Table 2 How residents learn to participate competently in multidisciplinary team meetings: perceived facilitators and barriers

Awareness of the educational function of MDTMs among medical specialists and residents

Both medical specialists and residents acknowledge the educational objectives of MDTMs*

Education is an explicit goal of the MDTM (f)

Specialist [MO1]: “First, the MDTM must be described as a training moment. Second, learning objectives must be established and these goals must be acted upon during the meeting.”

Specialist [S4]: “If you do not pay attention to the education of residents, they will not learn. This also applies to their MDTM participation.”

Non-medical competences are largely ignored (b)

Resident [S1]: “Participating in MDTMs is not incorporated in my educational programme. Ridiculous actually (…) The feedback I received is solely focused on the medical content and not on other competences.”

Specialist [S4]: “Focus on the medical content is not enough (…) Focus on guiding residents on how to participate in MDTMs is the only way they can learn.”

Residents’ self-study methods

Residents copy behavioural styles of their supervisors (f)

Resident [MO3]: “I watch how my supervisors conduct the MDTM. I copy their behaviour because I assume that is how it should be done.”

Specialist [R2]: “I tell my residents that is important to see how I do the MDTM. Watch and learn. Then they can do the same.”

Residents accept their responsibility to be well prepared (f)

Resident [R9]: “I need to prepare for the meeting in order to understand what is important to discuss and what is expected from me.”

Resident [S4]: “If I have prepared well, I can pay full attention to all the information presented during the meeting and I can change my predefined treatment proposal. If I am not prepared, I usually can’t switch right away and my learning curve is much less.”

Educational conditions in MDTMs

Residents need time for observation to learn (f)

Resident [RO1]: “For now, I am just observing. I did prepare each case in advance and devised a treatment proposal for myself. I learn a lot by listening to the discussion and finding out if my ideas were right or wrong.”

Specialist [MO3]: “Residents need to observe (…) to learn to understand specialists’ considerations that lead to decisions.”

Residents cannot take on an active role (b)

Resident [MO1]: “I just listened. In a few months I will complete my training and should be an active member at the front table (…) I don’t feel qualified for that since I haven’t been trained to do this.”

Resident [S4]: “I tried a few times to give input, but it felt like I was being ignored, not taken seriously. It felt like I was not invited to participate in the discussion.”

Teaching role of medical specialists

Supervisors help residents prepare for the MDTM (f)

Specialist [R1]: “Before the meeting, I check how the resident has prepared for the MDTM and what they find important to discuss during the meeting. Then I can suggest adjustments.”

Resident [RO2]: “Before each MDTM I discuss the cases that we present with my supervisor. We then formulate a treatment proposal in advance. I find that very useful, because I now know that I am speaking on behalf of us both during the MDTM.”

Supervisor supports an active role for residents (f)

Specialist [RO2]: “I prepare and discuss all cases with the resident in advance. During the meeting I give my resident an opportunity to take on their role. The most difficult part for me is not to intervene.”

Specialist [N1]: “We give residents more speaking time than we give ourselves (…) so they can learn the trade.”

Supervisor provides back-up (f)

Resident [P2]: “My supervisor sits next to me at all times. It is a reassuring idea to have back-up if it gets too complicated for me.”

Resident [RO1]: “When I do not know the answer, I look sideways at my supervisor.(…) That is why the supervisor is also present at the MDTM, to help me with these cases.”

Supervisor gives feedback to residents (f)

Specialist [MO]: “I believe that residents learn through the master and apprentice principle. I want to be a good role model for them. Giving feedback on their performance is part of that role.”

Characteristics of MDTMs

Time constraints

Time constraints make it difficult for residents to ask questions or take part in the discussion (b)

Resident [S3]: “There is a lot of time pressure, with only two minutes discussion time per patient (…) This creates a barrier to asking for further explanation.”

Resident [RO1]: Usually there is only time to discuss complex cases, which are too complicated for me.”

MDTM is not a formal part of the residents’ educational programme (b)

Resident [S1]: “I cannot always attend MDTMs because of other daily tasks, even when my supervisor expects me to. (…) It would help if the meeting was booked in my schedule.”

