This material is protected by U.S. Copyright law.

Unauthorized reproduction is prohibited.

For reprints contact: Reprints@AlphaMedPress.com

Schwartz Center Rounds

Teams: Communication in Multidisciplinary Care
Richard T. Penson, Helena Kyriakou, Dan Zuckerman, Bruce A. Chabner, Thomas J. Lynch, Jr.

The Kenneth B. Schwartz Center at Massachusetts General Hospital, Department of Medicine,

Downloaded from www.TheOncologist.alphamedpress.org by guest on November 14, 2011

Division of Hematology-Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA

Key Words. Oncology Support Psychosocial Cancer

Learning Objectives
After completing this course, the reader will be able to:
1. Describe the roles of teams in multidisciplinary cancer care.
2. Discuss the strengths, weaknesses, and opportunities of team-based care.
3. Describe the historical and cultural context of modern medical team-based care.
CME Access and take the CME test online and receive 1 AMA PRA category 1 credit at CME.TheOncologist.com

Abstract
Shortly before his death in 1995, Kenneth B. Schwartz,
a cancer patient at Massachusetts General Hospital
(MGH), founded The Kenneth B. Schwartz Center at
MGH. The Schwartz Center is a nonprofit organization
dedicated to supporting and advancing compassionate
health care delivery that provides hope to the patient
and support to caregivers, and encourages the heal-
ing process. The Center sponsors the Schwartz Center
Rounds, a monthly multidisciplinary forum where care-
givers reflect on important psychosocial issues faced by
patients, their families, and their caregivers, and gain
insight and support from fellow staff members.
The evolving field of oncology increasingly requires
a team of medical specialists working in unison to deliver
optimal medical care. While this coordination may
maximize the technical synergy of care, it can challenge
interprofessional and interdisciplinary connections.
Poor and miscommunication and conflicts between
staff and between the family and providers adversely
affect patient care and quality of life. Furthermore, lack
of communication leaves a vacuum that sucks in fear. A
recent Newsweek article highlighted the challenges of
practicing in the age of high-tech medicine. The author
had to beg for a prognosis for her critically ill and dying
husband, with unhelpful subspecialists failing to com-
municate the bigger picture. This article explores the
tough issue of how teams handle uncertainty and bad
news and how patients and families can be better sup-
ported in the multifaceted paradigm of modern care.
The Oncologist 2006;11:520526

Presentation husband in an intensive care unit (ICU). While she expressed

The facilitator read out loud the Newsweek article, I her gratitude for the compassionate care her husband
Shouldnt Have Had to Beg for a Prognosis [1]. The woman received before his death, all the conflicting reports on his
in the article was venting her frustration about the care of her health left her desperately needing information and support.

Correspondence: Richard T. Penson, M.R.C.P., M.D., Division of Hematology-Oncology, Massachusetts General Hospital, Yawkey 9066,
55 Fruit Street, Boston, Massachusetts 02114-2617, USA. Telephone: 617-726-5867; Fax: 617-724-6898; e-mail: rpenson@partners.org
Received April 7, 2006; accepted for publication April 7, 2006. AlphaMed Press 1083-7159/2006/$20.00/0

