The old adage “no man is an island” is true both in life and in medicine. This saying is incredibly potent when we reflect on the limitations of each medical specialty functioning on its own in treating a patient with multiple comorbidities.
When I was working as a doctor in Borneo, I observed a near-complete lack of teamwork between doctors of different disciplines. For example, the hematology team would do their own rounds and write their own plan for a particular patient. An hour later, the surgical team would see the same patient and prescribe their plan.
In other words, patients who require the expertise of various disciplines are seen by different groups of doctors who do not communicate with each other. This sometimes results in contradictory treatment plans, which the main attending doctor would need to resolve.
We have enough data to know that multidisciplinary meetings do indeed affect treatment plans. In Cancer Treatment Reviews, Pillay and colleagues investigated the impact of such meetings in an oncology setting.
“Results have generally indicated that multidisciplinary teams and/or clinics were associated with changes in staging/diagnosis, initial management plans, higher rates of treatment, shorter time to treatment after diagnosis, better survival, and adherence to clinical guidelines,” they wrote.
This is an encouraging sign since multidisciplinary meetings can take considerable time and resources to organize. Multidisciplinary meetings require close coordination between the relevant specialists, with each party given enough time to air their questions and suggestions. Time must also be allocated for the healthy exchange of ideas.
Pillay and colleagues conducted a literature review on the benefits of multidisciplinary cooperation. They found that multidisciplinary meetings are usually conducted weekly or biweekly. In an oncology setting, these meetings are usually attended by medical oncologists, radiation oncologists, surgeons, pathologists, radiologists, and nurse specialists.
“Given that multidisciplinary meetings involve significant financial costs and may lengthen the process of clinical-decision making, it is important to assess if the benefits of conducting such meetings outweigh potential costs,” the research team wrote. “The current literature provides evidence that multidisciplinary meetings lead to significant changes in the way patients are assessed and managed.”
Multidisciplinary Work in Alagille Syndrome
Aside from oncology, many other disciplines can benefit from multidisciplinary meetings. A disease that has been shown to benefit from multidisciplinary cooperation is Alagille syndrome.
In the Journal of Multidisciplinary Healthcare, Menon and colleagues wrote about the systems that are typically affected in Alagille syndrome. For example, hepatic involvement, which occurs in around 75% to 100% of cases, usually involves a paucity of interlobular bile ducts or cholestasis. Cardiac involvement, which also occurs in nearly all patients with Alagille syndrome, can result in peripheral pulmonary artery stenosis, pulmonary atresia, and congenital heart disease.
Read more about Alagille syndrome etiology
Skeletal disease occurs in around 33% to 87% of patients with Alagille syndrome; the most common manifestations are butterfly vertebrae, hemivertebrae, and spina bifida occulta. Renal involvement, found in 19% to 73% of patients, usually manifests as ureteropelvic junction anomaly or renal tubular acidosis. Approximately 56% to 88% of patients experience ocular anomalies, such as posterior embryotoxon, optic drusen, and pigmentary retinopathy.
The point of this list is to highlight how Alagille syndrome transcends any particular medical discipline. Because hepatic pathology occurs in almost all patients, it is sometimes considered a hepatic disease. This is perhaps understandable, considering that patients with Alagille syndrome are at a high risk of developing end-stage liver disease requiring liver transplantation.
An Alagille Syndrome Carrier With Multiple Comorbidities
However, the sole focus on the hepatic (and cardiac) pathologies in Alagille syndrome is often insufficient. In the International Journal of Obstetric Anesthesia, Maisonneuve and colleagues wrote about treating a 22-year-old pregnant woman who was a carrier of Alagille syndrome and had multiple comorbidities.
The patient underwent liver transplantation at 3 years of age due to neonatal cholestatic jaundice. Thirteen years later, at 16 years of age, she underwent renal transplantation due to chronic renal failure. At 19 years old, she was found to have a pseudo-aneurysmal dilation of the left internal carotid, which her physicians suspected to be a form of arterial dysplasia common in Alagille syndrome.
Read more about Alagille syndrome complications
“At a multidisciplinary meeting it was agreed that, despite the patient’s severe scoliosis, epidural insertion would be attempted if she went into spontaneous labor and, since the Valsalva maneuver was relatively contraindicated due to left internal carotid ectasia, an elective forceps delivery was planned,” Maisonneuve and colleagues explained. The patient later managed to deliver a 4.5 lb girl vaginally.
This case study highlights how complex a disease such as Alagille syndrome can be. By the time the authors of the study saw the patient, she had already been seen by hepatic, renal, and neurology specialists. This demonstrates that the best way, indeed the only way, to manage Alagille syndrome well is to do so in a multidisciplinary setting. Put simply, multidisciplinary cooperation is important because it can improve the clinical outcomes and the prognosis of patients.
Menon J, Shanmugam N, Vij M, Rammohan A, Rela M. Multidisciplinary management of Alagille syndrome. J Multidiscip Healthc. 2022;15:353-364. doi:10.2147/JMDH.S295441
Pillay B, Wootten AC, Crowe H, et al. The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: a systematic review of the literature. Cancer Treat Rev. 2016;42:56-72. doi:10.1016/j.ctrv.2015.11.007
Maisonneuve E, Morin F, Crochetière C, et al. Multidisciplinary management of a hepatic and renal transplant patient with Alagille syndrome. Int J Obstet Anesth. 2012;21(4):382-383. doi:10.1016/j.ijoa.2012.08.003