Patient and physician perceptions of lung cancer care in a multidisciplinary clinic model

Original Article

Patient and physician perceptions of lung cancer care in a multidisciplinary clinic model

G. Linford, MD MSc*, R. Egan, MSc PhD, A. Coderre-Ball, PhD, N. Dalgarno, PhD, C.J.L. Stone, MD§, A. Robinson, MD*, D. Robinson, BSc Hon||, S. Wakeham, BSc Pharm||, G.C. Digby, MD MSc(HQ)*,§#




Lung cancer (lc) is a complex disease requiring coordination of multiple health care professionals. A recently implemented lc multidisciplinary clinic (mdc) at Kingston Health Sciences Centre, an academic tertiary care hospital, improved timeliness of oncology assessment and treatment. This study describes patient, caregiver, and physician experiences in the mdc.


We qualitatively studied patient, caregiver, and physician experiences in a traditional siloed care model and in the mdc model. We used purposive sampling to conduct semi-structured interviews with patients and caregivers who received care in one of the models and with physicians who worked in both models. Thematic design by open coding in the ATLAS.ti software application (ATLAS.ti Scientific Software Development, Berlin, Germany) was used to analyze the data.


Participation by 6 of 72 identified patients from the traditional model and 6 of 40 identified patients from the mdc model was obtained. Of 9 physicians who provided care in both models, 8 were interviewed (2 respirologists, 2 medical oncologists, 4 radiation oncologists). Four themes emerged: communication and collaboration, efficiency, quality of care, and effect on patient outcomes. Patients in both models had positive impressions of their care. Patients in the mdc frequently reported convenience and a positive effect of family presence at appointments. Physicians reported that the mdc improved communication and collegiality, clinic efficiency, patient outcomes and satisfaction, and consistency of information provided to patients. Physicians identified lack of clinic space as an area for mdc improvement.


This qualitative study found that a lc mdc facilitated patient communication and physician collaboration, improved quality of care, and had a perceived positive effect on patient outcomes.

KEYWORDS: Quality of care, multidisciplinary models, process improvement, lung cancer, patient experiences


Lung cancer (lc) is the leading cause of cancer-related mortality, with a 5-year survival of less than 20%1. Delays in lc diagnosis and management are common2,3 and have been attributed in part to the complexity of lc care, which requires the coordination of a diverse group of physicians, including respirologists, medical and radiation oncologists, and thoracic surgeons4,5. Unfortunately, delays in care can lead to tumour progression6 and patient distress7,8.

Multidisciplinary clinic (mdc) models have demonstrated effectiveness in patient management for other cancer types9,10. Unfortunately, mdcs are uncommon in lc care5, and until recently, there has been a paucity of data supporting their implementation for this patient group11,12. However, evidence is increasingly showing that lc mdcs might improve care coordination, communication between providers, and compliance with guidelines, and might reduce delays in diagnosis and treatment1114. Nonetheless, development and implementation of lc mdc models have been limited by a scarcity of literature identifying optimal clinic characteristics and structures, ideal mixes of specialist and allied health providers, and implementation strategies2,5,12,15. Evaluation of lc mdcs is limited by the heterogeneity of existing models and the challenges in defining essential components12,16,17. Additionally, very few studies have evaluated the effect of lc mdcs on patient and health care provider experiences5,12,18. A better understanding of those experiences can help to inform the development of such care models.

The Kingston Health Sciences Centre (khsc) recently implemented a lc mdc that reduced the time from lc diagnosis to oncology assessment by 10 days and the time to treatment by 25 days14. Time to treatment improved substantially (more than time to oncology assessment), which was hypothesized to be attributable to improved provider communication and real-time collaborative physician management discussions. To further study the potential benefits and drawbacks of the mdc, we collected patient, caregiver, and health care provider experiences within that care model.