The Oncologist 2006;11:520526 www.TheOncologist.com

Penson, Kyriakou, Zuckerman et al.
She later recorded this all too common experience for many
families in this setting, one that exemplifies the challenge of panicky and grasping at straws. The virus that had
effective communication in multidisciplinary care.
I was once a stalker. My victimsyes, there were sev-
eralwere high on the social scale, but they were not
celebrities. They were doctors.
My husband, Doug, died recently after a sud-
den illness put him in an intensive-care unit for 38
days. Being new to the world of hospitals, I stumbled
around blindly for days before I figured out what all
family members starved for up-to-date details about
the health of their loved ones learn quickly: informa-
tion comes from the
doctor, and in order to
get that information Deep into the Information Age,
you must be present
when the doctor visits why is this still a do-it-yourself process?
the patient each day,
whenever that may be.
I understand that what with juggling office
hours and visits to hospitalized patients, doctors have
demanding schedules. But do they understand that
when your loved one is in the hospital, the rest of your
life doesnt just go away? Hospitals operate on the
premise that we, the family, must make ourselves read-
ily accessible to the doctornot by phone but in per-
sonor else the doctor is not accountable.
Any time you are not in the patients room (and,
indeed, the hospital prefers that you not linger there), it dying? This doctor, bless him, took the time to explain
is assumed that you are in the waiting room. When the
doctor arrives, the nurse calls to let you know. If youve only of the particular organ system he specialized in,
stepped out to grab something to eat, make phone calls
with some degree of privacy or dash home to feed kids
or pets, theres a good chance youll miss the doctor
unless youve networked with others who are waiting
and they are able to summon you quickly.
If you miss the doctor, dont expect him to call you
later with a report on how your loved one is doing. And
forget about calling him at his office. Some reception-
ists wont even pretend to deliver a request to the doc-
tor for a phone call from anyone other than a patients
ICU nurse.
To make matters worse, there isnt just one doctor.
My husband had eightnot uncommon with critically
ill patients. Some of Dougs physicians made their
rounds before visiting hours. Those I could do nothing
about. Most tended to come around midmorning, but a
few mavericks appeared in the afternoon or evening,
varying their schedules daily. I sometimes bagged my
quarry as late as 8:30 p.m.
www.TheOncologist.com
521
By Dougs second day of hospitalization, I was
given him breathing problems had attacked several
areas of his body. I could not communicate with him:
a respirator was breathing for him and he was sedated.
But the cardiologist told me that Doug was doing rea-
sonably well, and I naively took solace in this mild pro-
nouncement. That is, until a lung specialist zipped into
the room, put his stethoscope to Dougs chest and said,
Hes not getting better. Hes worse. He may die. Any
questions? I was too stunned to be coherent.
Later, a nephrologist informed me that Dougs
Downloaded from www.TheOncologist.alphamedpress.org by guest on November 14, 2011
kidneys were failing and he needed dialysis. I told this
doctor what the prior two
specialists had said, hop-
ing he could reconcile
their conflicting reports.
Instead, he plied me with
questions about their
findings that I could not answer.
After he left, I fled the room, gasping for breath,
to tearfully summon Dougs parents from Florida and
call his brother in New Jersey. When I returned to the
ICU, his nurse told me somewhat indignantly that shed
been trying to find me, as there were more doctors to
see. Oh, boy!
Finally, a specialist in infectious diseases appeared.
He seemed sympathetic to my bewilderment, so I
begged for an explanation: was Doug holding his own or
that each of the doctors Id seen had given an assessment
not of Dougs overall condition. So although his heart
was doing reasonably well, his lungs and kidneys were
failing and he was definitely in danger of dying.
I hold no grudge against the hospital that treated
my husband, and I encountered a number of compas-
sionate nurses and doctors during Dougs hospital stay.
As far as I know, they did everything in their power to
help him, and I am grateful for that. But it seems that its
no ones job to ensure that the family has a clear picture
of what is happening. If specialists are uncomfortable
discussing anything outside their area of expertise
perhaps because of a fear of lawsuits or because they
havent had time to familiarize themselves with the
factsthen the hospital needs to designate someone
to fill in the information gaps. I had to do this myself
by gleaning tips from sympathetic doctors and nurses,
and learning how to decipher medical jargon.
Deep into the Information Age, why is this still a
do-it-yourself process?
522 Teams: Communication in Multidisciplinary Care

Dialogue
Time and Communication
Oncologist: About 2 months ago one of my patients told
me, My dog was recently admitted to a veterinary hos-
pital, and I cant tell you how different the experience
was from my clinical care. The veterinarian called me
every single day and told me how my dog was doing
and what the plan was for that day. When I was admit-
ted to MGH, the doc-
tors only spoke to my
family when they did
Often after a provider sits down and
son who can talk with the family. I previously worked at
a community hospital in the Chicago area and worked
on a floor taking care of tons of patients dying of their
disease. When we didnt know what else to do, wed turn
to our chaplain, who was always very good at trying to
coordinate efforts between the staff and the family.
Oncologist: I find it difficult to ask the patient, What
exactly did the cardiologist tell you? or What did
the pulmonologist say?
rather than reading the
chart. That just doesnt