Specialist [MO1]: “Residents consider the MDTM as an extra task. (…) They feel pressure to perform well. (…) So they stay away from the MDTM if they haven’t been able to prepare for the meeting due to other daily tasks.”

Regulations and organisation

Residents are seated in the front row / seated within the inner circle of an U-shaped setting (f)

Resident [P1]: “In the beginning I sat at the back (…) Now I try to sit at the table, because then you feel more involved. You can look other participants in the eye instead of looking at their backs.”

Resident [P3]: “The previous MDTM room was very small. Then I had to sit at the back. Now we have a new, bigger room and I can sit at the front Table. I feel much more involved now. Saying something is easier.”

There is an assigned responsibility for residents in the division of tasks (f)

Specialist [N1]: “Usually, residents prepare and present the cases. Only in complex cases do specialists take over. (…) We encourage them to propose a treatment plan as well.”

Resident S2: “My task is to present the cases. I have learned how I am supposed to do that; what information I share and what is not necessary.”

Residents are responsible for tasks that hinder active MDTM participation (b)

Resident [S3]: “I was expected to take the minutes and participate actively at the same time, but I was not able to concentrate on the content.”

Resident [S1]: “At one MDTM I had to chair, present cases and take the minutes. Sometimes supervisors would ask me what my treatment plan was. Most of the time I could not answer because I had too much on my plate.”

The participation period of residents in one tumour-specific MDTM is too short (b)

Resident [RO1]: “Every six months I focus on a different tumour type with its own tumour-specific MDTM. (…) So, every time I start to feel comfortable with getting a bigger role in the MDTM, I switch to another tumour type and it starts all over again.”

Resident [MO3]: “I am now doing my colorectal internship for 6 months. It takes me time to acquire the right amount of knowledge to participate in discussions and to know what is expected of me in this particular MDTM. By the time I have taken on a more active role, my internship is almost over.”

Team dynamics and behaviour

Atmosphere and hierarchy within MDTMs

The MDTM lacks an open and friendly atmosphere (b)

Resident [RO3]: “Specialists can communicate quite violently with each other. (…) Communication training for the core team members might help them understand how a resident feels in this setting.”

Specialist [P3]: “One of the specialists grumbles regularly, although he means well. (…) At first, it can be quite threatening.”

The hierarchal position of residents hinders their MDTM participation (b)

Resident [MO3]: “Due to my position as a resident, it is difficult for me to express an opposing opinion to a specialist.”

Specialist [MO2]: “There is always one participant, usually a professor, who is in charge and who has the final say. I believe that younger participants should be given more space to express different opinions.”

Residents are not seen as full team members (b)

Resident [RO3]: “I have the feeling that they (medical specialists) doubt everything I say. Especially because I sometimes see them email each other afterwards.”

Resident [N1]: “When an older and therefore more experienced radiologist says something, all other members automatically listen to him and not to what I say. Even if I am strongly convinced that I am right.”

Residents are not familiar with the other team members (b)

Resident [MO2]: “I feel more free to speak if I have been to the MDTM multiple times, because then I am more familiar with the team and feel part of the team.”

Resident [P2]: “I was very nervous about attending the MDTM. I stepped into a large room with many screens and a group of people that I do not know. (..) I thought: ‘O my god, this is never going to work’.”

Creating a safe and open learning environment

There is scope to make mistakes (f)

Specialist [MO1]: “If the resident says something that I think is not quite right, I give them the space to make their arguments. Then I say: ‘Maybe there is another option …. I feel this is more respectful than interrupting right away.”

Resident [RO]: “If I say something that my supervisor thinks is not quite complete, she takes over. Then I cannot take back control.”

Residents are continuously assessed on their functioning (b)

Resident [S3]: “The setting of the meeting feels like an exam (…). It creates a barrier preventing me from speaking.”

Residents’ personal characteristics

Resident lacks self-confidence and assertiveness (b)

Resident [P3]: “Sometimes I do not dare to speak, because then I think: ‘I am just a resident, what do I know? (…) I am too shy.”

Resident [P4]: “To be secure in drawing conclusions, you need to have the medical knowledge, but also the confidence in yourself that you can communicate within the team. (…) I am assertive, but I know that other residents have more of a struggle.”