As an academic tertiary care centre, khsc serves a predominantly rural catchment area of more than 500,000 people. The region served by khsc sees 600–700 new lc patients annually, 60% of whom are managed through the Lung Diagnostic Assessment Program (ldap), a rapid assessment clinic responsible for the management of patients from initial suspicion of malignant disease to diagnosis. At khsc, approximately 75% of patients with suspected lc are seen by a respirologist in the ldap; the remaining 25% with suspected operable disease are triaged directly to a parallel thoracic surgery clinic. The region served by khsc has the lowest 5-year lc survival in the province of Ontario, at 15.0% in 201719.


Within the ldap, we implemented a weekly mdc involving respirologists, medical oncologists, and radiation oncologists. Patients with a new lc diagnosis were offered concurrent, same-visit oncology consultation. Physicians participated in the weekly mdc on a rotating schedule, with a usual attendance of at least 1 physician per specialty, and a minimum attendance of 1 respirologist and 1 oncologist. At every mdc, physicians met in a short case conference to do an advance chart review for patients booked into the clinic, to discuss the need for oncology consultation, and to begin to develop management plans. Stone et al.14 summarized the details of the mdc implementation and improvement process.

Study of the Interventions

When designing the present study, we planned to correlate our previously documented and published improvements in timeliness of care14 with patient and provider experiences in the mdc. Our expectation was that reducing siloed care would improve the patient and caregiver experience. We therefore conducted a qualitative research study and adopted an exploratory design20 to describe patient, caregiver, and health care provider experiences in a traditional model of care compared with the mdc.

Eligible patients in the mdc model were those who had received a new diagnosis of lc of any stage (iiv) after having undergone investigations coordinated by an ldap respirologist and who were returning to the mdc (February 2017 onward), where at least 2 physician assessments took place (respirologist plus at least 1 oncologist). Patients recruited from the traditional model of care were seen by a respirologist either within the 3 months before mdc implementation (November 2016 to January 2017) or after mdc implementation (February 2017), but outside the mdc model (usually because of scheduling conflicts). In all cases, the primary caregivers of the patients were invited to participate in interviews. A random number generator was used to create a randomized list of patients from the database of those who had been assessed at the ldap of the Cancer Centre of Southeastern Ontario. Patients who were deceased, who had moved, or who had a non-lc diagnosis were excluded (supplementary Figure 1). One researcher (GL) contacted patients initially with a letter in the mail, followed by a telephone call inviting participation. One researcher (RE) used e-mail messages to invite the participation of all physicians involved in the mdc. The study was approved by the Queen’s University Health Sciences and Affiliated Hospitals Research Ethics Board.

Data Collection

Before leading the patient and caregiver interviews, a team of 4 researchers received training on how to conduct qualitative research. One researcher (RE) conducted the physician interviews and focus group. Interview protocols for patients and physicians were informed by a systematic review previously published by our research team12 and were developed through team discussion and consensus. To mitigate bias and address reflexivity21, researchers involved in the development, design, or implementation of the mdc did not conduct interviews. However, 1 researcher (GCD) was a focus group participant, and 1 researcher (AR) was an interview participant. Both GCD and AR were physicians in the mdc. Two researchers (CJLS, GCD) had been involved in quantitative data collection and analysis of the mdc. All team members were aware of the improved timeliness of care demonstrated in the mdc model. To allow for arm’s length discussion and to reduce power differentials, health care providers were interviewed by a qualitative researcher without a medical background (RE). All interviews were audio-recorded and transcribed verbatim. We reached data saturation when no new information was collected from the interviews. Pseudonyms replaced all identifying information before data analysis.

Patient and Caregiver Interviews

We used purposive sampling22 to ensure that data were obtained from patients who met the inclusion criteria [supplementary Figure 1(A)]. Interviewers coordinated the interview, obtained written consent, and met with the patient with or without their caregiver for an in-person interview in a secure confidential location. The semi-structured interviews used questions designed to elicit information from patients and caregivers about their lc journey, the process, and their perceptions of the quality of their care [supplemental Appendix 1(A)]. Interviews lasted between 30 and 60 minutes.