Downloaded from www.TheOncologist.alphamedpress.org by guest on November 14, 2011

engender a lot of confi-
their rounds. It was talks to the family, the family comes out dence in the medical sys-
very difficult to get
information. stunned and overwhelmed with the tem.

Nurse: This is a very information. By the time they start to
u n for t u nat e ca se
but not unusual. I process it and come up with questions,
have worked both
in rural and urban we are out the door to the next patient.
hospita ls, a nd no
matter where Ive gone, patients and their providers
still struggle with these issues. The first issue has to
do with time: time for the providers to get together to
discuss patients care, and time for the family with the
provider. The other issue is communication. Often
after a provider sits down and talks to the family, the
family comes out stunned and overwhelmed with the
information. By the time they start to process it and
come up with questions, we are out the door to the
next patient.
Nurse: The family will often then approach me and ask
what they should do. When I remind them that they
spoke to the doctor about that, they will say, Oh, yeah,
I forgot. They just cant take it all in.
Doctors Communicating with Families
Oncologist: When there are several providers involved
in the clinical care, it always makes it harder. There
seemed to be nobody in charge of helping the family in
the Newsweek article get the information they needed.
At MGH there is a MICU (Medical), SICU (Surgical),
NeuroICU (Neurological) attending that is in charge
of consolidating the care and the information. The real
challenge is to achieve that when we are all very busy. I
am not sure anyone has come up with a really good solu-
tion, and it tends to require a personal commitment.
Nurse: The author mentioned that there should be one per-
Oncologist: I think many
of us in adult oncology
have always felt ver y
strongly about our respon-
sibility to the patient.
What I am hearing from
everyone today and in reading this article is that we
probably have that same responsibility to the family
members. I have always believed that a good family
meeting saves you oodles of time. A good family meet-
ing makes the entire hospitalization so much easier. A
good 20-minute family meeting, when you are doing
nothing but focusing on that family, will make the rest
of the admission a lot smoother.
Patients Communicating with Doctors
Oncologist: Let me ask you, when you counsel patients
about how to be effective in communicating with the
doctor, what do you say?
Nurse: I usually tell them that they should have a list of
questions ready, and when they think of things, to write
them down. They should let the doctors know when
they first walk in the room about their list of questions
so that the doctor can budget their time. I also reassure
them that Im also available to provide explanations.
Patients appreciate some of the subtleties of hospital
life, like the difference between radiation oncology,
medical oncology, and surgical oncology, but some-
times explaining this to the patient and the different
perspectives is important; why the surgical oncologists
are looking at the CT or the PET scan can help them
to understand the different priorities. It helps them to
realize that everybody contributes in clinical care.

