Multidisciplinary management of patients with cancer in France: The SINPATIC qualitative study

Figures & data

Figure 1. The four-dimensional model of collaboration (from D’Amour et al.).

Figure 2. The health professionals and patients’ perceptions of professional roles, collaboration, and care pathways.

The direction of solid arrows indicates the burden of the expectation (e.g. the arrow marked “Cure” indicates that the patient expects the oncologist to cure the cancer). The direction of dotted arrows indicates the direction of information transmission (e.g. case notes are sent by the hospital to the GP).

Table 1. Characteristics of the health professionals and patients included in the SINPATIC study.

	Patients N = 19	General Practitioners N = 17	Medical specialists N = 15	Nurses N = 8
Sexe
Female	11 (58%)	6 (35%)	11 (73%)	7 (88%)
Age (means ; [min-max])	63,3 [36-84]	54,8 [32-76]	48,2 [36-65]	41,5 [37-51]
Type of cancer
Prostate	4 (21%)
Breast	9 (47%)
Colonorectal	4 (21%)
Lung	2 (11%)
Type of treatment
Curative	16 (84%)
Palliative	3 (16%)
Status of cancer
Local	11 (58%)
Metastatic	8 (42%)
Type of practice
Solo practice		2 (12%)
Group practice		8 (47%)
Health Centre		7 (41%)
Location of practice
Urban		12 (71%)
Rural		5 (29%)
Teaching activity		13 (76%)
University hospital			11 (73%)
Medical specialty
Oncologists			11 (73%)
Gynaecologist			3 (20%)
Surgeon			1 (7%)
Oncology training
Yes				3 (38%)

Table 2. A Selection of verbatim comments from the SINPATIC health professionals and patients.