Physician Interviews

Convenience sampling was used to invite physician participants. The original plan was to conduct physician focus groups for each subspecialty to ensure freedom to discuss challenges in synchronous care coordination between specialties. However, because of scheduling difficulties, one “focus group” (labelled as such for the purposes of this paper) was conducted with 2 respirologists in the form of a joint interview (approximately 60 minutes in duration), and all medical and radiation oncologists were interviewed independently. The same open-ended interview protocol was used for the focus group and for the individual physician interviews. Interview questions focused on the barriers and challenges in the mdc, recommendations for the mdc, and perceptions of effects on patient care and health outcomes [supplemental Appendix 1(B)].

Data Analysis

Data were analyzed using an inductive thematic design20. We first immersed ourselves in the data by having 3 researchers (ACB, GCD, ND) read 1 patient and 1 physician transcript. Transcripts were coded using open coding in the ATLAS.ti qualitative data analysis software application (version 8: ATLAS.ti Scientific Software Development, Berlin, Germany). To ensure interrater reliability, codes were then compared. When differences arose between the researchers, a discussion ensued until a shared meaning of the codes and consensus was reached. A codebook was developed, and 1 researcher (ACB) coded the remaining transcripts, with new codes added as additional interviews were conducted and new viewpoints emerged. Coding the transcripts occurred throughout the data collection process. Once all transcripts were coded, the research team met to discuss the codes, to determine subthemes, and to identify overarching emergent themes. Using comparative analysis23, we identified commonalities and differences between the participant groups as they related to each theme.


Participant Characteristics

For the specified time frames, we identified from the database 182 patients seen in the traditional model of care and 77 patients seen in the mdc model of care. A random number generator was used to identify 72 patients from the traditional model and 40 patients from mdc model to serve as our contact list, with many patients excluded before contact for the reasons outlined in supplementary Figure 1(A,B). The remaining 15 patients in the traditional model and 25 patients in the mdc model served as our final contact list. Interviews were conducted with 6 patients from each model. Table I presents the demographics of the interviewed patients.

TABLE I Demographics of the interviewed patients


Of 9 physicians who had participated in the mdc clinic at the time of study recruitment, 8 (88.9%) agreed to participate in the qualitative study, including 2 respirologists, 2 medical oncologists, and 4 radiation oncologists.

The analysis resulted in 57 codes, which were grouped into 12 subthemes, from which 4 overarching themes emerged. Those themes were communication and collaboration, efficiency, quality of patient care, and effects on patient outcomes.

We identified each interview and focus group participant using pseudonyms: MDC1–6 for patients treated in the mdc model, T1–6 for patients treated in the traditional model patient, FG1 for the respirologist focus group, MO1 and MO2 for the medical oncologists, and RO1–4 for the radiation oncologists. Tables IIV identify selected quotations for each subtheme identified.

TABLE II Theme 1: Communication and collaboration—selected patient, caregiver, and physician quotes


TABLE III Theme 2: Efficiency selected patient, caregiver, and physician quotes


TABLE IV Theme 3: Quality of Patient Care—selected patient, caregiver, and physician quotes


TABLE V Theme 4: Impact on Patient Outcomes—selected physician quotes


Theme 1: Communication and Collaboration

The Communication and Collaboration theme describes interactions between physicians and patients, and also those between physician specialties, including information provided to patients (Table II).

Information Provided to Patients

All patients seen in the mdc described receiving sufficient information, having it explained in a way that helped them to understand their illness, and receiving consistent information between physicians (MDC3, MDC6). Of the 6 patients in the traditional model, 5 also spoke about receiving sufficient and consistent information (T1, T3). One patient seen in the traditional model (T2) spoke of receiving disjointed information and receiving the news of their diagnosis without further information about next steps, although this patient’s circumstances were unique in that transfer to the emergency room from the clinic was required, and the individual expressed dissatisfaction about being “seen by several doctors” there. Notably, 2 physicians spoke of consistent messaging (FG1, MO1), and 6 spoke about providing focused information to patients to avoid overwhelming them (MO1, RO1, FG1).