OTncologist
he
Penson, Kyriakou, Zuckerman et al.
Nurse: I think patients and families often dont understand
how the medical system works. We really can seem
like we are nuts when so many different people need to
come in and ask the patient the same questions over and
over again.
Facilitator: What about the role of social work in the hos-
pital setting? Are social workers able to help facilitate
meetings between the physicians and the families?
Social Worker: I think that
in some of the smaller A good 20-minute family meeting,
hospitals, the social
worker is still doing a when you are doing nothing but
lot of the coordination
between the family focusing on that family, will make the
and the staff. We have
really gotten away
rest of the admission a lot smoother.
from that. The staff
are more available to family and do really communi-
cate effectively and repeatedly, and it comes from sev-
eral directions and to both patient and several family
members so that they have more people listening and
hearing the message.
Nurse: One of the barriers is the level of communication.
For a lot of people, if you say esophagitis, they are
going to nod but they will have no idea what it means.
People nod because they dont want to seem stupid, but
they will have absolutely no clue what it meant.
Oncologist: Symptoms are only words until you have them.
For example you can tell a patient they are going to get
esophagitis and that esophagitis is a common compli-
cation of radiation and chemotherapy, and theyll look
at you and theyll nod. Even when you explain it in com-
monplace 5th grade language, it rarely really describes
the real experience.
Providing a Prognosis
Fellow: As a physician who has recently started doing a lot
of inpatient care, I think there seem to be two broad
issues. One has to do with the logistics of communica-
tion and how it can be carried out. It speaks to the com-
plexity of inpatient care and it definitely resonates. As
a house officer, I remember being that intern sitting in
front of the board, and the way the whole system is set
up, with a board or a big sheet of paper, and the patients
just transform into a series of numbers. You would
have someone running the dialysis machine and you
have the cardiologist there. I felt like the best thing that
www.TheOncologist.com
523
could happen was if the patient had a cancer diagno-
sis because I often think the oncologist can be a go-to
person. It would be nice if we could go back to the day
when there was one doctor. I think that there has been
a diffusion of responsibility. There was no one go-to
person. In some ways, the house doctor could make it
easier for the team to do that because they are there for
12 or 24 hours at a time.
Secondly, I also think the real challenge of deliver-
ing bad news and a poor
prognosis was driving
some of the difficulties
Downloaded from www.TheOncologist.alphamedpress.org by guest on November 14, 2011
with communication.
When you start to sense
that someone is close to
death or a bad outcome
is near, its hard to accept
it, even when you see it.
It is worse for the family
not to know or not to get any information. Anticipating
their uncertainty can be the most difficult thing of all.
Although families are very forgiving about what we
tell them, it can come back to bite us more if we never
saying anything at all.
Palliative Care Physician: It is good to identify a spokes-
person for the family. On the other side of the coin, I
wouldnt want to let the admitting doctor or the team
leader off the hook. I think it is incumbent on the doctor
who is in charge every now and then, deliberately, to set
time aside and go over the prognosis and the plan with
the patient and the family. If it is an outpatient area,
then maybe this could occur once a month. If it is an
inpatient area, I think every 2 days, or maybe once a
week would be adequate.
We do avoid discussing prognosis because that is
what triggers all the other questions. You know, Doc-
tor, I thought he would be all right, but now youre
telling me that he wont be all right. Now they want
to know what the options are and, Why didnt we do
this, and, Why dont we do that. Once you deliver
the prognosis, it triggers a long sequence of questions.
Physician: Some interesting data that are now in press
show that patients who are aware of their prognoses are
much more anxious, more terrified, and measurably
more depressed than patients who dont know. Denial
does seem to serve a purpose.
Oncologist: I think a good doctor has to feel out how much
information the patient generally wants to know. Some
524 Teams: Communication in Multidisciplinary Care

patients and families dont really want to know that
much, and thats the way they want to be. Other fami-
lies and patients actually do want to know the details,
and they should be told, if they are asking.
Oncologist: One gentleman I saw this week knew he was
dying and desperately wanted to know what was going
to happen, what was he going to be feeling, what would
come of his disease. He had not asked anyone about
this because he just
couldnt, and now
he was so afraid that I think patients and families often dont
cation, beyond improving the accuracy of diagnoses and
enabling better management decisions, provides both profes-
sional and personal rewards [3].
Specialists, Teams, and Medicalization of Care
In the fifth century B.C., the Greek physician Hippocrates,
the Father of Medicine, challenged supernatural explana-
tions for diseases, as a champion of a rational approach to
treatment in the new age of reason while advocating a holis-
tic approach to patient
treatment [4]. For centu-
ries, physicians treated

