients with cancer (El Saghir et al, 2014). Because tumor boards often deal with more than one type of cancer, members collaborate with others who have specialized knowledge of oncology and physiology (Fleissig et al, 2006). Members often include, but are not limited to, surgeons, medical oncologists, radiologists, interventional radiologists, radiation oncologists, pathologists, oncology nurses, behavioral specialists, specialty physicians such as gynecologists or pulmonologists, and in few cases, patient-care coordinators. The team composition varies depending on cancer type, since certain cancers specific to an organ or disease require a specialist to participate to make the best decision (Fleissig et al., 2006). Additionally, the structure of clinician involvement varies by specialty and hospital

protocols.
The tumor board, in whole, plays a very important role in cancer management. Its aim is to ensure effective coordination of multidisciplinary perspectives among its key members who possess the appropriate skills and experience in order to make the best treatment decision and provide optimal patient care. Quoting Fleisseg et al (2006), the multidisciplinary tumor board “would thereby ensure high-quality diagnosis, evidence-based decision making, optimum treatment planning, and delivery of care (p. 936). Thus, effectiveness in the tumor board relates to its ability to coordinate multidisciplinary input so that consensus on an appropriate diagnosis and treatment plan is made at the meetings (i.e. there is always a decision-making outcome) to ensure the highest quality of patient care for each patient under review at the meetings.
Surprisingly, while tumor boards have a very important role in cancer management, there is no recommended structure or process with demonstrated optimal group practices for treatment decision-making in the United States, nor are tumor board decisions monitored or regulated by an independent party (El Saghir et al, 2014; Gatcliffe, & Coleman, 2008; Lamb et al., 2013; Landrum et al., 2012). Even within the same institution, tumor boards differ in structure and process despite the fact that the same members often attend these different boards.
Consensus recommendations leading to treatment decisions are often made by attending physicians present in the tumor board and not by adhering to established clinical guidelines or protocol (El Saghir et al., 2014; Keating et al., 2012). Also, many prior studies have found that many times, when decisions are made, follow-up may or may not take place (El Saghir et al., 2014; Keating et al, 2012). In addition, studies have found there is typically no feedback loop following tumor board review (El Saghir et al., 2014; Keating et al, 2012; Lamb et al, 2013; Landrum et al., 2012). As a result of perceived inadequate structure, TBs have faced great criticism, particularly of their value and effectiveness (Blayney, 2012; El Saghir et al., 2014; Keating et al, 2012).
In a recent study by Taplin et al., (2015), the authors assert:
“We currently have relatively limited direct evidence about how these [team-based] factors influence MDT effectiveness in the cancer care context. These are areas ripe for investigation. Understanding and testing how various inputs, processes, and contextual factors influence MDT outcomes is critical for understanding how to best structure and invest in creating effective team-based approaches to care” (Taplin et al, 2015, p. 245).