Multidisciplinary Environment

All patients in the mdc model and 5 patients in the traditional model felt that that their physicians operated as a team (MDC3, MDC6, T1, T3), given their observations that physicians were working and meeting together on their plan of care. Of the physicians, 6 discussed the benefits of working in a multidisciplinary environment and the effect it had on removing professional silos (MO1, RO4, FG1).

Communication Between Physicians

All physicians reported perceived improvements in communication with each other in the mdc model, repeatedly referencing their ability to have synchronous communication with the other physician specialists (MO1, RO2).

Improving Collegial Relationships

The respirologists and 2 radiation oncologists believed that the clinic improved collegial relationships through a better understanding and appreciation of each other’s roles and responsibilities—facilitating peer education and helping to develop treatment plans as a team (RO2, FG1).

Theme 2: Efficiency

The Efficiency theme identifies perceived changes in efficiency because of the mdc (Table III). Patients and physicians in the mdc model discussed wait times for cancer diagnoses and treatment. Physicians also discussed improvements to work efficiency.

Effect on Wait Times

One patient in the mdc described their journey as being quick (MDC2). Another mdc patient reported frustration with waiting for tests between appointments and believed that it took too long to start treatment (MDC5). Of the patients in the traditional model, 4 also acknowledged that appointments, testing, and treatment start happened quickly (T6), although 1 of those patients (T3) later expressed a feeling that there “was a lot of hurry up and wait” with regard to completion of testing, receipt of test results, and formulation of a management plan. All 3 physician groups (all physicians) believed that the mdc reduced wait times to see oncologists, shortened time to diagnosis, and reduced time to treatment (MO2, RO1, FG1).

Seeing More Patients per Clinic

All 3 physician groups (6 physicians) spoke about the perceived increased efficiency in having only 1 nursing assessment or preliminary screening completed for the 3 physician assessments (MO1, RO1, FG1). The radiation oncologists specifically believed that the mdc clinic increased the number of patients they could see in clinic because of more efficient nursing assessments and improved patient flow.

Theme 3: Quality of Patient Care

The Quality of Patient Care theme describes patient comfort, confidence, and satisfaction with care; the convenience of multiple same-day assessments; and the effects on the patient experience and availability of family support (Table IV).

Patient Comfort, Confidence, and Satisfaction

All patients seen in the mdc spoke about feeling confident and satisfied with their care and feeling comforted by having multiple physicians addressing their concerns (MDC2). Of the 6 patients seen in the traditional model, 5 also expressed feelings of comfort, confidence, and satisfaction with their care (T2, T5, T6). However, the 1 patient in the traditional model who required transfer to the emergency room from the clinic expressed significant concern over the perceived lack of advocacy in his treatment plan. All 3 physician groups (6 physicians) believed that the mdc increased patient comfort, confidence, and satisfaction. They also perceived an overall reduction in patient and provider anxiety about treatment and outcomes (MO1, RO3, FG1).

Effect on Family Presence

Of the patients seen in the traditional model, 3 commented on the need to coordinate with family members to make multiple trips to attend appointments, and 1 patient (T5) commented on a family member having to take time off work for that purpose. Meanwhile, all patients seen in the mdc model described how their families were able to physically attend appointments because of reduced time away from work and minimized travel time (MDC4). Of the physicians, 4 indicated that the mdc and same-day assessments would improve patient support by enabling caregiver accompaniment (RO3, FG1).

Effect of Same-Day Assessments

Of patients seen in the traditional model, 3 noted the inconvenience of multiple appointments on separate days (T4). Of patients seen in the mdc model, 5 expressed appreciation for same-day assessments (MDC1). A 6th patient seen in the mdc clinic required an additional physician assessment on another day and expressed no concern about making the additional trip. Of the physicians, 3 (RO4) commented on a lack of physical workspace and computer workstations and a need to redesign the workspace to suit the needs of multiple physicians working in the mdc clinic. The issue of space was not remarked upon by patients.