Downloaded from www.TheOncologist.alphamedpress.org by guest on November 14, 2011

he didnt know if he their patients ailments
could ask. I had to
understand how the medical system as singular practitioners
encourage the patient works. We really can seem like we are and operated in the inti-
to ask these types of mate setting of the home
questions. nuts when so many different people need or within religious com-
munities. The first push
Social Worker: The real- to come in and ask the patient the same toward the centralization
ity is that patients live of this approach through
longer and have hap- questions over and over again. the emergence of medical
pier lives because we specialization began to
do have so many specialists. No one person could pos- occur in the 19th century, foremost in the medical commu-
sibly treat people in situations like this. I grew up with nities of Paris, with the renaissances enlightenment and sci-
family doctors. The family doctor to my grandmother entific expansion of medical knowledge through systematic
was probably the most important person to her well- observation and research [5]. The transitions from vocation
being outside of my parents. I think people are looking to profession to business mirror societal change in the past
for that kind of intimacy, but the system does not make 200 years. The U.S. had only two hospitals, in Philadelphia
that possible for all caregivers today. I think we have to and New York, at the beginning of the 19th century. In the
think about how to designate a point person, or work first hospital survey in 1873, there were 178 hospitals, with
together as a team so that people get well-coordinated the number rising to 4,359 in 1909 with all the [modern]
care but also get that sense of being known. As a social criticisms of medicine being cited by the 1920s [6]. Shaped
worker working in the NICU, my job was often to say by new ideas about the etiology of disease and the hope of
to patients what the doctor or the nurse really wanted secular healing, families came to depend on the care of
to say, and to say to the doctor or the nurse what the strangers [6]. Despite the myths of a utopian past or a uto-
patients really wanted to say. In a sense we were inter- pian future, it is clear that, in the past century, the pace and
preting that caregiver to the family in order to facilitate the provision of care have accelerated, perhaps best illus-
a sense of cooperation and trust. trated in the past 50 years by the staggering transitions in
care of myocardial infarction since it took President Dwight
Discussion D. Eisenhower one doctor and 24 hours to get to hospital to
Open and clear communication between the physician and the introduction of coronary care units (1960), defibrillation
the patient and his or her family is critical for gathering data (1962), thrombolysis (1985), glycoprotein IIb/IIIa inhibi-
and successfully implementing a treatment plan. Though tors (1995), primary angioplasty (1995), and active medical
the main aim of communication is to elicit and impart infor- management [7].
mation, the way that this is accomplished can have a profound
effect on the relationship between the doctor and the patient, Team Dynamics
the ability to develop shared trust in a therapeutic relation- Building a team is a valuable investment. There are very
ship, and a patients approach to his or her disease and treat- tangible benefits in seeking input from diverse perspectives.
ment. Communication remains one of the most important A memorable historical example being President Abraham
influences on the quality of medical practice and can deter- Lincolns choice of three men for his administration who
mine the nature of clinical outcomes [2]. Good communi- were political opponents during the previous election. By

