The Role of Multidisciplinary Teams in Chronic Pain Management

Conditions such as chronic pain can be extremely complex and may require input from a number of different specialties in order to diagnose patients and provide effective treatments. As a result, there has been an increase in the use of multidisciplinary teams (MDTs) in the management of patients with pain. However, the expertise on offer can vary considerably, and while the use of MDTs is often beneficial to patients, not all teams are completely integrated. There are also unresolved issues surrounding liability, should a problem with a patient’s care subsequently lead to litigation.

There is no fixed composition of an MDT, but a typical team will include practitioners from many medical disciplines. By incorporating a wide range of specialties, patients benefit from the integration of various areas of expertise and the different treatments they offer. In addition, the team will be better placed to assess and manage the multiple physical, psychological and social aspects of chronic pain (1). Thus, the core members of a team will usually include practitioners from three or more of the following medical specialties:

• Pain Medicine Physicians. As well as carrying out interventional procedures, pain medicine physicians are vital in the pharmacological provision of adequate pain relief, leading to improvements in sleep, mood and exercise tolerance (1,2).
• As pain management is now recognised as a subspecialty of neurology, neurologists are increasingly likely to be involved in MDTs treating patients with non-cancer pain (1).
• These doctors are experienced in the treatment of patients with chronic pain arising from inflammatory diseases of the musculoskeletal system and connective tissue, degenerative conditions of the joints and spine and soft tissue disorders (1).
• Orthopaedic Surgeon. Surgical intervention may be an option in some cases. Orthopaedic surgeons often perform functional assessments of patients (1).
• Psychologists/psychiatrists. Many patients with chronic pain suffer from psychological/psychiatric symptoms, such as anxiety, depression and post-traumatic stress disorder, and can benefit from appropriate psychological/psychiatric treatment. There may be psychosocial barriers to recovery which can be improved by programmes, such as cognitive behavioural therapy, that increase psychosocial well-being by helping to change a patient’s thoughts, feelings and beliefs about their pain (1,2).
• Physiotherapists/physical therapists. Chronic pain often leads to the avoidance of physical activity, either due to the fear of reinjury or because it makes existing pain worse. Physical therapy, which aims to target the musculoskeletal conditions which cause or result from pain, is important in the treatment of many complex pain conditions (1,2).

Nurses also play an important role in most MDTs. Coordination of care is often their responsibility: they will be called upon to assess patients and supervise medication regimes, and to conduct non-pharmacological interventions such as relaxation and other strategies (2). Additional team members come from a wide range of non-medical fields, many of whom practice in the community and will work to support the patient in various aspects of daily life. Practitioners might include pharmacists, occupational therapists, complementary therapists, dieticians and educational therapists (3). As well as specialist practitioners, the patient’s primary care provider often plays a central role in the MDT. He or she is responsible both for the long-term management of the patient according to the suggested treatment plan and also for referring the patient for additional assessment and treatment if and when this is required. Therefore, good communication between the MDT and the primary care provider is as important as the collaboration between the team members themselves (1).

Surprisingly, not all MDTs include a pain medicine physician. While usually coming from a background in anaesthesia, pain medicine physicians have undergone extensive further training in order to gain specific knowledge of the evaluation, diagnosis and treatment of different types of pain (4). Thus, they have in-depth knowledge of pain physiology and can evaluate patients with complex conditions. Much of the patient’s experience of pain is subjective and there are no tests available to prove its existence (4,5). This means that diagnosis can be difficult and a number of different diagnoses may be made to explain the same set of symptoms (6,7). As pain medicine is a specialist field, only a pain medicine physician will have the necessary experience and proficiency to provide an accurate diagnosis (7,8). Pain medicine physicians can be particularly useful in litigation, as chronic pain cases are often dependent on the plausibility of expert witnesses, and they are able to offer an opinion on causation, treatment and prognosis, and thus provide input to help guide the legal teams in determining an appropriate level of compensation.

The benefits of MDTs for patients have been consistently demonstrated (9,10). As well as a reduction in pain intensity, patients show improvements in physical functioning, quality of life and psychological factors (9). A meta-analysis of 65 studies of multidisciplinary treatment for chronic back pain showed that patients treated in this way reported lower subjective ratings of pain than those receiving conventional unimodal treatment or no treatment at all. Additionally, patients in the MDT group reported a lower use of the healthcare system and were twice as likely to return to work as patients in the other two treatment groups combined (11). MDTs work because there is a continuity of care, which can be delivered to the patient in a coordinated treatment programme. This avoids duplication of investigations and also ensures that treatment failures can be identified quickly (9).

However, while an MDT offers input from several different disciplines in the same location, this does not always mean the patient’s condition is treated in an integrated manner. It is common for some of the members of the team to be involved on a part-time basis only and this may be particularly frequent in smaller practices who do not see enough patients to justify a permanent full-time team. In addition, although teams should hold regular meetings in which cases are discussed, not all of them do so. A study in Canada found that less than 80% of teams held such meetings, and only about a quarter of teams held a weekly meeting (2). Problems can also arise if communication within the team is not open and free from animosity. If an overbearing individual dominates the team, true collaboration cannot take place and the team becomes dysfunctional, to the possible detriment of patient safety (10).

Perhaps a bigger problem is the question of liability in the event of harm to a patient as the result of a decision or treatment recommendation made by an MDT. In medical law, responsibility lies with individuals and not with groups. Unlike a corporation or statutory body, an MDT has no official legal identity. Instead, any decisions made by the team are considered to have been made on the basis of the individual opinions of the doctors present at the meeting. However, each doctor can only be held responsible for the part of the decision that lies within their area of expertise. Furthermore, the soundness of the decision relies upon all of the relevant information having been made available to the MDT. It is the responsibility of the primary clinician, who may be a part of the team or the patient’s primary care provider, to ensure that this happens, and that all of the information provided is accurate (10,12).

Once a recommendation has been made by an MDT, it should be explained to the patient so that he or she can make an informed decision. It is particularly important that any disagreements within the MDT team, along with the reasons for them, are also communicated to the patient (10,12). Disagreements can occur in MDT meetings, but are not always formally recorded, despite the fact that documentation of dissent would obviate the personal responsibility of that particular clinician, should the MDT later be found liable (12). Likewise, if the referring clinician decides to depart from the conclusions reached by the MDT, this should be explained to the patient. The doctor must consider the implications of deviating from the MDT’s plan without justification, and should therefore provide clear documentation of their reasons for doing so. Without such explanations, any consent given by the patient may well be considered invalid. Additionally, if the patient becomes aware of disagreements after an incident of alleged harm, it is more likely that he or she will seek recourse through litigation. Thus, where significant changes to treatment are made after the MDT discussion, it may be prudent to inform the team of this and invite a new discussion, in case the clinical decision is later challenged in court (10).

Chronic pain is a complex condition, often affecting the physical, psychological and social well-being of the patient. The MDT is considered to be the optimal treatment modality for many forms of chronic pain (2,10). However, it is unclear where liability lies in the event of a patient coming to harm as the result of an MDT decision and as yet this situation is untested in UK courts (10,12). As litigation levels continue to rise, it seems inevitable that MDT decision-making will be examined in the future (10).

References

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