Themes	Verbatims
Perceptions of the patient’s medical history and background	‘And then one day, I had bad bronchitis after the flu and Dr F. examined me carefully. She listened to my back and heart, and then she put her hand there and asked “What’s that?” because it was big.’ P2 ‘I talked to her again about her screening, and then she admitted out of the blue - at the end of a consultation to renew her prescription for antihypertensives - that she had a lump but didn’t want to tell me about it, because, well, she knew that it was cancer. And so then I asked her if I could examine it. She agreed and, effectively, I felt a lump in her breast’. GP2 ‘This is a patient who was not at the start of the cancer care pathway. I saw her exactly at the time when signs of metastatic recurrence first appeared’. O2 This theme was not mentioned by N2 ‘And it was only then - and this is the strange thing - in October 2016 that someone said the word “cancer” for the first time. It took three years for someone to tell me “you have cancer”. Until then, I had been told “you have a problem, you have ganglions, you have metastases” but the word “cancer” only appeared in October 2016’ P1 ‘In fact, it was the haematologist. It is not at all usual but as he [the patient] had a first oncological disease, it was the haematologist who told him about the prostate cancer and it was the haematologist who presented the case at his urology team meeting’O1 ‘I think that I did it [announced the diagnosis] because Mr F trusted me and he kept me informed on a very regular basis. I didn’t need to intervene because there were lots of other physicians involved in the follow-up’ GP1 This theme was not mentioned by N1 ‘In March, I started to have stomach pain. I didn’t take it seriously at first, except that it didn’t go away. It lasted two months. […]. I was taken to the emergency department at X Hospital. They found that I had bowel obstruction and that I had to have surgery on the following day. So that went OK, I had the operation, and so I spent two weeks in hospital.’ P11 ‘The diagnosis, it wasn’t me who announced it.’ GP11 ‘I think that she had been operated on in another hospital and they asked me for an opinion. Well, I don’t remember which hospital it was. They asked me for an opinion on social, um, medical management. She came for a consultation, and I think that, ultimately, she wanted to be treated at X.’ O11 This theme was not mentioned by N11
Failure to discuss tasks distribution and coordination within the hospital alone	‘[Interviewer]: How do they work together? [P3]: Well, I don’t know at all about that…. I don’t know’ P3 ‘I coordinate. I need to coordinate, otherwise I don’t feel that I’m in my role as a GP. So for Mrs L, it’s the same – I am the physician who does it all. In as much as I say “I do it all” GP3 ‘In fact, all this organisation happens through weekly or fortnightly concertation meetings where all the stakeholders meet. It’s that that helps, the meetings that are obligatory. It’s that that helps’ O3 ‘Well, sometimes, what’s strange can be the lack of agreement between the hospital physicians and the private practitioners’ N3 ‘They [the oncologists] prescribed drugs to prevent the nausea – which didn’t prevent anything, in fact – and then in case I caught a cold or anything, they prescribed antibiotics for me because if I had fever, it could be dangerous. But they were telling me that I still had to go and see a doctor before taking them.’ P4 ‘She comes to see her GP so that I can extend her sick leave. It’s a good reason too because she was working.’ GP4 ‘Most of my patients don’t see their GP any more. The patients say “no, I don’t go to see him/her [the GP] because he/she says that it’s the oncologist that you need”, and you are obliged to renew prescriptions that aren’t even yours’ O4 No nurse in this quartette
The stakeholders’ expectations and perceived needs	‘I reckon that the GP is the one who has to be aware of all your major or minor health niggles. I am being treated very well at the hospital, and so I don’t know what more the GP can do… It is not with him that the disease started.’ P11 ‘Patients with high blood pressure or diabetes, that’s my job. Diagnosing cancer, that’s my job. Treating it and following it up, that’s not my job, or at least it’s not my core activity.’ GP11 ‘I expect that if my patient has a temperature of 38.5° or a sore throat, or pain urinating or pain somewhere, then they should see the GP and not me. So, in my view, I think that the GP is useful - very useful at the start of treatment to set up the administrative procedure for the full reimbursement of healthcare costs by the social security, that’s clear! And then for the treatments, managing all the small everyday problems that don’t necessarily require action from the oncologist’ O11 ‘I say that the patients only go to see the oncologist, but we’re the same – we’re only going to refer people to the oncologist. Even if we have a general problem, we refer them straight away to the oncologist.’ N11 ‘And I find that oncologists and physicians in general do not know the patient, they never take account of the patient’s wish to be kept informed or their ability to analyse things too. And I want to be given data so that I can understand, analyse and decide.’ P2 ‘I didn’t have any records for the patient on chemotherapy – nothing. I didn’t get any advice on how to manage the side effects.’ GP2 ‘The main stakeholder in patient management is the oncologist […] I have lots of patients who are far away, even in physical terms, and that there’s all that management of side effects to do, and it’s good to have someone (the GP) who can help me manage that.’ O2 ‘And yes, it’s true that this is a big problem in private practice because sometimes, if we don’t dig a bit and we don’t ask a few questions, we turn up and the person says “I have these injections” but they don’t tell us why. So, we have to ask questions and it’s true that we rarely get a follow-up file from the hospital or perhaps they don’t give it to us – I don’t know.’ N2
Interactions between the stakeholders	‘In principal, he gets some reports. I know that my urologist has sent him one, and the pulmonologist was supposed to – I hope that she did, although I don’t know if there is any dialogue between them.’ P6 ‘[Interviewer]: And so what relationships do you have? [GP6]: There are no relationships. A report from time to time, that’s all. I read the letter, of course, but then they don’t say much in the letter.” GP6 ‘Knowing the teams and the various people involved well, that helps to circulate information more quickly, in fact. For the patients, it’s enormously reassuring for them to know that the oncologist, the radiotherapist, and the anaesthetist know each other. We can exchange information very easily, which is very reassuring for the patient’ O6 No nurse in this quartette ‘But one day, she tried to get the oncologist (Dr V) on the phone. She didn’t get through, so she called her back. I think that Dr V wants to communicate too, it’s someone who’s at the hospital and wants to communicate with my GP.’ P2 ‘The only one I’ve been able to contact is Mrs V. We communicate by e-mail. She was very nice. I called her once or twice when he began to have metastases but it’s true that she’s the only one I’ve been able to form a link with. The others were not available. I didn’t have the oncology records. I received discharge letters but not at the right time.’ GP2 ‘I talked to her GP regularly at first (and less often now less). I referred her to a palliative care network and I had a good relationship with the team who looked after her.’ O2 ‘And yes, it’s true that this is a big problem in private practice because sometimes, if we don’t dig a bit and we don’t ask a few questions, we turn up and the person says “I have these injections” but they don’t tell us why. So, we have to ask questions and it’s true that we rarely get a follow-up file from the hospital.’ N2

P, patient; N, nurse; GP, general practitioner; O, oncologist or other cancer specialist.