OTncologist
he
Penson, Kyriakou, Zuckerman et al.
seeking their input, he ultimately gained their admiration
and respect, and they became his allies [8]. Team com-
munication has moved from dogma to dynamic in the high
stakes world of business and management. Beyond sports
rhetoric, the keys to success, and beyond the pursuit of
excellence, there is synergy in what is available in a team.
With everyone playing a role, with clearly defined goals in
a culture that values communication, strengthens the weak-
est link, invests, makes things happen, and works at it hard,
anything becomes achievable [9]. Great teams need great
leaders, epitomized in
the military paradigm.
The West Point Acad- Teams are not born but made, and all
emy motto Duty. Honor.
Country may be far from cycle through forming, storming,
compassionate care, but
embracing a sense of
norming, and reforming or dissolving.
personal responsibility,
living by a code of integrity, and acknowledging a sense of
being part of something bigger than yourself can ennoble
even the most menial task [10].
While the political, business, and military models are
perhaps more obviously goal-oriented, medicine is a com-
plex, multifaceted industry. Achieving better outcomes
and improving quality, targets success on multiple levels,
beyond care that is free from unavoidable distress and
suffering for patients, families, and caregivers in general
accord with patients and families wishes, as defined by
the Institute of Medicine [11]. Teams are not born but made,
and all cycle through forming (creation), storming (con-
flict), norming (functional), and reforming or dissolving
(dysfuctional) [12].
Overcoming Barriers to Communication
Potential barriers to communication need to be defined
and explored. Families need the medical team to balance
honesty and realism with sensitivity and support [13]. Mul-
tiple studies have shown that patients generally want to
know their cancer diagnoses and prognoses. Despite this,
more than 40% of oncologists withhold prognoses if they
are not specifically asked or if family members request that
the patient not be told [14]. In the U.S., the law has clearly
defined a clinicians obligation to provide as much infor-
mation about a disease course and treatment as the patient
desires [15]. Helping prioritize information in manageable
amounts will make it constructive and aid the patients and
familys involvement in shared decision making.
Communication
A number of studies in acute care settings have shown that
patient and family well-being are directly linked to the qual-
www.TheOncologist.com
525
ity of communication among a medical team [2]. In the field
of HIV/AIDS, fragmented care has been shown to lead to lack
of adherence, poor outcomes, and a lack of access to services
that arise from navigating a complicated medical system [16].
It has been acknowledged in the past that interdisciplinary
strategies are still needed to improve disease management
and that successful interventions aimed at improving com-
munication between physicians and family members now
typically involve a multidisciplinary team consisting at a
minimum of physicians, nurses, and social workers [2].
Several intervention
studies have shown that
Downloaded from www.TheOncologist.alphamedpress.org by guest on November 14, 2011
improving communica-
tion in an ICU setting
can protect dignity and
improve quality of life by
making an earlier transi-
tion to palliative care [17].
Daily multidisciplinary rounds in ICUs can be used to estab-
lish goals, steps and consensus on the course of care for each
patient [2]. One in five Americans will die in an ICU, but
very few will be able to communicate their wishes for end-
of-life treatment, leaving the decision making in the hands
of the physicians and family. A patient-centered approach
to communication involves empathizing and actively seek-
ing patient and family participation in decision making by
all the involved parties, directly or by proxy [18].
In a recent study, bereaved family members retrospec-
tively identified areas for improvement in the process of
transitioning from chemotherapy to palliative care [17].
Many of the difficulties experienced during this difficult
period of transition involved challenges in communica-
tion. Despite the limited available options, families did not
want physicians to state that there were no more options,
but rather present palliative care as an option that offers its
own rewards and benefits. The other commonly cited criti-
cism related to physicians being unwilling to explore the
emotional impact of the illness, providing sufficient infor-
mation available in an atmosphere relaxed enough to allow
families to ask questions, including asking about prognosis,
respecting uncertainty, and helping families understand
more about medical management and complex treatments.
Fundamentally, it takes a concerted and committed
effort to seek to be and to remain connected with families
and keep them informed.
How to Improve Communication in
Multidisciplinary Teams