Meeting Patient Expectations

All patients seen in the mdc model found that the clinic met or exceeded their expectations for care (MDC2). Of patients seen in the traditional model, 5 also expressed overall satisfaction with their care (T1).

Theme 4: Effect on Patient Outcomes

The Effect on Patient Outcomes theme describes the predicted effect of the mdc as perceived by the physician groups (Table V).

Physician Predicted Effect

Each group of physicians expressed their views about how the mdc clinic could positively affect patient outcomes by reducing the time to oncology assessment and treatment (MO2, RO2, FG1). Many physicians also discussed the potential to improve resource use, including decreased testing and consolidation of appointments (RO1).


This study describes patient, caregiver, and health care provider experiences in a novel lc mdc model compared with a traditional siloed model of care. We identified 4 themes from our interviews: communication and collaboration, efficiency, quality of patient care, and effect on patient outcomes. Patients in both care models had, overall, a very positive impression of their care. Patients seen at the mdc consistently reported the convenience of consolidating multiple physician assessments into one visit and the positive effect that consolidation had on facilitating caregiver presence at appointments. Our results are consistent with a previous study by Kedia et al.13 of patients with lc and their caregivers in a mdc model, which found that the mdc improved physician collaboration and patient convenience, while reducing patient confusion and anxiety and decreasing test redundancy.

We build on previous work by evaluating physician perspectives of the mdc model, an area that has not previously been assessed12,13. Physicians reported several perceived benefits of the mdc model, including improvements in communication and collaboration, clinic efficiency, quality of care, and patient outcomes. All physician groups described improved communication (attributed to real-time face-to-face discussions with colleagues) and indicated that the mdc improved collegiality and collaborative relationships through a better appreciation of each other’s roles and expertise. Finally, physicians felt that the mdc increased patient comfort and satisfaction by combining physician assessments and that it reduced overall patient and caregiver anxiety through consistent messaging, facilitation of caregiver attendance, and reduced wait times.

Physician perceptions of the benefits of the mdc are important because the physicians were the only individuals in the study to experience both models of care, providing a direct comparison between the models. Importantly, the benefits reported by physicians were consistent with measured improvements in the timeliness of oncology assessment and treatment14 and provide plausible explanations for the previously identified improvement in time to lc treatment in the mdc model. The improved collegiality and interpersonal relationships reported by the physician group is noteworthy. Physician burnout is common, and one of the best studied organizational strategies to prevent burnout has been cultivating a work community and creating connectedness between physicians24. Burnout affects the quality of patient care in that it influences patient safety, patient satisfaction, physician turnover, and health care system costs24,25. An unanticipated benefit of the mdc appears to be an improved collegial and team-based culture among thoracic oncologists, which could be contributing to an improved work experience for physicians, warranting further evaluation.

Patients seen in both care models generally reported high satisfaction, despite data from the mdc model demonstrating improved wait times and physician-perceived improvements. One possible explanation for that observation is that most patients with cancer who were living and well enough to be interviewed would report positive experiences of the health care system. That explanation is supported by a study showing that patients with cancer underreport adverse events26. It also points to a possible limitation, in that patients experienced only a single model of care at the time of their lc diagnosis, making a comparison of perceived efficiency between models challenging.

Patients did report two notable differences between the traditional and mdc models. First, patients seen at the mdc consistently reported the convenience and efficiency of the model, a finding that is in keeping with previous research13. Additionally, several patients seen at the mdc reported that having concurrent appointments made it more likely that family members could attend for support. Caregiver attendance at appointments is important, because many patients with newly diagnosed advanced lc have an inaccurate understanding of their diagnosis27, and caregivers assist with medical decision-making, psychosocial support, and health care system navigation28. Although 1 patient seen under the traditional model reported dissatisfaction with perceived disjointed communication and poor patient advocacy, that patient had a unique clinical course that required urgent transfer to the emergency department directly from the ldap clinic.