The current study addresses this fundamental knowledge gap by providing empirical understanding of the social-hierarchical structure and related behavior of hospital tumor boards and how these factors influence decision-making processes and outcomes. While researchers have previously investigated aspects of interdependencies among healthcare workers, little is known about tumor board structures and the effect of social hierarchy on their interactions during decision-making. This qualitative ethnographic study explored the social environment in tumor boards. Through the emergence of themes related to social hierarchy, its analysis focused on social factors and informal hierarchical structures, their presence in multidisciplinary tumor boards, and their effect on treatment decision-making.
This line of inquiry is important because the consideration of social hierarchy in this inductive exploration of tumor board group decision-making environments might help address the fundamental knowledge gap regarding tumor board decision-making and effectiveness. Decision-making can be a highly politicized process; researchers have linked decision-making processes to legitimacy, institutional power, and levels of individual power and knowledge, among other factors (Abolafia, 2010; Brown, Colville, & Pye, 2014; San Martin-Rodriguez et al, 2005; Taylor et al. 2012; Zilber, 2007). Although the inclusion of multiple professionals from different medical disciplines has been believed to enhance treatment decision-making by incorporating perspectives that reflect diverse backgrounds and areas of expertise (Aguirre-Duarte, 2015; Zwarenstein et al, 2013), in practice, there are barriers to effective interdisciplinary collaboration, particularly in the medical profession (Firn, Preston, & Walshe, 2016). The historically hierarchical culture of the medical field has been noted to adversely impact interdisciplinary processes by privileging the input of certain professionals and effectively silencing the voices of lower status team members (Gotlib et al, 2014; Todorova et al, 2014). Thus, hierarchy affects participation among its demarcated members, allowing those who are status-advantaged in the social order greater opportunity to interact in a group over those members who are either status-neutral or disadvantaged.
According to March and Simon (1958), “The organizational and social environment in which the decision maker finds himself determines what consequences he will anticipate, what ones he will not, what alternatives he will consider, what ones he will ignore” (p. 137). The social environment faced by multidisciplinary tumor boards is highly complex with interdisciplinary differences within multidisciplinary teams and vast differences in patient cases reviewed by tumor boards. What is more, cancer care is complex and today, there are a multitude of oncological treatment outcomes available for patients diagnosed with cancer. Because no two patients are alike, decision outcomes vary between patients, so each requires a customized approach specific to his or her needs. While the collective aim of the tumor board is to coordinate multidisciplinary perspectives to help the oncology team devise the best treatment program for the patient on a timely basis, optimizing oncology care, treatment decision making is not straightforward under the various degrees of complexity and conditions of ambiguity tumor boards face in patient cases. Additionally, when social forces exist in groups, this might complicate matters in the organization, thus an exploration of social hierarchy is warranted.
Literature and theories on social hierarchy explain status organizing processes and status order where people work to accomplish a particular goal (Ridgeway & Walker, 1995), similar to the tumor board. They suggest that based on the perception of an individuals’ capability in relation to others, the perceived value of an individual’s contributions to a group’s activities depends on members’ places in the social and organizational hierarchy. Accordingly, the behaviors of group members are influenced by their place in the social order and one’s position in the hierarchy affects his or her behavior in the group, as well as how influential he or she is in the ultimate treatment decision outcome. Collaboration in hospital tumor boards might be necessary for optimal patient care, but interdisciplinary differences and social hierarchical factors might have an influence on interactions during decision-making, impacting group effectiveness. Thus, it is important to consider social hierarchy when explaining the social phenomena found to exist in multidisciplinary tumor boards.
Standard theories of group decision-making assume that there is some hierarchy of individual beliefs and choices and this hierarchy dictates attractiveness of taking action (March & Olsen, 1976). It assumes that people spend their energy on making choices on situations that will provide them the highest return. This theory, however, “ignores the importance of roles, duties, and standard operating procedures for determining behavior and it underestimates the uncertainty of self-interest” (March & Olsen, 1976, p. 253). The simple fact is that people’s roles and responsibilities are behaviorally important to involvement, as supported in hierarchy literature and theory. People make decisions not only because it is in their best interest to do so but also because they are expected to according to the role they play in the organization as well as the situation in which is presented. This study seeks to understand the social environment in hospital tumor boards and how individual roles in this multidisciplinary environment might affect treatment decision-making.

Theoretical Framework: Status, hierarchy, and biases in collective decision-making processes
To best answer the research question, two theoretical contexts framed the ethnographic analysis of this study and were used to help explore the research question: (a) Berger and Conner’s (1974) expectation states theory (EST), and (b) Berger, Cohen, and Zelditch’s (1972) status characteristics theory (SCT).

EST and SCT were used to understand the social phenomenon of social hierarchy which emerged in the data shown to affect the interaction and decision-making process for cancer patients. Together, they provide a useful lens through which to explore the research question and interpret the study findings, as well as an explanatory framework for hierarchical development and sustainment within goal-focused multidisciplinary groups. Both theories were chosen because combined, they best explain how social hierarchies are present, how they are formed and how they influence behavior in goal-oriented groups. The basic assumptions of the theories are presented

next.

Expectation States Theory. Expectation states theory embodies a set of interconnected theories (Berger & Webster, 2006:268) that explain status organizing processes and status order where people work to accomplish a particular goal. The theory states that the perceived value of an individual’s contributions to a group’s activities depends on members’ places in the social and organizational hierarchy. Expectations states theory is based on expectations of an individual’s capability in relation to others, particularly in goal-oriented groups. According to this theoretical program, statuses generate expectations about relative capabilities, which, in turn dictate and influence the behaviors of members in the group. Put simply, one’s position in the social hierarchy (their status in the status order) affects their assumed capability and therefore, dictate their behavior in the group, as well as how influential he or she is in the ultimate treatment decision outcome.

Status Characteristics Theory. The influence of status can be best explained through a close examination of the status characteristics theory, which is a sub-theory within the expectations states theoretical program and reviews the development or progression of status organizing processes (Berger, Wagner & Webster, 2014; Berger & Webster, 2006). According to Berger & Webster, (2006), “A status organizing process is one in which evaluations and beliefs about characteristics of actors become bases of observable inequalities in face-to-face interactions (p. 271). This process is based on individuals’ evaluations of themselves and others. These evaluations then become observable in the unbalanced interactions among the group members. The principal idea of the status organizing process can thus be characterized according to status characteristics (i.e., the way in which others “classify” another’s status). A status characteristic is “any characteristic possessed by a member or members that informs beliefs and expectations for that member(s) and how they become organized (Berger & Webster, 2006).
According to Berger & Webster, (2006), status characteristic theory explains how task groups develop performance expectations based on observable status-distinguishing characteristics possessed among group members and how these characteristics determine their behavior. The status beliefs are the social representations, which consensually view a particular category of people as worthy of their status and proficient than another, and this affects the perceptions of value and expectations of a member’s contribution and consequently worthiness becomes a presumed competence.

EST and SCT as a useful theoretical framework for studying TBs
Hierarchy is structural, derived through social interaction, built by the possession of valued resources, and maintained by norms of dominatio