Various interventions aimed at increasing team communi-
cation in medical settings have allowed staff members to
communicate issues or structure routine work practices to
526
anticipate minor difficulties before they became full blown
problems. For example, multidisciplinary work evaluations
in a PICU at the end of each shift worked to enhance team
communication and protect against emotional exhaustion
[19]. Other interventions are more broadly based and can
prevent conflicts arising from differences in status, edu-
cation, roles, and goals [20]. Look for common concerns
among the group in order to develop a foundational sense of
solidarity, explore concerns, and allow each member to be
heard and acknowledged. For some clinicians, identifying
both their thoughts and feelings is important but a high-risk
strategy in some medical fields. Successful conflict resolu-
tion rests on the acknowledgment that this is a gradual pro-
cess in which an issue may need to be revisited several times
before achieving full resolution [20].
References
1 Payne D. I shouldnt have had to beg for a prognosis. Newsweek, August
22, 2005. Available at http://www.msnbc.msn.com/id/8938144/site/
newsweek.
2 Boyle DK, Miller PA, Forbes-Thompson SA. Communication and end-of-
life care in the intensive care unit: patient, family, and clinician outcomes.
Crit Care Nurs Q 2005;28:302316.
3 Fallowfield LJ, Baum M, Maguire GP. Effects of breast conservation on
psychological morbidity associated with diagnosis and treatment of early
breast cancer. Br Med J (Clin Res Ed) 1986;293:13311334.
4 Marketos SG, Skiadas PK. The modern Hippocratic tradition. Some mes-
sages for contemporary medicine. Spine 1999;24:11591163.
5 Weisz G. The emergence of medical specialization in the nineteenth cen-
tury. Bull Hist Med 2003;77:536575.
6 Rosenberg C. The Care of Strangers: The Rise of Americas Hospital Sys-
tem. New York: Basic Books, Inc, 1987:437.
7 Messerli FH, Messerli AW, Luscher TF. Eisenhowers billion-dollar heart
attack--50 years later. N Engl J Med 2005;353:12051207.
8 Goodwin D. A Team of Rivals: The Political Genius of Abraham Lincoln.
New York: Simon & Schuster, 2005:944.
9 Maxwell J. The 17 Indisputable Laws of Teamwork. Nashville, TN:
Thomas Nellson Publishers, 2001:258.
10 Snair S. West Point Leadership Lessons: Duty, Honor and Other Leader-
ship Principles. Naperville, IL: Sourcebooks, Inc., 2004:279.
Teams: Communication in Multidisciplinary Care
Conclusion
Good communication can offer the most rewarding aspect
of comprehensive medical treatment. However, the fast-
paced, multispecialist approach of modern medicine all
too often triggers a crisis in care, particularly for the criti-
cally ill and dying. Proactively coordinating information
and support, when there is uncertainty and bad news, can
be a challenge, yet teams inherently provide the solution
and a network that can enable the delivery of optimal mul-
tifaceted care.
Disclosure of Potential Conflicts
Downloaded from www.TheOncologist.alphamedpress.org by guest on November 14, 2011
of Interest
The authors indicate no potential conflicts of interest.
11 Powis J, Etchells E, Martin DK et al. Can a good death be made better?:
A preliminary evaluation of a patient-centred quality improvement strat-
egy for severely ill in-patients. BMC Palliat Care 2004;3:2.
12 Tuckman B, Jensen M. Stages of small group development revisited.
Group Organization Studies 1977;2:419427.
13 Back AL, Arnold RM, Tulsky JA et al. Teaching communication skills to
medical oncology fellows. J Clin Oncol 2003;21:24332436.
14 Groopman J. The measure of our days. New York: Penguin USA,
1998:238.
15 Baile WF, Buckman R, Lenzi R et al. SPIKES-A six-step protocol for
delivering bad news: application to the patient with cancer. The Oncolo-
gist 2000;5:302311.
16 Willenbring ML. Integrating care for patients with infectious, psy-
chiatric, and substance use disorders: concepts and approaches. Aids
2005;19(suppl 3):S227S237.
17 Morita T, Akechi T, Ikenaga M et al. Communication about the end-
ing of anticancer treatment and transition to palliative care. Ann Oncol
2004;15:15511557.
18 Back A. Patient-physician communication in oncology: what does the
evidence show? Oncology (Williston Park) 2006;20:6774; discussion
7778, 83.
19 Sluiter JK, Bos AP, Tol D et al. Is staff well-being and communication
enhanced by multidisciplinary work shift evaluations? Intensive Care
Med 2005;31:14091414.
20 Rider E. Twelve strategies for effective communication and collaboration
in medical teams. BMJ Career Focus 2002;325:S45.
OTncologist
he
 Teams: Communication in Multidisciplinary Care
Richard T. Penson, Helena Kyriakou, Dan Zuckerman, Bruce A. Chabner and Thomas J.
Lynch, Jr.
The Oncologist 2006;11;520-526;
DOI: 10.1634/theoncologist.11-5-520
This information is current as of November 14, 2011

Updated Information including high-resolution figures, can be found at:

& Services http://theoncologist.alphamedpress.org/content/11/5/520

Downloaded from www.TheOncologist.alphamedpress.org by guest on November 14, 2011