Our interviews explored patient perceptions of being overwhelmed with information from multiple physician assessments and the potential for inconsistent messaging from mdc physicians, because those factors had been raised as potential concerns in prior studies13. We found that patients and caregivers seen in the mdc reported receiving an appropriate level of detail about their diagnosis and plan; furthermore, consistent messaging and collaboration between team members was a perceived strength of the mdc. Physicians had primarily positive impressions of the mdc, but as an improvement opportunity, identified a need to design clinic space to better support multidisciplinary work.

Our study has several unique strengths. First, we were able to correlate our results with a simultaneous quantitative analysis of the mdc, which corroborated physician perceptions of improved clinic efficiency and reduced wait times14. Additionally, although most analyses of lc mdcs to date have emerged from American institutions using private pay systems12, ours represents a unique initiative in Ontario, where patients have universal health coverage, which helps with the potential generalizability of our findings. In addition, the relatively small size of the thoracic oncology program at our centre enabled participation by almost all physicians involved in the mdc program. Finally, as opposed to focus groups used in other studies13, we used individual in-person interviews of patients and caregivers, which facilitated a more natural and confidential interaction and allowed for interviewers to ask follow-up questions when necessary.

As with any attempt to evaluate subjective experiences, our study has inherent limitations. The retrospective nature of the study could have led to both selection bias and recall bias, in that patients who remained alive to be interviewed might have been likely to have more favourable disease characteristics or better response to therapy. Given the high mortality associated with lc, many of the patients we identified for interview were unfortunately deceased or too unwell to participate. Furthermore, patients who declined to be interviewed might have had a less positive clinical experience. Similarly, facilitating in-person interviews for patients outside of the city was challenging and might have affected the type of patients we were able to recruit. Another limitation to our study is the lack of an evaluation of the thoracic surgery presence in the mdc. We have been working with thoracic surgery to increase their involvement in the mdc clinic, but none of the patients in our study received a same-day thoracic surgery consultation. Future qualitative studies of patient and caregiver experiences in mdcs could ideally enrol and interview participants prospectively to reduce the effect of selection and recall bias.


Diagnosis and management of lc is complex—in part because it requires the contributions of multiple medical specialists. Previous studies have shown that creating a multidisciplinary environment can minimize the time to oncologic assessment and treatment. Our qualitative assessment of patient, caregiver, and physician experiences found that a lc mdc model has additional benefits compared with a traditional clinic model, including improved communication with patients, collaboration between physicians, clinic efficiency, and quality of care. Physicians perceived the mdc to have positive effects on patient outcomes, an observation that correlates with measurable data. Future studies of a lc mdc care model are warranted.

Supplementary Information


Funding for this study was obtained from the Department of Medicine Research Award at Queen’s University. The sponsor had no role in the study design or conduct.

Portions of this work were previously published in abstract form: Linford G, Robinson D, Wakeham S, et al. Patient, caregiver, and provider perceptions of care before and after implementation of a multidisciplinary lung cancer clinic: a qualitative assessment of an improvement initiative. Poster presented at: the International Forum for Quality and Safety in Healthcare; Glasgow, Scotland; 27–29 March 2019; and moderated poster presented at: the Canadian Respiratory Conference; Ottawa, Ontario, Canada; 11–13 April 2019.


We have read and understood Current Oncology’s policy on disclosing conflicts of interest, and we declare that we have none.


*Department of Oncology, Cancer Centre of Southeastern Ontario,
School of Nursing, Queen’s University,
Office of Professional Development and Educational Scholarship, Faculty of Health Sciences, Queen’s University,
§Department of Medicine, Kingston Health Sciences Centre,
||School of Medicine, Queen’s University,
#Division of Respirology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON.


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Correspondence to: Geneviève C. Digby, Queen’s University, Richardson House, 102 Stuart Street, Kingston, Ontario K7L 2V6. E-mail:

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Current Oncology, VOLUME 27, NUMBER 1, February 2020

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ISSN: 1198-0052 (Print) ISSN: 1718-7729 (Online)